Hodor, Aphasia, and What It Means IRL

An update to last year’s blog post, by popular demand from friends, colleagues, and many Internet strangers!

[SPOILERS FOR GAME OF THRONES SEASON 6]

Last April, I wrote this blog post about Hodor definitively not having aphasia. It went viral. I presented about the post and its impact at the annual ASHA convention in Denver.

Two weeks ago, my husband John and I were watching Season 6 of Game of Thrones together. This scene came on.

He immediately looked at me and said, “Uh oh. You’re in trouble.” Cue flurry of e-mails, texts, and Facebook messages, indeed.

In the name of journalism, I sat down with Marissa Artman of Second City Speech to discuss the latest developments in Hodor’s diagnostic profile. Artman is a speech-language pathologist and founder of the Chicago Aphasia Network, a support group for adults living with aphasia in the Chicagoland area. 

Now, armed with full picture, we once again return to the question: does Hodor have aphasia?

 

His “hodor” is definitely acquired

Aphasia is an acquired communication disorder. “Acquired”, in the medical world, refers to symptoms or conditions that arise (due to a medical event or diagnosis) that were not there previously. To quote Artman, "It's like a lightning bolt. There was a thing that happened that causes the event that makes aphasia. whether it’s the TBI, or the stroke, or whatever. An event happens. And without that event, aphasia doesn’t happen."

In the books, the description of Hodor strongly suggests that he always “hodor’d”, was always “simple-minded”, and there is no reference to any significant childhood event that would have caused this state. For this reason, and given his constellation of apparent linguistic, cognitive, and adaptive impairments, I likened his condition to something most similar to developmental delay last year.

In S06E02, it is clearly established that Hodor was not always hodoring. Something happened (of lightning proportions indeed, as it turns out). In the days following this first flashback episode, fan theories abounded as to why Hodor lost his speech. Speculations ranged from run-of-the-mill “kicked in the head by a horse” (a traumatic brain injury!) to “magically cursed” (…magical…brain injury?).

Whether this discrepancy between the books and show was a deliberate retcon, standard book-to-screen adaptation phenomenon, or a sign that GRRM was intentionally vague and misleading in his original text to surprise readers later on is unknown. What is clear, though, is that HBO Hodor does not have developmental delay, and his communication disorder is clearly acquired.

 

His intelligence is intact…

The purpose of my original post was less to definitively diagnose Hodor, but rather to dispel the harmful assumption that aphasia should be equated with “simple-mindedness” (as written by the National Aphasia Association, on this same topic).

Since the Hodor saga has reached its conclusion, I have been rather fascinated by viewers’ notions about Hodor’s intelligence. After the reveal in S06E02, many people seized upon the notion that it turns out Hodor was intelligent this entire time, and everyone just assumed he was simple-minded because of his speech pattern. The Atlantic published an article this week in which a literary scholar describes Hodor as “functionally mute but had an active intelligence…someone who seems to have all the tropes of a developmentally disabled individual but he’s not [one]”.

I have mixed reactions to these reactions. On the one hand, this is a turning point for aphasia awareness and communication disabilities as a whole: a person’s speech performance is not indicative of their intelligence. As I read over comments lamenting the various tragic details of Hodor’s experience in S03E05, many people referenced the trapped life he led, how sad it is that everyone assumed he was stupid because he couldn’t speak. This experience holds true for many people with communication disabilities.

 

…or is it?

On the other hand, I’m not convinced that Hodor’s intelligence remained completely intact. There are scenes from earlier seasons in which his awareness and adaptive abilities (functional life skills) are clearly not “within normal limits”, to borrow a clinical term. [Video is SFW]

For example, he seems unaware that being naked makes people uncomfortable, and is terrified during a thunderstorm, displaying behaviors similar to that of a young child. He does seem able to follow directions, and is emotionally intuitive, as the Atlantic author notes.

So, is it aphasia, or not?

 

Diagnostic considerations

While aphasia is specifically a communication disorder of language, exclusive of intelligence, aphasia and cognitive disability will commonly co-occur, due to the nature of brain damage. To establish some basics about acquired communication disorders:

  • It is possible to have cognitive impairment without linguistic impairment, such as in Alzheimer’s (cognitive impairment will often reduce the capacity to use language abstractly and in complex ways, but this is not due to issues with language itself).
  • It is possible to have linguistic impairment without cognitive impairment, which is what occurs in aphasia.
  • It is possible to have both cognitive and linguistic impairments, co-occurring due to damage in multiple areas of the brain.
  • Within the faculties of both language and cognition, it is possible to have deficits in specific subsets (e.g., memory deficits but intact reasoning; expressive deficits but intact comprehension, etc.).
  • Interpersonal emotional skill (what may commonly be called “empathy”) is not directly tied to cognitive or linguistic ability. Autism, for example, is commonly identified through social interaction deficits, many times despite high cognitive-linguistic ability. Other disabilities, such as dementia and Down syndrome, have relatively intact social-emotional abilities despite decline or deficits in cognitive skills.

In cases of brain injury and stroke, it is common to identify the area of the brain that was damaged and pair that information with observed symptoms (X area was damaged, so it makes sense that the patient can no longer do X-function). In Hodor’s case, I’m not going to begin to speculate what sort of brain damage is caused by “magically-induced time-travel paradox brain damage with a likely side of pre-traumatic stress disorder”. (Although that would make delightful fodder should any neuropsychologist friends care to attempt!) The most I will venture is that it seems to have been neurologically far-reaching enough to impact his language and cognition, each in varying degrees. [Apraxia also possibly comes to mind, as we observe the motor speech breakdown sequence during Wyllis’ seizure…?]

 

Conclusion: aphasia or not?

Given the developments in S06, something akin to aphasia is a much more likely and appropriate diagnosis compared to the profile presented last year. Personally, I feel that Hodor also presents with some TBI-like cognitive impairments following his involuntary warging episode, and now presents with a complex clinical profile that includes both linguistic and cognitive deficits. 

Artman questioned why it was that the public so quickly glommed on to “aphasia” as his single defining diagnosis, taking his speech symptoms out of context and ignoring other unusual behaviors. “I’m surprised that they didn’t pick autism, honestly, with the sensory behaviors like in the thunderstorm tower scene, where he’s rocking back and forth. And that’s such a popular diagnosis right now…I wonder why aphasia was just grasped out of a book somewhere.”

While he is clearly capable of comprehending more than he can utter, we don’t think it’s safe to assume that Hodor has totally intact comprehension, reasoning, and executive function abilities. It seems apparent that his social-emotional interaction skills remained relatively unchanged, as he is demonstrably empathetic.

In sum: while he does seem to have something akin to expressive aphasia, that is not nearly all that is going on with him.

 

Our takeaway, IRL

On the whole, Hodor’s story in S06 turns what was an aphasia awareness disaster (“simple-minded” aphasia posterboy) into a huge win. Viewers are painfully aware of just how stereotyped and mistreated Hodor was, due to his communication disability, which is likely not equal to his cognitive ability. Clinicians can debate how intelligent or not Hodor is, but to me, this is an overall win even if (perhaps especially if) people assume he is 100% cognitively intact and can’t speak. Speech performance is not a yardstick for intelligence.

There are two additional lessons that can be learned here, though.

One, awareness of the complexity and nuance required for the diagnostic process—even for fictional characters. What was alarming to me in the original article that I responded to was an apparent surface assumption that limited verbal ability = aphasia. While limited expressive language ability is certainly a hallmark of aphasia, aphasia is not the only communication disorder that yields this pattern.  "There’s any number of language, or cognitive, or other impairments you can have that manifest as having one word," explains Artman, who works extensively with patients who use alternative and augmentative communication devices. Assuming that every person with limited verbal output has aphasia is a bit like assuming everyone with a headache has a brain tumor.

Additionally, aphasia itself takes many, many forms. Below are a few examples of people, fictional and non, with different forms and degrees of aphasia.

Two, Hodor’s disability is complex. As we attempt to ascribe real-world diagnoses and labels to Hodor, this should be the main takeaway. To label Hodor with expressive aphasia, or Broca’s aphasia, or even unspecified aphasia and simply leave it at that fails to take into account Hodor as an entire person, both before and after his episode.

This, I think, is what is most wonderful about Hodor’s fully-completed story. Diagnostic labels are limited, but disabilities are complex. A diagnosis does not define a disability, and a disability does not point to one diagnosis inherently. Diagnostic labels and disability symptoms all too commonly lead to assumptions about what a person can or cannot do, what they do or do not understand, what they do or do not want. Hodor was boxed into the identity of simple-minded nearly-mute stableboy for his entire life because of the assumptions of others.

In conclusion, I could not be more thrilled with the general lesson that our beloved Hodor now stands for, at the end of his story. Appearances can be deceiving, and so too is abled or disabled performance. Diagnostic labels are useful, but cannot capture the totality of an individual person. Hodor, like all people with diagnoses and disabilities, is much more than his diagnosis.

It is with fitting, heartbreaking irony that Hodor now sends a message to the world. How do you interact with someone who has a communication (or any other) disability?

Hold the door...open.

Posted on May 30, 2016 .