Brain Research Reviews 31 1999 83–104 www.elsevier.comrlocaterbres
Expletives: neurolinguistic and neurobehavioral perspectives on
D. Van Lancker a,b,), J.L. Cummings c
aDepartment of Neurology, UniÕersity of Southern California, Los Angeles, CA, USA
bDepartment of Speech-Language Pathology and Audiology, New York UniÕersity, School of Education, 719 Broadway, Suite 200, New York, NY, 10003,
cDepartments of Neurology and Psychiatry and BiobehaÕioral Sciences, UniÕersity of California at Los Angeles, Los Angeles, CA, USA
Accepted 5 October 1999
Severe aphasia, adult left hemispherectomy, Gilles de la Tourette syndrome GTS , and other neurological disorders have in common
an increased use of swearwords. There are shared linguistic features in common across these language behaviors, as well as important
differences. We explore the nature of swearing in normal human communication, and then compare the clinical presentations of
selectively preserved, impaired and augmented swearing. These neurolinguistic observations, considered along with related neuroanatomi-
cal and neurochemical information, provide the basis for considering the neurobiological foundation of various types of swearing
behaviors. q1999 Elsevier Science B.V. All rights reserved.
Keywords: Neural basis of behavior cursing; Aphasia; Gilles de la Tourette’s syndrome; Coprolalia; Basal ganglia; Limbic system
1. Background........................................................................ 83
2. Swearing in normal individuals ............................................................. 84
3. Swearing in aphasia following stroke and left hemispherectomy ............................................ 86
4. Gilles de la Tourette syndrome GTS .......................................................... 88
5. Exploring coprolalia in GTS: does the Markov model work?.............................................. 91
6. Comparison of swearing in aphasia and GTS ...................................................... 93
7. Emotional and prosodic processing ........................................................... 95
8. Cerebral laterality .................................................................... 96
9. Pathological basis to GTS: a basal-ganglia disorder................................................... 96
10. Limbic system-basal ganglia hypothesis......................................................... 97
11. Conclusion ........................................................................ 98
References .......................................................................... 99
Swearing, the use of deistic, visceral and other taboo
words and phrases, has long held a unique and colorful
)Corresponding author. Department of Speech-Language Pathology
and Audiology, New York University, School of Education, 719 Broad-
way, Suite 200, New York, NY, 10003, USA. Fax: q1-212-995-4356;
status in language behavior. Public awareness of swearing
is far keener than, say, interest in relative clauses or the
semantic features of nouns, yet the topic is much less
studied. Swearing and related verbal usage has ubiquitous
social, legal and political implications, which have touched
each and every person at some time or other. Laws against
swearing in public still exist in some states and, infor-
mally, fines may be incurred in social settings 126 .
Knowledge of swearwords takes hold early in child lan-
0165-0173r99r$ - see front matter q1999 Elsevier Science B.V. All rights reserved.
PII: S0165-017 3 9 9 0 0060-0
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10484
guage development 117 and often quickly achieves a
solid status in the second language learner 181 . Shortly
after the Norman Conquest of England, King William of
Orange was said to use his native language, French, except
for swearing, which he did in English 65 .
Even more dramatically, swearing takes a prominent
role in various neuropathologies of language. For example,
swearing is frequently one of a small set of speech func-
tions — ‘‘automatic speech’’ — selectively preserved in
the severely aphasic patient. Swearwords and phrases are
produced with normal articulation and prosody, in stark
contrast to the remaining speech and language disability.
Some manifestations of swearing behaviors in clinical
settings may be reactive to the disease condition. Exces-
sive swearing occurs in traumatic brain injury 267 and in
paraplegic, spinal cord patients 149 . It occurs in the
elderly in association with depression 43,226 , encephali-
wx wx wx
tis 118 , dementia 239 and klazomania 16 . Post-ictal
swearing has been reported in epilepsy 50,221 . Tardive
Tourettism, sometimes with coprolalia, has been reported
following use of neuroleptics 15,73 including in a
Japanese patient 141 . Pathological use of expletives and
taboo words and phrases is a key feature of Gilles de la
Tourette syndrome GTS 222 and certain other move-
ment disorders, especially Sydenham’s chorea, which has
clinical similarities to GTS 144,264 .
Despite its obvious role in normal and impaired com-
munication, serious study of the neurology of swearing
behavior is lacking. Neurological treatments of emotional
behaviors discuss related phenomena, such as pathological
laughing and crying, but not swearing e.g., Ref. 20 .
This neglect is due possibly in part to a universal negative
response to use of swearwords, and in part to a belief that
swearing is peripheral to more interesting aspects of com-
municative behaviors. Given the range and variety of
observations, the topic appears to be linguistically and
neurologically complex. Whatever the reasons for a tradi-
tional lack of explanatory commentary on swearing, ad-
dressing this question is warranted to advance understand-
ing of the neurobiology of communicative behavior. De-
scriptive work on historical 123,181 and contemporary
80,101,124,130–132,139,210 normal swearing patterns
has appeared, and sufficient observations from neurologi-
cal patients have accumulated to merit an overview and
exploration of the neurology of swearing.
2. Swearing in normal individuals
The definition, characterization and classification of
swearwords is itself daunting. A useful division breaks the
types of words used into the categories of ‘‘deistic’’
Ž. Ž .
religion-related and ‘‘visceral’’ body functions-related ,
but the actual array of expletives extends into many se-
mantic domains. Data reviewed by Flynn 92 suggest that
sex-related insults are a cultural universal. Particular atten-
tion is commonly paid to the genitals and related regions
in insult behavior. Hughes 123 observes that ‘‘Swearing
draws upon such powerful and incongruous resonators as
religion, sex, madness, excretion and nationality, encom-
passing an extraordinary variety of attitudes’’ p. 3 . Galla-
horn 101 divides his data on normal swearing into three
categories: ‘‘curse words,’’ ‘‘anal-erythral terms’’ and
‘‘genital words’’. It is the use more than the item itself that
determines the swear-like force of the expression.
In his book on the history of swearing, Montagu 181
distinguishes between swearing ‘‘damn it’’ , cursing
‘‘damn you’’ , and oaths ‘‘by God’’ . He offers fourteen
categories of swearwords that have been utilized through
Ž. Ž .
the ages: 1 Supernatural or infernal powers e.g., ‘‘God’’ ;
Ž. Ž . Ž.
2 Sacred matters of religion e.g., ‘‘holy mass’’ ; 3
Ž. Ž . Ž.
Saints; 4 Sacred places e.g., ‘‘Jerusalem’’ ; 5 Future
life ‘‘Heavens’’ ; 6 Ancestors and heroes; 7 Ruler or
authority e.g., ‘‘by the royal robe’’ ; 8 Oaths by natural
objects sun, German ‘‘Donnerwetter’’, English ‘‘thun-
x.Ž. Ž .
derstorm’’ ; 9 Vulgar or obscene words body parts ;
10 ‘‘Bloody’’ and its variants; 11 Miscellaneous phrases
having unusual force ‘‘hang it’’, ‘‘gracious’’, ‘‘shiver my
.Ž. Ž .Ž.
timbers’’ ; 12 Classical divinities ‘‘by Jove’’ ; 13
Animals, plants, products ‘‘goose’’, ‘‘mackerel’’ ; 14
Name of valued personal attributes e.g., ‘‘maidenhead’’ .
A 15th class may be added: social insults, including racial
and ethnic slurs.
Euphemisms, flux of popular terms, and variations in
social attitudes toward the words considered ‘‘taboo’’
further complicate the matter 97,123 . Although crosslin-
guistic surveys are few, observations by anthropologists
suggest that most people in most cultures use expletives
181 ; they do so at different times, in various contexts,
with varying emotive content to the expressions. Accord-
ing to Hughes, 123 , ‘‘virtually all societies, even the
most modern, retain some taboos against swearing’’ p. 8 .
For our purposes, and admittedly using a circular defini-
tion, it is sufficient to identify the group of words that are
socially opprobrious, essentially because they are consid-
ered shocking or obscene. We call this large set of words
‘‘expletives’’, ‘‘swearwords’’ or ‘‘taboo expressions’’, and
we refer to this activity as ‘‘swearing’’ or ‘‘cursing.’’ We
will consider subdivisions as they are useful to this analy-
sis.Although etymologies and historical examples from
literary sources are readily available, there are only a few
sets of available recorded data on the incidence or fre-
quency of use of taboo expressions across contemporary
population samples. Steadman 240 approached the topic
by asking subjects to compile lists of taboo words; males
provided the greater number. de Klerk 139 investigated
use of expletives by male and female adolescents of
differing social and educational backgrounds, and found
differences associated with gender and ‘‘social power’’.
Foote and Woodward 94 asked college students to list
words ‘‘obscene to you’’ using both written and tape-re-
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 85
corded response formats. Mode of production did not
affect quantity of responses, but more examples of obscene
language were produced by males than females. These
authors classified the items into ‘‘denotative classes’’ called
‘‘body process’’, ‘‘body part’’, ‘‘body product’’,
‘‘ancestral allusion’’, ‘‘religious blasphemy’’, ‘‘animal’’,
‘‘social deviation’’, ‘‘ethnic-racial slur’’, and ‘‘unclassi-
fied’’. The most frequent exemplars of each class, in order
of frequency, are given as a in Table 1.
A study by Gallahorn 101 tabulated and analyzed use
of taboo words by psychiatric ward personnel at psychi-
atric staff meetings, consisting of the ward chief, four
1st-year residents, the head nurse, three staff nurses, five
aides and occasional other nurses, aides, and social work-
ers. Gallahorn noted daily events on ward, who attended
the meeting, the time spent discussing a patient, and the
taboo words used. He noted who used the words and to
whom they were addressed. During 128 days, 372 taboo
words were used, averaging 2.9 each meeting see Table
1b . Twenty-eight different words were produced, which
Gallahorn classified into ‘‘curse words, analerythral, and
genital words’’. ‘‘Curse words’’ were most commonly
produced, with more words on days with specific issues.
Interestingly, expletive usage diminished during socially
stressful periods on the psychiatric ward. A similar, briefer
survey was conducted by Nuwer 192 , who asked 30
neurologically normal subjects to list the words ‘‘he or she
would use when upset, but would not use in polite com-
pany or when speaking before an audience’’ p. 364 .
Twelve words resulted from this survey, which could be
classified into two general types: ‘‘religious profanities
and obscenities related to physical acts and organs’’ p.
364 shown as Table 1c .
The most extensive survey work has been done by Jay
130–132 , giving frequency counts of specific expletives
as correlated with speaker’s gender, age, context, theme,
and other variables. A large field study of cursing language
used in public by speakers over the age of 45 revealed that
most cursing is made up of 18 words Table 1d , and that
males curse more than females. Four most frequently used
Žwx w x.
words hell, god damn , shit and Jesus Christ account for
57% of the observations. Data from nursing home resi-
dents over age 70 are similar Table 1e . The top ten
swearwords of West Coast speakers ages 70 and under
obtained from field observations are shown in Table 1f
131 . To explore the words people use privately, survey
questionnaires were administered to an elderly population
in western Massachusetts, containing 26 taboo words de-
rived from Jay’s previous field studies 132 . Subjects were
asked to rate the words for frequency of personal use and
for offensiveness. The results are summarized in Table 1g.
A wide variety of different types of swearwords occur
among the 10 most frequently used.
Linguistic analysis of expletives has been sparse. Pe-
rusal of the grammar of expletives reveals that taboo
words appear to function differently from other words. A
linguistic analysis of swearing in Australian English noted
that swearwords ‘‘combine morphologically and syntacti-
cally with other items in a number of interesting ways,
some of which are peculiar to them’’, while others are
merely ‘‘preferred’’ by them Ref. 244 , p. 18 . To dis-
cuss the grammar of swearwords, Taylor utilized the no-
tion of ‘‘schemata’’, or formulae, developed by Lyons
Ref. 162 , p. 177 . Each word, phrase, or sentence schema
has its own shape and variations: for example, the phrase
schema ‘‘rrin therrhell heck ’’ where the first slot can
Data on normal occurrences of swearing descending order of frequency, with counts in parentheses
Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž.
a Nine most frequent swear words fuck 33 , cunt 23 , shit 33 , bastard 25 , God damn 15 , son of a bitch 19 , whore 10 , nigger 8 , fascist 2 ,
by college students Ref. 94 , p. fuckin’ 2
Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž.
b Swear words spoken by psychi- damn 87 , hell 84 , crap 41 , God 34 , shit 33 , bitch 17 , Christ 16 , screw 11 , pissed off 10 , ass 6 ,
Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž.
atric ward personnel in 6-month pe- bastard 5 , butt 3 , can 3 , whore 3 , hot pants 2 , slut 2 , reamed 1 , shaft 1 , son of a bitch 1 , balls 1 ,
riod Ref. 101 , p. 311 come 1 , fuck 1 , laid 1 , piece of ass 1 , pimp 1 , shack up 1 , wet dream 1
Ž. Ž wx
c Normal usage survey Ref. 192 , shit, God, damn, ass, fuck, Jesus, hell, crap, cock, prick, bitch, fart
Ž. Ž. Ž .Ž. Ž. Ž .Ž. Ž. Ž. Ž. Ž. Ž.
d ‘‘Public production lexicon’’ of hell 45 , God damn 33 , shit 33 , Jesus Christ 28 , fuck 24 , damn 22 , ass 19 , bitch 13 , bastard 12 ,
Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž.
18 unique words by speakers over asshole 6 , bullshit 4 , balls 2 , prick 2 , blows 1 , blowjob 1 , dildo 1 , Jew 1 , motherfucker 1
the age of 45 132
Ž. Ž . Ž . Ž . Ž. Ž. Ž .Ž. Ž. Ž. Ž.
e Nursing home residents, over age hell 60 , damn 27 , shit 15 , ass 9 , bitch 4 , Jesus Christ 3 , son of a bitch 2 , bastard 1 , piss 1
Ž. Ž . Ž . Ž. Ž. Ž. Ž. Ž. Ž. Ž.
f Top 10 swear words of West fuck 212 , shit 129 , God 68 , hell 50 , damn 45 , bitch 25 ,motherfucker 23 , ass 22 , asshole 17 , bullshit
Coast speakers ages 1–70 131 15
Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž.
g 26 swear words, rated for fre- hell 5.12 , damn 5.11 , goddamn 4.13 , shit 3.86 , bullshit 3.72 , son of a bitch 3.52 , ass 3.51 , Jesus Christ
Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž.
quency in personal use in an elderly 3.45 , bitch 3.33 , pig 3.30 , bastard 3.28 , fart 2.95 , asshole 2.82 , piss 2.76 , whore 2.45 ;.tits 2.33 , slut
Ž. Ž. Ž. Ž. Ž. Ž. Ž. Ž.
population in western Massachusetts 2.32 , queer 2.28 , prick 2.23 , fuck 2.05 , nigger 1.98 , cock 1.95 , dipshit 1.93 , fag 1.86 , peckerhead
132 . frequency 1 meant ‘‘never’’ 1.73 , spic 2.63 , danger 4.45 , dirty 4.44 , table 4.21 , flower 4.17
and 9 meant ‘‘very often’’. Four
nonswear words were included
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10486
be filled by ‘‘how’’, ‘‘what’’, ‘‘why’’, etc., and the
second with ‘‘fuckin’’, ‘‘bloody’’, ‘‘flamin’’, etc. Sen-
tence schemata can be specified in the same way. Taylor
concludes that people swear according to certain types of
rules, and that the swearing behaviors in Australian En-
glish can be well specified for descriptive and pedagogical
Dong 79 argued that there are two words of the form
‘‘fuck’’; only one of these, the one with the meaning
‘‘fornicate’’, functions as a verb; the second, as in ‘‘fuck
you’’, or ‘‘fuck these problems’’, although superficially
appearing to be a verb, is not a verb. This conclusion is
based on a number of linguistic arguments, including that
when the word is combined with other words, the resultant
phrase does not have the external syntax of a VP verb
phrase ; for example, it is not possible to include adverbial
elements e.g., ‘‘by midnight’’ . These expressions, includ-
ing ‘‘damn’’ and ‘‘Goddamn’’, when used in apparently
sentential frames, have ‘‘neither a declarative nor interrog-
ative nor imperative meaning. These utterances simply
express a favorable or unfavorable attitude on the part of
the speaker towards the thing or things denoted by the
noun phrase’’ p. 6 . This is a bold claim, because current
linguistic theory characterizes the sentence S , the basic
unit of language, as being made up of a noun phrase NP
and a verb phrase VP ; by definition, each VP has a verb
V . Thus, Dong 79 identified a category of words —
certain expletives — that do not fit anywhere in this
characterization. Rather than calling the utterances in which
words like ‘‘fuck’’ and ‘‘damn’’ appear ‘‘sentences’’,
Dong recommends the term ‘‘epithet’’, and that the taboo
words themselves be called ‘‘quasi-verbs’’. Thus there is
linguistic evidence that expletives form a separate class in
3. Swearing in aphasia following stroke and left hemi-
As stated by Jackson 128 , ‘‘The speechless patient
may occasionally swear’’ p. 160 . In his treatise ‘‘On
affectations of speech from disease of the brain’’ in the
section on recurrent utterances pp. 172–204 , he discusses
a patient with one recurrent utterance who also ‘‘swore
when vexed’’ p. 173 . Another patient said ‘‘Oh, my
God’’ and ‘‘Oh my goodness will’’; still another’s exclu-
sive utterance was ‘‘pooh’’. Jackson also cites Trousseau’s
reports of patients saying ‘‘sacre nom de Dieu’’ a French
expletive, literally ‘‘sacred name of God’’, rather like ‘‘Oh
my God’’ in English and another the abbreviated version
‘‘Sacon, sacon’’ p. 184 . Jackson’s interpretation of the
use of recurrent utterances was that the severely aphasic
patient had lost the ability to ‘‘propositionalize’’, leaving
only expletives, interjections and oaths. In his view, a
speechless patient may retain the word ‘‘no’’, and yet have
only the interjectional or emotional, not the propositional,
use of it p. 160 . Thus, expletives were deemed essentially
to be ‘‘involuntary’’. Later, Critchley 64 elaborated on
the notions of ‘‘automatic’’ and ‘‘propositional’’ speech,
with the former being ‘‘expressive’’ and the latter ‘‘com-
municative’’ Ref. 64 , p. 229 . But in discussing recur-
rent utterances, Critchley observed that the utterance reper-
tory of the patient can ‘‘largely fulfill the wishes and needs
of the patient’’. Ref. 64 , p. 230 . This suggests, in
contrast to the view of Jackson, that recurrent utterances,
including swearing, can be used voluntarily.
In the decades since these early observations, it has
been noted commonly that persons with aphasia emit
preserved and fully intact utterances classified as ‘‘auto-
matic speech’’. This observation is striking in global apha-
sia, where speech is almost nonexistent, and in nonfluent
aphasia, where speech is effortful and limited to high
frequency single words and short phrases, pronounced with
errors in articulation and in speech melody. In varying
combinations in different persons with aphasia, ‘‘auto-
matic’’ material, including counting from one to ten and
other serial speech alphabet, days of the week , familiar
Ž. Ž .
expressions how are you , pause-fillers well, ya know ,
and expletives flow fluently with effortlessly normal artic-
ulation and prosody 248 .
A chronically aphasic patient we studied made liberal
use of the expression ‘‘Jesus Christ’’, produced fluently in
comparison with his otherwise severe word finding diffi-
culties and effortful speech. Another produced the term
‘‘shit’’ fluently and liberally. We have had reports of
‘‘motherfucker’’ as a recurrent utterance in American en-
glish speakers with severe aphasia. Patient R.N., diagnosed
with global aphasia following a stroke that involved frontal,
temporal and parietal areas of the left hemisphere, was
unable to speak, name, or repeat, and his auditory–verbal
language comprehension was severely limited. He pro-
duced no speech other than ‘‘well’’, ‘‘yeah’’, ‘‘yes’’,
‘‘no’’, and the two expletives ‘‘goddammit’’ and ‘‘shit’’
256 . These words were produced with good articulation
and prosody. R.N. used these expressions spontaneously
and expressively, in answer to questions, and in attempts
to talk. However, R.N. was unable to produce these utter-
ances on command. When asked to read the written word
‘‘shit’’ aloud, although his affective response to the re-
quest indicated he had comprehended the written word, he
was unable to produce the spoken word, despite intense
effort and concentration over several attempts. R.N. sus-
tained damage to the supplementary motor area on the left
hemisphere, which is known to play an important role in
speech initiation. Whether this damage is specific to the
spontaneous or automatic versus elicited volitional dis-
crepancy seen in R.N.’s swearing remains to be studied.
Following up on the anecdotal observations by Critch-
wx w x
ley 64 and Jackson 128 of aphasic swearing, investiga-
tors examining usage in British English and German have
recently performed new surveys of residual expressions
spoken by persons with severe aphasia Table 2 . Lum and
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 87
Recurrent utterances in severe aphasia: Britishaand Germanbcorpora
British bloody hell, bloody hell bugger, fuck fuck fuck, fuck off, fucking fucking hell cor blimey, oh you bugger, oh boy
Ž. Ž.Ž .
German ach je oh Lord , ach Gottchen oh God , ach ohroh really
British alright, because, down, off, no, yep, yes yes yes, well I know, because, away away away, funny thing funny thing,
goody goody, It’s a pity pity pity, now wait a minute, pardon for you, so so, better better, sister sister
Ž. Ž . Ž . Ž . Ž .Ž.
German tja well , natuerlich of course , na also there you are , siehste you see , zacki zacki quick quick , so so ,
Ž. Ž . Ž . Ž . Ž . Ž .
also well , so so so so, so, so , doch butryet , na na na wellrnow , Hallo hello , macht nix doesn’t matter ,
Ž. Ž.Ž. Ž.
weiss es nicht don’t know , danke danke, ya, nein nein nein, nee nope , ja ja yes yes , ya yawohl yes indeed ,
das ist alles hinten, that is all behind us nicht traurig sein don’t be sad , bitte sehr please
British two two two, three three, I want to one two, I try one two, I think one two
German drei three
British I bin to town, I can’t, I can talk, I can try, I can talk and I try, I did not hear, I told you, I said, I want to, you can’t
Ž. Ž .
German Ich bin I am , I will arbeiten und lernen I want to work and study
British Bill, Billy, John, Parrot, Percy’s died, BBC
German Heidi, Bayern, Mama-Oma ma-grandma , Mama, Hans nein Hanni, Monika, Moni
British I’m a stane, milk, money, off, oil, factory, policeman, on the corner, paper and pencil, piano, Wednesday, so and so,
somewhere somewhere, time a time, tingaling, today, washing machine, sewing machine
German Das war wesentlich wichtig gewesen this was essentially important , Bauern farmers , Reisen trips , Mittag noon ,
Sie Sie, Dir you
Code 57 .
Blanken 24 .
Ellis 160 studied nonpropositional speech in aphasia in
British English using six tasks, carefully designed to per-
mit a comparison with ‘‘propositional’’ speech ability.
Nonpropositional tasks were counting 1–10, reciting the
days of the week, months of the year, and nursery rhymes,
repeating familiar phrases, and naming a picture with help
of a familiar phrase, in 28 patients with anomic, Broca’s,
conduction, global or Wernicke’s aphasia. The proposi-
tional match for counting, for example, was reading the
individual Arabic numbers. Of the six tasks, counting
1–10 and naming a picture with the help of a familiar
phrases reliably differentiated between nonpropositional
and propositional speech behaviors. Six patients showed a
clear ‘‘nonpropositional advantage’’. A similar investiga-
tion revealed superior sentence completion for familiar
idiomatic expressions as a form of nonpropositional speech,
compared with sentence completion for propositional ex-
pressions 252 . A functional imaging study compared
counting 1–10 with generating names of animals. Results
indicated that left anterior regions in and near Broca’s area
areas 44 and 45 were activated during the animal naming
task, but not during counting by normal subjects 254 .
In the first actual catalogue of recurrent utterances,
Code 57 reported on 69 ‘‘real word recurrent utterances’’
produced by 75 adult speakers of British English 39 male,
36 female , who suffered aphasia due to a cerebral vascu-
lar accident. From a survey study utilizing this patient
population, Code tabulated a list of real word recurrent
utterances, falling into seven categories. Pronounqverb
was the most common present in 14 of 75 patients and
expletives formed the second most frequent 11r75 . Other
categories of recurrent utterances were proper nouns
Ž. Ž. Ž.
5r75 , yesrno 4r75 , numbers 5r75 , repetitions
Ž. Ž.Ž .
14r75 and other 22r75 see Table 2 . In his overview
of linguistic output observed in adults who have undergone
a left hemispherectomy, Code 60 concluded that utter-
ances of the isolated right hemisphere consist primarily of
automatic and nonpropositional speech p. 331 . A second
study of aphasic speech targeted native speakers of Ger-
man 23–25 . The majority of ‘‘lexical automatisms’’
Žthese authors’ terms for the term ‘‘real word recurrent
utterances’’ used by Code documented from 30 patients
were emotional expressions, such as ‘‘ach je’’ Oh Lord
and ‘‘ach Gottchen’’ oh God and interjections, such as
Ž. Ž . Ž.
‘‘tja’’ well , ‘‘natuerlich’’ of course and ‘‘also’’ well .
see Table 2 . Nonlexical recurrent utterances also occur;
see Refs. 27,58 .
Although much has been written in clinical descriptions
about preserved production of ‘‘automatic speech’’, little
has appeared regarding the observe, impairment of count-
ing, swearing, and other overlearned expressions. One
exception comes from a case of a loss of some types of
overlearned speech behaviors, following a stroke to the
right basal ganglia 235 . A 75-year-old, right-handed man,
bilingual in Hebrew and French, was unable, in contrast to
prestroke function, to recite familiar verses, including well
known prayers and blessings in his native language, He-
brew; count 1–20, or sing familiar songs. He could no
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10488
Transcription of utterances by EC adult left hemispherectomy in a 5-min videotaped interview
Time Expletive Spont words Pausefills Sentence init Naming target Response Rep target Rep response Nonverbal vocs
0 goddammit one un I can’t
goddammit three boy that’s a
I, no place well
well, as book m-book uh mm
goddammit uh house uh-house duhh
1no deÕelop de-ve-lop
eh remember sandwich neah
ah President Pres-en-dent
2 god– uh remember No-vem laugh
goddammit nah NoÕember November sigh
oh, yes safety pin sood safe nah
no safety s-no wha
well, yes measuring tape tape
shit oh, yes tape meas-
4 goddammit I don’t
ah I couldn’t
say in then
ah watch laugh
5 look-y ahh
longer recite familiar blessings, some of which had been
his habit to say daily since he was a young child. His
attempts at longer prayers, such as ‘‘shema Yisrael’’, had
correct rhythm but not the correct words, word order, or
intonation p. 1772 . Although he had not used expletives
a great deal prior to his brain lesion, postmorbidly he no
longer cursed or swore; he also ‘‘could not provide the
correct expletive for situations described to him nor could
he complete a curse’’ p. 1772 .
Well-preserved swearing occurred in E.C., a right-
handed adult, following neurosurgical removal of his left
hemisphere, leading to near total extirpation of proposi-
tional speech. The surgery included removal of all four left
cerebral lobes, limbic forebrain, left thalamus and basal
ganglia 232,233 , following development of an infiltrating
tumor. E.C. was interviewed by N. Geschwind 5 months
after neurosurgical removal of his left hemisphere see
Table 3 . The patient was right handed, and there was no
left-handedness in his family 266 . In the 6 min interview
there is a discrepancy in speech production ability related
to type of utterance. E.C. was unable to name any of 4
target items safety pin, measuring tape, watch, clock ; he
repeated mono- and polysyllabic words book, house, de-
velop, November with articulatory effort and errors e.g.,
‘‘president’’ was repeated as pres-en-dent . His sponta-
neous words were ‘‘one’’, ‘‘three’’, ‘‘I’’, and ‘‘no place’’,
and pause fillers, such as ‘‘um’’, ‘‘boy’’, ‘‘well, yes’’,
and ‘‘well, no’’, and many instances of ‘‘ah’’, and ‘‘oh’’.
In addition, numerous nonverbal communicative vocaliza-
tions occurred during the interview, such as sighs, brief
laughter, and ‘‘tsk’’. The most prevalent speech was
swearing, featuring seven productions of ‘‘Goddammit!’’,
one of ‘‘God!’’ and one instance of ‘‘shit’’ in the 5-min
session Table 3 . Besides the greater quantity noted for
expletives over other types of speech, the speech quality
was better, and sounded normal, in comparison to other
speech spontaneous or repeated which was usually effort-
ful, uncertain and dysfluent. Similar observations were
made by Zangwill 266 who interviewed E.C. 18 months
after surgery, noting E.C.’s ability to swear.
4. Gilles de la Tourette syndrome GTS
GTS is a movement disorder first described by Itard
127 and Gilles de la Tourette 104 , and brought to
modern understanding by Shapiro and Shapiro 222 , Com-
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 89
ings and Comings 63 , and numerous others for reviews
see Refs. 44,56,86,88,106,109,112,129,146 151,183,186,
195,218,220,239,247 . The vocal tics required for diagno-
sis of the disorder are classified as a hyperkinetic motor
speech disorder 71 . The clinical symptom of coprolalia,
or foul speaking, is present in approximately 25–50% of
persons with GTS, depending on the nature and age of the
population, and how the clinical population is sampled,
whether in cross-section or longitudinally. Incidence analy-
ses 223 performed in 146 GTS patients Ref. 85 with
coprolalia documented the highest frequency terms and
the range of terms that have been reported to occur,
providing a listing of coprolalic expressions in order of
frequency Table 4 . As clinicopathological correlates dis-
Reported GTS expressions across languages
GTSsnumber of GTS patients with coprolalia.
UK fuck, cunt, bastard, piss, sod, cock, shit descending order of frequency
bŽ. Ž. Ž. Ž. Ž. Ž.Ž. Ž.
Spain puta whore , mierda shit , cono cunt , joder fuck , maricon fag , cojones balls , hijo son de puta, hostia host
cŽ. Ž . Ž. Ž . Ž . Ž .
Brazil merda, bosta shit , fihlo de puta son of a whore , bunda ass , buceta cunt , cacete, caralho cock , porra sperm ,
va tomar no cu fuck off
Denmark kaeft shut up , svin swine , fisse, kusse cunt , pik cock , rov ass , pis piss , gylle manure , Sgu by God
Peru no seas malcreado don’t be bad , batidoras national, ajo ajo, carajo, serve me coffee
f–i Ž. Ž . Ž. Ž .Ž.
Germany Nutte, Hure, Prostituierte whore ; Arshloch asshole , Scheisse shit ; Leiche corpse , Tod death verfaulte Knochen
Ž. Ž .
rotten bones , Eingeschlagene Schaedeldecke smashed skull ;
j–k Ž. Ž. Ž . Ž .Ž.
Hong Kong tiu fuck , shui bum , tui ma motherfucker , tiu so aunt fucker tiu fuck , ‘‘shut up,’’ ‘‘behave properly,’’
‘‘Why are you such a nuisance’’
Sri Lanka shit Indian English ; hu, huththi whore .
m,y Ž. Ž .Ž. Ž.
Italy taci, cretinaccio shut up, stupid ; smettila, imbecillaccio stop it, imbecile bastardo bastard , rognoso scabby with scabs ,
Ž. Ž. Ž . Ž . Ž .
vaffan’culo fuck you , riccione faggot , figlio di puttana son of a bitch , stronzo piece of shit , minchia cunt, fem. genitalia ,
minchione stupid cunt , zoccola whore, fem. rat
n–p Ž. Ž. Ž.Ž. Ž . Ž .
Japan sukebe lecherous , chin chin cock , bakatara stupid , dobusu ugly , kusobaa shit grandma , chikusho son of a whore ,
female sexual parts ,
USA fuck, shit, cunt, mother-fucker, prick, dick, cocksucker, nigger, cockey, bitch, pregnant-mother, bastard, tits, whore,
fu. .., doody, penis, queer, pussy, coitus, cock, ass, shi. .., bowel movement, Fangu fuck in Italian , homosexual,
screw, fag, faggot, schmuck, blow-me, wop descending order of frequency
God damn it, damn fool, ‘‘other four-letter expressions’’
Fuck my your fucking fucking fucking cunt t
fuck, shit, ass, bitch, cock, fart, suck descending order of frequency
you fucking idiot, asshole
fuck you, shit on you
fucka, fu. .. x
fuck, shit American Sign Language
Lees et al. 152 20 GTS .
Lees and Tolosa, 1993 8 GTS .
Cardoso et al. 48 9 GTS .
Reuger et al., 1986. 17 GTS .
Asam 7 1 GTS .
Asam and Traeger 10 1 GTS .
Hering 120 1 GTS .
Beckers 18 2 GTS .
Marneros 165 1 GTS .
Lieh-Mak et al. 155 9 GTS .
Singer 231 3 GTS .
lwx Ž.Ž .
Perera 196 , Perera 1983 2 GTS .
Escalar et al. 87 2 GTS .
Kuniyoshi et al. 141 1 Tardive GTS .
Nishida 189 1 GTS .
Nomura and Segawa 190 4 GTS .
Shapiro et al. 227 85 GTS .
Lucas 158 4 GTS .
Martindale 168,169 1 GTS .
Nuwer 192 12 GTS .
Caplan et al. 47 1 GTS .
Wallen and Areneta 258 1 GTS .
Milman 177 4 GTS .
Lang et al. 147 1 GTS .
de Divitiis 78 .
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10490
tinguishing the various clinical manifestations of the move-
ment disorder have not been established, and as the vari-
ants wax and wane within patients, it may be most useful
to view verbal, vocal, and other motor tics in GTS as
variants in a hyperkinetic syndrome.
Insight into the nature of swearing in GTS can be
obtained by crosslinguistic investigation. Cross-cultural
clinical commonalities in patients with GTS were observed
as early as 1973. It was reported that approximately 60%
of patients sampled in the US 193 , France ns107 ,
Germany ns57 , United Kingdom ns54 , Italy ns
46 , Eastern Europe ns25 , Scandinavia ns9 , India
Ž. Ž. Ž.
ns5 , Japan ns2 , Czechoslovakia ns4 , Poland
Ž. Ž. Ž.
ns2 Hong Kong ns2 and Hungary ns1 had
coprolalia 1,5 , but the authors did not provide examples
of specific vocalizations in the different languages. Boshes
32 described ‘‘Jamie’’, who ‘‘swore continuously’’ and
‘‘spewed forth an uncontrollable string of obscenities’’ p.
715 but specific words are not listed. Pary 195 reports
‘‘episodic cursing’’. Many authors refrain in this manner
from giving specific coprolalic examples. This practice
retards our ability to perform linguistic analysis of the
specific utterances. In this article, we document all specific
instances to gain insight into the phenomena of neurologi-
cal swearing; and we indicate when coprolalia was re-
ported without specific instances. All examples gleaned
from the international literature are given in Table 4.
An important contribution to our understanding comes
from the American coprolalic linguistic corpus of Shapiro
et al. 223 . Besides this work, several other authors have
provided American English examples 47,107,110,158,
177,187,258 and coprolalic American Sign Language ex-
amples 147 . Lees et al. 152 provide a listing of British
coprolalic utterances. The most frequent coprolalic items
observed clinically in the UK are provided by Lees 151 .
Cases have been described for English spoken in Australia
51,53 , and for Canadian English, at least two studies have
reported coprolalia in GTS 49 with one study reporting
that 60% of the GTS subjects used coprolalic expressions
180 . The New Zealand English report speaks of ‘‘four-
letter obscenities’’ in a GTS patient 114 . A child in
Ireland displayed tics accompanied by cursing which was
disruptive socially 161 . A British study includes the
utterance ‘‘maman’’ mama ; this patient had French par-
ents 89 .
Several French cases indicate usage of coprolalia 119
or ‘‘obscene words’’ 153 , but do not list the actual
words; another gives the example ‘‘trois fois par semaine’’
three times a week 265 .
Spanish examples are given in Singer 226 . Four Ar-
gentinean cases were described 175 ; in another study,
28% of Brazilian GTS patients had coprolalia, with exam-
ples given 48 , and a Brazilian patient with coprolalia and
compulsive screaming is described without examples 111 .
Other Portuguese language cases have been described 93 .
A GTS patient from Guyana, South America, had copro-
lalia 81 . A few unusual examples from a Peruvian report
include ‘‘no seas malcreado’’ don’t be bad and ‘‘serve
me coffee’’ 269 see Table 4 . Briones et al. 37 describe
‘‘gritas y insultas; autenticas barbaridades; palabras soe-
ces’’ ‘‘screams and insults; authentic barbarisms; vile
words’’ pp. 16–17 all pointing to variants of expletives
but lacking specific examples.
Chinese investigators reported on five 156 and then on
18 GTS patients 155,231 in Hong Kong, 60% of whom
had single or multiple word coprolalic expressions. In
Japanese patients, coprolalia is reported 136 , and exam-
ples are given 48,141,189,190 .
Numerous papers from Germany provide clinical de-
scriptions and some offer specific coprolalic utterances
7–10,18,56,120,165,214 . Certain terms occur across sev-
eral patients Arshloch, asshole , Scheisse, Nutte pros-
titute , while others occur in a single person Leiche
corpse , Tod death . A Dutch coprolalic patient is de-
scribed 238 . The Danish study of 65 patients lists specific
coprolalic utterances 202 .
Coprolalia has been reported in Italy 77 with examples
87 . A few such examples differ somewhat in that they
take the form of imperatives ‘‘taci, cretinnacio’’; ‘‘shut
up, stupid’’ that may be self-directed. de Divitiis 78
provided specific coprolalic examples of a 23-year-old
male GTS patient in a letter responding to our request see
Table 4 .
Three papers describe patients in Czechoslovakia
90,102,242 . Five reports of 38 Polish 29,140,209,
245,268 and Russian 11 patients mention ‘‘bad’’ or
‘‘obscene’’ words. A Russian report 172 reviewed eight
patients from 9–13 years. GTS patients followed a stereo-
typical chronological sequence, with simple involuntary
facial, head and shoulder movements, nonverbal vocaliza-
tions, screams, inarticulate sounds, and, in three patients,
‘‘bursts of foul language’’. However, the only examples
given are the Russian words for ‘‘yes, yes’’ and ‘‘no, no’’.
Two patients in Sri Lanka were described by Perera
196 , who responded to our inquiry by letter by providing
the specific words in Indian English and Sinhalese spoken
by his young subjects given in Table 4 . Eapen and
Srinath 82 reported coprolalia in an Indian subject but no
examples were given. GTS in the Middle East has been
reported 85,203 . Clinical descriptions appear in publica-
tions from Israel 100,154 . A 37-year-old Turkish male
with GTS and spinal muscular atrophy had coprolalia, but
no examples were given 217 .
Coprolalic signing has included signs for ‘‘fuck’’ and
‘‘shit’’ 147 . These signs are to be distinguished from
copropraxia, the obscene gestures that also occur in GTS.
Perusal of Table 4 reveals that the vocalized words
encountered as part of the clinical presentation in GTS,
whether described as a category or in specific terms, are
best characterized as obscene or socially taboo terms,
primarily with sexual content, sometimes as social slurs or
insults, with minor appearance of imperatives shut-up ,
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 91
phrases of morbid content death , and a few other miscel-
5. Exploring coprolalia in GTS: does the Markov model
The claim that observed coprolalic utterances in English
GTS speakers can be explained by elementary phonatory
positioning 192 related to Markov processes of random
sequencing has been championed in the GTS literature.
This hypothesis suggests that randomly generated strings
of letters or phonemes utilizing higher order probability
tables, where more weight is given to those units with a
higher probability of occurrence, can account for copro-
lalic productions. This claim is untenable for at least five
First, linguists have explained in detail why Markov
processes, having exclusively transitional-probabilistic
properties, are irrelevant to speech and language, which is
structured on several hierarchical levels 54,122,176 . Even
if that were not the case, the example given by Nuwer of
‘‘third order probabilistic computer-generated strings of
letters’’ is unconvincing p. 366 .
SE KIN HE SPER GOT IN THE WORSE FART
YOUESS WELL DIN OPTION IN ITIMENTRAND
TWO AS TO BE JURGAINS FART ASSE GIVE
ONEGS LOVE BE HALLETURN MAY POCK
MOUNT ME SAM WE SNOTLEAKETIFULN’T
MIGH TOON’T MIT BAR SOMADE SAM SAY
It is unconvincing because only one of the phonetic combi-
nations alleged to represent GTS vocalizations appears on
the clinical coprolalic listings in Table 4, except for the list
assembled by Nuwer 192 , and the second randomly
generated item asse only approximates a GTS vocaliza-
tion, which occurs in a low position on the descending
frequency lists in Table 4. Further, the hypothesis would
have to explain why the other combinations seen proba-
bilistically do not occur as part of the GTS repertory or
speech performances generally . The numerous other co-
prolalic utterances, including the multisyllabic expressions,
are unaccounted for. The coprolalic productions of one
GTS patient were analyzed by Martindale 168 see Table
4 , who found that the tics and tic strings consisting of
from 1–7 words exhibited a complex syntax. These pro-
ductions could not be described by ‘‘a grammar in which
any tic element may follow any other’’ — a zero-limited
grammar p. 271 . Nor could the coprolalic productions be
characterized by a one-limited grammar ‘‘one in which
every word is constrained only by the preceding word’’ ,
because tic elements are constrained by more than merely
the words preceding them. Thus the various permutations
of the coprolalic utterance ‘‘Fuck your my your, my
fucking fucking cunt’’ required a two-limited finite state
grammar, which is a level of structure well beyond free
combination of elements, and at least one step beyond
immediately constrained transitional states.
Secondly, the phonetic composition of the most often
observed GTS verbal tics in English does not consist of the
most frequent phonemes in English. Numerous frequency
listings make possible an objective evaluation of phonemes
involved in frequent coprolalic utterances e.g., Refs.
46,76,98,157 . An analysis of relative occurrence of
speech sounds as determined from telephone conversations
Ref. 91 , p. 95 reveals that w, t, th as in then , y, d, and
m are the six most frequent sounds in word-initial position,
having ratings of 9.38 for w, 7.86 for t, 6.72 for th, 6.48
for y, 6.21 for d, and 5.89 for m see Table 5 . In contrast,
the ‘‘top’’ three coprolalic words 223 see Table 4 under
USA contain initial phonetic elements of f, sh, and k,
which occur in 14th ratings3.96 , 18th ratings1.74 ,
and 9th ratings5.55 place, respectively on the phoneme
frequency list. Similarly, the phoneme frequency data for
conversational American English presented in Kent 137
calculates f at 3% of sounds, sh at 1% of sounds, and k at
5% of sounds. For coprolalic consonants in final position,
k, t, and nt, Fletcher’s chart 91 for final consonants
places k at 2.85, t at 14.30, and nt at 4.40. Medial vowels
are uh and ih. While ih is ranked highest 10.27 on a
frequency table for spoken English, uh at 4.14 is 11th out
of a total of 18 vowels. Thus, the sounds of American
coprobalic items are actually among the less probable to
occur in American speech.
For British English, examine the three most common
coprolalic utterances given in Table 4, noting their initial
sounds are f, k and b. According to Fry’s 98 analysis of
the frequency of British vowels and consonants in conver-
sation reproduced in Refs. 105,65 , and a similar result
appears for the consonants: f and k are 9th and 14th,
respectively; the vowels are 1st and 9th. In summary, of 19
consonants and vowels making up the three most frequent
coprolalic words in American and British English, 12
sounds rank between 9th and 18th in phoneme frequency
counts. Of these 19 phonemes, only two vowels and the
final t or d rank in the first three phonemes in phoneme
frequency counts. Thus, facts derived from the statistical
ranking of phoneme frequencies do not descriptively ac-
count for the phonetic shapes of the three most often used
coprolalic utterances in either British or American English.
While too few German examples are available in the
literature to determine a definitive frequency ranking of
coprolalic utterances, a similar result appears from choos-
ing the first 3 1–2 syllable words Nutte whore , Hure
wx w x
whore , Arshloch asshole , and comparing them to a
mean frequency of occurrence of letters in a German text
Ref. 122 , p. 99 . We find that N is ranked 2, T is ranked
6, H is ranked 7, R is ranked 3, A is ranked 9, and L is
ranked 11 see Table 5 . Again, relevant letter frequency is
not among the highest for these words. Added to this range
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10492
of relatively low probabilities is the uniqueness of the
letter combinations. We conclude that phoneme or letter
frequency counts are not germane to coprolalic utterances.
An occasionally expressed corollary of the Markov hy-
Phoneme and letter frequency tables
After Fletcher 91 American English conversation
Vowels Initial consonants Final
articles excluded Consonant
Sound-type Rank Sound-type Rank Sound-type Rank
pin 10.27 w 9.38 t 14.30
pine 7.58 t 7.86 r 13.05
pan 6.89 th then 6.72 n 12.52
pen 6.60 y 6.48 l 8.40
peel 6.44 d 6.21 z 6.01
pool 6.26 m 5.89 m 5.48
pot 5.21 h 5.75 d 4.44
pane 4.78 k 5.55 v 4.23
pole 4.74 s 5.46 ng 3.57
pawn 4.15 n 4.99 s 3.13
pun 4.14 b 4.64 f 1.37
pull 2.96 g 4.33 th with 1.25
pout 1.69 l 4.31 p 1.24
par 1.31 f 3.96 ch 0.53
pair 1.09 r 2.78 b 0.42
purr 0.80 p 2.54 g 0.38
pew 0.26 th thin 2.02 sh 0.32
poise 0.19 sh 1.74 j 0.14
v 1.25 th myth 0.04
f 0.83 zh 0.01
After Fry 98 , British english conversion
All consonants All vowels
Sound % Sound %
n 7.58 sof a10.74
t 6.42 bit 8.33
d 5.14 bet 2.97
s 4.81 bite 1.83
l 3.66 but1.75
th then 3.56 bait 1.71
r 3.51 beat 1.65
m 3.22 bawd 1.45
k 3.09 f ather 1.37
w 2.81 hawed 1.24
z 2.46 hoot 1.13
th thin 0.37
Table 5 continued
After Hoermann 122 , German: written text
Letter Frequency Letter Frequency
E 147 004 G 26672
N 88351 M 21336
R 68 577 O 17717
I 63770 B 15972
S 53 881 Z 14225
T 47310 W 14201
D 43854 F 13598
H 43554 K 9558
A 43309 V 7350
U 31877 UE 5799
L 29312 P 4992
C 26 733 AE 4907
pothesis was that coprolalic productions in English consti-
tute ancient, ‘‘Germanic’’ utterances, formed of naturally
vocalized, ‘‘gutteral’’ phonetic elements. Here, also, the
facts do not meet the presumptions. Two highly popular
coprolalic utterances, ‘‘fuck’’ and ‘‘cunt’’, are not attested
in Old English 65 .
A third counterargument against the Markov proposal
arises from observations of semantic consistency. The
variety of coprolalic utterances across languages as shown
in Table 4, including nonIndoeuropean languages, consti-
tute an obvious content category of obscene or taboo
words of highly diversely configured phonetic compo-
sition. This fact of semantic category overrides any contri-
bution of recurring or ‘‘more frequent’’ phonological
elements to the classification. In rare cases where the
coprolalic utterance falls outside of the semantic category
of taboo words, as in self-directed imperatives or morbid
phrases , we nonetheless note that the phonetic elements
form a coherent phrase e.g., ‘‘serve me coffee’’ , not a
In addition, as a fourth point, actions and mental events
conceptually related to the most common coprolalic se-
mantic subcategory, sexual terms, co-occur with coprolalic
productions. That is, copropraxic behaviors of sexual
touching and obscene hand gestures are common. This
co-occurring behavior lends further support to the notion
that it is a semantic-cognitive category that is involved, not
a probabilistic tendency toward an accidental concatena-
tion of sounds.
Finally, the report of coprolalic signing 147 removes
the symbolic output completely from the realm of letter or
phonemic strings, and given the signed forms, supports the
role of the semantic category obscenity , not phonetic
In conclusion, the Markov model is unable to account
for coprolalic utterances, even the monosyllabic examples.
It is the notion of a particular semantic category, that is,
words with socially taboo andror emotionally charged
meanings, that accounts for nearly all coprolalic items. An
explanation for swearing in GTS that is based in neurobiol-
ogy and not involving probabilities is presented below.
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 93
6. Comparison of swearing in aphasia and GTS
Among speech pathologies, swearwords taboo expres-
sions occur most prominently in aphasia and GTS. Here
we explore the similarities and differences in swearword
presentation in the two conditions. Swearwords have in
common that they are socially taboo utterances, those to be
avoided in ‘‘polite company’’, and that are therefore,
mildly or intensely, ‘‘offensive’’ terms. Unfortunately,
there is no available corpus of aphasic recurrent utterances
for American English, and thus it is necessary to compare
the larger GTS coprolalic corpus for American English
223 with the British corpus for aphasia provided by Code
57,59 . Listings for both speech pathologies are available
in German for comparison. The overview of crosslinguistic
coprolalic utterances provided above will help explore
questions about the clinical presentation of vocalizations in
Differences are found in the manner and in the content
of speech performance for these terms. In aphasia, swear-
ing is selectively preserved in the context of severely
impoverished speech; in GTS, swearwords are overpro-
duced in the context of functional speech. In the aphasic
and left hemispherectomized adult speakers, swearing is
produced nearly normally in articulation, prosody, and
fluency. In the GTS speaker, the coprolalic expression is
defective in articulation and prosody, relative to the ongo-
ing, conversational speech in which it is occurring. Many
reports of coprolalic utterances in GTS describe them as
distortions: they are overly loud, or ‘‘shouted’’, impre-
cisely articulated, expressed with aberrant voice quality,
and sometimes unintelligible, while speech of the patient
with GTS is otherwise normal but see Ref. 159 .
Another difference lies in ‘‘substitution’’ behavior. Per-
sons with coprolalia have been reported to utilize eu-
phemisms in place of the socially offensive term 165 , for
example, using ‘‘gut’’, ‘‘good’’ ‘‘schoen’’, ‘‘fine’’
‘‘wunderbar’’ ‘‘wonderful’’ for ‘‘Scheisse’’ ‘‘shit’’ and
‘‘Arshloch’’ ‘‘Asshole’’ . Shimberg 225 , giving an
overview of GTS for the general public, states that some
persons with GTS learn to mask words, saying, for exam-
ple, ‘‘fake’’ for the more offensive word ‘‘fuck’’. A
similar process may be underway in the observation that
some persons with GTS ‘‘shout’’ words regularly occur-
ring in sentences 50,212,220,259 , possibly to accommo-
date the coprolalic inpulse in this other way. Neither a
substitution process nor compensatory shouting is ob-
served in aphasia.
Another important difference in manner of production
between adult aphasia and GTS lies in the ‘‘sensory’’
factor proposed for tic behaviors in GTS. Patients report
that they first feel an urge, which is very strong, to
perform a movement e.g., vocalization , and then they
‘‘voluntarily’’ perform the movement 41,143,145 . In a
survey, 147 71% of GTS patients were found to have a
‘‘feeling that tics are imminent’’; 76% experience a sensa-
tion preceding the tics; 25% feel that the sensation will be
relieved by tics. Sensations are described as generalized,
psychic, and focal, and if the sensations involve the phar-
ynx or larynx, then ‘‘vocalizations may be produced’’
143 , p. 733 . One patient describing personal inner
experiences stated that ‘‘coprolalia is a response to the TS
sensitization of the vocal tissues used in forming sounds;
somewhere in the mouth or throat lips, teeth, larynx,
tongue , tissues and air impinge on each other to activate a
single sensory site’’ Ref. 28 , p. 1345 . In another pa-
tient, coprolalic practice was reduced by injection into
vocal folds of botulinim toxin, suggesting that GTS may
involve a ‘‘sensory reflex arc’’ and that the effect of the
injection is to reduce ‘‘local build-up of tension or muscle
contraction’’ on the laryngeal area 219 . There is no
evidence or suggestion of a comparable premonitory sen-
sory component to swearing behavior in aphasia, but this
has not been studied directly.
As coprolalic vocalizations often occur during ongoing
conversation, several studies have evaluated whether or
how their occurrence is related to linguistic structure. One
study evaluating verbal tics in three GTS subjects reported
that two of the subjects produced 70% of tics at natural
pausing points, before and after clauses, while the third
subject produced most tics within stressed words 95 .
Martindale 169 studied the syntactic and semantic corre-
lates of verbal tics in a two h sample of speech in a GTS
subject. Tics were produced at the rate of 4.6 per minute,
often in strings; they appeared to occur at points of low
information or uncertainty, often before conjunctions and,
but and pronouns. In another study, most vocal tics were
produced at the beginnings or ends of a speech clause,
somewhat less during the clause. A small number of tics
were produced in silence 159 .
Other questions pertain to how GTS vocalizations com-
pare to vocal tics occurring in normal speech production.
The notion of normal use of vocalizations has been de-
scribed by Goffman 108 , who states that ‘‘the public
utterance of self-talk, imprecations, and response cries
constitutes a special variety of impulsive, blurted actions,
namely, vocalized ones’’ p. 116 and by Darwin 72 who
discusses the universality of sound emission as emotional
expression. A comparison of GTS vocal verbal and non-
verbal tics with measures of the same behaviors taken
from normal speakers was conducted 159 . The nonverbal
tic frequent in GTS was also observed in normal speakers,
but verbal tics occurred only in GTS speakers about
The volitional component of tics is said to distinguish
GTS vocal tic production from abnormal motor behaviors
in the choreas 145,193 . Swearing in aphasia is best
explained by stating that the word choice is fixed but the
use is somewhat volitional in spontaneous speech, in that
the recurrent utterance can be used expressively, along
with facial and other gesturing. What is not known is
whether a typical recurrent utterance can be elicited from
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10494
the aphasic speaker- whether hershe can produce the
utterance on command. In contrast, GTS patients have
been repeatedly demonstrated to easily produce their co-
prolalic utterance at will and on command, without the
sense of inner tension that accompanies spontaneous co-
prolalia, and without the phonetic distortion. One study
utilized a habituation technique as therapy for coprolalia,
eliciting numerous repetitions of the affected utterance,
until the patient reported no longer being able to say the
word. Following these therapeutic sessions, the compulsive
vocal emissions were temporarily reduced 10 . Voluntary
and spontaneous tics may use different underlying mecha-
nisms; EEG studies 193 reported an absence of the
pre-movement potential normally associated with volun-
tary motor acts prior to GTS tics, which suggested that the
tics are not generated through normal motor pathways
utilized for willed human movements p. 113 . Thus to the
extent that we can locate swearing behavior on a spectrum
from ‘‘voluntary’’ to ‘‘involuntary’’, significant differ-
ences appear in GTS versus aphasic swearing.
Longitudinal studies identify other differences between
swearing in GTS and aphasia. Aphasic speakers generally
emerge from the acute phase with a fixed repertory of
recurrent utterances, which may change and grow some-
what with time, and which eventually may evolve to
propositionally formed expressions 2 . In the chronic pa-
tient, by definition, little change in swearing occurs. In
contrast, GTS vocal phenomena often are reported to begin
as partial, soft and indistinct sounds, which develop even-
tually into louder and clearer vocalizations. Some authors
have speculated that the process is one of a change from a
willed act to a motor habit, that this process is more rapid
in GTS sufferers than in normal persons, and that copro-
lalic behavior progresses from a stage of volition or semi-
volition to compulsion. Some patients report having a
related thought e.g., authentic semantic content behind
the utterance for a while, and then eventually the copro-
lalic utterance proceeds motorically, as it were, on its own.
At the later stages, GTS patients may no longer be aware
of the quantity of their vocalizations. Coprolalia in GTS
has been reported to wax and wane 263 . While careful
studies still are needed, aphasic swearing appears to main-
tain a more stable course.
Coprolalic signing has been reported 147 in a hearing
young adult female with GTS and verbal coprolalia, who
learned fluent sign in her late teens. Although studies of
aphasic signing deficits following left hemisphere damage
in deaf persons have appeared 121 , there is no report of
recurrent automatic speech or residual swearing in sign
19 . However, focused studies on this question have not
yet been done.
Physiological versus psychiatric variables are of differ-
ing significance in GTS and aphasia. Even though the
previously held exclusive role of psychoanalytic explana-
tions for coprolalia, such as hostility toward a parent as the
cause of the verbal tics, is no longer seriously held, some
role of psychological factors is recognized by most persons
working with GTS sufferers 125 . Onset of symptoms is
often associated with a traumatic incident 263 . For exam-
ple, in his case report of a 13-year-old Saudi female
patient, El-Assra 85 states that ‘‘her condition started
seven years previously when she became extremely fright-
ened one night by a group of cockroaches in a dark toilet’’.
p. 397 . The patient exhibited facial tics four days later,
followed by multiple tics of neck, shoulders and hands;
soon utterances appeared, and these developed into copro-
Environmental conditions exacerbate or ameliorate the
intensity of the symptoms 225 ; for example, coprolalia
may be ‘‘worse at home when the individual feels safer’’
p. 31 ; or, in an opposite presentation, worse in the
presence of others 85 . In discussing GTS symptoms,
Bruun and Budman 38 observe ‘‘fewer tics in the office
setting than reported by history’’ p. 28 , and they note the
ability of children to mask their symptoms by use of social
setting affects aphasic swearing. Cultural factors have been
said to influence coprolalic output, with ‘‘quasicoprolalia’’
in Japanese and other Asian GTS cases 129,191 , presum-
ably attributable to lower acceptability of swearing in
Asian culture. Similarly, in aphasia, though to a lesser
extent, less swearing has been reported for German- than
American-speaking aphasic patients, especially in the pres-
ence of the clinician 31 .
Meyer and Rose 174 report psychological factors as
contributing to the clinical picture in GTS. Milman 177
reported that three of four boys with coprolalia also had
‘‘body anxiety and sexual anxiety’’ p. 894 . Pitman and
Jenike 199 studied a patient with obsessive-compulsive
disorder OCD and coprolalia, seeing a role for psycho-
logical factors in the genesis of tic symptomatology. In-
deed, OCD, a neuropsychiatric condition, often appears
clinically in association with GTS 68,96 ; many authors
view an array of motor and behavioral abnormalities as
constituting a spectrum of related phenomena e.g., Refs.
62,241 which include copropraxia. Beckers 18 gives a
strongly psychodynamic interpretation of the clinical pre-
sentations of five patients, although he reported psy-
chotherapy not to be useful in these cases. Lumsden et al.
161 reported a success of family therapy in reducing tics
and coprolalic utterances in an 11-year-old child. Given
that the content of the verbal tics is primarily the feature of
social offensiveness, a significant interface between neuro-
logical and psychiatric features is compelling, and appears
to be a much more significant factor in GTS than aphasia.
Tables of data on swearing in British, German and
American samples in aphasia and GTS reveal little overlap
in pathological swearing. In British, ‘‘fuck’’ appears in
both pathological conditions; in American English, ‘‘shit’’
appears in both conditions. One or both words occur in
various instantiations in most other languages reporting
GTS examples: Spain, Brazil, Germany, Hong Kong, Sri
Lanka, and American Sign Language. These two are the
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 95
words all groups have in common. However, there are
differences in content of the swearword corpus for each
group. Perusal of Tables 1–4 allow comparison of reported
swearing or coprolalic behaviors of normal, aphasic, and
GTS patients. Normal adults use the more mildly obscene
terms in most surveys Table 1 .
In a further difference, aphasic recurrent utterances
include social interjections, sentence stems, proper nouns,
yesrno, numbers, and a large class of miscellaneous words
and phrases Table 2 . In contrast, in GTS, linguistic
vocalizations, visceral and sexually charged obscenities
and insults predominate in a spectrum with nonverbal
vocal and manual gestures Table 4 . We have previously
concluded that specified semantic content is a key parame-
ter in GTS coprolalia. This notion is consistent with fre-
quent reports of sexual preoccupation and copropractic
movements involving sexual gestures 62,69 . These kinds
of words and these gestures are not characteristic of apha-
Taboo expressions are hyperactivated in GTS, and a
subset of these are preserved in left hemisphere damage
and removal. Aphasic speakers retain a set of ‘‘automatic
utterances’’ which include swearwords as the second most
common type, while GTS vocalizations concentrate on
sexually offensive terms, extending sometimes to those not
commonly used as swearwords e.g., ‘‘pregnant-mother’’,
‘‘homosexual’’ , but including an array of nonverbal vocal
sounds. In left hemisphere dysfunction, taboo expressions
emphasize swearwords ‘‘of frustration’’ ‘‘fuck’’, ‘‘shit’’,
‘‘goddammit’’ . Behaviors in GTS extend to sexual con-
tent in copropraxia and mental coprolalia. No such associ-
ated behaviors are observed in focal left hemisphere dis-
ease. Thus the psychosocial dimensions associated with
coprolalia are not present in aphasic swearing.
Persons with GTS are able to transmute, mask and
postpone the vocalizations. Coprolalic frequency is influ-
enced by social setting. While in aphasic swearing,
crosslinguistic cultural differences in production frequency
of expletives have been reported cf. differences between
English and German corpora , variability with social set-
ting is not prominent, and masking of the form of the
residual utterance in aphasia does not occur.
The clinical-linguistic observations are consistent with
the notion of hyperactivation or release from inhibition of
emotionally and sexually charged behaviors in GTS. For
patients with left hemisphere damage, swearing most likely
appears because it is stored and processed differently from
newly created, propositional speech and thus remains
Studies of the linguistic vocalizations of GTS are com-
plete enough to conclude that sexual-emotional content
characterizes the coprolalia. Thus the notion of a hyperac-
tivation of sexual-emotional processing in vocal and gestu-
ral behaviors is useful in accounting for many of the
clinical symptoms. Habitual vocal–motor patterns may
help originate and maintain the vocalizations. For focal
damage to the left hemisphere, habitual ‘‘island’’ preserva-
tion of motor patterns appear to more essentially underlie
the swearing behavior. In severe aphasia, we propose that
overlearned motor patterns best explain these phenomena.
Frustration, and the genuine expression of emotion, can
and does often trigger the production of the expressions.
Since selectively preserved swearing is seen in extensive
damage to the left hemisphere as well in the left hemi-
spherectomized adult, a role of the right hemisphere is
likely. With one report of deficient swearing and other
automatic speech behaviors in association with a right
basal ganglia lesion 235 , the notion of an interaction of
basal ganglia and right hemisphere is attractive.
7. Emotional and prosodic processing
There have been ample reports of emotional processing
by the right hemisphere 33,40,55,133,246,260 as well as
proposals that right hemisphere dysfunction contributes to
psychoaffective disorders 70 . Emotional changes also are
associated with basal ganglia disorders 170 ; there are
numerous reports of changes in mood and motivation
22,61,66,70,170,173,201,211 . Heightened social aware-
ness may be a right hemisphere property 237,250,251 .
Prosody, the melody of speech, emerges importantly in
emotional speech. This has been recently a major field of
study, with findings of an effect of either left or right
hemisphere andror a basal ganglia damage on prosodic
ability. Some greater role of the right hemisphere has been
reported in prosodic performance, although the reason for
this finding — whether attributable to cognitive, acoustic,
or other factors — has remained elusive. Studies of emo-
tional prosodic comprehension in GTS are rare. One study
75 using the Profile of Nonverbal Sensitivity PONS test
of nonverbal communication 208 found no deficits in
comprehension of emotional meanings in speech prosody
in five patients with GTS and coprolalia. Other studies of
persons with basal ganglia disease have reported deficient
emotional-prosodic comprehension, whether the move-
ments were of the hyperkinetic variety, as in Huntington’s
patients 234 or hypokinetic, Parkinson’s disease
Prosodic production in speech, although a highly active
field of study in normal speakers 215,216 and in neuro-
logical subjects, has not been investigated in GTS. How-
ever, impressionistically, abnormalities involving loudness,
timing, and pitch are observed in the pathological verbal–
vocal expressions of GTS. Acoustic analyses of these
expressions would be of great interest. As mentioned
above, in studies of brain damage, changes in speech
prosody production 138,255 and comprehension occur
with damage to either hemisphere 257 as well as to
subcortical structures 45,253 . Singing of familiar songs is
often intact in aphasia, in adult left hemispherectomy and
in selective anesthetization of the left hemisphere in Wada
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10496
testing 113 ; reports of singing ability in GTS have not
appeared. Singing, like swearing, appears to remain apart
from propositional language function. Since data are avail-
able on prosodic function in various other neurological
diseases, prosodic studies of coprolalia and swearing in
aphasia would be of value and interest in understanding
8. Cerebral laterality
While the left hemisphere mediates most linguistic be-
haviors, the right hemisphere is important for broader
aspects of communication 249–251 . Right hemisphere
behavioral functions appear to differ from those mediated
in the left hemisphere with regard to type of stimulus
preferred 6,21,34 . In visual and auditory domains, cere-
bral laterality studies consistently show a superiority for
right hemisphere processing of the configurational aspect
of stimuli 30,236 . Simply stated, the left hemisphere
specializes in analyzing sequences, while the right hemi-
sphere gives evidence of a superiority in processing pat-
terns. These generally accepted facts about hemispheric
specialization pertain to our review of swearing, in that
expletives make up a unitary, ‘‘nonanalytic’’ stimulus,
which in all likelihood is stored and processed as a whole.
In contrast, words making up propositional language are
composed of the building blocks of phonemes, mor-
phemes, and syllables, which can be rearranged in various
ways. The differences between expletives and composed
words and phrases, considered with known differences
between left and right hemisphere processing, lead to a
consideration of the right hemisphere as a more likely
candidate in modulating the motoric production of exple-
tives. This theoretical possibility is supported by the obser-
vations of intact swearing in severe aphasia following
extensive left hemisphere damage and left hemispherec-
tomized adult patients.
9. Pathological basis to GTS: a basal-ganglia disorder
While there is no doubt that brain damage underlies
swearing behaviors in aphasia, it is only more recently
agreed that a neurochemicalrneurophysiological disorder
underlies GTS 150 . The effectiveness of neuroleptics
gave the first clue to these mechanisms 148 . Evidence for
a genetic basis of the disease further supports this view
Neuropathological studies of GTS are inconclusive
227 . Examination of three GTS patients at autopsy re-
vealed meningitic thickenings in the region of exit of the
facial nerve in one case, meningitic and vascular changes
throughout the brain in the second case, and no changes in
the third; others suggested that small cells in the corpus
striatum were decreased in size and density 263 . Devin-
sky 74 proposed midbrain involvement as the site of
damage; this proposal was based on metabolic abnormali-
ties implicating the midbrain, similarities between GTS
and encephalitis lethargica, and brain stimulation studies
135 ; midbrain involvement, with a focus on the periaqua-
ductal gray matter, was also later proposed from radiologic
data 213 . A recent post-mortem study showed abnormali-
ties in the globus pallidus with profoundly diminished
dynorphin-like immuno-staining in this region 116 . A
post-mortem study of three patients with GTS revealed
significantly increased dopamine uptake carrier sites in the
caudate and putamen 230 . Although no reproducible
autopsy changes have been described that definitely local-
ize the pathology of GTS to a basal ganglia region, several
lines of evidence support the basal ganglia as the principal
location of dysfunction in GTS.
Of many GTS patients studied with computerized tomo-
graph CT , only 10% have shown abnormalities, and
these appear in various brain systems 17 . Despite these
inconsistencies, there is increasingly compelling evidence
that GTS is a basal ganglia disorder. Studies using mag-
netic resonance imaging show reduced volumes of the
caudate nuclei, lenticular nuclei, putamen, and globus pal-
lidum compared with controls 198 . Activated brain imag-
ing findings are inconsistent, but also tend to implicate
basal subcortical structures. Older studies reported higher
glucose metabolism in the basal ganglia of GTS patients;
other studies by the same group found glucose metabolic
rates to be lower than normal subjects in frontal, cingulate
insular cortex, and inferior corpus striatum 51 . Baxter
and Guze 17 found higher glucose metabolic rates in the
putamen of GTS patients compared to normal subjects.
More recently, studies of brain metabolism and brain blood
flow have shown diminished perfusion and glucose
metabolic activity in the caudate nuclei and variably in the
thalamus, anterior cingulate, and dorsolateral pre-frontal
cortex 83,84,182,261 . Correlative hypometabolism ap-
pears in bilateral temporal lobes of GTS subjects 84 .
Braun et al. 35 studied 18 GTS patients aged 18–49 and
reported an association of clinical symptoms with ‘‘in-
creasing, apparently dysfunctional synaptic activity in the
medial, lateral, and caudal orbitofrontal cortices’’ p. 151 .
In vivo studies of dopamine receptor binding revealed
increased D2 dopamine receptor binding in the head of the
caudate nucleus and increased dopamine transporter activ-
ity in this same area 164,262 . Disordered biogenic amine
metabolism also is supported by reduced levels of ho-
movanillic acid in cerebral spinal fluid of patients with
GTS 42,52,229 .
Taken together with the clinical response to dopamine
blocking agents such as pimozide evidenced by most
patients with GTS 202 , the available evidence strongly
supports dysfunction of the striatal structures including
caudate, globus pallidus, and putamen in patients with
GTS 262 . Shapiro and Shapiro 222 and others point to
the effectiveness of neuroleptics, especially those with
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 97
dopamine D2 blocking effects, as implicating dopamine
dysfunction in GTS. Similarly, Singer 228 assigns an
important role in GTS to frontal-subcortical circuits based
on evidence from dopaminergic neurotransmission. Other
disorders such as Sydenham’s chorea, hemiballismus, car-
bon monoxide intoxication, and post encephalitic Parkin-
sonism, where coprolalia has been reported, also involve
the basal ganglia. Thus, coprolalia of the involuntary,
ego-dystonic type manifested in GTS appears to be at least
partly a manifestation of basal ganglia dysfunction.
The basal ganglia are increasingly recognized to have
important roles in cognitive, emotional, and behavioral
functions as well as in motor activity. The effect of basal
ganglia damage on speech and language function has been
described 39,45,76 . In one model of basal ganglia func-
tion, the basal ganglia are said to provide an internal
timing cue to the supplementary motor to release an action.
Georgiou et al. 103 present evidence that GTS involves
‘‘dysfunction of basal ganglia and interconnections with
frontal lobes’’ p. 190 . Studies of three cases of tic
disorder associated with pediatric cerebral malignancies
suggested a role for ventral striatum, corpus callosum,
thalamus, midbrain as important in tics 197 . Following a
notion first proposed by Balthasar 14 in 1957, Palumbo et
al. 194 reviewed a large number of cases and proposed a
‘‘developmental basal ganglia syndrome’’ underlying GTS
and related disorders.
10. Limbic system-basal ganglia hypothesis
The caudate, globus pallidus, putamen, and substantia
nigra are positioned in frontal-subcortical circuits between
frontal cortical regions and thalamic nuclei. These
cortical-striatal-pallidal-thalamic circuits mediate executive
function, motivation, social behavior, and diverse aspects
of emotion 66 . The basal ganglia receive abundant pro-
jections from the limbic system, and the frontal-subcortical
circuits integrate limbic input in the orbitofrontal-subcorti-
cal circuit and the anterior cingulate-subcortical circuit
115 forming at least five structurally and functionally
separate ‘‘circuits’’ 3,66 . Thus, dysfunction of the basal
ganglia simultaneously produces abnormalities of limbic
system function and of limbically mediated emotional
activities. Nespoulous and Lecours 188 propose a limbic
source of coprolalic speech. A number of studies point to a
disorder of the cingulate gyrus — a critical component of
the limbic system — in GTS. Stimulation of anterior
cingulate cortex in humans has been associated with lick-
ing, touching lips, and other stereotyped GTS movements,
and it is known that the anterior cingulate cortex receives
dopamine innervation from the midbrain 243 . Several
patients have been treated by stereotaxic surgery directed
toward the limbic system e.g., 77 . Following successful
treatment of GTS by bilateral limbic leukotomy, Robertson
et al. 204 proposed the importance of cingulate cortex in
the mediation of emotionally charged language.
The limbic system has been implicated in emotional
vocalization in animals. In Macaque monkeys, emotional
vocalization occurs with stimulation of the anterior cingu-
late gyrus, amygdala, diagonal band-substantia innominata,
ventral septal region, hypothalamus, nucleus accumbens,
ventral anterior and midline nuclei of the thalamus, and the
tegmentum 205 . Similarly, studies with the squirrel mon-
key revealed that emotional vocalization occurred with
stimulation of the hypothalamus, midline thalamus, amyg-
dala, substantia innominata, septum, orbitofrontal cortex,
cingulate cortex, and anterior inferior temporal cortex 134 .
Ploog 200 reported from animal studies that vocalization
following brain stimulation occurred only in subcortical
cites, while human speech was considered to be primarily
cortically represented. Based on his observations on animal
vocalization, Robinson 25,206,207 has proposed two lev-
els of the nervous system involved in human speechrlan-
guage behavior: an older system, which terminates in
cingulate gyrus at the bilateral, rostral end of limbic sys-
tem, and which is capable of emotive speech behavior; and
a newer system which is cortical, unilateral, and involved
in planning. Myers 184 similarly proposed that animal
vocalization and human speech are dichotomous.
A similar and related dichotomy is proposed for learn-
ing and memory. Simply stated, the two disparate systems
proposed 178,179 are those for establishing habitual pat-
terns or ‘‘nondeclarative’’ also called ‘‘procedural’’
memories as distinctive from those for establishing new
learning or ‘‘declarative’’ memories 4 . From many kinds
of evidence, the basal ganglia are associated with motor
programs that are well established 99,167 . Marsden 166
stated that ‘‘the basal ganglia are responsible for the
automatic execution of learned motor plans’’ p. 514 . A
recent review of behaviors associated with the basal gan-
glia included aspects of motor control, preparation for
action, the formulation of strategies and responses, and the
establishment and selection of emotional responses 211 ,
p. 20 . Baev 12,13 proposes that the basal ganglia pro-
vide a ‘‘model’’ of the motor behavior to be executed.
Basal ganglia function with integrated limbic components
form a likely origin for expletives: these are habitual motor
programs with emotional content.
The basal ganglia in concert with limbic activity
account together for coprolalic production 185 ; the
coprolalic phenomena are thus attributed to a motivational
disorder involving limbic projections to striatum. Copious
interconnections between basal ganglia sensorimotor and
limbic pathways are known from neuroanatomical studies:
basal ganglia caudate nucleus, putamen, globus pallidus,
and substantia nigra are richly interconnected with limbic
structures. The nucleus accumbens receives inputs from
several limbic structures: anterior cingulate, hippocampus,
amygdala 115 . Parallel as well as multiple reciprocally
connected structures lead to optimal conditions for ‘‘cros-
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–10498
stalk’’, such that pathologies could produce ‘‘a variety of
symptoms relating to the motor, cognitive, and limbic
function of the basal ganglia’’ 115 , p. 261 . The role of
basal ganglia in initiating motor behaviors 167 , and the
known circuitry of frontal-subcortical connections 171 ,
provide the basis for positing hyperactivated initiation of
emotionally charged, overlearned vocal output as patho-
physiological basis of coprolalia.
A similar view emerged from specific studies of GTS
verbal behaviors. Following comparisons of language ver-
sus speech behaviors in GTS subjects, Ludlow et al. 159
proposed that the pathology may involve an imbalance
between cortical and limbic systems for processing speech
and language in GTS. These authors noted that the stereo-
typic speech, gestural and motor behaviors of GTS may be
produced without inhibition by the cortical system, and
therefore ‘‘fail to be further modified into purposive be-
havior’’ p. 360 . However, from their language studies,
they also suggested that in GTS, the cortical system also
may be impaired, resulting in ‘‘paucity of speech, lan-
guage, and written expression’’. This may be due, in their
model, to suppression of the supplementary motor area,
while the ‘‘production of stereotypic sets of behaviors is
heightened through increased activation of the cingulate
gyrus. The suppression of one region may be independent
of the increased activation of the other, accounting for the
independence of the two sets of symptoms’’ p. 360 . A
somewhat related proposal comes from Nauta 185 , who
suggested that GTS reflects a disorder not only in the
motor domain, but in the motivational mechanisms of the
limbic system. Baxter and Guze 17 focus on a functional
neuroanatomical involvement of the basal ganglia, pre-
frontal cortex, and limbic system in GTS, pointing to
well-known circuitry involved in the ’gating’ and ’screen-
ing’ of motor outputs, sensory inputs, and possibly even
’thoughts.’ They propose that it is ‘‘impairment in these
gating and screening functions of the striatum’’ which
results the variety of expressed phenomena in GTS, which
include both motor behaviors and sensations p. 299 .
Swearing is a common human act and is frequent in
neurological disorders such as spinal cord injury, head
trauma, and aphasia where patients experience frustration
and evidence the emotion through cursing. This type of
cursing differs from the involuntary ego-dystonic type of
coprolalia, in which speech production is separate from
personal intentionality. Ego-alien coprolalia is distinctly
uncommon and is confined to a few neurological diseases.
Coprolalia is most common in GTS, was well described in
post-encephalitic Parkinsonism, and has been noted in
cases of secondary GTS produced by herpes encephalitis,
carbon monoxide poisoning, Sydenham’s chorea, post-
stroke hemiballismus, and head injury 16,224 . Despite
the differences between normal cursing and coprolalia,
there also are substantial shared features: both use some of
the same words, the words have a highly emotional con-
tent, and both normal cursing and coprolalia depend on
invoking the emotional signaling systems — use of verbal
cries andror taboo words — in the communicative act.
Comparison of documented expletives for normal, aphasic,
and GTS speakers provided in Tables 1–4 shows notable
similarities as well as differences in the respective taboo
word repertories. Too little is known about swearing in
aphasia, with only the British and German corpora avail-
able, compared to fuller information in normal subjects
speaking American English, and a now broad reportage of
linguistic backgrounds for coprolalia. More complete in-
formation might change the picture. However, with the
current data, it appears that the most frequent expletives
‘‘damn’’, ‘‘shit’’, ‘‘fuck’’ occur in all three conditions,
while sexual taboo items predominate in normal and GTS
speakers, with fewer such items uttered in aphasia.
With yet so little known of relevant neurological mech-
anisms, our conclusions about brain-behavior correlates are
of necessity speculative. Comparison of animal and human
communicative behaviors suggest that two functional sys-
tems, one for emotional vocalization and the other for
propositional speech, may exist. The purpose of animal
vocalization is nearly exclusively social in nature with
some vocalizations indicating anger and warning and oth-
ers facilitating social interactions 75,163 . From this per-
spective, coprolalia in humans might represent the abnor-
mal release of vocalizations mediated by limbic system
structures and normally intended to perform the social
functions of repulsing intruders and expressing anger and
dissatisfaction. The ego dystonic, alien nature of coprolalia
in GTS and related syndromes stems from the involuntary
occurrence of these vocalizations analogous to the involun-
tary occurrence of the motor tics. We hypothesize that
coprolalia represents a limbic vocal tic whose unique
content is informed by the social and emotional commu-
nicative purposes of limbic vocalizations. The considerable
evidence of basal ganglia dysfunction in GTS implicates
those structures in concert with limbic activity. The verbal
form is unitary, not compositional i.e., is not generated by
combining smaller, permutable units, such as phonemes,
syllables and morphemes , in contrast to words in the
propositional language system, and thus possibly draws on
right hemisphere cortical mechanisms for execution.
Voluntary normal cursing and cursing in aphasia may
share the anatomy and physiology of coprolalia. Normal,
aphasic and coprolalic cursing have in common the expres-
sion of certain identical linguistic productions, as well as
the unitary, noncompositional structure of the stimulus.
Persons suffering from aphasia, in whom left hemispheric
areas mediating propositional speech are dysfunctional,
may have access to structures mediating limbic vocaliza-
D. Van Lancker, J.L. CummingsrBrain Research ReÕiews 31 1999 83–104 99
tion, modulated by basal ganglia structures and facilitated
by right hemisphere cortical structures. Normal cursing
typically occurs in periods of anger, frustration, and other
intense emotional situations where limbic system struc-
tures are activated and limbic vocalizations may be facili-
tated. In many normal and aphasic individuals, cursing
also occurs frequently as habituated verbal productions.
The overlearned and emotive vocal-motor ‘‘gestures’’ of
cursing are hyperactivated in GTS and remain residually
available in the aphasic speaker.
We appreciate the help of Dr. Alexander Smirnof and
Dr. Costintino Iadacola in translating articles from Russian
and Italian. Cathleen Bannister-Marx assisted in library
research and translation of Spanish articles. Videotaped
recording of a hemispherectomized patient was provided
by Dr. J.E. Bogen. Dr. Van Lancker is supported in part by
a grant from the Pew-McDonnell Foundation. Dr. Cum-
mings is supported by an NIA Alzheimer’s Disease Re-
search Center Grant, an Alzheimer’s Disease Research
Center of California Grant, and the Sidall-Kagan Founda-
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