Multidisciplinary Assessment and Diagnosis of Conversion Disorder in a Patient with Foreign Accent Syndrome

Abstract

Multiple reports have described patients with disordered articulation and prosody, often following acute aphasia, dysarthria, or apraxia of speech, which results in the perception by listeners of a foreign-like accent. These features led to the term foreign accent syndrome (FAS), a speech disorder with perceptual features that suggest an indistinct, non-native speaking accent. Also correctly known as psuedoforeign accent, the speech does not typically match a specific foreign accent, but is rather a constellation of speech features that result in the perception of a foreign accent by listeners. The primary etiologies of FAS are cerebrovascular accidents or traumatic brain injuries which affect cortical and subcortical regions critical to expressive speech and language production. Far fewer cases of FAS associated with psychiatric conditions have been reported. We will present the clinical history, neurological examination, neuropsychological assessment, cognitive-behavioral and biofeedback assessments, and motor speech examination of a patient with FAS without a known vascular, traumatic, or infectious precipitant. Repeated multidisciplinary examinations of this patient provided convergent evidence in support of FAS secondary to conversion disorder. We discuss these findings and their implications for evaluation and treatment of rare neurological and psychiatric conditions.

Full text

Behavioural Neurology 24 (2011) 245–255 245
DOI 10.3233/BEN-2011-0332
IOS Press
Clinical Note
Multidisciplinary assessment and diagnosis of
conversion disorder in a patient with foreign
accent syndrome
Harrison N. Jonesa,∗, Tyler J. Storyb,c, Timothy A. Collinsb, Daniel DeJoycand
Christopher L. Edwardsd,e
aDepartment of Surgery, Division of Speech Pathology and Audiology, Duke University Medical Center, NC, USA
bDepartment of Medicine, Division of Neurology, Duke University Medical Center, NC, USA
cDepartment of Communications, North Carolina State University, Duke University Medical Center, NC, USA
dDepartment of Psychiatry, Division of Medical Psychology, Duke University Medical Center, NC, USA
eDepartment of Medicine, Division of Hematology, Duke University Medical Center, NC, USA
Abstract. Multiple reports have described patients with disordered articulation and prosody, often following acute aphasia,
dysarthria, or apraxia of speech, which results in the perception by listeners of a foreign-like accent. These features led to the
term foreign accent syndrome (FAS), a speech disorder with perceptual features that suggest an indistinct, non-native speaking
accent. Also correctly known as psuedoforeign accent, the speech does not typically match a specific foreign accent, but is rather
a constellation of speech features that result in the perception of a foreign accent by listeners. The primary etiologies of FAS are
cerebrovascular accidents or traumatic brain injuries which affect cortical and subcortical regions critical to expressive speech
and language production. Far fewer cases of FAS associated with psychiatric conditions have been reported. We will present the
clinical history, neurological examination, neuropsychological assessment, cognitive-behavioral and biofeedback assessments,
and motor speech examination of a patient with FAS without a known vascular, traumatic, or infectious precipitant. Repeated
multidisciplinary examinations of this patient provided convergent evidence in support of FAS secondary to conversion disorder.
We discuss these findings and their implications for evaluation and treatment of rare neurological and psychiatric conditions.
Keywords: Foreign accent syndrome, conversion disorder, neuropsychological assessment, case study, speech disorders
1. Introduction
Foreign accent syndrome (FAS) is a rarely encoun-
tered speech disorder that presents with abnormalities
in articulation and prosody which are perceived by lis-
teners as sounding similar to a foreign accent. Tradi-
tionally, FAS is most commonly associated with left-
hemisphere lesions [1] secondary to CVA [2–13] and
traumatic brain injury (TBI) [14–17]. The condition is
∗Corresponding author: Harrison N. Jones, PhD, Duke University
Medical Center, 155 Baker Hose, Trent Dr., DUMC 3887, Durham,
NC 27710, USA. Tel.: +1 919 684 6271; Fax: +1 919 684 8298;
E-mail: harrison.jones@duke.edu.
often preceded or accompanied by other communica-
tion disorders such as aphasia, dysarthria, and apraxia
of speech [18]. More recently, FAS has been associ-
ated with a variety of neurological illnesses, including
multiple sclerosis [19,20], primary progressive apha-
sia [21], cerebellar hypoperfusion [22], and metastatic
breast cancer [23]. Several case reports of patients with
FAS and psychiatric illness without a known brain le-
sion have also appeared, including patients with bipo-
lar disease [24], psychosis [25,26], psychogenic ill-
ness [27], and conversion disorder [28,29]. In this pa-
per, we describe the multidisciplinary assessment and
diagnosis of FAS secondary to conversion disorder.
ISSN 0953-4180/11/$27.50 2011 – IOS Press and the authors. All rights reserved

246 H.N. Jones et al. / Conversion disorder and foreign accent syndrome
2. Patient description
The patient was a 39-year-old, right-handed African-
American woman, born and raised in the southeastern
region of the United States. She described an unremark-
able birth and developmental trajectory with no histo-
ry of a learning disorder or behavioral problems dur-
ing childhood. She obtained her high-school diploma
without academic incident and worked in childcare pri-
or to the onset of chronic daily headaches. She denied
a history of emotional, physical, or sexual abuse. She
also denied notable use of alcohol, tobacco, or illicit
substances. During the course of her treatment, she
initiated the process of application for long-term dis-
ability and did not return to work during her treatment
or follow-up. Although not working, there were few
if any functional impairments noted by her evaluation
and treatment team or described by the patient.
She presented to the emergency department (ED)
of an academic medical center for treatment of per-
sistent headache, decreased right-sided sensation, gait
disturbance, and disruption of speech articulation and
prosody. She presented to the ED approximately three
months after the onset of headaches she described as
a severe, throbbing pain in the right temporal-parietal
region intermittently accompanied by nausea, vomit-
ing, photophobia, and phonophobia. She reported at
that visit having “multiple” evaluations at other hospi-
tals for the same complaints. Upon presentation, she
reported onset of her sensory, speech, and gait symp-
toms three to four days prior to seeking medical atten-
tion at our ED. She was taking ibuprofen at the time
of admission and reported allergic responses to dextro-
propoxyphene, hydrocodone, and naproxen. She was
evaluated in the ED with a CT scan of the brain, and
treated with sumatriptan for her migraine with some
improvement. She was scheduled to follow-up with
neurology on an outpatient basis and discharged home.
3. Neurological examination
The patient was first seen in the neurology clinic
approximately 1 month after her ED visit. The pa-
tient and her family reported previous assessments in
multiple facilities with unremarkable brain imaging re-
sults. Although she reported improvement, she discon-
tinued sumatriptan as it reportedly caused her to feel
ill and was associated with chest discomfort. She de-
scribed only two days over the prior four months prior
to neurology assessment as headache free. Examina-
tion in the neurology clinic on her initial visit found
inconsistent sensory examination with features of non-
physiologic sensory loss including “splitting the mid-
line”. Motor examination found inconsistencies, with
normal strength observed in all extremities during por-
tions of the clinic visit and effort dependant weakness
during formal motor testing of the extremities.
Over the course of two years, she was evaluated in
the neurology clinic eleven times. General physical ex-
amination was repeatedly normal, as were cranial nerve
examinations and tendon reflexes. Markedly variable
weakness, which generally appeared effort dependent,
in one or both lower extremities and the right upper
extremity, was repeatedly exhibited. Strength testing
during formal examination and observed physical be-
havior in clinic frequently were inconsistent. For ex-
ample, no effort would be exhibited during formal mo-
tor testing of the right leg, yet the ability to use the
right leg to step off the exam table and bear weight
when walking was easily observed. The patient’s gait
revealed the following features which have been found
to be associated with psychogenicgait disorders: exag-
gerated effort, gait fluctuations, uneconomic postures,
and dramatic give way weakness [30]. There was no
evidence of hemiparesis. Finger nose finger and heel
knee shin testing were preserved without evidence of
ataxia. There were no abnormal spontaneous move-
ments and muscle tone was normal. Additional evi-
dence for the presence of a psychogenic gait disorder
was provided by the presence of a positive “chair test”
as described by Okun and colleagues [31]. This test
requires both walking and self-propelling in a swivel
chair with wheels and the results are compared. Okun
et al. reported that improved performance on the chair
versus walking, or a positive “chair test”, was sugges-
tive of a psychogenic gait disorder.
She reported episodes of memory loss and “black-
outs”. History from the patient and family regarding
the “blackouts” were suboptimal, but it was found that
the patient had preserved consciousness, and appeared
to be cognitivelynormal during these events, consistent
with a fugue event. There was no history elicited of
seizure activity or tonic clonic activity
Speech was produced initiated and fluently with
appropriate content. She demonstrated the ability to
answer questions, name objects, repeat words and
sentences, and verbally express herself in connected
speech. When asked questions regarding her speech
difficulty, she offered spontaneous responses that were
organized, grammatically correct, and pragmatical-
ly appropriate. No phonemic or semantic paraphasias

H.N. Jones et al. / Conversion disorder and foreign accent syndrome 247
were present. Additionally, she was able to follow
commands and comprehend conversational speech. Al-
though a foreign-sounding accent was present and she
had a slow rate of speech with mild distortions and
prosodic abnormalities, her speech was not characteris-
tic of a particular dysarthria type(s) and associated neu-
romotor deficits (e.g., spasticity, incoordination) known
to accompany neurologic disease and manifestupon the
speech mechanism. Not surprisingly in a condition also
appropriately known as pseudoforeign accent, listeners
could not agree on the “origin” of the accent though a
Jamaican accent was most commonly described. Her
speech accent varied over time though FAS always per-
sisted to some degree. She completed a pain scale rat-
ing during each neurology visit as this was her primary
complaint. Her pain scale rating ranged from 4 to 9 on
an equal-appearing interval scale of 0-10 (i.e., 0 =no
pain; 10 =worst pain ever) and over multiple visits,
it was noted that her pain scale rating did not corre-
late with the severity of her physical findings on exam.
Her gait disorder and “foreign accent” varied with no
perceived relationship to her reported pain complaints,
though she reported that the severity of her headache
influenced how affected her speech was. CT of the
head, MRI of the brain with and without contrast, MRI
of the cervical spine, and EEG results were unremark-
able. Her neurologic presentation was considered most
consistent with a functional disorder.
4. Neuropsychological assessment
Approximately 18 months after symptom onset, she
was referred for a neuropsychological assessment. On
the day of assessment, positive and appropriate affect
was exhibited with no outward signs of a current mood
disorder. She did not show observable signs of pain or
discomfort. Thought processes were logical and linear,
and she denied suicidal,homicidal, or paranoid content.
She was pleasant and cooperative throughout testing.
She described difficulty with memory, concentra-
tion, judgment, reasoning, and word-finding. The pa-
tient and her husband stated that these symptoms start-
ed with the onset of headache and varied in severity de-
pending on the intensity of her pain. Severe headaches
were also associated with intensified speech disruption
and agraphia, though she did not exhibit agraphia on
the day of her evaluation. She described an episode ap-
proximately three months prior when she was unable to
remember the names of family members for four days.
She estimated that she slept approximatelysix hours
per night when taking zolpidem, though she also de-
scribed several occasions of insomnia lasting three or
more days due to severe cephalagia. The patient denied
symptoms of depression or anxiety. A 30-pound weight
loss over the preceding two months was reported,which
she attributed to nausea secondary to headache.
A comprehensive neuropsychological examination
using standardized instruments to address all major
cognitive domains was administered. Specific measur-
es by domain included: general intellectual function –
Wechsler Adult Intelligence Scale-3rd Edition [WAIS-
III, selected subtests; 32]; reading achievement and
estimated premorbid ability – Wide Range Achieve-
ment Test [WRAT, 33]; executive function, processing
speed, working memory, and attention – Trail Mak-
ing Test [34], Stroop Color and Word Test [35], Ruff
Figural Fluency [36], and WAIS-III subtests; memo-
ry – California Verbal Learning Test-2nd Edition [37],
Wechsler Memory Scale-3rd Edition [38], and Brief Vi-
suospatial Memory Test-Revised [BVMT-R, 39]; lan-
guage function – Boston Naming Test [40], Multilin-
gual Aphasia Exam [41], and categorical fluency (i.e.,
animal naming); visual-constructional skills – WAIS-
III Block Design and Brief Visuospatial Memory Test
-Revised (BVMT-R) figure copy; fine motor speed –
Finger Tapping, Grooved Pegboard; effort and test en-
gagement – Green Word Memory Test [42], Test of
Memory Malingering [43]; and mood – Beck Depres-
sion Inventory-II [44].
Raw test scores and performance categories based
on normative data are presented in Table 1. Her test
results revealed severe impairments in several cogni-
tive domains including memory, executive functions,
language, and fine-motor skills. More subtle deficits
were present on tests of attention, working memory,
and auditory comprehension. In contrast, letter fluency,
category fluency, confrontation naming, and nonverbal
recall were within normal limits.
While test results suggested the presence of a se-
vere cognitive disorder, there were concerns regarding
the validity of the exam. Effort testing fell below ex-
pectation for immediate recognition (IR =87.5), de-
layed recognition (DR =77.5), and consistency (CNS
=70.0) on the Green Word Memory Test, a forced-
choice word recognition procedure developed to assess
effort and engagement in neuropsychological proce-
dures. Her exam was also notable for variability in per-
formance inconsistent with task difficulty. For exam-
ple, simple auditory comprehension fell below expec-
tation, while comprehension of more difficult, multi-

248 H.N. Jones et al. / Conversion disorder and foreign accent syndrome
Tab le 1
Neuropsychological assessment data
Category Test Scaled scores Description
Premorbid Estimate WRAT Reading 46 Average (high school)
Intellectual Functioning WAIS-III
FSIQ 65 Impaired
VIQ 76 Borderline Impaired
PIQ 60 Impaired
WMI 71 Borderline Impaired
PSI 69 Impaired
Executive Functions Trail Making Test
Trails A 146” Severely Impaired
Trails B 239”, 1 error Impaired
Stroop Color and Word Test
Word 32 Severely Impaired
Color 9 Severely Impaired
Color/Word 27 Impaired
Ruff Figural Fluency Test
Designs 25 Impaired
Perseverative Errors 0 High Average
WAIS-III
Digit Span 10 Borderline Impaired
Similarities 16 Borderline Impaired
Matrix Reasoning 4 Impaired
Memory WMS-III
Logical Memory-I (LM) 15 Severely Impaired
LM-II 9 Borderline Impaired
Faces-I 36 Average
Faces-II 36 Average
California Verbal Learning Test-II
Tot al 30 Im pai red
Immediate Free Recall 5 Impaired
Immediate Cued Recall 11 Low Average
Delayed Free Recall 9 Borderline Impaired
Delayed Cued Recall 11 Low Average
Recognition 11 Impaired
BVMT-R
Total 22 Low Average
Delayed 6 Impaired
Recognition Hits 5 Borderline/Low Average
Language
Boston Naming Test 41 Low Average
COWA ‘FAS’ 35 Average
Animal Naming 12 Low Average
Multilingual Aphasia Exam
Repetition 5 Impaired
Auditory Comprehension 15 Borderline Impaired
Token Test 40 Low Average
Reading Comprehension 16 Borderline
Visuospatial WAIS-III
Block Design 19 Borderline Impaired
BVMT-R
Copy 12/12 Within normal limits
Sensorimotor Grooved Pegboard
dominant hand 149, 1 error Impaired
nondominant hand 130 Impaired
Finger Tapping
dominant hand 11.8 Severely Impaired
nondominant hand 21.4 Severely Impaired
Effort and Motivation TOMM
Trial 1 46 Within normal limits
Trial 2 47 Within normal limits
Green Word Memory Test
Immediate 87.5 Caution
Delayed 77.5 Failed
Consistency 70.0 Failed
Mood Beck Depression Inventory-2 13 Subclinical
Legend: WRAT Reading: Wide Range Achievement Test-Reading; WAIS-III: Wechsler Adult Intelligence
Scale-3rd Edition; FSIQ: Full Scale Intellectual Quotient; VIQ: Verbal Intellectual Quotient; PIQ: Performance
Intellectual Quotient; WMI: Working Memory Index; PSI: Processing Speed Index; WMS-III: Wechsler Memory
Scale-3rd Edition; BVMT-R: Brief Visuospatial Memory Test-Revised; COWA ‘FAS’: Controlled Oral Word
Association Test, Version FAS; TOMM: Test of Memory Malingering.

H.N. Jones et al. / Conversion disorder and foreign accent syndrome 249
step directions was within normal limits. Additionally,
cued verbal recall on a list-learning task was reasonably
intact, while performance on a subsequent recognition
trial was severely impaired. Finger-tapping speed also
fell in the severely impaired range with the patient’s
raw score falling below criteria often used to verify
adequate effort [45].
5. Cognitive-behavioral and biofeedback
assessment
Following referral, she was seen for an initial assess-
ment followed by 13 sessions of behavioral interven-
tion over an 18-month period. Initial biofeedback as-
sessment included psychological testing to determine
the patient’s suitability for biofeedback and to assist in
the psychiatric diagnostic process. A diagnostic clin-
ical interview, the Minnesota Multiphasic Personality
Inventory, Second Edition (MMPI-2) [46], the Neu-
roticism Extroversion Openness Personality Inventory,
Revised (NEO-PI-R) [47,48], the Symptoms Check-
list, 90-items, Revised (SCL-90-R) [49], the BDI [44],
and State Trait Anxiety Inventory (STAI) [50] were
all utilized to assess the patient’s psychiatric status. In
interview, the patient described a “severe, continuous
throbbing headache” concentrated on the right-side of
her head which produced nausea. She also reported
severe, chronic lower back pain. Her medical histo-
ry was significant for memory problems, “black outs”,
and FAS onset around the time of her headaches. Fam-
ily medical history was reportedly significant for dia-
betes, cancer, obesity, Alzheimer’s disease (maternal
grandparent), and headache.
Her responses to the validity items of the MMPI-
2 revealed questionable validity (F-K =16) and re-
sults were thus interpreted with caution. Clinical sc-
ales revealed a 1–3/3–1 code-type with a pronounced
conversion-V profile. Individuals with this pattern of
responses typically present with significant somatic
concerns which are exacerbated in proportion to the
magnitude of stressors (Scale 1 T =80; Scale 2 T =59;
Scale 3 T =87). Somatic complaints may be used as a
proxy for the magnitude of psychological distress [46].
Patients with conversion disorder may manage emo-
tional distress by converting negative emotional reac-
tions and feelings into physical complaints that are in-
terpreted as more socially acceptable. Such individuals
often present as confused and disorganized.
Consistent with suspected conversion disorder, she
scored in the “very low” range on the Neuroticism
scale of the NEO-PI-R. Notably, this scale evaluates
negative emotional symptoms associated with anxiety,
anger and hostility, depression, self-consciousness, im-
pulsiveness, and vulnerability. She also scored in the
Average range on the Extraversion, Agreeableness, and
Conscientiousness scales.
Responses on the SCL-90-R, a general checklist of
psychiatric symptoms, produced a single clinical ele-
vation (T 65) on the Somatization scale (T =65)
indicating her endorsement of numerous, distressing
physical symptoms with little emotional concern. Con-
sistent with previous results, she did not elevate scales
which typically reflect emotional distress. On the STAI,
scores of 35 for state anxiety and 38 for trait anxiety
were obtained, both of which are two standard devia-
tions below the mean for reported anxiety in her age/sex
peer group. Lastly, she scored below the clinical range
for symptoms of depression on the BDI-2 (BDI-2 =
11). She strongly endorsed physical symptoms, such as
appetite disturbance, but denied those associated with
emotional distress, such as sadness, anhedonia, guilt,
and irritation. Overall, the clinical interview and results
of testing were most consistent with an Axis I psy-
chiatric diagnosis of conversion disorder with mixed
presentation.
6. Motor speech examination
Twenty months after her initial presentation to the
ED, she was seen for a motor speech examination. The
exam included a clinical interview regarding the nature
and history of her speech problems and examination of
the speech mechanism during a variety of tasks. The
speech mechanism comprises the structures of the res-
piratory mechanism, larynx, velopharynx, and orofa-
cial mechanism, also commonly referred to as the pro-
cesses of respiration, phonation, resonance, and artic-
ulation, respectively. Prosody of speech is often con-
sidered a fifth speech process, though it is best concep-
tualized as comprising multiple speech features (e.g.,
intonation, stress, rate, rhythm) which result from the
complex interactions of the structures of the speech
mechanism.
The clinical interview obtained during this exam ap-
peared to reveal some new or different details regarding
her medical history, particularly as it pertained to her
communication. She described the acute onset of se-
vere headache approximately two years prior to evalua-
tion, which confined her to bed for two or three days. It
was difficult to determine the patient’s communication

250 H.N. Jones et al. / Conversion disorder and foreign accent syndrome
status at this time, but she endorsed the notion that she
likely made limited attempts to communicate due to the
severity of her headache. However, this was followed
by a period of two or three days of complete mutism,
then the onset of speaking in what others perceived as
a “foreign accent” which she did not notice until it was
brought to her attention. The patient denied a history
of travel out of the United States and had rarely left her
home state. She reported limited exposure to individ-
uals who spoke with a foreign accent and denied any
substantial experiencewith a second language. Neither
her speech change nor her headache had ever resolved,
though the severity of both were described as variable.
The motor speech examination consisted of auditory-
perceptual and instrumental measurement approaches.
Tasks for auditory-perpetual speech assessment includ-
ed high-effort nonspeech and speech tasks [51], rep-
etition of words and sentences, reading of a standard
passage (e.g., “The Grandfather Passage”), and elici-
tation of connected speech. Quantitative measurement
approaches included lingual strength testing with a sin-
gle use, air-filled intraoral silicone tongue bulb and the
Iowa Oral Performance Instrument (IOPI; IOPI Med-
ical LLC) and measurement of maximum inspiratory
and expiratory pressure (i.e., strength) with a respi-
ratory pressure meter (RPM; RPM01, Micro-Direct).
Results of the speech examination follow:
6.1. Respiratory mechanism
Assessment of the respiratory mechanism revealed a
brisk sniff and a rapid, coordinated pant suggesting nor-
mal inspiratory strength and intact ability to complete
a relatively simple, maximum performance respiratory
task, highly dependent on respiratory muscle control
and coordination of both the inspiratory and expiratory
muscle systems. During isolated testing, her maximum
loudness and range of loudness was reduced, though
loudness in connected speech was within normal lim-
its. Respiratory strength was measured using the RPM.
Maximum inspiratory pressure (MIP) and maximum
expiratory pressure (MEP) were obtained over three
trials and the mean was obtained. MIP was 9 cm H20
(11, 7, 9; sd =2) and MEP was 17 cm H20 (17, 19,
16; sd =1.53). Normative data from Chen and Kuo
in 160 healthy participants age 18–65, including 20
females 30–39 years old, are useful to interpret these
findings [58]. In the 20 healthy females with a mean
age of 35.8 years studied by Chen and Kuo, mean MIP
was 76.0 cm H20 (sd =15.3) and MEP was 92.8 cm
H20 (sd =18.8).
These findings suggest that her inspiratory and ex-
piratory muscle strength was more than four standard
deviations below the mean, representing profound res-
piratory muscle weakness. Overall, testing revealed
substantial deficits in the respiratory mechanism, par-
ticularly in isolated, effort dependent tasks, though res-
piratory performance appeared adequate for some iso-
lated speech tasks, connected speech, and performance
of ADLs. Regarding the later, for example, she was not
observed to have shortness of breath or other evidence
of respiratory difficulty when ambulating 100 feet or
more. The finding of such profound respiratory weak-
ness in an effort dependent task such as MIP and MEP
testing is difficult to reconcile with her overall physi-
cal performance. Such severely decreased respiratory
strength, for example, would be expected to result in
speech signs that were not present, such as severely
decreased speech loudness and the use of short phrases
to allow for frequent respiration. Additionally, deficits
in the respiratory mechanism in patients with FAS have
not, to our knowledge, previously been reported.
6.2. Larynx
No dysphonia was present in connected speech,
though an elevated fundamental frequency (i.e., habitu-
al pitch) was present. During isolated laryngeal testing,
a high-pitched, tremulous, and breathy dysphonia was
present. Pitch range was variable. Similar to testing
of the respiratory mechanism, performance was more
disordered on isolated tasks than in connected speech.
Laryngeal involvement is not typical in patients with
FAS .
6.3. Velopharynx
Velopharyngeal assessment suggested a slight res-
onance imbalance perceived as mild, variable hyper-
nasality. Isolated tested of velopharyngeal performance
appeared consistent with her connected speech perfor-
mance. Hypernasality or other resonance abnormalities
are not commonly reported in organic FAS.
6.4. Orofacial mechanism
Severe right-sided lingual deviation with protrusion
was present during oral motor examination. During
speech diadochokinesis, the patient was asked to pro-
duced “puh”, “tuh”, and “kuh” as rapidly, precisely,
and evenly as possible. Her productions were irregular
and distorted, and the rate of speech decreased with in-

H.N. Jones et al. / Conversion disorder and foreign accent syndrome 251
creased length of production. Speech sound distortions
including substitutions, prolongations, omissions, and
insertions were evident in connected speech. Vowels
were perceived to be more distorted than consonants
overall. Tonguebulb testing of lingual strength with the
IOPI revealed tongue weakness greater than two stan-
dard deviations below the mean [53]. Many articulatory
deficits present in this patient’s speech are commonly
reported in patients with FAS.
6.5. Prosody
Multiple prosodic abnormalities were present. Rate
of speech was slow. Articulation rates in syllables/sec
were obtained from the oral reading of the Grandfather
Passage and from a brief sample of spontaneous speech.
The procedure employed by Tsao and Weismer [54]
to assess oral reading rate was utilized in that pause
times equal to or longer than 150 ms were deducted
from speaking time. Also, for those phonetic contexts
within a sentence in which a word with a final stop
sound was followed immediately by a word with an
initial stop sound (e.g., “ancient black,” “frock coat”), a
pause had to be longer than 300 ms to be deducted (55).
To measure articulation rate in spontaneous speech,
pause times longer than 250 ms were deducted from
total speaking time and time spent producing interjec-
tions (e.g., “uh,” “um,”) were not included in the total
time. Mean articulation rate during oral reading was
3.40 syllables/sec (sd =0.53). Rate of speech within
the 11 individual sentences in the Grandfather Passage
ranged from 2.08–4.12 syllables/sec. Tsao and Weis-
mer reported a mean of 3.72 syllables/sec for the 15%
of their participants who demonstrated the slowest oral
reading articulation rates. Compared to these data, the
speaker in the present study evidenced an oral reading
articulation rate that was more than one standard devi-
ation below the mean of their slowest group. The FAS
speaker’s articulation rate in spontaneous speech was
somewhat faster. The overall mean rate based on 186
spoken syllables was 4.05 syllables/sec. The sample
contained 20 runs of speech uninterrupted by 250 ms
or longer pauses or interjections.The mean articulation
rate/run was 3.86 syllables/sec (sd =0.66). These runs
of speech ranged from 2–22 syllables in length and the
articulation rates ranged from 2.39–4.85 syllables/sec.
There was a significant correlation between length of
run in syllables and articulation rate (r=0.740, df =
20, p<0.001) in that longer runs of speech were spo-
ken at a faster articulation rates. These spontaneous
speech rates are at the low end of ranges reported in the
literature [56,57].
Intonation and stress were both aberrant. Intonation
was characterized by unusual, excess pitch variability,
while stress was characterized by reduced distinctions
between stressed and unstressed syllables. Overall nat-
uralness of speech was found to be severely affected
due to its overall very unusual profile of features.
6.6. Speech assessment
Motor speech examination revealed more distributed
involvementof the speech mechanism than is common-
ly reported in FAS. Speech signs in FAS are almost in-
variably related to deficits in articulation and prosody,
while this patient also presented with marked involve-
ment of respiration and phonation. Resonance was also
affected, though less severely. Many of the patient’s
speech signs, especially those uncommonly reported
in FAS, were only revealed or were magnified in iso-
lated testing, suggesting effort-dependent variability.
Connected speech performance was much more con-
sistent with previous descriptions of FAS and empha-
sized speech signs related to articulatory and prosodic
deficits such as sound distortions, substitutions, pro-
longations, omissions, and insertions, more prominent-
ly in vowels than consonants; disordered rate, intona-
tion, stress, and speech naturalness; and decreased in-
telligibility. More unusually in FAS, mild and variable
hypernasality was also present, as well as an elevated
fundamental frequency.
7. Interventions
7.1. Medical therapy
Patient was treated over a multiyear period for chron-
ic daily headaches with migraine features that were re-
ported of sudden and unprovokedonset. She was treat-
ed with a range of neuroleptic and psychotropic medi-
cation towards the management of affective disturbance
and headache pain. More specifically, by the time she
was evaluated for biofeedback, she had been unsuc-
cessfully treated with topiramate, amitriptyline, dulox-
etine, and sumatriptan for her headache. At the time
of the psychological evaluation as part of her entry into
the biofeedback program, she was at the end of an un-
successful trial of duloxetine 60mg/day. Her mood and
headache pains reportedly remained unaffected. Dur-
ing neurological management subsequent to the refer-

252 H.N. Jones et al. / Conversion disorder and foreign accent syndrome
ral for biofeedback, she reported that behavioral tech-
niques and pain copin g skills training were elevating her
mood and producing stability in her headache pains. In
addition to headaches, she complained of diffuse joint
pain. Thyroid profile, sedimentation rate, and rheuma-
toid factor evaluation were all checked and found to be
in the normal range.
7.2. Pain management intervention
Behavioral interventions for pain management in-
cluded biofeedback, pain coping skills training, and
progressive muscle relaxation training [58,59]. Pain
systematically increased from a 4/10 at the first ses-
sion to a 10/10 by the sixth session, with a focus on
her cognitive and affective responses. By the sixth ses-
sion, she was grimacing, exhibiting a slowed gait, and
reporting significantly more pain sites, including her
hip. She was described by her therapists as affectively
“flat” and minimally responsive to issues unrelated to
her physical functioning. She noted that many of her
relationships had been altered, but attributed this to her
pain and physical limitations. Sessions seven through
13 continued with aggressive behavioral interventions
for her chronic pain, though symptom relief was not
obtained. The patient was subsequently referred to an-
other headache clinic in her local area.
7.3. Speech therapy
Following her motor speech examination, she was
offered a behavioral treatment program targeting her
speech sound errors. During her first and only treat-
ment session, the patient demonstrated greater than ex-
pected difficulty improving the accuracy of her speech
sounds, even with the production of vowels in isolation
with maximal modeling and cueing from the clinician.
The patient did not return for her next visit. When she
was called for follow-up, she indicated that she was sat-
isfied with her current speech and did not desire further
intervention to address her speech changes.
8. Discussion
Duffy [60] defines the clinical features of FAS as
variability in the perceived accent by listeners due to
changes in vowels (e.g., distortions, prolongations, in-
sertions, omissions), consonants (e.g., voice, manner,
and place distortions; substitutions), and prosody (e.g.,
inappropriate pitch contours, altered stress, reduced
rate). Such speech characteristics indicate prominent
involvement of articulation and prosody, producing the
impression of a foreign accent to listeners. Rarely does
the speech pattern match the non-native speech encoun-
tered in a specific language; thus, the term pseudofor-
eign accent is also appropriate. By any measure, FAS
is a rarely encountered communication disorder, with
Haley and colleagues [29] estimating the presence of
about 50 cases in the literature. We present a case of
FAS secondary to conversion disorder based on multi-
disciplinary assessment and treatment. Our patient was
a 39-year-old African-Americanfemale who presented
with FAS and chronic daily headache. She reported
physical discomfort, lacked a clear functional purpose
to her symptoms, and denied emotional distress.
Published cases of FAS associated with psychiatric
disease are less common but have been reported with
increasing regularity over the last decade and have in
many ways expanded the definition of what constitutes
FAS. Reeves, Burke, and Parker [25] and Reeves and
Horton [26] described a total of four patients with psy-
chosis who exhibited signs of FAS which correlated
in severity to the severity of their psychotic signs and
whose speech gradually returned to baseline with im-
provement of their psychosis. Gurd and colleagues [61]
reported a case of FAS with an unclear etiology in a
47-year-old female who presented with FAS one month
following the sudden onset of aphasia and headache.
The onset of a French sounding accent was followed
shortly by onset of a “bizarre” gait. Although the pa-
tient had several small lesions on imaging, the authors
“doubted whether all of the patient’s symptoms could
be accounted for organically” (p. 715). Verhoeven and
colleagues [28] described an instance of probable con-
version disorder involving a 51-year-old woman who
experienced a “psychotrauma” when she was nearly
involved in accident while riding her bicycle. She de-
veloped FAS and a progressive gait disturbance over
the course of the following eight years. Most recent-
ly, Haley et al. [29] reported a case of FAS associat-
ed with conversion disorder in a 36-year-old female
with intermittent episodes of neurological symptoms,
such as increased speech and gait disturbances, sensory
changes, and weakness. Between acute exacerbations
typically lasting two to four days, the patient’s accent
was considered milder.
Based on review of the available literature and our
own clinical experience, we suggest that patients with
non-organic FAS exhibit a different clinical course and
exhibit different findings on examination. In the case
of our patient, her clinical course was very atypical

H.N. Jones et al. / Conversion disorder and foreign accent syndrome 253
compared the findings reported in patients with FAS
secondary to neurologic lesions. For example, she re-
ported waking up one morning with a severe headache
that confined her to bed. Two or three days later, she
awoke speaking with a foreign accent that she only
noticed when others commented on the change. She
reported mutism occurred during this period to her
speech pathologist and psychologist, but never report-
ed this symptom to her ED physicians or neurologist.
Two months later, her persistent headache and speech
changes finally caused her to seek medical attention in
the ED. Her right-sided sensory loss and abnormal gait
did not appear for several more months. This course
is clearly very atypical for a patient with FAS due to
organic etiology such as CVA or TBI. Additionally, she
never demonstrated a lesion of any sort with multiple
imaging studies over several years.
Reports identifying conversion disorder in FAS are
uncommon so it is difficult to isolate particular fea-
tures which may differentiate organic versus nonorgan-
ic FAS. However, two reports of conversion disorder
associated with FAS in the literature [28,29] also pre-
sented with unusual gait, similar to the present case. In
the present case, as well as the patient described by Ha-
ley and colleagues [29], the bilateral gait abnormalities
during relapses were suspicious for psychogenic gait
disorders, while in the case described by Verhoeven and
colleagues [28], an eight year history of progressive
gait disturbance eventually left the patient wheelchair
bound. Hemiplegia, with or without facial weakness,
may also be encountered in FAS, though recovery or
improvement often occurs.
Patients with nonorganicFAS also appear to present
with more distributed involvement of the speech mech-
anism than those with organic FAS. While organic
FAS is almost exclusively defined by articulatory and
prosodic speech changes, in cases of probable and con-
firmed non-organic FAS, more distributed involvement
may be encountered. Laryngeal involvement in the
form of dysphonia appears particularly common in non-
organic FAS [27,61]. In our case, dysphonia was only
present in isolated testing. This high-pitched, tremu-
lous vocal quality was not present in connected speech.
A similar but more pronounced disconnect was present
in assessment of the respiratory mechanism. Although
careful auditory-perceptual assessment of respiratory
function suggested performance grossly within normal
limits for speech production, instrumental strength test-
ing of the respiratory mechanism via digital pressure
gauge manometry during maximal inhalation and ex-
halation (i.e., MIP, MEP) revealed profound respiratory
weakness. Such respiratory weakness would have seri-
ous implications for pulmonary morbidity and mortali-
ty and does not appear compatible with her respiratory
function during speech or with other observed physical
exertion (e.g., ambulating in clinic).
Conversion disorder is a controversial diagnosis. Pa-
tients are often diagnosed with a psychosomatic illness
based on the absence of medical data supporting an or-
ganic cause [62]. One problematic assumption is that
all potential organic causes are known and recogniz-
able. A conversion diagnosis also leaves little room to
specify both functional and organic etiologies to a pre-
senting condition [63], and the diagnosis itself typically
relies on null or inconsistent findings. While misdiag-
nosis is a concern with conversion disorder, data from
Mace and Trimble [64] reveal that if patients undergo
comprehensive neurological exams prior to a diagno-
sis of conversion disorder, less than 15% were misdi-
agnosed up to 10 years later. In the present case, we
suggest that convergent data from repeated examina-
tions by an appropriate multidisciplinary team further
reduces the likelihood of misdiagnosis.
Consistent with this approach, we have presented a
case of probable conversion disorder based on conver-
gent data from repeated encounters with a multidis-
ciplinary team comprising multiple specialties includ-
ing neurology, radiology, neuropsychology, psychia-
try, and speech-language pathology. These encounters
consistently revealed effort-dependent inconsistencies
in the patient’s exam results without evidence of an
underlying physiological cause. Neuropsychological
testing revealedpoor effort on several memory and mo-
tor tasks, as well as discrepancies between simple and
complex procedures that is atypical of neurological dis-
ease. Similarly, speech function was often found to
be more disturbed in isolated testing than in connected
speech. Her responses to psychological questionnaires
produced profiles highly consistent with a somatoform
disorder due to excessive somatic dysfunction in the
absence of reported emotional distress. While conver-
sion disorder remains a controversial diagnosis, errors
can be minimized by a thorough neurological exam and
follow-up consultations from appropriate disciplines.
In our attempts to assess and treat this patient, we col-
laborated across multiple specialties with independent
examinations. Our convergent findings assisted in rul-
ing out an organic etiology in this unusual case of FAS
secondary to conversion disorder.

254 H.N. Jones et al. / Conversion disorder and foreign accent syndrome
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