Apr 30 2010

Foreign Language Syndrome

Last week it was widely reported that a Croatian girl awoke from a brief coma speaking fluent German, to the surprise of her mother and the doctors. The case was hailed as a mystery and “medically unexplainable.”  The story spread mainly through those paper with less than a stellar journalistic reputation – but today that matters much less than it used to. Now stories get on the internet, regardless of their source, and become part of the seamless viral spread of information.

There actually isn’t a legitimate foreign language syndrome, and superficially the story is highly implausible. (Incidentally, there is a foreign accent syndrome, but this is really just a speech deficit that causes altered pronunciation that happens to superficially resemble a specific accent.) Croatian is a Slavic language, but has some German words mixed in due to its history with the Hapsburg Monarchy. The reports indicate that the girl studied German in school – and so she could speak it before her coma. Not much of a mystery, really.

We discussed the story on the SGU, prompting a listener from Croatia to write in with more details (local media always seems to have more detailed and accurate reporting). Ivan Osman wrote to me:

Now the interesting part is that after she woke up from the coma she could speak German a lot more fluently than before and not a word in Croatian. My guess is that Sepsis caused a brain damage in left temporal lobe. Probably mostly in Broca’s Area, thus disabling her in speaking Croatian but not damaging her knowledge of German language. At that point her brain probably switched to best alternative and her passive knowledge of German sprang to life. Without possibility to fall back to Croatian vocabulary there is no dilemma in which words to choose and how to use them so her German must have sounded a lot better to doctors and her parents. In my opinion the most unsettling thing about this story is not mystical nonsense around it but a quote from a neuropsychiatrist that was connected to this case. He said “This case is medically unexplainable” – only a day after the whole incident. Seems to me that people like him should not be even remotely connected to science. If he is capable of abandoning any rational explanation only a day after girl woke up. I could understand if he spent 50 years researching on that particular case and/or related cases and then states he can’t explain it. But his reckless statement made this story a mockery of journalism and his career instead of interesting medical case what it probably is.

The new detail here I had not previously read is that she stopped speaking Croatian. The story was distorted in the English press so that the interesting point seemed to be that she was speaking German, which is not interesting because she already could speak German. They missed the really interesting point – not that she could speak German, but that she could not speak Croatian.  Ivan brings up an interesting question – can you neur0logically lose your primary language, and retain (and even improve) a secondary language?

This situation is called bilingual or polyglot aphasia. Aphasia is a language deficit due to brain injury. For some quick background – the major language areas include Broca’s area (posterior dominant frontal lobe), which is responsible for translating language into speech – essentially for the subtle and agile control of all the muscles of speech. Damage to the Broca’s area produces what we call non-fluent speech – it is broken, hesitating, and stuttering. But if this were the only area of the brain damaged comprehension would be intact, and the content of speech would be normal. A Broca’s lesion would also not discriminate among languages, and so Ivan’s hypothesis can be rejected.

The other primary area is Wernicke’s area (posterior superior dominant temporal lobe) which is responsible for translating ideas into words and words into ideas – this is our dictionary. Damage here results in impaired comprehension of language. Speech is fluent, but the content is mixed up, and may contain neologisms (inventing new nonsense words), letter and word substitution, and generally nonsensical speech. There is also the arcuate fasciculus, which connects Wenicke’s to Broca’s. An isolated lesion here will impair repetition of words that are heard, but comprehension and fluency will be intact.

It should also be noted that when a second language is learned after around the age of four, then other parts of the brain are used for that language function in addition to the language cortex – but the primary language cortex is still required. It is currently not clear if languages learned together from infancy (compound bilinguals) are encoded in identical places in the brain or separate, although there is some evidence that they may not entirely overlap. This could allow for the differential damage of one language over another.

Generally, with aphasia (damage to any part of the language cortex) polyglot languages are lost and recovered together (in parallel). Also generally speaking, secondary languages (especially those learned after age four – called coordinate bilinguals) are more impaired and recover slower than primary languages.

There are various kinds of non-parallel polyglot aphasia reported. One language may be more severely lost, or recover later than another. There may also be involuntary switching between languages (inserting words from one language when trying to speak the other). And cases have been reported where a patient could only speak one language at a time, sometimes on alternating days.

To further complicate matters is the question of speech therapy. Most often speech therapy given in either language will improve speech in all languages. However, the primary language is usually chosen for therapy – the first language learned, or the dominant language currently used. There are cases, however, of differential recovery – recovery only in the language that is receiving speech therapy.

Neuroscientists are still trying to make sense of all this. One proposal is that in polyglots, while speaking one language, the other language(s) have to be inhibited. If this ability to inhibit one language is impaired, then this will result in involuntary switching or mixing up the languages. It is further proposed that some patients with aphasia may have the inability to turn off the inhibition of one language – so the language may still be there, but permanently inhibited and unavailable. Such cases are rare but provide a window into the organization of multiple languages in the brain.

Getting back to our Crotian girl, as I stated above I doubt she has a Broca’s lesion. She also likely does not have a dense Wernicke’s lesion either, as this would impair comprehension in every language. But there is other cortex involved in language, so-called association cortex involved in processing input and output from the primary language cortex. And language memory is also more widely distributed, especially for secondary or multiple languages.

The question is – could she have an unusual form of aphasia that is impairing her ability to disinhibit her Croatian language, leaving her only able to speak German? This could theoretically have the effect of making her German seem more fluent, because she does not have to expend mental energy inhibiting her Croatian – that has become automatic. This would be doubly rare (perhaps unique) because Croatian is her primary language, and German her secondary language.

This story has suddenly become more interesting. I would like to hear more details about the case, like how old she was when she learned German. It is, of course, possible that her language change is more psychological and neurological. But in any case she deserves a detailed evaluation by a speech expert and the case should likely be reported in the technical literature (not just the lay press, who managed to mangle it).

I hope her doctors do not persist in the silly notion that her case is “unexplainable” – there is actually a literature on this question and neuroscientists are making progress in sorting out how multiple languages are processed in the brain. This case, if properly explored, could provide a valuable addition to that literature.

This case may also demonstrate, therefore, why the scientific and critical approach to anomalous cases is more valuable than the mystery-mongering (“unexplainable”) approach. It is better to assume that we can figure things out, if we are willing to try.

16 responses so far

16 thoughts on “Foreign Language Syndrome”

  1. SkepLit says:

    I would love to see this turned into a therapy! My primary language is English but I studied German for years. If science had developed a temporary and reversible means to disinhibit my primary language just before my German final exams, I would have been a very happy man indeed!

    When I ran across this story on the web I barely even let it register in my brain. They headlines clearly wanted it to seem like magic or a miracle. To find out that, in fact, it may shed light on language function in the brain is FAR more interesting.

    I can not wrap my head around the mindset that prefers a statement like “It’s a mystery” to “It’s a mystery and we should figure it out”.

  2. canadia says:

    After one course in linguistic anthropology this I can at least hypothesize a scientific cause (as Ivan and Steve did an admittedly better job above) for this occurrence.

    How does a trained doctor look at this and say “unexplainable”? He must either be quite religious (looking for a miracle) or just wanted to sound cool and be quoted by a bunch of newspapers. Or he’s the most unimaginative person ever. Either way, EPIC FAIL on his part.

  3. Eternally Learning says:

    It seems to me that maybe the most likely explanation (while still giving someone we don’t know the benefit of the doubt) is that this guy simply didn’t have all the facts and reacted to what he was being told. For all we know this guy may have already gone back on that statement after studying the case further. I’m not saying this guy didn’t jump the gun, as he certainly overspoke (saying “I cannot explain this case” would be far more accurate than saying this case cannot ever be explained), but I think it’s equally jumping the gun to try and draw conclusions from a clip from a quote of a person we don’t know, and pretty rash to say he should be removed from his position. I think the most we can say without knowing more is that he made a stupid statement that was jumped on by a press looking to sensationalize the story.

  4. CivilUnrest says:

    I’m giving the doc the benefit of the doubt and assuming that what he meant was “I don’t know why the hell she can only speak German” and was misquoted/mistranslated into saying that it is “unexplainable”

  5. “the girl studied German in school”

    enough said. 🙂

  6. eean says:

    A friend of my parents had a major brain injury. Her secondary language certainly seemed to come bak first, but she was fluent in both so certainly no one considered it a medical mystery..

  7. hyperlalia says:

    My mother (a native English speaker) spent a year living in Mexico and became fairly proficient in Spanish. After having been back in the US for a year or two she went under general anesthesia for a dental surgery, and on waking from the procedure was only able to speak Spanish for 20 or so minutes before her English came back. The nurse in the recovery room was a little weirded out but everyone had a good laugh after the fact.

  8. banyan says:

    Would she have actually lost Croatian or could she just not consciously use it?

    Do you suppose that if she were given a task to pick up some items and told in Croatian that the red items would give her an electric shock that she would avoid the red items, subconsciously or otherwise?

    How did they determine that she doesn’t remember Croatian anyway? Self-report?

  9. p m says:

    Interesting case. I wonder if the patient is doing this voluntarily. The story is quite unlikely.

    First, the cause of coma is not explained.

    If the coma was caused by a structural brain lesion (stroke, encephalitis, etc), presumably her doctors would have that diagnosis in mind instead of talking about “a miracle”. Most brain lesions that cause coma are extensive/obvious enough that they’re hard to miss, clinically. Strategically located small lesions in the brainstem and/or thalamus can cause coma, but they wouldn’t be expected to produce language deficits. And most brain diseases that cause coma don’t resolve fully in 24 hours. From the sounds of the (very short) article, it seems the patient’s only residual symptom is that she’s speaking German instead of Croatian. So the possibility that she had a stroke (for instance) severe enough to cause coma seems unlikely.

    Of course her coma might have been due to a quickly reversible metabolic or toxic state (hypoglycemia, say, or carbon monoxide poisoning). She might well have woken from such a coma but been left with residual brain damage. But generally speaking, toxic/metabolic insults to the brain cause symmetric damage to structures (hippocampal neurons, the basal ganglia, Purkinje cells) that aren’t directly involved in language performance. Isolated aphasia would be a very unusual pattern of residual deficit after coma.

    Second, and more importantly, the language syndrome doesn’t make much sense.

    From the article it seems she is having no trouble communicating in German. It would be interesting to know if she can write, in German or Croatian or both.

    An inability to speak (at all, in any language) with otherwise preserved communication (writing, reading, understanding) is aphemia, the so-called “baby Broca’s” syndrome. Aphemia is more like an apraxia of speech or anarthria (ie, a motor disorder) than aphasia as such — language performance is entirely preserved except for the final step of initiating speech. It’s quite rare. It can be accompanied by other manifestations of orobuccal apraxia (loss of volitional expressive movements of the mouth) in the opercular syndrome.

    Another anarthric syndrome (again, affecting all languages) is cerebellar mutism, a sequela of surgical removal of a cerebellar/4th ventricular tumor seen in young children. The idea is that this is caused by damage to the lower cranial nerves (which lie near the surgical area, in the brainstem) that activate the larynx and the rest of the speech apparatus. But there may also be an emotional/volitional component to the syndrome. Again, communication is completely preserved except for the lack of speech. Patients usually start speaking again but are left with dysarthria.

    Diagnostically, the challenge in sorting out anarthria/mutism/aphemia is that the apparent inability to speak with otherwise preserved communication can be a voluntary phenomenon. This is a psychological/psychiatric disorder that has been known since Kussmaul described patients with “voluntary mutism” in 1877. It’s mostly seen in children, though I have seen one patient with this syndrome who presented acutely (as a suspected stroke) in her early 20’s. A little self-reflection will show that mutism isn’t too difficult a syndrome to carry off voluntarily — the classic “silent treatment”, taken to extremes.

    Which brings me back to this case.

    She’s not aphasic if she can communicate normally in spoken German or in written language of any sort. She’s not aphemic if can speak normally in German. This is not the typical post-surgical setting of cerebellar mutism.

    The theory that she might have selective involvement of association cortex (the so-called “dictionary” involved in anomic aphasia) is also unlikely, I’m afraid. While different areas of the brain are involved in speaking native/early languages and those learned later in life, the areas of association cortex involved in each would not be expected to be completely dissociated — this girl doesn’t have a “German gyrus” separate from a “Croatian gyrus” that could be damaged selectively. Anomic aphasias are also rarely, if ever, absolute. Patients with damage to association cortex may have some trouble with naming and word-finding, but fluency is usually relatively spared and spoken communication is usually fairly well preserved. We’re not told if she’s even trying to speak Croatian, but “unable to speak” suggests the deficit is absolute. That’s very hard to explain, neurologically.

    So I think it’s very likely that this is simply a case of the girl deciding to speak German instead of Croatian. I’m not sure whether this is entirely deliberate on her part (an attention-getting stunt), or not (a somatization pattern of unconscious manifestation of psychological symptom). And I’m not sure how her “24 hour coma” fits in to the picture. But I’ll be very surprised if there’s ever a clear neurological diagnosis made in her case.

    One final point: in elementary school, our French immersion teachers (anglophones) who would refuse to speak any English during school hours, forcing us to deal with them entirely in French. Was that foreign language syndrome? If they’d kept up the act successfully for a week, or a month, would we expect to find a lesion in the dominant hemisphere? Would we be writing them up in the newspaper as “a miracle”?

  10. Mr. K Dilkington says:

    Don’t forget, if you’re on Lost love cures aphasia.

  11. BillyJoe7 says:

    There are several possibilities for the “explanable” quote:

    – it was a misquote and what he actually said was something like: “I can’t explain it at the moment”
    – it was not a misquote but the quote was short hand for “I can’t explain it at the moment”
    – it was not a misquote and the doctor meant it, but, on reflection is capable of self correction.
    – it was not a misquote and the doctor meant it and he’s going to stick with it no matter what becausae he believes in miracles.

    There may be more, but let’s see what happens.

    Recently, the doctor supporting the evidence of facilitated communication in the case of the guy with alleged “locked in syndrome” was fully capable of reconsidering his opinion in the light of new evidence presented to him. He turned out to be more of a hero than a villain.

  12. HHC says:

    If the young girl awoke from a coma speaking German and not Croatian, it could be that the patient’s immediate recall and recent memory is intact, but there is impairment in remote memory. Why not allow the young patient more time for language recovery, afterall, the primary language area is approximately a fifth of the cerebral cortex. This sounds like a national pride problem according to the media, German first, Croatian second.

  13. bindle says:

    Is it possible the doctors had all awoken that day thinking in Australian?

  14. HHC says:

    bindle, Nope, the guy woke up Croate first and doctor second.

  15. trepto says:

    Interesting. I had a roommate many years ago who, like myself, had taken French in school and was self-learning fangirl Japanese. We used to get ludicrously drunk and converse in what we called Frapponaise, a slurry of mostly French verbs and Japanese nouns/adjectives with English thrown in from time to time. Funnily, the drunker we got, the more expansive our vocabularies became, perhaps related in some way to the alcohol affecting our default foreign-language-quashing state? Unfortunately, we had no friends who were fluent in Japanese and could verify that what we thought we were saying (and what we understood the other to be saying) was at all correct, but our French was reported on the following mornings as being significantly superior to our skill when sober.

  16. fausto4783 says:

    I’m a cardiologist and I wish to tell you a very interesting case that happened to me few years ago.
    A forty year old colleague of mine, italian, had something like a seizure just after going to sleep. In the morning she didn’t go to work and her brother went home to see what happened. He found the sister in a comatose state, and when she recovered began to speak in reverse italian (i.e. instead speaking dog god).
    She was angry because the shocked brother couldn’t understand her; in fact she was sure to speak correctly. After this in the hospital she started to speak a fluent French. She learned french at school many years before but she never lived in France nor in a french speaking country. After few days she began to speak again italian but splitting the words in the single syllables. She lost some calculation capacity in the same way. After years of logopedy (she married her logopedist) she turned again to speak italian but with a clear french accent; she continued to speak and understand an excellent french. Furthermore she was able to understand spanish and arabian. Now every time she has a high fever, the initial symptoms come out again and she needs some days to recover. She had a lot of examinations (RMN, SPECT, CT); it seems that something is impaired in the zone of the primary and secondary languages: at SPECT the blood and metabolysm is more present in the secondary language area than in the primary one.
    This person is alive and, for the rest in good shape.
    Hope this can help in speculating about the nature of this strange and ,under certain conditions, desirable situation. You can contact me for further informations.

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