The nature of communication difficulties after TBI Observational studies in the 1970s (Levin et al., 1979; Thomsen, 1975) described communication difficulties following severe TBI that did not easily fit within the conventional rubric of aphasia. Aphasia was reported in few people (2-30 per cent) with TBI (Heilman et al., 1971; Sarno, 1980; Sarno & Levita, 1986). On the other hand, relatives described a range of deficits in the sphere of communication. Their family member with TBI was described as slow and hesitant, without initiative in social settings and restricted to a limited repertoire of stereotypic expressions, or otherwise tangential, inappropriate and over-talkative (Levin et al., 1979; Thomsen, 1975). Initially, it was suggested that these difficulties might represent a sub-clinical aphasic language disorder (Sarno, 1980; Sarno & Levita, 1986) but it is now widely accepted that these kinds of difficulties reflect underlying cognitive impairment rather than language per se.