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Functional Speech and Voice Disorders
... Common presenting subtypes of functional communication disorders include functional stuttering, functional foreign accent syndrome, infantile speech, puberphonia (i.e., habitual use of high-pitched voice), and functional aphonia (i.e, inability to phonate/produce voice). 19 Functional swallowing disorders most often manifest as disruptions in the sensory and/or motor aspects of oral, pharyngeal, and/or esophageal aspects of swallowing. Common sensory-based symptoms include chronic cough and globus sensation (i.e., sensation of a constant "lump" in the throat) without dysphagia, gastroesophageal reflux disease, or esophageal motility disorder. ...
... While research continues to grow in SLPs role in FND, studies have found excellent potential for patient improvement through the behavioral and psychotherapeutically informed treatment approaches a SLP trained in FND treatment can provide. 19 CONCLUSION As described above, rehab therapists have a vital role in the multi-disciplinary treatment of the patient with FND. The use of psychologically informed practice, expert consensus recommendations, knowledge of current literature, and nontraditional approach to rehab strategies are essential elements to optimize treatment outcomes. ...
Functional Neurological Disorder (FND) is a common condition encountered by rehabilitation therapists (physical therapists-PT, occupational therapists-OT, and speech and language pathologists-SLP) in pediatric practice. In an effort to bridge the knowledge and experience gap, PT, OT and SLP experts have published consensus recommendations for the rehab therapist's treatment of FND1-3 with additional research emphasizing a psychologically informed4,5 and wellness approach.6 This article highlights the unique role of each rehab discipline in treating FND, reviews functional diagnoses specific to PT, OT and SLP, and introduces a unique stepwise or ladder approach to treatment that can be utilized in the inpatient or outpatient setting.
... Importantly, the requisite of a psychological stressor has been eliminated from the FND criteria in the Diagnostics and Statistics Manual of Mental Disorders-Fifth Edition, although the role of conversion remains a topic of discussion (Cretton et al., 2020). The current approach to these disorders includes diagnosis based upon the presence of clinical signs, including inconsistency, suggestibility, distractibility, and incongruity (Baker et al., 2021;Duffy, 2016;Freeburn & Baker, 2023;Utianski & Duffy, 2022). There is increasing research that supports a biological basis for these disorders (Aybek & Vuilleumier, 2016;Edwards et al., 2023) that is "functional" in nature, in contrast to the structural basis of lesion-based (motor speech) disorders. ...
... SLPs in clinical practice are encouraged to educate their health care colleagues about our role with this population. SLPs who are working with these patients are encouraged to, if they have not already, evolve their understanding of this condition along with the current viewpoints of neurology Espay et al., 2018), to make the diagnosis of functional speech disorders based on the positive clinical signs (Baker et al., 2021;Duffy, 2016), approach the counseling and education with validation and empathy (Freeburn & Baker, 2023;Utianski & Duffy, 2022), and seek resources for support, when necessary. ...
Purpose
The purpose of this article is to offer an evaluation of speech-language pathologists' (SLPs') experiences with and knowledge of functional speech disorders. Functional speech disorders occur as a part of functional neurological disorders, a complex disorder that is often overlooked and misdiagnosed. Through an assessment of experience with and common myths about functional speech disorders among SLPs, the importance of providing education to SLPs about this patient population is discussed.
Method
As a part of the presentation about functional speech disorders during the 2023 American Speech-Language-Hearing Association Health Care Summit, 122 participants were asked to anonymously respond to a series of questions that outlined their demographics, training in functional speech disorders, and experiences with this patient population. Descriptive data are presented.
Results and Conclusions
Among attendees, 58% were exposed to functional speech disorders in graduate school while 75% had seen a patient with a functional speech disorder, most of whom had also diagnosed the patients' communication disorder. This study highlights the role of the SLP in identifying and managing functional speech disorders and the increased attention this patient population has received over time, as well as the work yet to be done. Functional speech disorders are a legitimate clinical entity, for which a diagnosis can be made based on positive clinical features (i.e., is not a diagnosis of exclusion). The call to action includes guidance for clinicians, educators, and academic training programs to support this patient population. See the Appendix for a plain language summary.
... The methodologies followed by speech therapists rely on the diagnosis of people who stammer forming a structured pathway towards improved communication fluency hence making quality of life better. the basic elements of speech therapy revolve around counseling regarding diagnosis, educating the client and the family, change facilitation, and increasing selfmonitoring efforts (Freeburn & Baker, 2023). ...
The development of normal speech and language is a difficulty faced by stammerers. Meanwhile, the associated social and psychological problems are the factors that contribute to the worsening of the situation. Though all the therapies for stammering are designed after research each therapy has a different impact on the individual due to changes in situations. The same applies to the provision and the difference of opinion among people about the therapist and the therapeutic process. This study aimed to highlight the point of view of stammerers regarding speech and language therapists. The study was based on a qualitative research design. The data was collected from a sample of N=20 using a purposive sampling technique from hospitals all over Pakistan. An open-ended questionnaire was used for data collection and thematic analysis was used for analysis. The results identified 5 major themes i.e. unsatisfactory experience, satisfactory experience, factors enhancing the outcomes of speech therapy, factors related to the client that can impact the process of therapy, and the skills of the therapist. Further, different psychological, social, and environmental factors are explored that impact the therapy process and bring a change in the perspective. Further, resources are required to improve the training environment of Speech and Language pathologists.
... Sus características pueden ser muy similares a las alteraciones estructurales, pero un examen clínico juicioso ayuda en su correcta diferenciación. Frecuentemente hay otros síntomas de TNF como espasmo facial funcional, exageración de los movimientos faciales o mioclonías funcionales, y pueden coexistir con un compromiso estructural (61). ...
Introducción: los trastornos neurológicos funcionales son un motivo de consulta frecuente en la práctica clínica y una causa importante de discapacidad y costos.
Materiales y métodos: artículo de revisión narrativa que sintetiza las últimas dos décadas en investigación clínica en esta área.
Resultados: se describe un diverso grupo de síntomas motores, sensitivos, cognitivos, visuales y eventos paroxísticos en los que no hay lesión estructural del sistema nervioso, así como tampoco una enfermedad neurológica conocida. En su génesis interactúan factores biológicos, neuronales y ambientales con los mecanismos cognitivos, emocionales y conductuales que se originan en experiencias de vida adversas o aprendizaje desadaptativo.
Discusión: el diagnóstico de estas condiciones no se hace por exclusión, sino que se sustenta en un abordaje clínico basado en la presencia de datos a la anamnesis y signos positivos al examen físico. El manejo de estos va desde la primera consulta, la comunicación del diagnóstico, el establecimiento de confianza con el paciente y el uso de recursos terapéuticos como la psicoterapia, la terapia física y la ocupacional.
Conclusiones: a lo largo de esta revisión, se brindan las herramientas para entender los trastornos neurológicos funcionales, desde su fisiopatología y hasta el diagnóstico y el tratamiento.
... In fact, it may be necessary and/or appropriate for the SLP to provide resources to educate other medical professionals who are unaware of or have outdated views about this disorder. With uniquely tailored intervention, utilizing previously outlined management principles (Baker et al., 2021;Duffy, 2016;Freeburn & Baker, 2023;Utianski & Duffy, 2022), FSDs can be effectively managed. It is worth noting that the principles for managing the FAS phenotype are not really different from those utilized to treat any FSD. ...
Purpose
When nonnative speaking patterns emerge following neurologic insult or injury, it has often been referred to as foreign, or nonnative, accent syndrome (FAS). In many other cases, FAS can occur as a manifestation of a functional speech disorder (FSD). The purpose of this clinical focus article is to (a) describe the methods utilized in identifying and managing a functional communication disorder characterized by nonnative speech, language, and nonverbal communication intrusions, accompanied by a functional movement disorder and (b) describe the patient's lived experience.
Method and Results
The patient is a 59-year-old monolingual English-speaking gentleman with a remote history of episodic stuttering, who later developed an abrupt onset of a nonnative speaking style that changed in quality over time. He also developed gait difficulties that, after visiting with several neurologists, were judged to reflect a functional neurological disorder. During the speech evaluation session, an “Eastern European accent” was noted, along with nonnative word use and word order. A diagnosis of FSD characterized by foreign accent was made, and intervention was undertaken as detailed in the clinical focus article and demonstrated in the accompanying video. With behavioral intervention, the patient was able to correct sound-level changes in structured tasks such as reading and repetition and then in conversation. Language dialect–like changes resolved without direct intervention. The nonspeech movement disorder was addressed with intensive occupational and physical therapy.
Conclusions
The patient presented with functional FAS, which was effectively managed with symptomatic, targeted behavioral intervention. His experience demonstrates the importance of patient advocacy in acquiring an accurate diagnosis and appropriate management recommendations.
Supplemental Material
https://doi.org/10.23641/asha.24653430
Background
Functional speech disorder (FND‐speech) is a subtype of functional neurological disorder, yet quantitative characterization of its motor and cognitive‐linguistic features remains underexplored.
Objective
This study aimed to quantitatively characterize FND‐speech by comparing acoustic and linguistic features in individuals with FND‐speech with healthy control subjects (HCs). The potential of digital speech features to serve as adjunctive diagnostic markers was also evaluated.
Methods
Thirty adults with FND‐speech (females, n = 25; males, n = 5) and 47 age‐, sex‐, education‐, and handedness‐matched HCs (females, n = 29; males, n = 18) were compared using lexicosyntactic, rate‐based, and acoustic markers extracted from a structured picture description task. Supervised machine learning was employed to classify FND‐speech versus HCs.
Results
Lexicosyntactic features showed moderate predictive power (area under the curve [AUC] = 0.80), as did rate‐based features (AUC = 0.81). Acoustic features demonstrated high discrimination (AUC = 0.98), and a combined model incorporating all feature categories achieved similar performance (AUC = 0.98).
Conclusions
This proof‐of‐principle pilot study successfully classified FND‐speech versus HCs, highlighting the potential of digital speech markers to serve as adjunctive diagnostic markers for FND‐speech. Out‐of‐sample replication and larger‐scale classifier efforts incorporating neurological controls are needed. © 2025 International Parkinson and Movement Disorder Society.
Background
Functional Communication Disorders (FCDs) are one specific presentation of Functional Neurological Disorder (FND). FND is characterised by neurological symptoms, such as sensory and motor symptoms, which are not explained by neurological disease. Speech and language therapists (SLTs) have expertise in managing communication disorders, including FCDs, though is not known is what clinicians do in practice to treat and manage FCDs.
Aim
To explore the clinical practices of SLTs who regularly manage FCDs in the UK, including the assessment and intervention approaches taken.
Methods & Procedures
An online survey was developed using Qualtrics software and piloted before dissemination. Participants were experienced SLTs working in the UK who managed at least three FCD referrals a year. The survey was developed with a mix of qualitative and quantitative questions. The survey was disseminated via social media and professional networks.
Outcomes & Results
There were 73 completed responses to the survey. Participants reported working with a range of FCDs clinically, with functional stuttering and articulation disorders seen most frequently. SLTs reported working with a wide range of multidisciplinary professionals when managing patients with FCDs, though lack of access to mental health professionals was raised as an issue. SLTs reported using a combination of formal and informal communication assessments. Interventions varied, with a wide range of psychological approaches informing treatment. Lack of specific training, evidence base and negative attitudes around functional neurological disorder (FND) were raised as ongoing issues.
Conclusions & Implications
Therapists encountered a wide range of FCDs as part of their clinical practice, though there was a significant disparity in the service and interventions offered. SLTs feel their input can be effective, but lack the resources, training and evidence‐based interventions to provide adequate care.
WHAT THIS PAPER ADDS
What is already known on the subject
FCDs are one manifestation of FND and can present as a wide range of communication disorders. SLTs encounter FCDs as part of clinical practice, but report feeling unsure and underprepared to manage these disorders. Consensus recommendations have provided some guidance on how to manage these disorders, though what was not known was what practising SLTs are doing in practice with FCD patients: what assessment, intervention and management strategies they use, and what they feel are the facilitators and barriers to effective management.
What this study adds to the existing knowledge
This is the first UK‐wide survey of FCD SLT clinical practice. The survey found that SLTs are seeing a range of FCDs as part of their clinical practice. SLTs reported that they feel their input is effective, that they had confidence in their ability to provide assessment and intervention, and that SLT for FCDs should be routine. SLTs reported using a wide variety of approaches to assessment and intervention. Barriers to effective management included a lack of resources, training, negative staff attitudes towards FND, and lack of research and evidence‐based interventions.
What are the practical and clinical implications of this work?
This survey has found that SLTs working across the UK are providing input for patients with FCDs, but frequently reported feeling isolated and lacking clinical peer support. This shows the potential for networking groups to support SLTs to learn and share resources. There is a training need for SLTs and other healthcare professionals to tackle pervasive negative attitudes towards FND. Common themes in intervention approaches were found, but there was variability in the specific approach taken. This requires further research to guide SLTs on the best evidence‐based practice.
Purpose
Functional speech disorders (FSDs), a subtype of functional neurological disorders, are distinguishable from neurogenic motor speech disorders based on their clinical features, clinical course, and response to treatment. However, their differential diagnosis and management can be challenging. FSDs are not well understood, but growing evidence suggests a biopsychosocial basis distinct from structural lesions that cause neurogenic motor speech disorders.
Method and Results
Following an overview of FSDs, four patients are described to illustrate the range of clinical manifestations, biopsychosocial contexts, and responses to treatment of FSDs. The path to differential diagnosis is discussed, with particular attention to positive features that led to the FSD diagnosis. Approaches to education, counseling, and management are discussed.
Conclusions
This case series demonstrates that FSDs can present with a variety of manifestations including dysfluencies, articulation errors, dysphonia, rate and prosodic abnormalities, and combinations of disruptions in speech subsystems. FSDs may present in the context of known recent or remote physical or psychosocial trauma or, as in many cases, in the absence of an identifiable triggering event. FSDs are recognizable by positive clinical features and should not be considered a diagnosis of exclusion. With appropriate identification, counseling, and treatment, FSDs may resolve, sometimes rapidly; in some cases, treatment may be prolonged or ineffective.
We present a practical overview of functional neurological disorder (FND), its epidemiology, assessment and diagnosis, diagnostic pitfalls, treatment, aetiology and mechanism. We present an update on functional limb weakness, tremor, dystonia and other abnormal movements, dissociative seizures, functional cognitive symptoms and urinary retention, and 'scan-negative' cauda equina syndrome. The diagnosis of FND should rest on clear positive evidence, typically from a combination of physical signs on examination or the nature of seizures. In treatment of FND, clear communication of the diagnosis and the involvement of the multidisciplinary team is beneficial. We recommend that patients with FND are referred to specialists with expertise in neurological diagnosis. FND is a common presentation in emergency and acute medical settings and there are many practical elements to making a positive diagnosis and communication which are useful for all physicians to be familiar with.
Background
Functional neurological disorder (FND) is common across healthcare settings. The Diagnostic and Statistical Manual of Mental Disorders states that speech and swallowing symptoms can be present in FND. Despite this, there is a dearth of guidelines for speech and language therapists (SLTs) for this client group.
Aims
To address the following question in order to identify gaps for further research: What is known about speech, language and swallowing symptoms in patients with FND?
Methods & Procedures
A scoping review was conducted. Six healthcare databases were searched for relevant literature: CINAHL PLUS, MEDLINE, ProQuest Nursing and Allied Health Professionals, Science Citation Index, Scopus, and PsychINFO. The following symptoms were excluded from the review: dysphonia, globus pharyngeus, dysfluency, foreign accent syndrome and oesophageal dysphagia.
Main Contribution
A total of 63 papers were included in the final review; they ranged in date from 1953 to 2018. Case studies were the most frequent research method (n = 23, 37%). ‘Psychogenic’ was the term used most frequently (n = 24, 38%), followed by ‘functional’ (n = 21, 33%). Speech symptoms were reported most frequently (n = 41, 65%), followed by language impairments (n = 35, 56%) and dysphagia (n = 13, 21%). Only 11 publications comment on the involvement of SLTs. Eight papers report direct speech and language therapy input; however, none studied the effectiveness of speech and language therapy.
Conclusions & Implications
Speech, language and swallowing symptoms do occur in patients with FND, yet it is a highly under‐researched area. Further research is required to create a set of positive diagnostic criteria, gather accurate data on numbers of patients with FND and speech, language or swallowing symptoms, and to evaluate the effectiveness of direct speech and language therapy involvement.
Importance
Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes.
Observations
Functional Neurological Symptom Disorder/Conversion Disorder was adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replacing the term psychogenic with functional and removing the criterion of psychological stress as a prerequisite for FND. A diagnosis can now be made in an inclusionary manner by identifying neurological signs that are specific to FNDs without reliance on presence or absence of psychological stressors or suggestive historical clues. The new model highlights a wider range of past sensitizing events, such as physical trauma, medical illness, or physiological/psychophysiological events. In this model, strong ideas and expectations about these events correlate with abnormal predictions of sensory data and body-focused attention. Neurobiological abnormalities include hypoactivation of the supplementary motor area and relative disconnection with areas that select or inhibit movements and are associated with a sense of agency. Promising evidence has accumulated for the benefit of specific physical rehabilitation and psychological interventions alone or in combination, but clinical trial evidence remains limited.
Conclusions and Relevance
Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.
Background
Medically unexplained loss or alteration of voice—functional dysphonia—is the commonest presentation to speech and language therapists (SLTs). Besides the impact on personal and work life, functional dysphonia is also associated with increased levels of anxiety and depression and poor general health. Voice therapy delivered by SLTs improves voice but not these associated symptoms. The aims of this research were the systematic development of a complex intervention to improve the treatment of functional dysphonia, and the trialling of this intervention for feasibility and acceptability to SLTs and patients in a randomised pilot study
Methods
A theoretical model of medically unexplained symptoms (MUS) was elaborated through literature review and synthesis. This was initially applied as an assessment format in a series of patient interviews. Data from this stage and a small consecutive cohort study were used to design and refine a brief cognitive behavioural therapy (CBT) training intervention for a SLT. This was then implemented in an external pilot patient randomised trial where one SLT delivered standard voice therapy or voice therapy plus CBT to 74 patients. The primary outcomes were of the acceptability of the intervention to patients and the SLT, and the feasibility of changing the SLT’s clinical practice through a brief training. This was measured through monitoring treatment flow and through structured analysis of the content of intervention for treatment fidelity and inter-treatment contamination.
Results
As measured by treatment flow, the intervention was as acceptable as standard voice therapy to patients. Analysis of treatment content showed that the SLT was able to conduct a complex CBT formulation and deliver novel treatment strategies for fatigue, sleep, anxiety and depression in the majority of patients. On pre-post measures of voice and quality of life, patients in both treatment arms improved.
Conclusion
These interventions were acceptable to patients. Emotional and psychosocial issues presented routinely in the study patient group and CBT techniques were used, deliberately and inadvertently, in both treatment arms. This CBT “contamination” of the voice therapy only arm reflects the chief limitation of the study: one therapist delivered both treatments.
Trial registration
Registered with the ISRCTN under the title: Training a Speech and Language Therapist in Cognitive Behavioural Therapy to treat Functional Dysphonia - A Randomised Controlled Trial.
Trial Identifier: ISRCTN20582523 Registered 19/05/2010; retrospectively registered. http://www.isrctn.com/ISRCTN20582523
Summary: Primary muscle tension dysphonia (pMTD) is a voice disorder that occurs in the absence of laryngeal pathology. Dysregulated activity of the paralaryngeal muscles is considered the proximal cause; however, the central origin of this aberrant laryngeal muscle activation is unclear. The Trait Theory (Roy and Bless, 2000a,b) proposed that specific personality traits can predispose one to laryngeal motor inhibition and pMTD, and this inhibition is mediated by a hyperactive “behavioral inhibition system (BIS)” composed of limbic system structures (and associated prefrontal connections). This case study used functional magnetic resonance imaging to detect brain activation changes
associated with successful management of pMTD, thereby evaluating possible neural correlates of this poorly understood
disorder.
Method: A 61-year-old woman with pMTD underwent functional magnetic resonance imaging scans before and immediately after successful treatment using manual circumlaryngeal techniques. Experimental stimuli were blocks of repeated vowel production and overt sentence reading.
Results: Significantly greater activation was observed pre- versus post voice therapy in all regions of interest during sentence production, that is, periaqueductal gray, amygdala, hypothalamus, anterior cingulate cortex, hippocampus, dorsolateral prefrontal cortex, Brodmann area 10, and premotor and inferior sensorimotor cortex.
Conclusions: Our findings are compatible with overactivation of neural regions associated with the BIS (cingulate cortex, amygdala, hypothalamus, periaqueductal gray) and motor inhibition networks (e.g., pre-supplementary motor area) along with the dorsolateral prefrontal cortex and medial prefrontal cortex. Heightened input from limbic regions combined with dysfunctional prefrontal regulation may interfere with laryngeal motor preparation, initiation, and execution thereby contributing to disordered voice in pMTD.
Objective:
The purpose of the study was to replicate and extend previous research on the relation between perceived present control and voice handicap and to further examine the psychometric properties of a present control scale adapted for patients with voice disorders (Misono, Meredith, Peterson, & Frazier, 2016).
Method:
Sample 1 consisted of 1,129 patients recruited from a voice disorder clinic who completed measures of perceived present control, distress, and voice handicap in the clinic. Sample 2 consisted of 62 patients from the same clinic who completed measures of present control, distress, voice handicap, and general control beliefs online at baseline and measures of present control and voice handicap again 3 weeks later (n = 59).
Results:
With regard to the psychometric properties of the voice-adapted present control scale, alpha coefficients were above .80 and the 3-week test-reliability coefficient was .69. There was mixed support for the hypothesized 1-factor structure of the scale. In Sample 1, present control was more strongly associated with lower voice handicap than was distress and accounted for significant variance in voice handicap controlling for distress. In Sample 2, present control at baseline predicted later voice handicap, controlling for general control beliefs and distress.
Conclusions:
Present control appears to be a promising target for adjunctive interventions for patients with voice disorders. An evidence-based online present control intervention (Hintz, Frazier, & Meredith, 2015) is being adapted for this patient population. (PsycINFO Database Record
Psychogenic speech and voice disorders (PSVDs) may occur in isolation but more typically are encountered in the setting of other psychogenic disorders. We aimed to characterize the phenomenology, frequency, and correlates of PSVDs in a cohort of patients with psychogenic movement disorders (PMDs). We studied 182 consecutive patients with PMDs, 30 of whom (16.5 %) also exhibited PSVD. Stuttering was the most common speech abnormality (n = 16, 53.3 %), followed by speech arrests (n = 4, 13.3 %), foreign accent syndrome (n = 2, 6.6 %), hypophonia (n = 2, 6.6 %), and dysphonia (n = 2, 6.6 %). Four patients (13.2 %) had more complex presentations with different combinations of these patterns. No differences in gender, age at onset, and distribution of PMDs were observed between patients with and without PSVD. PSVDs are relatively frequent in patients with PMDs and are manifested by a wide variety of abnormal speech and voice phenomena, with stuttering being the most common presentation. Speech therapy and insight-oriented counseling may be helpful to some patients.
This retrospective study examined the demographic, speech, neurologic, and psychiatric characteristics of 49 people without and 20 people with neurologic disease who, as adults, developed stuttering-like dysfluencies attributable to psychological factors. In both groups, men and women were equally represented, age of onset was usually before age 60, and educational achievement approximated the national average. The duration of stuttering at the time of assessment varied from days to years. Stuttering most often was only one of a number of presenting complaints that raised concerns about organic disease in both groups. In those with confirmed neurologic disease, closed head injury, seizure disorder, and degenerative neurologic disease were the most common neurologic diagnoses; a relatively small number of patients had a history or current evidence of aphasia, apraxia of speech, or dysarthria. Conversion reaction, anxiety or hysterical neurosis, and depression were the most frequent psychiatric diagnoses across the two groups. About 70% of treated patients in both groups improved rapidly and dramatically during behavioral therapy, providing strong evidence of psychogenic etiology. The mechanisms that may lead to psychogenic stuttering, and the characteristics that may and may not help distinguish psychogenic from neurogenic stuttering, are discussed.
Non-organic disorders are frequently encountered in clinical medicine, but the number of reports on non-organic language disorders is limited. There is a lack of diagnostic criteria for this entity.
Aims: The paper describes three patients with a language disorder that is not ascribed to concomitantly present brain lesions and compares the clinical and linguistic features with those of previously reported cases of non-organic language disorder.
Methods & Procedures: Case studies and cross-tabulation of characteristics of our reported patients and of patients reported earlier in the literature.
Outcomes & Results: All three reported patients had a prior history of psychiatric disorders, and lived alone or were involved in conflicting situations. All of them presented cerebral lesions as documented by neuro-imaging but with a linguistic presentation that is totally incompatible with true aphasia and therefore not related to the documented lesions. Characteristic linguistic features included abrupt onset of a nonfluent language disorder with agrammatism, overgeneralisations, paraphasias preceded by pauses, and error variations. Comprehension was unaffected. Additionally dysarthria with hypophonia and reduced speech rate was striking. The linguistic symptoms fluctuated over time, dependent on cognitive distraction and context.
Conclusion: The presence of a brain lesion does not imply the organic nature of all symptoms including language deficits. We argue the necessity of taking into account non-organic language behaviour in the differential diagnosis of aphasia. The common characteristics reported in our cases may serve as a basis for the future development of diagnostic criteria.
The primary objective of this discussion paper is to review the available evidence for the role of psychogenic and psychosocial factors in the development of functional voice disorders (FVD). Current theoretical models linking these factors to the aetiology of FVD and to vocal hyperfunction are then considered. Since there is a paucity of solid empirical evidence to date, general patterns of evidence derived from single case reports and case series are examined first, followed by those empirical studies using more sophisticated methodologies. The discussion is structured around a framework that includes the following psychosocial areas of enquiry: demographic profiles of individuals with FVD; stressful incidents preceding onset; personality traits; coping styles and psychiatric disorder. Current evidence and associated theoretical models suggest that cognitive, affective, neurophysiological and behavioural aspects culminate in the development of these complex voice disorders. The implications of these findings are discussed with respect to clinical practice and clinical training, with suggestions for future scientific research.
In the lead article, Hersh (2010) draws attention to the significant phase of ending therapy for clients and in particular, for their therapists. Hersh highlights three main tensions that underpin this process: real versus ideal endings, making and breaking of the therapeutic relationship, and balancing of respect for client autonomy over considerations of caseload and resources. In this paper, I offer a commentary on the first two of these issues by drawing upon my experience as a speech-language pathologist/family therapist specializing in voice, and as an academic fostering the development of student clinicians. This is then linked to parallel discussions in the recent psychoanalytic and psychotherapy literature. I support Hersh's premise that the implicit processes and emotions associated with this final phase of therapy need to be made more explicit and suggest that this is more likely to occur when clinicians acknowledge that they too experience rewards and losses in the therapeutic relationship. I challenge the notion that any therapeutic relationship once established is ever entirely broken.
Background:
While expert consensus recommendations support the use of speech and language therapy (SLT) for patients with functional speech disorder (FND-speech), there is limited published data on clinical outcomes.
Objective:
To retrospectively report the treatment outcomes and clinical characteristics of patients with FND-speech that attended outpatient SLT as part of a multidisciplinary program for functional neurological disorder (FND).
Methods:
In this case series, we included adult patients with FND-speech that consecutively participated in outpatient SLT at our institution between October 2014 and September 2021. Baseline demographic and neuropsychiatric characteristics were extracted from the medical records, along with data on FND-speech phenotypes, number of treatment sessions received, and clinician-determined outcomes. Only descriptive statistics were used to report findings.
Results:
Twenty patients met inclusion criteria; ages ranged from 21-77, with a mean of 51.6±16.2 years. 85% of the cohort presented with mixed FND-speech symptoms. Patients attended a range of 2-37 visits, with an average of 9.2±8.0 visits over 4.4±3.5 months. At the last treatment session, 3 patients were asymptomatic, 15 had improved, and 2 had not improved; 8 individuals that improved received video telehealth interventions.
Conclusion:
This case series lends additional support for outpatient SLT in the assessment and management of individuals with FND-speech, and may help clarify patient and provider treatment expectations. Additional prospective research is needed to investigate baseline predictors of treatment response and further define the optimal frequency, intensity, duration, and clinical setting for SLT delivery in this population.
Background
A challenge for clinicians and researchers in laryngology is a lack of international consensus for an agreed framework to classify homogenous groups of voice disorders. Consistency in terminology and agreement in how conditions are classified will provide greater clarity for clinicians and researchers.
Objective
This scoping review aimed to examine the published literature on frameworks, terminology, and criteria for the classification of voice disorders.
Design
Seven online databases (MEDLINE, Embase, CINAHL, PsycInfo, Scopus, Cochrane Collaboration, Web of Science) and grey literature sources were searched. Studies published from 1940 to 2021 were included if they provided a descriptive detail of a classification framework structure and described the methodological approaches to determine classification. A narrative synthesis of the main concepts including terminology, classification criteria, grouping of conditions, critical appraisal items and gaps in research was undertaken.
Results
A total of 2,675 publications were screened. Twenty sources met inclusion criteria, including published articles and grey literature. Thirty-five classification groups and over 150 sub-groups were described. The classification group labels, and criteria for inclusion of conditions varied across the frameworks. Several key themes in terminology and criteria useful for classification are discussed, and a core set of suggested terms and definitions are presented.
Conclusions
The quality of research on classification frameworks for voice disorders is low and not one system encompasses all voice disorders across the whole spectrum. Continued high quality research using consensus methodology and inter-rater reliability scores is recommended to develop and test an internationally agreed classification framework for voice disorders.
Functional speech and voice disorders represent a common subtype of functional movement disorder (FMD). This chapter reviews the epidemiology of functional speech and voice disorders, the general approach to their diagnosis, and the characteristics of specific functional speech and voice disorders that allow them to be distinguished from other neurological disorders affecting voice and speech production. While most commonly presenting as functional dysphonia, stuttering and prosodic abnormalities, functional speech and voice disorders can present with a variety of heterogeneous clinical features, and can be challenging to differentiate from motor speech disorders. As with other subtypes of FMD, a careful approach to the history and physical examination is required to arrive at the proper diagnosis. The potential for rapid reversibility of symptoms with appropriate treatment underscores the importance of prompt and accurate diagnosis of functional speech and voice disorders.KeywordsFunctional speech disorderFunctional voice disorderFunctional dysphoniaMuscle tension dysphoniaFunctional stutteringForeign accent syndrome
Functional speech/voice and cognitive symptoms are common in patients with functional movement disorder and related conditions. In this chapter, the emerging treatment of functional speech/voice disorders and functional cognitive symptoms are presented from the speech-language pathology (therapy) perspective. Core elements of functional speech/voice treatment include counseling around the diagnosis, patient education, change facilitation, and working toward increased self-monitoring of speech output. Therapeutic techniques to stimulate improvement in a patient’s atypical speech pattern should be individualized. The management of functional cognitive disorders is focused on supporting compensatory strategies that allow the patient to increase independence for managing instrumental activities of daily living. Overall, speech-language pathologists are an integral component of the interdisciplinary approach to the assessment and management of functional speech/voice disorders and functional cognitive disorder. Research is particularly needed to further define the role of speech-language pathology in the treatment of functional cognitive symptoms.KeywordsFunctional speech disorderFunctional voice disorderSpeech and language pathologySpeech therapyTreatment
The treatment approach to functional movement disorder (FMD) has evolved over time. Historically placed within the realm of psychiatrists, involuntary movements were attributed solely to emotional distress manifesting as physical symptoms (“conversion disorder”), with psychotherapy as the mainstay of treatment. Over the past decade, interest in rehabilitation based and multidisciplinary treatment approaches has grown and provided new pathways to help patients through targeted interventions aimed at retraining motor pathways and strengthening adaptive emotional responses. Treatment needs to be carefully planned and individualized based on patients’ clinical phenotype, symptom severity and relevant comorbidities, and may be delivered in an outpatient, intensive day rehabilitation or inpatient hospital setting. While consensus recommendations for physical, occupational and speech therapies have been a major step forward, standardization of FMD treatment approaches is currently lacking and the composition of treatment teams may vary locally. This chapter outlines important practical considerations when planning interdisciplinary FMD treatment and highlights important areas in need of additional research.KeywordsFunctional movement disorderFunctional neurological disorderMultidisciplinary teamInpatient rehabilitation
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery—albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.
Purpose
Patients with functional stroke can present with functional speech, language or swallowing symptoms, which are managed by speech and language therapists (SLTs). The aim of this study was to explore SLTs’ views and experiences of working with patients with functional stroke.
Methods
Constructivist grounded theory approach was used. Semi-structured interviews were the method of data collection. Constant comparative analysis was used to analyse data. Participants were eligible if they were SLTs who thought they had experience of working with functional stroke.
Results
12 participants were interviewed. Patients with functional stroke were a common occurrence on participants’ caseloads; yet they felt patients do not receive optimum care. All participants wanted to help their patients, yet felt they were working within a multitude of barriers to effective input. These included: stigma about the diagnosis, lack of pre-qualification training, quick discharge from inpatient settings, lack of access to mental health services and lack of clinical guidelines and care pathways.
Conclusions
As healthcare professionals, participants were keen to help their patients. However, they felt they did not have the skills or knowledge to help which caused professional turmoil. Reducing stigma and increasing awareness and knowledge of functional stroke are required to improve patient outcomes.
A functional disorder is a constellation of bothersome physical symptoms that compromise regular function but for which there is no identifiable organic or psychiatric pathology. Functional disorders can present with various symptoms. Common forms of functional disorders include functional neurologic symptom disorder (also referred to as "conversion disorder"), functional gastrointestinal disorders, chronic pain syndromes, and chronic fatigue. One-third to one-half of outpatient consultations in many practices are due to functional disorders. Functional disorders must be distinguished from structural and psychiatric disorders but should not be considered diagnoses of exclusion. Recovery is facilitated by good relationships between patients and practitioners, with good explanations of the pathophysiology of functional disorders and effective encouragement and education of patients.
Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of the initial neuropsychiatric assessment of functional movement disorders (FND-movt) and functional limb weakness/paresis (FND-par) have yet to be established. This is an important gap from both diagnostic and treatment planning perspectives. In this article, the authors performed a narrative review to characterize clinically relevant variables across FND-movt and FND-par cohorts, including time course and symptom evolution, precipitating factors, medical and family histories, psychiatric comorbidities, psychosocial factors, physical examination signs, and adjunctive diagnostic tests. Thereafter, the authors propose a preliminary set of clinical content that should be assessed during early-phase patient encounters, in addition to identifying physical signs informing diagnosis and potential use of adjunctive tests for challenging cases. Although clinical history should not be used to make a FND diagnosis, characteristics such as acute onset, precipitating events (e.g., injury and surgery), and a waxing and waning course (including spontaneous remissions) are commonly reported. Active psychiatric symptoms (e.g., depression and anxiety) and ongoing psychosocial stressors also warrant evaluation. Positive physical examination signs (e.g., Hoover's sign and tremor entrainment) are key findings, as one of the DSM-5 diagnostic criteria. The neuropsychiatric assessment proposed emphasizes diagnosing FND by using "rule-in" physical signs while also considering psychiatric and psychosocial factors to aid in the development of a patient-centered treatment plan.
Background:
There is large variability in the diagnostic approach and clinical management in functional movement disorders (FMD). This study aimed to examine whether opinions and clinical practices related to FMD have changed over the past decade.
Methods:
A survey to members of the International Parkinson and Movement Disorder Society (MDS).
Results:
We received 864/7689 responses (denominator includes non-neurologists) from 92 countries. Respondents were more often male (55%), younger than 45 (65%), and from academic practices (85%). Although the likelihood of ordering neurological investigations prior to delivering a diagnosis of FMD was nearly as high as in 2008 (47% versus 51%), the percentage of respondents communicating the diagnosis without requesting additional tests increased (27% versus 19%; p=0.003), with most envisioning their role as providing a diagnosis and coordinating management (57% versus 40%; p<0.001). Compared to patients with other disorders, 64% of respondents were more concerned about missing a diagnosis of another neurological disorder. Avoiding iatrogenic harm (58%) and educating patients about the diagnosis (53%) were again rated as the most effective therapeutic options. Frequent treatment barriers included lack of physician knowledge and training (32%), lack of treatment guidelines (39%), limited availability of referral services (48%), and cultural beliefs about psychological illnesses (50%). The preferred term for communication favored "functional" over "psychogenic" (p<0.001).
Conclusions:
Attitudes and management of FMD have changed over the past decade. Important gaps remain in the education of neurologists about the inclusionary approach to FMD diagnosis, and improving access to treatment.
Objective
Foreign accent syndrome (FAS) is widely understood as an unusual consequence of structural neurological damage, but may sometimes represent a functional neurological disorder. This observational study aimed to assess the prevalence and utility of positive features of functional FAS in a large group of individuals reporting FAS.
Methods
Participants self-reporting FAS recruited from informal unmoderated online support forums and via professional networks completed an online survey. Speech samples were analysed in a subgroup.
Results
Forty-nine respondents (24 UK, 23 North America, 2 Australia) reported FAS of mean duration 3 years (range 2 months to 18 years). Common triggers were: migraine/severe headache (15), stroke (12), surgery or injury to mouth or face (6) and seizure (5, including 3 non-epileptic). High levels of comorbidity included migraine (33), irritable bowel syndrome (17), functional neurological disorder (12) and chronic pain (12). Five reported structural lesions on imaging. Author consensus on aetiology divided into, ‘probably functional (n=35.71%), ‘possibly structural’ (n=4.8%) and ‘probably structural’ (n=10.20%), but positive features of functional FAS were present in all groups. Blinded analysis of speech recordings supplied by 13 respondents correctly categorised 11 (85%) on the basis of probable aetiology (functional vs structural) in agreement with case history assignment.
Conclusions
This largest case series to date details the experience of individuals with self-reported FAS. Although conclusions are limited by the recruitment methods, high levels of functional disorder comorbidity, symptom variability and additional linguistic and behavioural features suggest that chronic FAS may in some cases represent a functional neurological disorder, even when a structural lesion is present.
Introduction: Quality of life (QoL) has become widely accepted as a concept in clinical assessment of speech, language or communication difficulties. Since difficulties with speech, language or communication do have an effect on QoL it is questioned to what extent specifically communication-related QoL (CRQoL) is represented in measures applied in speech-language research.
Purpose: To conduct a systematic review analyzing the use of QoL measures in research involving adults with diagnosed adult-onset neurogenic speech-language-communication difficulties (NSLCD).
Method: Selected medical and psychological databases (e.g. Medline, EMBASE, CINAHL) were searched to identify relevant studies. Studies were eligible for review if they met the following criteria (1) the language was English, (2) they reported empirical data, (3) the diagnosis of NSLCD was confirmed by a speech-language pathologist or through an assessment and (4) at least one quality of life measure was used. There was no restriction on publication date. A standardized data extraction form was used to analyze information on the methodological details of each relevant study.
Results: 103 studies met inclusion criteria. The sub-populations addressed covered a wide range of NSLCDs, including aphasia, dysarthria, voice and cognitive communication disorders. Moreover, QoL assessment showed a large heterogeneity with 39 different QoL measures used, including 13 generic tools, 25 condition-specific tools and a visual analog scale. Communication-related items were present in only 19 of the QoL measures. Only four QoL tools that measure explicitly CRQoL were identified.
Conclusion: A range of different Qol measures was used. Consensus on a preferred methodology of QoL measurement in NSLCD would facilitate comparability across studies. Future studies might investigate CRQoL more intensively in people with NSLCD.
Background:
Stressful life events and maltreatment have traditionally been considered crucial in the development of conversion (functional neurological) disorder, but the evidence underpinning this association is not clear. We aimed to assess the association between stressors and functional neurological disorder.
Methods:
We systematically reviewed controlled studies reporting stressors occurring in childhood or adulthood, such as stressful life events and maltreatment (including sexual, physical abuse, and emotional neglect) and functional neurological disorder. We did a meta-analysis, with assessments of methodology, sources of bias, and sensitivity analyses.
Findings:
34 case-control studies, with 1405 patients, were eligible. Studies were of moderate-to-low quality. The frequency of childhood and adulthood stressors was increased in cases compared with controls. Odds ratios (OR) were higher for emotional neglect in childhood (49% for cases vs 20% for controls; OR 5·6, 95% CI 2·4-13·1) compared with sexual abuse (24% vs 10%; 3·3, 2·2-4·8) or physical abuse (30% vs 12%; 3·9, 2·2-7·2). An association with stressful life events preceding onset (OR 2·8, 95% CI 1·4-6·0) was stronger in studies with better methods (interviews; 4·3, 1·4-13·2). Heterogeneity was significant between studies (I221·1-90·7%). 13 studies that specifically ascertained that the participants had not had either severe life events or any subtype of maltreatment all found a proportion of patients with functional neurological disorder reporting no stressor.
Interpretation:
Stressful life events and maltreatment are substantially more common in people with functional neurological disorder than in healthy controls and patient controls. Emotional neglect had a higher risk than traditionally emphasised sexual and physical abuse, but many cases report no stressors. This outcome supports changes to diagnostic criteria in DSM-5; stressors, although relevant to the cause in many patients, are not a core diagnostic feature. This result has implications for ICD-11.
Funding:
None.
Background: Functional disorders of speech and voice, subtypes of functional movement disorders, represent abnormalities in speech and voice that are thought to be have an underlying psychological cause. These disorders exhibit several positive and negative features that distinguish them from organic disorders.
Methods and Results: We describe the clinical manifestations of functional disorders of speech and voice, and illustrate these features using six clinical cases.
Conclusions: Functional disorders of speech and voice may manifest in a variety of ways, including dysphonia, stuttering, or prosodic abnormalities. Given that these disorders have been understudied and may resemble organic disorders, diagnosis may be challenging. Appropriate treatment may be quite effective, highlighting the importance of prompt and accurate diagnosis. This article is protected by copyright. All rights reserved.
In this chapter, an overview of the heterogeneous group of functional voice disorders is given, including the psychogenic voice disorder (PVD) and hyperfunctional or muscle tension voice disorder (MTVD) subgroups. Reference is made to prevalence and demographic data, with empiric evidence for psychosocial factors commonly associated with the onset and maintenance of these disorders. Clinical features that distinguish between the different presentations of PVD and MTVD are described. While there are some shared characteristics, key differences between these two subgroups indicate that PVD more closely resembles the psychogenic movement disorders and a range of other functional neurologic disorders. Assessment procedures and auditory-perceptual features of the voice that distinguish these disorders from the neurologically based voice disorders are discussed, with case examples highlighting ambiguous features that may influence differential diagnosis. The clinical profiles of PVD and MTVD affirm approaches to clinical management by speech-language pathologists that integrate symptomatic behavioral voice therapy with “top-down” models of counseling or psychotherapy. They also support the proposition that PVD may be construed as a subtype of functional neurologic disorders.
Acquired psychogenic or functional speech disorders are a subtype of functional neurologic disorders. They can mimic organic speech disorders and, although any aspect of speech production can be affected, they manifest most often as dysphonia, stuttering, or prosodic abnormalities. This chapter reviews the prevalence of functional speech disorders, the spectrum of their primary clinical characteristics, and the clues that help distinguish them from organic neurologic diseases affecting the sensorimotor networks involved in speech production. Diagnosis of a speech disorder as functional can be supported by sometimes rapidly achieved positive outcomes of symptomatic speech therapy. The general principles of such therapy are reviewed.
Much is known regarding the physical characteristics, comorbid symptoms, psychological makeup, and neuropsychological performance of patients with functional neurological disorders (FNDs)/conversion disorders. Gross neurostructural deficits do not account for the patients' deficits or symptoms. This review describes the literature focusing on potential neurobiological (i.e. functional neuroanatomic/neurophysiological) findings among individuals with FND, examining neuroimaging and neurophysiological studies of patients with the various forms of motor and sensory FND. In summary, neural networks and neurophysiologic mechanisms may mediate "functional" symptoms, reflecting neurobiological and intrapsychic processes.
The improving access to psychological therapies initiative has highlighted the importance of managing mental health problems effectively, and research has shown excellent outcomes from cognitive behavioural therapy (CBT) interventions. Patients presenting with functional dysphonia will often also describe psychological distress including anxiety, depression and reduced general well-being, and it is felt that effective voice therapy needs to include the management of psychological well-being. The evidence for the use of CBT enhanced voice therapy is limited to date. Recent research has only started to identify the benefits of this approach and questions regarding how to achieve and maintain competence are essential.
Voice therapy outcomes are positive and patients receiving CBT with voice therapy have shown more improvement in their general well-being and distress.
CBT is a very well evidenced therapy and recommended by The National Institute for Health and Care Excellence (NICE) as the treatment of choice for mental health difficulties and medically unexplained symptoms. Allied health professionals are increasingly being trained to use CBT skills in the management of a number of symptoms/illnesses, and this should be considered for the management of functional dysphonia. However, there is a need for more research and detailed consideration of how therapists should be trained and supervised and how cost-effective this approach may be.
The prognosis of functional (or psychogenic) motor symptoms (weakness and movement disorder) has not been systematically reviewed.
We systematically reviewed PubMed for all studies of eight or more patients with functional motor symptoms reporting follow-up data longer than 6 months (excluding studies reporting specific treatments). We recorded symptom duration, physical and psychiatric comorbidity, disability, occupational functioning at follow-up and prognostic factors.
24 studies were included. There was heterogeneity regarding study size (number of patients (n)=10 491), follow-up duration clinical setting and data availability. Most studies (n=15) were retrospective. Reported symptom outcome was highly variable. Mean weighted follow-up duration was 7.4 years (in 13 studies where data was extractable). The mean percentage of patients same or worse at follow-up for all studies was 39%, range 10% to 90%, n=1134. Levels of physical disability and psychological comorbidity at follow-up were high. Short duration of symptoms, early diagnosis and high satisfaction with care predicted positive outcome in two studies. Gender had no effect. Delayed diagnosis and personality disorder were negatively correlated with outcome. Prognostic factors that varied between studies included age, comorbid anxiety and depression, IQ, educational status, marital status and pending litigation.
Existing follow-up studies of functional motor symptoms give us some insights regarding outcome and prognostic factors but are limited by their largely retrospective and selective nature. Overall, prognosis appears unfavourable. The severity and chronicity of functional motor symptoms argues for larger prospective studies including multiple prognostic factors at baseline in order to better understand their natural history.
Information on the nature and relative frequency of diagnoses made in referrals to neurology outpatient clinics is an important guide to priorities in services, teaching and research. Previous studies of this topic have been limited by being of only single centres or lacking in detail. We aimed to describe the neurological diagnoses made in a large series of referrals to neurology outpatient clinics.
Newly referred outpatients attending neurology clinics in all the NHS neurological centres in Scotland, UK were recruited over a period of 15 months. The assessing neurologists recorded the initial diagnosis they made. An additional rating of the degree to which the neurologist considered the patient's symptoms to be explained by disease was used to categorise those diagnoses that simply described a symptom such as 'fatigue'.
Three thousand seven hundred and eighty-one patients participated (91% of those eligible). The commonest categories of diagnosis made were: headache (19%), functional and psychological symptoms (16%), epilepsy (14%), peripheral nerve disorders (11%), miscellaneous neurological disorders (10%), demyelination (7%), spinal disorders (6%), Parkinson's disease/movement disorders (6%), and syncope (4%). Detailed breakdowns of each category are provided.
Headache, functional/psychological disorders and epilepsy are the most common diagnoses in new patient referral to neurological services. This information should be used to shape priorities for services, teaching and research.
Twelve patients (6 men and 6 women), ages 21-79 years, who, as far as it could be determined from their case histories, began to stutter for the first time in adulthood were classified by examining physicians and speech-language pathologists as having psychogenic stuttering. The case histories of these patients were examined to determine the details of their speech and allied complaints, the course and duration of stuttering, and if any psychologically stressful events surrounded the onset and development of the disorder. Minnesota Multiphasic Personality Inventory (MMPI) data on 10 of the 12 patients were analyzed independently. The main findings were (a) stuttering was the chief complaint of 11 patients; (b) all 12 patients had additional neurologic-like complaints that turned out to be nonorganic; (c) duration of stuttering from onset to examination ranged from 4 hr to 1.5 years; (d) the stuttering of most patients was variable in severity and returned to normal either spontaneously or as a result of speech therapy or psychotherapy; (e) psychologic stress was associated with the onset in 10 patients: the stress was chronic in 4 patients and acute in 6; (f) MMPI profiles of 9 of 10 patients were abnormal, with four profiles reflective of a conversion reaction; (g) differentiating neurologic from psychogenic stuttering and the need for interdisciplinary collaboration were essential in all 12 cases; and (h) speech therapy and psychotherapy are justified when psychogenic stuttering is diagnosed.
Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.
“Luckily I haven’t had one for a while”: Current management of clients with functional psychogenic voice disorder by speech pathologists in Australia. FNDS Conference Poster Presentation
- C Gregory
- R Stern-Pooley
- E Power