Friday, 27 May 2011

Can swearing help diagnose dementia?

I have what you could call a professional interest in swearing, or cursing, or profanity, or whatever you like to call it. My psychobiology lab at Keele University was the first to provide evidence showing that swearing helps most people to be able to withstand pain for longer. We have several other exciting studies underway looking at the role of the emotional response to swearing in producing the pain protective effect, as well as looking at how quickly we become used to swearing. When I have given talks on the psychology of swearing at universities and science festivals, one of the things I say is that swearing is fascinating because it involves an implied social contract. At an unspoken level, there is general agreement not to swear most of the time.

That we don’t swear very much is backed up by evidence from Professor Timothy Jay of Massachusetts College of Liberal Arts. From years of sitting in cafeterias taking careful notes while eavesdropping on conversations, Professor Jay has come up with some interesting estimates of the percentage of the daily spoken corpus taken up by swearing. His estimate is that swear words make up less than 1% of all the words people say in a day. Now, for us to be effective at not swearing, we all must learn the swear words that we are then supposed not to say. This means that as you walk around seeing different people from all walks of life, the rich, the poor, the old, the young, women and men, etc., you can tell yourself that it is most likely that every person you see will know some truly appallingly offensive swear words! Even, most probably, that lovely, sweet little old lady who you have seen about town.

This brings me to the paper that is the focus of this latest blog. It was written by a team of neurologists and psychologists at the University College of Los Angeles Easton Center for Alzheimer’s Disease Research. Their interest lay in dementias, that is, diseases of the brain usually affecting older people that often start with memory problems but go on to affect other mental abilities. There are many different kinds of dementia, for instance Alzheimer’s Disease, vascular dementia, Lewy body dementia and fronto-temporal dementia. While dementia is not a curable condition, some treatments can be helpful, but there are different treatments depending on the type of dementia. Therefore, it is important to be able to diagnose which particular type of dementia is affecting a patient. Unfortunately, correct diagnosis is often impossible until the brain can be cut open and examined in an autopsy, after the patient has died, which is rather late in terms of treating a patient!

Of course, while definitive dementia-type diagnoses are not possible until after death, many methodologies have arisen with the aim of making “best guess” diagnoses. For instance “consensus diagnosis” involves convening a panel of experts on the assumption that discussion and second opinions will help to limit overly subjective decisions. The idea behind the UCLA study was to see if something much simpler – the use of swear words during formal patient interviews – could help to distinguish different dementia sub-types. To explain how the researchers made the leap from consensus diagnosis to profanity, I must outline a commonly used psychological test often used to help determine dementia patients’ level of mental functioning.

The Controlled Oral Word Association Test asks participants to generate as many words as they can in 1 minute beginning with certain letters. The letters used in the standard form of the test are F, A and S, and so the test is colloquially known as the “FAS” test. A long history of asking people with various brain injuries and diseases to complete the FAS test has enabled neuropsychologists to identify a profile of the kinds of brain damage that lead to lower numbers of words generated on the test. People with damage to the frontal lobes of the brain find the FAS test particularly difficult, partly because the frontal lobes seem to be important for self-monitoring, which can be explained as the ability to keep track of responses already given, to carry out “effortful self-initiation” (i.e. willing oneself to think up words), and to inhibit inappropriate responses (i.e. withholding responses that are incorrect or improper, such as swear words).

The germ of the idea for the UCLA study appears to have arisen from the researchers having observed a patient believed to have fronto-temporal dementia produce only two words in the “F” section of the FAS test – “fuck” and “fart”. They argued that for such a patient to produce swear words is not surprising given that fronto-temporal dementia is caused by degeneration of the frontal lobes of the brain, and given also that one would expect people with impaired frontal lobe function to have difficulty inhibiting inappropriate responses, such as swearing. On the other hand, one would NOT expect to hear swear word responses in the FAS test in individuals with Alzheimer’s, where the pattern of brain damage if more widespread.

The actual study was very simple. The researchers looked back through their database of FAS test scores for all dementia cases with a consensus diagnosis of fronto-temporal dementia (32 individuals), and all cases with a clinician’s diagnosis of Alzheimer’s (38 individuals). The overall test results showed that each group produced similar numbers of words beginning with the letters F, A and S (about 5-9 words per letter, on average). However, fronto-temporal dementia patients were significantly more likely to produce the word “fuck”, with 6 of them producing it (19%), compared with none of the Alzheimer’s patients. Some fronto-temporal dementia patients also produced the words “ass” and “shit”; again, none of the Alzheimer’s patients produced these swear words.

In interpreting these results the researchers who carried out the study point out that, as some of the fronto-temporal dementia patients produced the word “fuck” but none of the Alzheimer’s patients did, this indicates that the production of the word “fuck” is “pathognomonic” for fronto-temporal dementia. “Pathognomonic” means “characteristic for a particular disease”. However, they acknowledge that basing a diagnostic tool on this phenomenon has limited sensitivity, reflecting that more than 80% of the fronto-temporal dementia patients did NOT produce the word “fuck”. They suggest that the underlying reason for the increased frequency of swear word responses reflects a diminished concern for social propriety and constrained verbal abilities, both of which can be associated with the frontal lobe impairment that is characteristic of fronto-temporal dementia. So, overall, this paper presents an interesting phenomenon, but the overall conclusion is that swearing can assist with diagnosing dementia only to a limited extent.

Nevertheless, this paper makes the cool psychology blog for several reasons. I like that the idea behind it stems from the researchers noticing that something interesting was happening in their clinics, and that they followed up those observations to produce a piece of research. I also like the idea that something as simple and everyday as swearing can reveal so much about a person, to the extent that it can indicate one kind of brain damage over another. Of course, dementia is very sad in all circumstances, but it must be particularly hard to watch a close relative succumb to fronto-temporal dementia and perhaps start to swear inappropriately and quite out of character. This would be particularly so if the patient was that lovely, sweet little old lady who I mentioned earlier on. In providing context and information this research may offer comfort to patients’ family members and friends.

It is also interesting to see that throughout this paper, no actual swear words are printed, rather we see “f*ck”, “*ss” and “sh*t”. I find this somewhat prudish for a piece of writing published as recently as 2010. The Guardian newspaper has printed swear words in full for some years now, and it can only be a matter of some small passage of time before all swear words are published in full in all sources. Interestingly, the research paper does reproduce the words “fag” and “fart” in full. A matter of editorial judgement?

The full reference for the original research paper is below. A pdf copy of the paper is not available to download for free but you may be able to obtain a copy through a university library subscription. Otherwise, you could try e-mailing the corresponding author, John M. Ringman. As I said in my previous blog, cite the full reference and be sure to ask very politely!

Richard Stephens
May 2011


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