Years ago, I received a consult from the hospital neurology intensive care unit that read, “29-year-old male with multiple CNS signs and symptoms. Please dissect and analyze speech and language.” Clever wording aside, this unfortunate man who had been admitted to the hospital following a blow to the head taught me and my speech-language pathology and neurology colleagues an important lesson. He did indeed have multiple problems with speech and language, but his problems were not organic. Today, they would be called functional in nature and, despite the blow to the head, likely reflected a conversion disorder in response to some very difficult life circumstances.
The patient needed a neurologist and speech-language pathologist to establish that there was no evidence of organic disease, and a speech-language pathologist, psychiatrist, and social worker to help manage his symptoms and their underlying triggers. Fortunately, he recovered from his speech-language symptoms quickly. This case, and hundreds of others over the years, highlight several important facts.
5 Facts about Acquired Functional Speech Disorders
1. These disorders are quite common
Unexplained physical symptoms without relevant organic pathology account for a substantial percentage of visits to general medical clinics, and many new patients seen in neurology outpatient clinics have functional/psychogenic neurologic symptoms. The frequency of these problems and the challenges they present have been described as “a crisis for neurology.”
2. We often fail to recognize them
Functional speech disorders are probably more frequent than many of us believe. This means that we may see these problems often but we fail to recognize them. The bottom line is that patients can develop functional speech disorders that mimic neurologic speech disorders in adulthood. Recognizing them as functional is critical to medical/neurologic diagnosis.
3. We need to discern these disorders from organic ones
The key to recognizing acquired functional speech disturbances is to know the rules of the game relative to organic, neurologically-based motor speech disorders. If we can recognize the typical manifestations of each type of dysarthria and apraxia of speech, we can map the boundaries of organicity and raise red flags when a speech problem goes beyond those boundaries. The development of these skills requires considerable clinical experience, but all clinicians need to recognize during their assessment of unusual acquired speech disorders that the boundaries can be crossed.
4. These disorders have typical manifestations
Acquired functional speech disorders can manifest in a wide variety of ways but most typically do so as voice abnormalities, stuttering-like dysfluencies, and articulation and prosodic abnormalities (including pseudoforeign accent).
5. They can be effectively and efficiently managed
The key that opens the door to effective management is confidence in the diagnosis. When a clinician is fairly certain that the problem is functional, and the affected individual understands that their difficulty may be controllable and reversible, assertive and supportive behavioral management often can be quite effective – even within the diagnostic session or one to two additional therapy sessions. Dramatic and rapid improvement not only helps to confirm the diagnosis, but also is very beneficial to the patient and often gratifying for the clinician.
Keeping these five facts in mind can help maintain diagnostic vigilance during assessment of people with acquired communication disorders. When this vigilance leads to recognition of an acquired speech disorder as functional in nature, it can have important implications for medical diagnosis and patient care.