BRAIN

AND

LANGUAGE

27, 239-246 (1986)

Severe Stuttering Associated
ALFREDO ARDILA

with Right Hemisphere

AND MARIA

Institute Neurologico

Lesion

VICTORIA LOPEZ

de Colombia

Following a right hemisphere stroke, a right-handed, 50-year-old male experienced
a permanent dysfluency characterized by phoneme and syllable reiterations and,
to a lesser extent, word and phrase reiterations. The reiterations occurred in
initial, medial, and final positions and for all sentence elements (e.g.. subject
nouns, object nouns, verbs, modifiers). There was a notable loss of verbal automatisms (poems, songs, etc.). The patient’s symptoms conform to the acquired
stuttering syndrome described by A. Helm. R. Butler, and D. F. Benson (1978,
Neurology, 28, 1159-l 165). 0 1986 Academx Press. Inc.

Stuttering has been defined as an elocution defect formed by syllabic
repetition and a difficulty in pronouncing various syllables, including
stopping and spasms of verbal fluidity (Perello, 1970). Espir and Rose
(1970) considered stuttering as a deviation of speech that attracts attention
and which adversely effects the speaker or listener because of an interruption of the normal speaking rhythms by involuntary repetition, prolongation, or arrest of sounds. Palilalia is a speech disorder characterized
by involuntary repetition of words or phrases during verbal output (Benson,
1979).
Horner and Massey (1983) mention two main patterns of neurogenic
dysfluency: cortical stuttering and palilalia, the latter usually associated
with bilateral pathology-either
frontal (Valenstein, 1975) or basal ganglia
(Boller et al., 1973). Transitory stuttering is usually associated with expressive language disorders. Permanent dysfluency expressed as stuttering
or palilalia, along with an intact language, is quite unusual.
It has been mentioned that focal damage on the right hemisphere
frequently leads to a slight tendency toward phonemic or syllabic repetition,
feigning acquired stuttering (Ardila, 1984). Nevertheless, it is quite unusual
to find cases of severe stuttering associated with damage on the right
hemisphere, that present an adequate level of linguistic functions (RoSend reprint requests to Alfred0 Ardila, Instituto Neurologico
Aereo 17021, Bogota, Colombia, South America.

de Colombia; Apartado

239
0093-934X/86 $3.00
Copyright
?Z 1986 by Academic Press. Inc.
All rights of reproductmn
in any form reaened.

240

ARDILA

AND

LOPEZ

senbek, Messert, Collins, & Wertz, 1978). Helm, Butler, and Benson
(1978) reviewed 10 cases of acquired stuttering, which is characterized
by absence of adaptation effect, occurrence of stuttering on any syllable
within a word, and stuttering in both grammatical and substantive words.
Permanent dysfluency was correlated with bilateral cerebral damage.
Transient stuttering was correlated with unilateral multifocal hemisphere
damage, generally associated with aphasia.
Horner and Massey (1983) have carefully presented the case of a 62year-old patient who showed a dysfluency of 25.8% following an occlusion
of the right carotid artery. The authors chose to call this dysfluency
“palilalia”
rather than “stuttering,”
due to the fact that repetition usually
occurred in both words and phrases. This dysfluency was found to be
associated with significant errors in reading, drawing, and copying. In
addition, the patient experienced dress apraxia and difficulty with topographic orientation and constructive tasks. The neurological evaluation
showed left homonymous hemianopia, left central facial paresis, and left
Babinski’s sign. The CT scan showed a low-density area which included
the whole territory of the right middle cerebral artery.
In the case we report here there was a considerably smaller cortical
area affected, almost limited to the right temporal lobe, but a more severe
dysfluency (44.8%), especially with reference to minor unities (phonemes
and syllables). We followed as closely as possible Horner and Massey’s
(1983) scheme for the evaluation of the dysfluency, in order to allow a
direct comparison of the two cases.
CASE HISTORY

Medical

Background

This is a 50-year-old, strongly right-handed patient (without lefthandedness family history or personal or family stuttering history before
the stroke); he is an engineer who had a thrombotic cerebrovascular
accident in September 1980, characterized by left hemiparesis and speaking
difficulty, which the patient describes as “kind of moaning without being
able to articulate words.” He was hospitalized after the accident and
received medical care in his home town. No further information regarding
the patient’s clinical history was available. He received physical therapy,
after which he regained movement of the left side of his body. He also
started to recover language; and, as speed in his speech increased, phonologic and syllabic repetitions and blockades began to occur.
In April 1983 he visited the Neurological Institute of Colombia. A CT
scan showed extensive low-density in the right temporal lobe (Fig. 1).
No motor or sensory disturbances were found. Oral comprehension was
excellent, and his language was correct in terms of grammar and lexical
selection. Nevertheless, dysfluency was outstanding throughout the examination, characterized by tonic blockades and many repetitions, primarily

SEVERE

FIG. I.

CT

scans.

Note

extensive

241

STUTTERING

low-density

areas

in the right

temporal

lobe

syllabic and phonemic, during word and sentence repetition as well as
in spontaneous oral speech. Many reiterations also occurred while he
was reading aloud. There was no adaptation effect with repeated reading
of a paragraph, during simultaneous reading with the examiner, or at a
slower reading speed paced by a metronome. No gestures or associated
synkinesis were observed. Even during repetitions, which were evident
in all positions (initial, medial, and final) and for all the grammatical
elements, the patient maintained a visual contact with his interlocutor.
His ability to name parts of the body, external objects, and colors was
normal. Word and sentence repetition showed the same characteristics
as oral spontaneous language. Writing was satisfactory and reading aloud
showed a large number of repetitions. Severe difficulties were found in
remembering
verbal automatisms:
familiar songs, poems, the National
Hymn, etc.
The patient was able to correctly draw simple figures after a verbal
request (flower, clock, cube), showing no signs of hemi-inattention
or
spatial confusion. He was able to find geographic sites on a map, to
perform simple arithmetical problems, and to rank numbers in columns.
He correctly showed and named fingers of the hand. There were no signs
of ideomotor or ideational apraxia (see Figs. 2 and 3).
When asked to express the changes experienced since the onset of
the problem, the patient mentioned (1) occasional muscle pain on the
left side of the body; (2) occasional feelings of double personality when
performing personal actions such as bathing, shaving, etc.; (3) occasional

ARDILA

242

FIG.

AND LOPEZ

2. Drawing by verbal order: a clock, a flower, and a cube.

lack of coordination
of simple tasks such as tightening the tie; (4) forgetfulness of things that had been previously learned by memory such
as sentences, poems, and songs; (5) temporary loss of memory (e.g.,
“Where did I leave the newspaper? my eyeglasses?“); (6) short, vague
states associated with various factors: e.g., “an unknown person resembles
somebody I know, ” “I have the feeling of going through past situations
or problems again.”
Language

The Boston test for diagnosis of aphasia was used (Goodglass & Kaplan,
1972). Figure 4 shows the patient’s language profile. Except for the faults

FIG.

3. Rey-Osterrieth

figure. Copy (upper) and memory (lower).

NAME:

SEVERITY

RAT IN G

FLUENCY

AUDITORY
CDMPREH.

NAMING

ORAL READING

REPETITION

PARAPHASIA

AUTOM.

SPEECH

READING
COMPREH.

WRlTlNG

MUSIC

PARlETAL

FIG.

4.

Patient’s

language

profile

in the Boston

Test

for Diagnosis

of Aphasia.

ARDILA

244

AND LOPEZ

due to his severe stuttering, there is no significant language impairment,
i.e., there is no aphasic impairment. His speech seems logical, coherent,
and appropriate to his educational level. The patient continues with his
professional activities as an engineer, meeting satisfactory performance
standards. His reading comprehension is normal, though while reading
aloud, he shows the same disturbances as in his oral language. In writing,
he shows a tendency toward separating letters, a phenomenon sometimes
observed in writing after right hemisphere damage (Ardila, 1984).
ANALYSIS OF DYSFLUENCY

Dysfluency evaluation followed that of Horner and Massey (1983). The
language sample (243 words) was made up of six different tasks:
(1) conversational
speech (25 words), (2) description of a picture (46
words), (3) sentence repetition (50 words), (4) counting (19 words), (5)
reciting (25 words), and (6) reading sentences (78 words).
The following errors were qualified: (1) phonemic repetition (e.g., lkkasal); (2) syllable repetition
(e.g., /li-libro/); (3) part-word repetition
(e.g., lmaki-makinal); (4) word repetition (e.g., /mesa-mesa/); and (5)
phrase or sentence repetition (e.g., ld no tiene-e’l no tienel). Any string
of uninterrupted reiterations of a single type was considered an “episode”
of dysfluency; each episode could contain one or more reiterations.
Table 1 shows the number of dysfluent episodes which occurred during
the six tasks, as well as the number of reiterations analyzed. For the
243-word sample, a total of 104 dysfluent episodes and 109 reiterations
(of all types across the episodes) were found (i.e., in 44.8% of all words).
Dysfluent episodes during reading (3 1.8%), repetition (21.2%), describing
TABLE
DISTRIBUTION

I

OF DYSFLUENCY

BY TASK

Distribution of
reiteration episodes

Task
Conversational
speech
Describing
a picture
Counting
Repeating
phrases
Reading
Reciting

TYPE

Distribution of
No. of reiterations

No.
of words

No. of
episodes

Percentage
of total
episodes
(104)

No.
of
reiterations

Percentage
of total
episodes
(191)

25

13

12.5

24

12.6

46
19

21
1

20.1
6.7

44
8

23.0
4.2

50
18
25

22
33
8

21.2
31.8
7.7

48
55
12

25.1
28.8
6.3

SEVERE

245

STUTTERING

a picture (20. I%), and conversational speech (12.5%) were more frequent
than in other tasks. Counting and reciting were the least affected by
reiterations.
Table 2 shows the distribution and respective percentages for the different
types of reiterations. The maximum repetition percentage was found in
syllables (33.5%) and phonemes (30.9%), while phrase reiteration was
minimal (5.2%). Word and part-word repetition were in the middle.
The number of repetitions per episode reached a maximum of seven
for all the repetition tasks and five for the conversational speech and
describing a picture task. The reciting and counting tasks reached a
maximum of three and two reiterations per episode, respectively.
DISCUSSION

The patient under study shows a series of important differences in
relation to the case reported by Horner and Massey (1983).
1. Damage is considerably less and apparently confined to the right
temporal lobe. Consequently there are fewer associated neurological and
neuropsychological
signs. Dress apraxia, depersonalization,
and deja vu
phenomena and some episodic amnesia are the only signs associated with
the severe stuttering.
2. The dysfluency is greater for this case (44.5% vs. 25.8%), affecting
basically minor unities (phonemes and syllables) which totaled 64.4% of
the observed reiterations. This fact allows us to consider this a case of
stuttering rather than one of palilalia.
3. Reiterations
are almost the same for picture describing (23.0%),
repetition (25.1%), and reading (28.8%); considerably smaller for counting
(4.2%) and reciting (6.3%). Conversational speech is in the middle (12.6%).
4. The severe loss of verbal automatisms (songs, poems, sentences,
National Hymn, etc.) showed by the patient call for special attention.
Such a loss, under the case of right hemisphere damage has already been
reported (Ardila, 1984; Luria, 1973).

DISTRIBUTION

Reiteration
Phoneme
Syllable
Part-word
Word
Phrase

type

TABLE
2
OF REITERATION EPISODE BY REITERATION

No. of
episodes
of reiteration
59
54
19
39
10

TYPE
Percentage
of
grand
total reiteration
episodes (191)
30.9
33.5
10.0
20.4
5.2

246

ARDILA

AND LOPEZ

It is worth mentioning some differences between the acquired stuttering
observed in our patient and developmental
stuttering (Perello, 1970):
1. The absence of synkinesis or abnormal movements of the lips,
tongue, inferior maxilla, eyebrows, eyelids, body, arms, or legs which
are associated symptoms of developmental
stuttering.
2. The absence of vasomotor alterations such as transpiration, blushing,
or paleness. Also, the patient does not seem to avoid situations which
necessitate verbal communication.
His behavior with reference to difficulties in communication
seems to correspond more to discontent than
to anxiety.
3. The invariability
of the symptomatology
in certain circumstances
(stress situations or procedures that produce adaptation effects, such as
repeating reading, simultaneous
reading with examiner, reading with
metronome).
4. The reiterations are observed for all the positions within the word
and for all kind of words.
Five distinctive characteristics of acquired stuttering stated by Helm
et al. (1978) have been confirmed: (1) no adaptation effect, (2) stuttering
not restricted to initial syllables, (3) stuttering occurs on small grammatical
and substantive words, (4) the speaker may be annoyed but not anxious,
and (5) a lack of secondary symptomatology (facial grimacing, fist clenching,
etc.).
Probably the most evident aspect of our patient is the association
between stuttering and the loss of verbal automatisms. Perhaps his stuttering
could be even interpreted as a disautomatization
of the speech outflow
as the underlying mechanism of this type of stuttering, somehow different
from developmental
stuttering.
REFERENCES
Ardila, A. 1984. Right hemisphere participation in language. In A. Ardila & F. OstroskySolis (Eds.), The right hemisphere: Neurology and neuropsychology.
(pp. 99-107).
New York: Gordon & Breach.
Benson, D. F. 1979. Aphasia,
alexia and agraphia.
New York: Churchill.
Boller, F., Boller, M., Denes, F., Timberlake, W. H., Zieper, I., & Albert, M. 1973.
Familiar palilalia. Neurology, 23, 1117-l 125.
Espir, M. L. E., & Rose, F. C. 1970. The basic neurology
ofspeech.
Oxford: Blackwell.
Goodglass, H., & Kaplan, E. 1972. The assessment of aphasia and related disorders.
Philadelphia: Lea & Febiger.
Helm, A., Butler, R., & Benson, D. F. 1978. Acquired stuttering. Neuro/ogy, 28, 11591165.
Homer, J., & Massey, W. 1983. Progressive dysfluency associated with right hemisphere
disease. Bruin and Language,
18, 71-85.
Luria, A. R. 1973. The working brain. Harmondworth: Penguin.
Perello, J. 1970. Transtornos
de1 habla. Barcelona: Ed. Cientifico-Medica.
Rosenbek, J. C., Messert, B., Collins, M., & Wertz, R. T. 1978. Stuttering following brain
damage. Brain and Language,
6, 82-96.
Valenstein, E. 1975. Nonlanguage disorders of speech reflect complex neuroiogic apparatus.
Geriatrics,
30, 117-121.