Expressive aphasia
Encyclopedia
Expressive aphasia also known as Broca's aphasia in clinical neuropsychology
Clinical neuropsychology
Clinical neuropsychology is a sub-field of psychology concerned with the cognitive function of individuals with neurological and psychiatric disorders. Neuropsychological assessment examines cognitive function in the broadest sense, including the behavioural, emotional, social and functional status...

 and agrammatic aphasia in cognitive neuropsychology
Cognitive neuropsychology
Cognitive neuropsychology is a branch of cognitive psychology that aims to understand how the structure and function of the brain relates to specific psychological processes. It places a particular emphasis on studying the cognitive effects of brain injury or neurological illness with a view to...

, is caused by damage to or developmental issues in anterior regions of the brain
Human brain
The human brain has the same general structure as the brains of other mammals, but is over three times larger than the brain of a typical mammal with an equivalent body size. Estimates for the number of neurons in the human brain range from 80 to 120 billion...

, including (but not limited to) the left posterior inferior frontal gyrus
Inferior frontal gyrus
The inferior frontal gyrus is a gyrus of the frontal lobe . It is labelled gyrus frontalis inferior, its Latin name...

 known as Broca's area
Broca's area
Broca's area is a region of the hominid brain with functions linked to speech production.The production of language has been linked to the Broca’s area since Pierre Paul Broca reported impairments in two patients. They had lost the ability to speak after injury to the posterior inferior frontal...

 (Brodmann area 44
Brodmann area 44
Brodmann area 44, or BA44, is part of the frontal cortex in the human brain. Situated just anterior to premotor cortex and on the lateral surface, inferior to BA9....

 and Brodmann area 45
Brodmann area 45
Brodmann area 45 , is part of the frontal cortex in the human brain. Situated on the lateral surface, inferior to BA9 and adjacent to BA46.This area is also known as pars triangular ...

). Expressive aphasia is one subset of a larger family of disorders known collectively as aphasia
Aphasia
Aphasia is an impairment of language ability. This class of language disorder ranges from having difficulty remembering words to being completely unable to speak, read, or write....

. It is characterized by the loss of the ability to produce language (spoken or written). Expressive aphasia differs from dysarthria
Dysarthria
Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes...

, which is characterized by a patient's inability to properly move the muscles of the tongue and mouth to produce speech. Expressive aphasia contrasts with receptive aphasia
Receptive aphasia
Receptive aphasia, also known as Wernicke’s aphasia, fluent aphasia, or sensory aphasia, is a type of aphasia traditionally associated with neurological damage to Wernicke’s area in the brain,...

, which is characterized by a patient's inability to comprehend language or speak with appropriately meaningful words.

Presentation

Sufferers of this form of aphasia exhibit the common problem of agrammatism
Agrammatism
Agrammatism is a form of expressive aphasia that refers to the inability to speak in a grammatically correct fashion. People with agrammatism may have telegraphic speech, a unique speech pattern with simplified formation of sentences , akin to that found in telegraph messages...

. For them, speech is difficult to initiate, non-fluent
Fluency
Fluency is the property of a person or of a system that delivers information quickly and with expertise.-Speech:...

, labored, and halting. Similarly, writing is difficult as well. Intonation
Intonation (linguistics)
In linguistics, intonation is variation of pitch while speaking which is not used to distinguish words. It contrasts with tone, in which pitch variation does distinguish words. Intonation, rhythm, and stress are the three main elements of linguistic prosody...

 and stress patterns are deficient. Language
Language
Language may refer either to the specifically human capacity for acquiring and using complex systems of communication, or to a specific instance of such a system of complex communication...

 is reduced to disjointed words and sentence construction is poor, omitting function word
Function word
Function words are words that have little lexical meaning or have ambiguous meaning, but instead serve to express grammatical relationships with other words within a sentence, or specify the attitude or mood of the speaker...

s and inflections (bound morpheme
Bound morpheme
In morphology, a bound morpheme is a morpheme that only appears as part of a larger word; a free morpheme is one that can stand alone.Affixes are always bound. English language affixes are either prefixes or suffixes. E.g., -ment in "shipment" and pre- in "prefix"...

s). A person with expressive aphasia might say "Son ... University ... Smart ... Boy ... Good ... Good ... "

For example, in the following passage, a Broca's aphasic patient is trying to explain how he came to the hospital for dental surgery:
Yes... ah... Monday... er... Dad and Peter H... (his own name), and Dad.... er... hospital... and ah... Wednesday... Wednesday, nine o'clock... and oh... Thursday... ten o'clock, ah doctors... two... an' doctors... and er... teeth... yah.


Patients who communicated with sign language before the onset of the aphasia experience analogous symptoms.

Severity of expressive aphasia varies among patients. In the most extreme cases, patients may be only able to produce a single word. The most famous case of this was Paul Broca
Paul Broca
Pierre Paul Broca was a French physician, surgeon, anatomist, and anthropologist. He was born in Sainte-Foy-la-Grande, Gironde. He is best known for his research on Broca's area, a region of the frontal lobe that has been named after him. Broca’s Area is responsible for articulated language...

's patient Leborgne, nicknamed "Tan", after the only syllable he could say. Even in such cases, over-learned and rote-learned speech patterns may be retained—for instance, some patients can count from one to ten, but cannot produce the same numbers in ordinary conversation.

While word comprehension
Understanding
Understanding is a psychological process related to an abstract or physical object, such as a person, situation, or message whereby one is able to think about it and use concepts to deal adequately with that object....

 is generally preserved, meaning interpretation dependent on syntax and phrase structure is substantially impaired. This can be demonstrated by using phrases with unusual structures. A typical Broca's aphasic patient will misinterpret "the dog is bitten by the man" by switching the subject and object. Note this element is a problem with receptive language, not expressive language, and is one reason why the problem is referred to as agrammatic aphasia.

Patients who recover go on to say that they knew what they wanted to say but could not express themselves. Residual deficits will often be seen.

Classification and diagnosis

Expressive aphasia is also a classification of non-fluent aphasia, as opposed to fluent aphasia. Diagnosis is done on a case by case basis, as lesions often affect surrounding cortex
Cerebral cortex
The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...

 and deficits are not well conserved between patients.

Causes

The most common cause of expressive aphasia is stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...

. A stroke is caused by hypoperfusion (lack of oxygen) to an area of the brain, which is commonly caused by thrombosis
Thrombosis
Thrombosis is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets and fibrin to form a blood clot to prevent blood loss...

 or embolism
Embolism
In medicine, an embolism is the event of lodging of an embolus into a narrow capillary vessel of an arterial bed which causes a blockage in a distant part of the body.Embolization is...

. Some form of aphasia occurs in 34-38% of stroke patients. Expressive aphasia occurs in approximately 12% of new cases of aphasia caused by stroke. In most cases, expressive aphasia is caused by a stroke in Broca's area or the surrounding vicinity. However, cases of expressive aphasia have been seen in patients with strokes in other areas of the brain. Patients with classic symptoms of expressive aphasia generally have more acute brain lesions while patients with larger, widespread lesions exhibit a variety of symptoms which may be classified as global aphasia
Global aphasia
Global aphasia is a type of aphasia that is commonly associated with a large lesion in the perisylvian area of the frontal, temporal and parietal lobes of the brain causing an almost total reduction of all aspects of spoken and written language. It involves a "left side blowout" which includes...

 or left unclassified.

Expressive aphasia can also be caused by trauma to the brain, tumor
Tumor
A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...

, cerebral hemorrhage, by extradural hematoma.

Understanding lateralization of brain function
Lateralization of brain function
A longitudinal fissure separates the human brain into two distinct cerebral hemispheres, connected by the corpus callosum. The sides resemble each other and each hemisphere's structure is generally mirrored by the other side. Yet despite the strong anatomical similarities, the functions of each...

 is important for understanding what areas of the brain cause expressive aphasia when damaged. In the past, it has been believed that the area for language production differs between left and right-handed individuals. If this were true, damage to the homologous region of Broca's area in the right hemisphere should cause aphasia in a left-handed individual. More recent studies have shown that even left-handed individuals typically have language functions only in the left hemisphere. However, left-handed individuals are more likely to have a dominance of language in the right hemisphere.

Treatment

Currently, there is no standard treatment for expressive aphasia. Most aphasia therapy is individualized based on a patient's condition and needs as assessed by a speech therapist. The majority of patients go through a period of spontaneous recovery following brain injury in which they regain a great deal of language function. In the months following injury or stroke, most patients receive traditional therapy for a few hours per day. Among other exercises, patients practice the repetition of words and phrases. Mechanisms are also taught in traditional therapy to compensate for lost language function such as drawing and using phrases which are easier to pronounce. Emphasis is placed on establishing a basis for communication with family and caregivers in everyday life. The following treatments are currently being studied to determine the best possible method for treating aphasia.

Singing and melodic intonation therapy

Melodic intonation therapy
Melodic intonation therapy
Melodic Intonation Therapy is a therapeutic process used by music therapists and speech pathologists to help patients with communication disorders caused by brain damage...

 was inspired by the observation that individuals with non-fluent aphasia sometimes can sing words or phrases that they normally cannot speak. This phenomenon has been noticed for the past 250 years. In some studies patients were able to sing entire songs with provided text that they could not speak with normal intonation. It is believed that this is because singing capabilities are stored in the right hemisphere of the brain, which is likely to remain unaffected after a stroke in the left hemisphere. The goal of melodic intonation therapy is to utilize singing to access the language-capable regions in the right hemisphere and use these regions to compensate for lost function in the left hemisphere. Because patients are better at singing phrases than speaking them, the natural musical component of speech is used to engage the patients ability to voice phrases. Melodic intonation therapy has been shown to work particularly well in patients with large lesions in the left hemisphere.

MIT therapy on average lasts for 1.5 hours per day for five days per week. At the lowest level of therapy, simple words and phrases (such as "water" and "I love you") are broken down into a series of high and low pitch syllables. With increased treatment, longer phrases are taught and less support is provided by the therapist. Patients are taught to say phrases using the natural melodic component of speaking and continuous voicing is emphasized. The patient is also instructed to use their left hand to tap the syllables of the phrase while the phrases are spoken. Tapping further triggers the rhythmic component of speaking to utilize the right hemisphere.

The efficacy of melodic intonation therapy has been proven by studies that show that MIT can result in greater recovery when compared to non intonation therapy. FMRI studies have proven that melodic intonation therapy uses both sides of the brain to recover lost function as opposed to traditional therapies that only utilize the left hemisphere. Furthermore, it has been seen that in MIT, individuals with small lesions in the left hemisphere seem to recover by activation of the left hemisphere perilesional cortex while in individuals with larger left-hemisphere lesions, there is a recruitment of the use of language-capable regions in the right hemisphere.

Constraint induced therapy

Constraint induced aphasia therapy (CIAT) is based on similar principles as constraint-induced movement therapy
Constraint-induced movement therapy
Constraint-induced movement therapy is a form of rehabilitation therapy that improves upper extremity function in stroke and other Central Nervous System damage victims by increasing the use of their affected upper limb....

 developed by Dr. Edward Taub
Edward Taub
Edward Taub is a behavioral neuroscientist on faculty at the University of Alabama at Birmingham. He is best known for his involvement in the Silver Spring monkeys case and for making major breakthroughs in the area of neuroplasticity and discovering/developing constraint-induced movement therapy;...

 at the University of Alabama at Birmingham. Constraint induced movement therapy is based on the idea that a person with an impairment (physical or communicative) develops a "learned nonuse" by compensating for their lost function with other means such as using an unaffected limb by a paralyzed individual or drawing by a patient with aphasia. In constraint induced movement therapy, the alternative limb is constrained with a glove or sling and the patient is forced to use their affected limb. In constraint induced aphasia therapy, the interaction is guided by communicative need in a language game context, picture cards, barriers making it impossible to see other players' cards, and other materials, so that patients are encouraged ("constrained") to use their remaining verbal abilities to succeed in the communication game.

Two important principles of constraint induced aphasia therapy are that treatment is very intense with sessions lasting for up to 6 hours over the course of 10 days and that language is used in a communication context where it is closely linked to (nonverbal) actions. These principles are motivated by neuroscience insights about learning at the level of nerve cells (synaptic plasticity) and the coupling between cortical systems for language and action in the human brain. Constraint induced therapy contrasts sharply with traditional therapy by the strong belief that mechanisms to compensate for lost language function should not be used unless absolutely necessary, even in everyday life.

It is believed that CIAT works by the mechanism of increased neuroplasticity
Neuroplasticity
Neuroplasticity is a non-specific neuroscience term referring to the ability of the brain and nervous system in all species to change structurally and functionally as a result of input from the environment. Plasticity occurs on a variety of levels, ranging from cellular changes involved in...

. By constraining an individual to use only speech, it is believed that their brain can reestablish old neural pathways and recruit new neural pathways to compensate for lost function.

The greatest advantage of CIAT has been seen in its treatment of chronic aphasia (lasting over 1 year). Studies of CIAT have shown that further improvement is possible even after a patient has reached a "plateau" period of recovery. It has also been proven that the benefits of CIAT are retained long term. However, improvements only seem to be made while a patient is undergoing intense therapy. A recent breakthrough has been achieved by combining constraint-induced aphasia therapy with drug treatment, which led to an amplification of therapy benefits.

Pharmacotherapy

In addition to active speech therapy, pharmaceuticals have also been considered as a useful treatment for expressive aphasia. This area of study is relatively new and much research continues to be conducted.

The following drugs have been suggested for use in treating aphasia and their efficacy has been studied in control studies.
  • Bromocriptine
    Bromocriptine
    Bromocriptine , an ergoline derivative, is a dopamine agonist that is used in the treatment of pituitary tumors, Parkinson's disease , hyperprolactinaemia, neuroleptic malignant syndrome, and type 2 diabetes.- Indications :Amenorrhea, female infertility, galactorrhea, hypogonadism, and acromegaly...

     – acts on Catecholamine
    Catecholamine
    Catecholamines are molecules that have a catechol nucleus consisting of benzene with two hydroxyl side groups and a side-chain amine. They include dopamine, as well as the "fight-or-flight" hormones adrenaline and noradrenaline released by the adrenal medulla of the adrenal glands in response to...

     Systems
  • Piracetam
    Piracetam
    Piracetam is a nootropic drug. Piracetam's chemical name is 2-oxo-1-pyrrolidine acetamide; it shares the same 2-oxo-pyrrolidone base structure with 2-oxo-pyrrolidine carboxylic acid . Piracetam is a cyclic derivative of GABA. It is one of the group of racetams...

     – mechanism not fully understood, but most likely interacts with cholinergic and glutamatergic receptors, among others
  • Cholinergic
    Cholinergic
    The word choline generally refers to the various quaternary ammonium salts containing the N,N,N-trimethylethanolammonium cation. Found in most animal tissues, choline is a primary component of the neurotransmitter acetylcholine and functions with inositol as a basic constituent of lecithin...

     drugs (Donepezil
    Donepezil
    Donepezil, marketed under the trade name Aricept by its developer Eisai and partner Pfizer, is a centrally acting reversible acetylcholinesterase inhibitor. Its main therapeutic use is in the palliative treatment of mild to moderate Alzheimer's disease. Common side effects include...

    , Aniracetam
    Aniracetam
    Aniracetam is an ampakine and nootropic of the racetam chemical class purported to be considerably more potent than piracetam. It is lipid-soluble and has possible cognition-enhancing effects. It has been tested in animals extensively, Alzheimer's patients, and temporarily-impaired healthy subjects...

    , Bifemelane
    Bifemelane
    Bifemelane is a pharmaceutical drug used in the treatment of senile dementia in Japan. It has nootropic, neuroprotective, and antidepressant effects, and acts through the cholinergic system in the brain. Bifemelane is also useful for the treatment of glaucoma....

    ) – acts on acetylcholine
    Acetylcholine
    The chemical compound acetylcholine is a neurotransmitter in both the peripheral nervous system and central nervous system in many organisms including humans...

     systems
  • Amphetaminic
    Amphetamine
    Amphetamine or amfetamine is a psychostimulant drug of the phenethylamine class which produces increased wakefulness and focus in association with decreased fatigue and appetite.Brand names of medications that contain, or metabolize into, amphetamine include Adderall, Dexedrine, Dextrostat,...

     drugs (Dexamphetamine, Methylphenidate
    Methylphenidate
    Methylphenidate is a psychostimulant drug approved for treatment of attention-deficit hyperactivity disorder, postural orthostatic tachycardia syndrome and narcolepsy. It may also be prescribed for off-label use in treatment-resistant cases of lethargy, depression, neural insult and obesity...

    )


The most effect has been shown by piracetam and amphetamine which may increase cerebral plasticity
Neuroplasticity
Neuroplasticity is a non-specific neuroscience term referring to the ability of the brain and nervous system in all species to change structurally and functionally as a result of input from the environment. Plasticity occurs on a variety of levels, ranging from cellular changes involved in...

 and result in an increased capability to improve language function. It has been seen that priacetam is most effective when treatment is begun immediately following stroke. When used in chronic cases it has been much less efficient.

Bromocriptine has been shown by some studies to increase verbal fluency and word retrieval with therapy than with just therapy alone. Furthermore, its use seems to be restricted to non-fluent aphasia.

Donepezil has shown a potential for helping chronic aphasia.

No study has established irrefutable evidence that any drug is an effective treatment for aphasia therapy. Furthermore, no study has shown any drug to be specific for language recovery. Comparison between the recovery of language function and other motor function using any drug has shown that improvement is due to a global increase plasticity of neural networks. Pharmaceutical therapy remains an important area of study in aphasia treatment.

Transcranial magnetic stimulation

In transcranial magnetic stimulation
Transcranial magnetic stimulation
Transcranial magnetic stimulation is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain...

 (TMS), magnetic fields are used to create electrical currents in specified cortical
Cerebral cortex
The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...

 regions. The procedure is a painless and noninvasive method of stimulating the cortex. TMS works by suppressing the inhibition process in certain areas of the brain. By suppressing the inhibition of neurons by external factors, the targeted area of the brain may be reactivated and thereby recruited to compensate for lost function. Research has shown that patients can show increased object naming ability with regular transcranial magnetic stimulation than patients in therapy without TMS. Furthermore, this improvement has been proven to be permanent and remains upon the completion of TMS therapy. However, some patients fail to show any significant improvement from TMS which indicates the need for further research of this treatment.

Mechanisms of recovery

Mechanisms for recovery differ from patient to patient. Some mechanisms for recovery occur spontaneously after damage to the brain while others are caused by the effects of language therapy. FMRI studies have shown that recovery can be partially attributed to the activation of tissue around the damaged area and the recruitment of new neurons in these areas to compensate for the lost function. Recovery may also be caused in very acute lesions by a return of blood flow and function to damaged tissue that has not died around an injured area. It has been stated by some researchers that the recruitment and recovery of neurons in the left hemisphere apposed to the recruitment of similar neurons in the right hemisphere is superior for long term recovery and continued rehabilitation. It is thought that because the right hemisphere is not intended for full language function, using the right hemisphere as a mechanism of recovery is effectively a "dead-end" and can only lead to partial recovery.

Among all types of therapies it has been proven that one of the most important factors and best predictors for a successful outcome is the intensity of the therapy. By comparing the length and intensity of various methods of therapies, it was proven that intensity was a better predictor of recovery than the method of therapy used.

Prognosis

In most individuals with expressive aphasia, the majority of recovery is seen within the first year following a stroke or injury. The majority of this improvement is seen in the first four weeks in therapy following a stroke and slows thereafter. When compared to patients with the most common types of aphasia, patients with expressive aphasia tend to show the most improvement within the first year. This may be due to an expressive aphasiac's awareness and greater insight of their impairment (unlike in receptive aphasia) which motivates them to progress in treatment. Studies have also found that prognosis of expressive aphasia correlates strongly with the initial severity of impairment. Those with the greatest initial disability tend to show the greatest improvement among test groups. Within the first year, the diagnosis of patients with expressive aphasia may change to anomic aphasia. Similarly, patients diagnosed with global aphasia
Global aphasia
Global aphasia is a type of aphasia that is commonly associated with a large lesion in the perisylvian area of the frontal, temporal and parietal lobes of the brain causing an almost total reduction of all aspects of spoken and written language. It involves a "left side blowout" which includes...

 may be re-diagnosed with expressive aphasia upon improvement. Typically, little improvement is seen after the first year following a stroke. However, it has been seen that continued recovery is possible years after a stroke with effective treatment using methods such as constraint induced aphasia therapy. Depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...

, anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...

, and social withdrawal are all factors which have been proven to negatively affect a patient's chance of recovery.

Location and size of the brain lesion may also play a role in the prognosis of aphasia. It has been seen in receptive aphasia that larger lesions correlate to slower recovery. It has also been seen that patients with aphasia caused by sub cortical
Cerebral cortex
The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...

 lesions have a better chance of recovery than those with aphasia due to cortical stroke.

History

Expressive aphasia was first identified by the French neurologist Paul Broca
Paul Broca
Pierre Paul Broca was a French physician, surgeon, anatomist, and anthropologist. He was born in Sainte-Foy-la-Grande, Gironde. He is best known for his research on Broca's area, a region of the frontal lobe that has been named after him. Broca’s Area is responsible for articulated language...

. By examining the brains of deceased individuals who acquired expressive aphasia in life, he concluded that language ability was localized in the ventroposterior region of the frontal lobe. One of the most important aspects of Paul Broca's discovery was the observation that the loss of proper speech in expressive aphasia was due to the brain's loss of ability to produce language as opposed to the mouth's loss of ability to produce words.

The discoveries of Paul Broca were made during the same period of time as the German Neurologist Carl Wernicke who was also studying brains of aphasiacs post-mortem and identified the region now known as Wernicke's area
Wernicke's area
Wernicke's area is one of the two parts of the cerebral cortex linked since the late nineteenth century to speech . It is involved in the understanding of written and spoken language...

. Discoveries of both men contributed to the concept of localization which states that specific brain functions are all localized to a specific area of the brain. While both men made significant contributions to the field of aphasia, it was Carl Wernicke who realized the difference between patients with aphasia who could not produce language and those who could not comprehend language (the essential difference between expressive and receptive aphasia
Receptive aphasia
Receptive aphasia, also known as Wernicke’s aphasia, fluent aphasia, or sensory aphasia, is a type of aphasia traditionally associated with neurological damage to Wernicke’s area in the brain,...

).

Expressive aphasia in popular culture

*The protagonist of Stephen King
Stephen King
Stephen Edwin King is an American author of contemporary horror, suspense, science fiction and fantasy fiction. His books have sold more than 350 million copies and have been adapted into a number of feature films, television movies and comic books...

's novel Duma Key
Duma Key
Duma Key is a horror novel by American novelist Stephen King published in 2008. The book reached #1 on the New York Times Bestseller List. It is King's first novel to be set in Florida or Minnesota.-Plot:...

exhibited symptoms of a condition similar to receptive aphasia after suffering brain damage in an industrial accident. When trying to recall some words, he would frequently substitute a synonym of a similar-sounding word, such as trying to say "chair" but instead saying "burn" (a synonym of "char") and "friend" (a synonym of "chum").

Famous sufferers

  • Aubrey Plaza
  • Ram Dass
    Ram Dass
    Ram Dass is an American contemporary spiritual teacher and the author of the seminal 1971 book Be Here Now. He is known for his personal and professional associations with Timothy Leary at Harvard University in the early 1960s, for his travels to India and his relationship with the Hindu guru Neem...

  • Osmar Santos
    Osmar Santos
    Osmar Santos is a Brazilian painter and journalist. He was a very successful radio and television sports commentator in the 1980s and early 1990s, known for his outstanding verbal fluency and for his numerous catchphrases, which still punctuate Brazilian football culture...

  • Bob Woodruff
  • Kevin Ryder
  • Gabrielle Giffords
    Gabrielle Giffords
    Gabrielle Dee "Gabby" Giffords is an American politician. A Democratic member of the United States House of Representatives, she has represented since 2007. She is the third woman in Arizona's history to be elected to the U.S. Congress...


External links

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