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Susan Edwards: Fluent Aphasia.

Susan Edwards: Fluent Aphasia. Cambridge: Cambridge University Press, 2005. xii + 230 pp. ISBN 978-0-521-79107-6.

Over the last several decades, a large part of aphasia research has focussed on persons with Broca's aphasia and agrammatism, although these people are relatively rare in the clinical setting, comprising perhaps 1-2% of the aphasic clients seen. In her book, Fluent Aphasia, Susan Edwards notes that fluent aphasics comprise approximately 80% of the patients seen in the University of Reading Clinic. This number corresponds roughly to the proportion of fluent aphasics treated in other rehabilitation clinics as well. In spite of the vast majority of patients in everyday clinical life presenting with fluent aphasia, very little theory-based research has focussed on this type of aphasia, much to the disappointment and frustration of practicing clinicians who need to treat these persons. When fluent aphasics are presented at all in the literature, they are primarily used as a contrasting group in research on agrammatism, where the theoretical focus remains on the nonfluent Broca's aphasics. With her book, Fluent Aphasia, Edwards attempts to fill this wide gap in the aphasia literature and encourages others to follow in her footsteps. As a clinician and linguist, she is able to present information on fluent aphasia from both the theoretical and clinical points of view, which adds to the strength of the book.

Edwards gears this monograph toward various students of aphasiology coming from psychological, linguistic or clinical backgrounds. As the author is very careful to define even basic concepts in aphasia, the monograph could be used as a textbook, providing students or medical staff with a general introduction to fluent aphasia, its assessment, and issues pertaining to its underlying causes. The book contains eight chapters and is basically divided into four parts: a description of fluent aphasia, assessment, theoretical aspects of fluent aphasia compared with nonfluent aphasia, and a case presentation. Chapter 1 provides a history and general description of Wernicke's aphasia. It begins with the original description given by Carl Wernicke and goes on to the syndrome classifications set down by Harold Goodglass and the Boston School (Goodglass and Kaplan 1983). It continues with a short discussion of the efficacy of classifying aphasia types and concludes with issues in mapping aphasia syndromes to various brain lesions. Chapter 2 describes possible production difficulties in fluent aphasia based on phonological form, lexical semantics and sentence construction. Chapters 3 and 4 present tools for the assessment of fluent aphasia. Chapter 3 describes the layout and use of some widespread tools for the general assessment of aphasia, namely the Boston Diagnostic Aphasia Exam (BDAE) (Goodglass and Kaplan 1983), the Western Aphasia Battery (WAB) (Kertesz 1982), and the Aachen Aphasia Test (AAT) (Huber et al. 1983), then goes on to describe some additional tests which focus particular aspects of language such as the Boston Naming Test (BNT) (Goodglass et al. 1983), the Psycholinguistic Analysis of Language Processing in Aphasia (PALPA) (Kay, Lesser, and Coltheart 1992), and the Verb and Sentence Test (VAST) (Bastiaanse et al. 2002). Chapter 4 focuses on tools used for the analysis of connected speech. Two possible methods of analysis are introduced and compared: the Northwestern continuous speech analysis developed by Thompson and her colleagues at Northwestern University in Chicago and the Reading aphasia analysis using text units developed by Garman and Edwards (1995). In chapters 5 and 6, Edwards focuses on theoretical aspects of fluent aphasia as compared with nonfluent aphasia. In particular, she presents two current hypotheses of syntactic deficits in agrammatism based on Chomsky's (1992) theory of syntax: 1) the Trace-Deletion Hypothesis (Grodzinsky 1995) which focuses on syntactic processing in comprehension and 2) the Tree-Pruning Hypothesis (Friedmann and Grodzinsky 1997) which attempts to account for agrammatic production. Edwards discusses the possible application of these two working hypotheses to the performance of persons with fluent aphasia, particularly when their performance patterns resemble those of persons with nonfluent agrammatic aphasia. Chapter 6 continues the discussion of language comprehension in fluent aphasia. She suggests that although Broca's and Wernicke's aphasics may show similar patterns in sentence comprehension, the underlying causes may be different. To round out the book and to demonstrate many of the assessments and issues already discussed, chapter 7 presents one man with chronic fluent aphasia and his changing aphasia profile over the years. This client provides a classic picture of Wernicke's aphasia. Chapter 8 concludes with a detailed summary of the characteristics of fluent aphasia as well as future issues in aphasia research including fMRI studies to provide more detailed mapping of neural activity in the brain. Edwards further emphasizes the need to focus on research for specifying, refining and improving aphasia therapy.

In describing the performance of persons with fluent aphasia, Edwards focuses primarily on issues in lexical access and possible grammatical deficits. Under the topic of lexical access, she demonstrates that aphasics often have trouble finding and producing the correct phonological form. Furthermore, and perhaps most importantly, they have difficulties accessing the precise semantic meaning for lexemes, both in production and comprehension. This deficit in accessing lexical semantics lies at the crux of the communication problem in fluent aphasia. Not only does the aphasic person have difficulty connecting the proper meaning with words, but also often fails to assign proper thematic roles. Because of the demonstrable deficits in processing lexical semantics, it has been questioned whether or not fluent aphasics also show a verifiable grammatical disturbance or whether apparent grammatical errors could be part and parcel of the semantic disruption. Edwards provides an in-depth discussion of this issue in chapters 5 and 6. While many difficulties can be explained with problems in accessing lexical semantics, she concludes that grammatical errors are widespread in fluent aphasia and fluent aphasics do not always have access to or cannot apply certain grammatical operations such as checking, even though the underlying grammatical representations per se are intact.

In reviewing this book, I would like to discuss two critical issues which arise from the initial premise that fluent aphasia is a clearly definable entity to be separated from nonfluent aphasia. Although by focusing her book on presenting and defining fluent aphasia, Edwards fills a gap in the literature successfully, my first issue concerns the need to classify aphasic patients at all as to fluency and if it may not be more beneficial to view fluent and nonfluent aphasics as two ends of a continuous spectrum rather than two distinctly definable syndromes. Edwards herself points out many problems with classifying aphasic patients as to syndrome, since many of them cannot be well-classified and there are many overlaps. This is true. But still she finds it somehow logical to divide aphasics into fluent and nonfluent groups without giving any real argument for this logic other than its tradition. Even after decades of research, no defining characteristic of fluency in persons with aphasia has been found. Just as there are no clear boundaries between the fluent aphasic syndromes, neither is the boundary between fluent and nonfluent clear. When speaking of nonfluent and fluent aphasia, most researchers still mean Broca's and Wernicke's aphasia. In the everyday clinical setting, where clients are not preselected, many are not so easily classifiable as to fluency. Due to many word-finding difficulties as well as constant overt and covert corrections, some so-called fluent aphasics are even less fluent than mild Broca's aphasics. By using the term fluent aphasia, Edwards claims to include all of the fluent aphasic syndromes (Wernicke's, conduction, anomic, and transcortical sensory), but really only presents examples of Wernicke's aphasia. Therefore, Edwards' typifying characteristics in the conclusion are really only valid for Wernicke's aphasia. Variations in fluent aphasia other than severity are hardly addressed. The other fluent syndromes (conduction, anomic, transcortical sensory) are mentioned but only defined very briefly with a sentence concerning repetition skills and comprehension. In a few studies, conduction and anomic aphasics appear but are assumed to be milder versions of the Wernicke's patients. Persons with transcortical sensory aphasia are not presented at all.

I would like to have seen Edwards break away from this classical division of aphasic persons, especially as the classical syndromes have no real relevance in clinical practice. In fact, because of the focus over the last decades has often been on defining syndromes, efforts focusing on treatment issues have been sacrificed. Even primary assessment tools such as the Aachen Aphasia Test (Huber et al. 1983), meant for clinical diagnosis and as a guideline for treatment, is more concerned with classification than error analysis. In fact, it provides no error analysis at all and so limits its own effectiveness in guiding therapy. Treatment needs to focus individual deficits. There are no treatments for Wernicke's aphasia or Broca's aphasia, but there are treatment methods which can be applied for example to particular phonological disorders or certain disorders of lexical semantics. An alternative focus would be on looking at how particular processing disorders might be manifested in the performance of aphasic patients, regardless of syndrome or fluency. Considering all types of aphasics, even the unclassifiable ones usually screened out in research, could also give us a real picture of how spectrums of symptoms may or may not fall together. This insight in turn may aid us in uncovering the real underlying causes of some of the symptoms of aphasia. Furthermore, it would provide a better basis for developing aphasia therapy, the need for which Edwards strongly emphasizes.

My second issue concerns the analysis of grammatical impairments in fluent aphasia. Although Edwards provides us with an interesting and very detailed discussion of lexical and grammatical deficits in fluent aphasia, she like many other researchers is resistant to positing the same underlying deficit in grammatical processing by Broca's and Wernicke's aphasics, even if their patterns converge. Such a proposal might mean giving up the notion of defining the nonfluent and fluent aphasic syndromes according to their grammatical deficits. Although the performance patterns of fluent and nonfluent clients--especially as seen in comprehension--may appear to be very similar, Edwards suggests they have different underlying causes. While those with nonfluent aphasia have a grammatical deficit which impedes for example the processing of thematic roles, clients with fluent aphasia have a lexico-semantic deficit which impedes their processing of thematic roles. In order to confirm this notion for comprehension, she draws on performance in production by fluent aphasics. Even Friedman and Grodzinsky (1997) have acknowledged that performance in production is not indicative of performance in comprehension. Both fluent and nonfluent aphasics have difficulty with lexical processing as well, so the arguments Edwards makes are not very convincing. Instead of trying to make clients fit a preordained theory, it would be better to make careful predictions of how a client might present when he or she has a particular processing deficit, then see which individual aphasic persons fit this pattern, regardless of classical syndrome. This may be especially beneficial in portraying the Trace-Deletion Hypothesis (Grodzinsky, 1990) and the Tree-Pruning Hypothesis (Friedman and Grodzinsky 1997). Instead of imagining that the abstract syntactic representations are psychologically real, we would have to come up with the actual processes involved in operations such as assigning theta-roles, checking and specifying nodes in the syntactic tree, then see which patients fit this pattern.

Though it may not have been Edwards' intention to provide a comprehensive portrayal of fluent aphasia and therefore my following criticism may not be entirely justified, I still find two chapters missing from her book which I feel are absolutely necessary in a monograph meant as a kind of textbook to provide students with a general introduction to fluent aphasia. I would like to have seen a chapter describing reading and writing abilities in fluent aphasia. Not only are these modalities necessary to complete the picture of what fluent aphasia is, but they are also an essential part of therapy in clinical practice. In comparing problems in reading and writing with those in the auditory and spoken modalities, some interesting patterns can be seen in the clinical setting, which have seldom been described or acknowledged in the literature. As a practicing clinician, Edwards would also be very familiar with these observations. First of all, Wernicke's aphasics often show much better reading comprehension than auditory comprehension. This better preserved ability can be and is used as a tool in clinical and everyday settings to improve communication with these clients. Secondly, Wernicke's aphasics may also show semantically based reading strategies, though only partially resembling the deep dyslexia seen in Broca's aphasics. Writing skills can differ radically from spoken skills. Some clients often say one word while writing another--either semantically or phonologically different. Another common pattern seen in fluent aphasia is that access to the written form of verbs is often faulty even when the client can say the verb he wants to write. Unfortunately, none of these issues are addressed in Edwards' monograph because written language has been left out completely.

The second missing chapter concerns therapy indications and methods in treating clients with fluent aphasia. Edwards is one of very few researchers who present clients in an extraordinarily human way, reminding us that aphasia is an illness and that persons with aphasia suffer immensely from their language impairment. This is strength of her book. Furthermore, she expressly calls upon the research community to focus on therapy needs and therapy research while urging therapists in turn to increase their knowledge of linguistic theory. Unfortunately, she provides us with no portrayal of possible therapies to be used with fluent aphasics. Especially as her targeted readers are students of language disorders--including future and practicing speech and language therapists--I would consider at least one chapter on the treatment of fluent aphasia as essential.

A further technical problem which needs to be mentioned is that Edwards' book is peppered with errors of all kinds. These are irritating, if not confusing at times, and detract somewhat from its overall value. There are typographical errors, wrong dates and page numbers in the text and in the bibliography, missing entries in the bibliography, miscounted data, a wrongly labelled table, explanations in the text which do not completely agree with the accompanying tables or figures, and occasionally repetitious or contradictory sentences. These many errors should be edited and corrected before the book is reprinted.

Despite its limitations in scope as well as its need for proper editing, this monograph provides a good portrayal of Wernicke's aphasia, so that it fills to some degree a blatant gap in the aphasia literature. Because of Edwards' care not to assume prior experience or knowledge of aphasia on the part of the reader, this monograph can be used as a textbook to provide students with basic knowledge of assessments and heavily discussed issues concerning Wernicke's and to some extent other fluent aphasias. By purposely not adhering to any one school of thought, Edwards is able to portray many conflicting arguments and unresolved issues in aphasia research. For all of these reasons, this book can be recommended to readers from many different fields who are interested in gaining insight into aphasia, its assessment, and its underlying causes.


Bastiaanse, R.; Edwards, S.; and Rispens, J. (2002). The Verb and Sentence Test. Bury St. Edmonds: Thames Valley Test Company.

Chomsky, N. (1992). The minimalist program for linguistic theory. MIT Occasional Papers in Linguistics, Vol. 1. Cambridge, MA: MIT.

Friedmann, N. and Grodzinsky, Y. (1997). Tense and agreement in agrammatic production: pruning the syntactic tree. Brain and Language 56, 397-425.

Garman, M. and Edwards, S. (1995). Syntactic assessment of expressive language. In Linguistics in Clinical Practice, 2nd ed., K. Grundy (ed.), 134-166. London: Taylor and Francis.

Goodglass, H. and Kaplan, E. (1983). The Assessment of Aphasia and Related Disorders. 2nd ed. Philadelphia: Lea and Febiger.

--; Kaplan, E.; and Weintraub, S. (1983). The Boston Naming Test. Philadelphia: Lea and Febiger.

Grodzinsky, Y. (1995). A restrictive theory of agrammatic comprehension. Brain and Language 50, 27-51.

Huber, W.; Poeck, K.; Weniger, D.; and Willmes, K. (1983). Der Aachener Aphasietest. Gottingen: Hogrefe.

Kay, J.; Lesser, R.; and Coltheart, A. (1992). The Psycholinguistic Analysis of Language Processing. Hove: Psychology Press.

Kertesz, A. (1982). The Western Aphasia Battery. New York: Grune and Stratton.


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Author:Christiansen, Julie Ann
Publication:Linguistics: an interdisciplinary journal of the language sciences
Article Type:Book review
Date:Jan 1, 2008
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