Aphasia factors vs. subtypes

One of the interesting things (to me anyway) that came out of our recent factor analysis project (Mirman et al., 2015, in press; see Part 1 and Part 2) is a way of reconsidering aphasia types in terms of psycholinguistic factors rather than the traditional clinical aphasia subtypes.

The traditional aphasia subtyping approach is to use a diagnostic test like the Western Aphasia Battery or the Boston Diagnostic Aphasia Examination to assign an individual with aphasia to one of several subtype categories: Anomic, Broca's, Wernicke's, Conduction, Transcortical Sensory, Transcortical Motor, or Global aphasia. This approach has several well-known problems (see, e.g., Caplan, 2011, in K. M. Heilman & E. Valenstein (eds) Clinical Neuropsychology, 5th Edition, Oxford Univ. Press, p. 22 - 41), including heterogeneous symptomology (e.g., Broca's aphasia is defined by co-occurrence of symptoms that can have different manifestations and multiple, possibly unrelated causes) and the relatively high proportion of "unclassifiable" or "mixed" aphasia cases that do not fit into a single subtype category. And although aphasia subtypes are thought to have clear lesion correlates (Broca's aphasia = lesion in Broca's area; Wernicke's aphasia = lesion in Wernicke's area), this correlation is weak at best (15-40% of patients have lesion locations that are not predictable from their aphasia subtype). 

Our factor analysis results provide a way to evaluate the classic aphasia syndromes with respect to data-driven performance clusters; that is, the factor scores. Our sample of 99 participants with aphasia had reasonable representation of four aphasia subtypes: Anomic (N=44), Broca's (N=27), Conduction (N=16), and Wernicke's (N=8); 1 Global and 3 TCM are not included here due to small sample size. The figure below shows, for each aphasia subtype group, the average (+/- SE) score on each of the four factors. Factor scores should be interpreted roughly like z-scores: positive means better-than-average performance, negative means poorer-than-average performance.

Credit: Mirman et al. (in press), Neuropsychologia

At first glance, the factor scores align with general descriptions of the aphasia subtypes: Anomic is a relatively mild aphasia so performance was generally better than average, participants with Broca's aphasia had production deficits (both phonological and semantic), participants with Conduction aphasia had phonological deficits (both speech recognition and speech production), and Wernicke's aphasia is a more severe aphasia so these participants had relatively impaired performance on all factors that was particularly pronounced for the semantic recognition factor. However, these central tendencies hide the tremendous amount of overlap among the four aphasia subtype groups for each factor. This can be seen in the density distributions of exactly the same data:

As one example, consider the top left panel: the Wernicke's aphasia group clearly had the highest proportion of participants with poor semantic recognition, but some participants in that group were in the moderate range, overlapping with the other groups. Similarly, the other panels show that it would be relatively easy to find an individual in each subtype group who violates the expected pattern for that group (e.g., a participant with Conduction aphasia who has good speech recognition). This means that the group label only provides rough, probabilistic information about an individual's language abilities and is probably not very useful in a research context where we can typically characterize each participant's profile in terms of detailed performance data on a variety of tests. Plus, as our papers report, unlike the aphasia subtypes, the factors have fairly clear and distinct lesion correlates.

In clinical contexts, one usually wants to maximize time spent on treatment, which often means trying to minimize time spent on assessment and a compact summary of an individual's language profile can be very useful. Even so, I wonder if continuous scores on cognitive-linguistic factors might provide more useful clinical guidance than an imperfect category label.

Mirman, D., Chen, Q., Zhang, Y., Wang, Z., Faseyitan, O.K., Coslett, H.B., & Schwartz, M.F. (2015). Neural Organization of Spoken Language Revealed by Lesion-Symptom Mapping. Nature Communications, 6 (6762), 1-9. DOI: 10.1038/ncomms7762.
Mirman, D., Zhang, Y., Wang, Z., Coslett, H.B., & Schwartz, M.F. (in press). The ins and outs of meaning: Behavioral and neuroanatomical dissociation of semantically-driven word retrieval and multimodal semantic recognition in aphasia. Neuropsychologia. DOI: 10.1016/j.neuropsychologia.2015.02.014.