Right hemisphere language disorders …

Alia Martin PhD

Neurobehavioral & Cognitive Disorders

Updated 08.04.2024
Released 12.19.2011
Expires For CME 08.04.2027

Right hemisphere language disorders

Author: Alia Martin PhD

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Editor: Victor W Mark MD

Right hemisphere language disorders

In This Article

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Introduction

Overview

The author describes language and communication deficits associated with right hemisphere brain damage due to, for example, cerebrovascular accident or traumatic brain injury. Topics include nonliteral language, such as metaphor and irony, humor, and theory of mind (ToM). In addition to symptom descriptions, the author presents a historical background, points out that impairments associated with right hemisphere brain damage extend beyond just communication, and describes some approaches to treatment. The author also presents evidence that the intact right hemisphere makes substantial contributions to communication, but the strong claim that the right hemisphere is “dominant” for specific language functions is not well supported.

Key points

	• Damage to the right cerebral hemisphere can impair communication ability, even in the absence of obvious aphasia.
	• Communication deficits associated with right hemisphere injury involve nonliteral language (eg, metaphor, irony, and indirect requests), speech prosody, discourse (eg, humor and story comprehension), and related cognitive abilities, such as inference, working memory, and Theory of Mind (ToM; ie, making inferences about the beliefs and emotions of other people to interpret their behavior).
	• Not all patients with right hemisphere brain damage exhibit pronounced symptoms.
	• Most of the impairments associated with right hemisphere brain damage are not clearly localized. They are associated with injury to different regions within the right hemisphere and with injury elsewhere in the brain, and are also associated with various etiologies, including traumatic brain injury and placement on the autism spectrum disorder.
	• There are assessment batteries and a limited number of evidence-based treatment protocols available for communication impairments associated with right hemisphere brain damage.

Historical note and terminology

Descriptions of the effects of right hemisphere brain injury on communication started to appear with increasing frequency in the last few decades of the 20th century, approximately 100 years later than modern descriptions of aphasia subsequent to left hemisphere brain damage (11; 23). The primary role of the left cerebral hemisphere for language in adult humans has not been challenged. Virtually all discussions of phonetic, phonological, lexical, and syntactic impairments revolve around left hemisphere injury. However, language and communication in natural settings involves considerably more than the “nuts and bolts” of the basic building blocks of literal language that are sensitive to left hemisphere brain damage. A patient can score well on most parts of an aphasia battery but still fare very poorly in natural communicative settings that require supralinguistic competence, such as appreciation of context, inferential ability, and understanding an audience. The nuances conveyed by nonliteral language, such as metaphor and irony, the meaning indicated by speech prosody, and the apprehension of a speaker’s main point in a story or conversation, underscore the relevance of the much wider range of language and language-related skills that are often affected by right hemisphere brain damage. The term “right hemisphere syndrome” is sometimes used as a label for the collection of deficits associated with right hemisphere brain damage. Consideration of the right hemisphere’s contribution to language and related cognitive domains provides a richer understanding of healthy and impaired communication.

This article does not cover aprosodia associated with right hemisphere brain damage because aprosodia is discussed in detail in a separate article.

Interest in right hemisphere language has increased steadily since the 1980s but has roots in previous work. The neurologic literature addressing visuospatial processing, attention, and unilateral spatial neglect in patients with right hemisphere damage is extensive (28). The importance of right hemisphere structures for emotion is well established (42; 71). Other work extends the range of impairments to include neurologic, emotional, and psychosocial (21). Weinstein and Kahn’s monograph on anosognosia highlighted the odd lack of insight exhibited by some patients (74; 59). Eisenson provides a first description of verbal production deficits in patients with right hemisphere brain damage (16).

Gardner and colleagues were among the first to investigate how right hemisphere brain damage might limit patients’ semantic processing in studies that led directly to later work. For example, Gardner and Denes described right hemisphere brain damaged patients’ difficulty with connotative meaning expressed in pictures: patients had trouble choosing an appropriate pictorial analog for a concept such as “wealth” from an array that included an arrow pointing up and another arrow pointing down (22). Winner and Gardner reported a related tendency to be concrete: when asked to select an appropriate picture to represent the meaning of a familiar metaphor (“heavy heart”), they would choose a man staggering under the weight of an oversized heart rather than a picture of a man crying (75). Since then, investigation of right hemisphere brain damage patients’ communication impairments has yielded an extensive catalogue of abnormalities (33; 62; 51; 39). In recent years, the catalog of deficits relevant to language and communication has expanded to include social and cognitive impairments tied to, for example, Theory of Mind (ToM), as will be discussed below.

The literature leaves some broad issues unresolved. One question is whether a single core problem can account for a range of impairments. Beeman, for example, proposes that the right hemisphere plays a relatively large role in “coarse-grained” processing (03). A second question is whether regions within the right hemisphere act as “centers” with primary responsibility for specific types of processing or, alternatively, whether a region simply contributes to normal levels of competence. Deficits can result from right hemisphere brain damage under either interpretation. A third issue is how the right hemisphere’s processing strengths combine with those of the left hemisphere to support normal communication. Although definitive answers to these questions are not available, a systems perspective is already well represented (60; 36; 50; 56; 14).

Clinical manifestations

Presentation and course

Individuals can exhibit any subset of “right hemisphere syndrome” subsequent to focal lesions in the right hemisphere or subsequent to other etiologies. For stroke patients, communication deficits may not be obvious on bedside testing, depending on the focus of the examiner, and may be overshadowed by, for example, hemiplegia or dense left neglect. Families may also have trouble articulating exactly what is not “normal” about the patient because the deficits can be subtle and variable; problems with nonliteral language, for example, will not be obvious if a speaker uses mostly simple, direct sentences. However, over time, communication deficits similar to those described below will result in social awkwardness that undermines a patient’s success in the workplace and within the family. It is common to see distinct profiles of impaired areas of pragmatic understanding, eg, with metaphor understanding more disturbed in some patients and indirect speech in others (69).

Stories and humor. Discourse is a broad term that often refers to connected sentences or utterances that form a larger unit, such as a story or conversation. One key feature is that the main point of discourse may be different from the sum of the individual sentence meanings. Another key feature is that understanding the main point requires a variety of resources and skills that can be affected by brain injury, including working memory, the ability to make inferences, understanding nonliteral language, and an appreciation of other people’s goals in a conversation as well as their knowledge.

One form of discourse consists of narratives, eg, stories. Early work revealed that patients with right hemisphere brain damage did not understand stories despite their comprehension of individual sentences. Wapner, Hamby, and Gardner suggested that patients with right hemisphere brain damage could report details of a story such as a fable but often failed to grasp the moral or main point (72). Joanette and colleagues established the general finding with a careful analysis of patients’ story recall (34), and studies by Hough extended the finding using shorter passages (32). Patients with right hemisphere damage also perform worse than controls at making logical and pragmatic inferences from stories depicted in pictorial stimuli (55). The basic finding that has been reported often is that right hemisphere brain-damaged patients’ understanding represents details and disparate elements but does not adequately reflect the inferences needed to apprehend main themes.

Because verbal narratives necessarily extend over time, part of the deficient performance by patients with right hemisphere brain damage might be secondary to problems with working memory and, for that reason, may not be specific to discourse. Tompkins and colleagues have shown that working memory limitations are relevant to understanding severity of impairment in patients with right hemisphere brain damage: patients with less working memory capacity perform worse on discourse-related tasks (66). The explanatory value of general cognitive disability, such as decreased working memory among others, is a critical avenue to pursue to determine exactly how much of a patient’s poor performance can be accounted for within a general cognitive perspective. There is, however, also evidence suggesting that the narrative comprehension deficit cannot be explained entirely in terms of working memory. For example, Myers and Brookshire asked patients with right hemisphere brain damage to explain Norman Rockwell paintings (52). Patients with right hemisphere brain damage exhibited abnormal output that missed the gist of a painting, even when working memory demands were reduced by having a painting in view.

Other work on narrative discourse used humor as a vehicle (57). The use of humor as a type of stimulus material was motivated in part by affective changes sometimes seen after right hemisphere brain damage; however, humor also provides convenient ways to manipulate discourse variables. Brownell and colleagues asked patients with right hemisphere brain damage to complete short story jokes by choosing the correct punchline from a set of alternatives (08). The main result was that the patients with right hemisphere brain damage appeared to understand that jokes as a narrative genre required a punchline that was incongruous—that did not follow from the body of the joke in a straightforward manner. However, the patients were deficient with respect to the second requirement: inferring how a punchline actually fit with the joke on a second level of interpretation. The patients with right hemisphere brain damage showed difficulty discriminating between a nonsense ending that was simply out of place and a joke’s correct punchline that was both surprising and coherent if reinterpreted to fit with the beginning of the joke.

Brownell and colleagues reported an analogous inference deficit using nonhumorous 2-sentence vignettes such as the following (09):

“Sally brought a pen and paper with her to meet the famous movie star.

The article was going to include comments on nuclear power by well known people.”

Reading just the first sentence led to the interpretation that Sally was seeking an autograph. After reading the second sentence that forms part of the same discourse unit, non-brain-damaged controls revised their interpretation to identify Barbara as a journalist. Patients had trouble with the revision and did not readily abandon their view of Sally as interested in autographs. The need for revision was present in jokes and in nonhumorous items, which places the likely account in the domain of all discourse rather than just humor. This result can be seen as an accentuated version of right hemisphere brain-damaged patients’ disinclination to work to integrate elements into a whole that makes sense of all the parts. Although patients with right hemisphere brain damage can integrate meaning across sentence boundaries in some situations, they often appear satisfied with (or limited to) considering each sentence on its own in a linear fashion without building a mental model of an entire story (43).

Nonliteral language. Other reports discuss the most frequently cited language symptom of patients with right hemisphere brain damage: their tendency to be literal. In one representative study, Van Lancker and Kempler asked patients with right hemisphere brain damage (and also aphasic patients with left hemisphere brain damage) to choose a picture to illustrate the meaning of common idioms such as “turning over a new leaf” (70). The basic finding was that patients with right hemisphere brain damage (but not aphasic patients with left hemisphere brain damage) tended to choose literal depictions (a man raking a leaf) rather than the figurative meaning (a man throwing a bottle of liquor into a trash can). Aberrant comprehension of even familiar phrases (eg, “heavy heart,” “turning over a new leaf”) illustrates the dense nature of the impairment for some patients. This basic result has been demonstrated in many studies and has been elaborated using single-word stimuli (10). The extension of the basic impairment to single words is valuable in large part because some researchers have capitalized on the flexibility of word stimuli to explore a variety of explanations for many right hemisphere brain damage symptoms using various patient populations and noninjured populations. One summary is that the right hemisphere appears particularly important for “coarse-grained” semantic processing, that is, for generating and maintaining weak or diffuse associations between words that could provide a basis for understanding extensions of word and phrase meaning and, perhaps, understanding the gist of longer discourse units (03).

Several authors have examined request comprehension and, to a lesser extent, production by patients with right hemisphere brain damage (19; 58). The main conclusion is that patients exhibit decreased use of conversational context as a guide, even though they are capable of recognizing and using some elements of requests. For example, a conventional request frame in American English is “Could you open the window?” The speaker’s intent is not to inquire about the ability to open a window; the intent is requesting the listener to open the window. Another conventional request marker is the use of “please.” Patients with right hemisphere brain damage fare better with such familiar request signals (07). They are less skilled at using implicit social and linguistic context to guide interpretation. Stemmer and colleagues, for example, varied factors such as the relative social power or status of a speaker and listener (58). A low-status speaker can use an indirect form to request something of a high-status listener without offending.

Difficulties understanding sarcasm, irony, and metaphor provide other examples of the problem (56; 15). One sees the joint effects of inattention to context and a tendency towards literal interpretations (12). The contextual factors that support irony are different from those most relevant to indirect requests but are most likely analogous with respect to how patients with right hemisphere brain damage consider them. For example, a particular utterance, “I am so glad the sun is shining,” can be used ironically on a day with miserable weather or literally on a beautiful summer’s day. As will be discussed below, more recent work has sought to account for deficits in irony under the rubric of general, extralinguistic impairments.

Question-asking. Another pragmatic aspect of communication is its use to gather information. Minga and colleagues studied question-asking in patients with right hemisphere brain damage relative to healthy adults and found that question types differed between the two groups: patients were more likely to ask content questions and less likely to ask polar (yes-no) questions than controls (47). In a follow-up study comparing question-asking between patients with right hemisphere damage and controls during a more naturalistic conversation, the patients asked fewer questions of any type, overall (46). Patients’ question-asking in this study was associated with measures of executive function and visuospatial skills. These studies suggest that appropriately and efficiently structuring a conversation to learn new information from a communication partner is another aspect of the pragmatic language deficits stemming from right hemisphere damage. Following along with a conversational topic and recognizing when it is one’s turn to speak are related conversational skills that may be impaired with right hemisphere damage (40).

Cognitive factors underlying communication deficits. Right hemisphere brain damage can also undermine successful communication indirectly. Working memory was mentioned as an important resource for language understanding and can likely also partially account for some impaired pragmatic performance given the amount of information that must be retained and updated (68). Similarly, competence in Theory of Mind (ToM; using the thoughts, beliefs, and emotions of others to understand their behavior) supports a great deal of language use in context (56; 41; 73). (The MedLink Neurology article Theory of Mind provides further detail.)

Patients with right hemisphere brain damage (but not aphasic patients with left hemisphere brain damage) show selective impairments in understanding cartoons based on ToM, and better performance on a control condition that used cartoons based on humor did not require ToM (27; 24). A study demonstrated that impairments in either executive function or ToM tend to co-occur with impairment in pragmatic language comprehension after right hemisphere brain damage, suggesting that the right hemisphere contribution to pragmatics likely involves executive function and ToM as underlying cognitive mechanisms (69).

Prognosis and complications

Research to address prognosis and assessment of right hemisphere language and communication disorders is still at an early stage (54). Communication deficits after a right hemisphere stroke do seem to influence social relationships and social network size (29), conversation patterns with close social partners (02), and overall social participation (30). These might be important points to consider when designing interventions.

Biological basis

Etiology and pathogenesis

The communication impairments mentioned above are associated with brain injury due to various causes (cerebrovascular accident, tumor, closed head injury, etc.). Precise localization of lesion within and to the right hemisphere is missing from many studies. A good portion of studies compare group performance of patients with right hemisphere brain damage to that of non-brain-damaged control groups because, often, the linguistic demands of the experimental tasks are too great to allow testing of patients with left hemisphere brain damage and significant aphasia. In addition, several studies have documented that impairments observed in patients with right hemisphere brain damage can be seen in patients with traumatic brain injury that affects frontal regions bilaterally (13) and also in individuals with diagnoses such as autism spectrum disorder and schizophrenia (26; 50).

However, some studies have compared individuals with left and right hemisphere damage directly on language and communication tasks. One study confirmed that patients with right hemisphere damage produced less typical interpretations of the meaning of scenes depicting social interactions, compared to healthy controls as well as patients with left hemisphere damage (01). Another study attempted to isolate areas in the right hemisphere that may be key players in the language deficits specific to right hemisphere damage (20). Patients with right hemisphere stroke who were presented with auditory sentence-to-picture matching showed more damage specifically to the right inferior frontal sulcus, when compared to patients with right hemisphere stroke who did not show impairment in this comprehension task (and left hemisphere stroke patients). A follow-up experiment on healthy controls found that the right inferior frontal sulcus was active during the sentence matching task as well as a working memory task. This study suggests that right hemisphere damage can have significant impact on language comprehension, possibly related to language-specific executive function deficits, when the inferior frontal sulcus is damaged (20).

One safe generalization is that much of the processing disrupted in patients with right hemisphere brain damage involves the participation of many brain regions, including, but not restricted to the right hemisphere (57; 60; 37; 17). Nonetheless, clinically important communication deficits are associated with right hemisphere dysfunction. A communication function that is not mediated primarily by the right hemisphere may still require participation by the right hemisphere to achieve normal levels of performance. The clinical importance of the “right hemisphere syndrome” persists, even as our understanding of how language function requires coordination among bilaterally distributed systems. In this article, a liberal criterion has been applied for including a function under the umbrella term “right hemisphere language”: that the function is disrupted by right hemisphere brain damage or that functional imaging suggests a role for the right hemisphere.

Neurologic or radiologic evidence for injury to the right hemisphere or the prefrontal regions bilaterally suggests that communication deficits may affect a patient’s prognosis.

Management

Compared to the array of treatment protocols designed for speech and language disorders associated with left hemisphere injury, there are relatively few treatment protocols designed for right hemisphere language impairments (05). One constraint is that the impairments associated with right hemisphere brain damage are often less well defined in both theoretical and functional terms than are the symptoms associated with aphasia. There are, however, guidelines and directions that can be usefully followed (62; 51; 04; 18). Some preliminary efforts to provide evidence-based treatment options have grown directly out of earlier work. These protocols also represent different approaches.

Lundgren and colleagues describe a training program that emphasizes practice making explicit semantic judgments as a means to improving oral metaphor interpretation in patients with right hemisphere brain damage (44; 06). The staged protocol is based on a simple analysis of metaphor: two nouns from different semantic domains share associations. For example, the metaphor “my job is a prison” consists of the two nouns “job” and “prison.” Although the two nouns have several associations that are not held in common, they share other associations: confinement, limits, unpleasantness, no escape, etc. The training has patients practice generating associations, evaluating associations, and identifying potential shared associations that could form a metaphor. One distinctive feature of the program is the use of simple graphic depiction of associations that greatly reduces memory demands, keeps patients focused, and supports practice. Preliminary results show that metaphor interpretation improves substantially and selectively coincident with the onset of treatment.

Tompkins and colleagues have used a different approach to treatment based on the previous literature documenting problems with suppression of meaning and coarse coding (61; 64; 67; 65). The strategy for Contextual Constraint Treatment is to capitalize on remaining strengths of patients with right hemisphere brain damage by using tasks targeting implicit or automatic processing rather than tasks requiring explicit metalinguistic judgments and by relying on contexts that bias interpretations without requiring revision or difficult inferences. Preliminary results were encouraging. Tompkins emphasizes the importance of clinical recognition of the heterogeneity of patients with right hemisphere language and communication impairments for considering treatment options, as well as sensitivity to lack of insight in patients when considering measurement via self report (63).

Minga and colleagues, the authors who established the RHDBank of transcripts from individuals with right hemisphere brain damage, studied whether “apragmatism” might an appropriate and useful term for the cluster of language deficits experienced by these individuals (49). A review by an international group of experts suggested that the diagnostic label was suitable, and its features were operationalized using RHDBank. The authors suggest that this label might improve consistency in describing and understanding right hemisphere language disorders as well as improve research and treatment.

Outcomes

Elements of the “right hemisphere syndrome” can be improved by treatment. However, there is a lack of data on maintenance of treatment gains over the long term, as well as a lack of data on recovery patterns of right hemisphere language impairments. Although communication deficits that follow right hemisphere stroke have not by themselves predicted rehabilitation outcomes, the severity of communication deficits did predict rehabilitation outcomes (31).

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Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Alia Martin PhD

Dr. Martin of Victoria University of Wellington has no relevant financial relationships to disclose.
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Editor

Victor W Mark MD

Dr. Mark of the University of Alabama at Birmingham has no relevant financial relationships to disclose.
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Former Authors

Hiram Brownell PhD

Patient Profile

Age range of presentation: 1 months to 65+ years
Sex preponderance: male=female
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

ICD & OMIM codes

ICD-10: Expressive language disorder: F80.1

Receptive language disorder: F80.2

Dysphagia and aphasia: R47.0
ICD-11: Developmental language disorder with impairment of receptive and expressive language: 6A01.20

Developmental language disorder with impairment of mainly expressive language: 6A01.21

Aphasia: MA80.0

Dysphagia: MD93

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Right hemisphere language disorders

Associated Disorders

Aphasia
Right hemisphere brain damage

Also Relevant

Aprosodia
Developmental language disorder
Disorders of articulation
Executive dysfunction

Clinical Categories

Neurobehavioral & Cognitive Disorders

Right hemisphere language disorders …

Right hemisphere language disorders

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Outcomes

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview.
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Questions or Comment?

Also in This Category

Metal neurotoxicity

Vascular cognitive impairment

Addictive disorders

Automatic-voluntary dissociation

Wilson disease

Pre-mild cognitive impairment

PART (Primary age-related tauopathy)

Anti-LGI1 encephalitis

Right hemisphere language disorders

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Outcomes

References

Contributors

Author

Editor

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Metal neurotoxicity

Vascular cognitive impairment

Addictive disorders

Automatic-voluntary dissociation

Wilson disease

Pre-mild cognitive impairment

PART (Primary age-related tauopathy)

Anti-LGI1 encephalitis

This is an article preview.
Start a Free Account
to access the full version.