What is the cause of this person's health issues?

Diagnostic Assessment: Functional Neurological Disorder with Communication/Swallowing Symptoms

This person is most likely experiencing a functional neurological disorder (FND) affecting communication, swallowing, or related functions, characterized by symptoms that are inconsistent with structural disease and driven by a biopsychosocial model of predisposing vulnerabilities, precipitating mechanisms, and perpetuating factors. 1

Key Diagnostic Features

The presentation described demonstrates classic hallmarks of functional communication and swallowing disorders:

• Internal inconsistency of symptoms: Resolution or reduced severity during spontaneous discussion when attention is diverted, or during automatic functions and emotionally expressive activities 1
• Disproportionate severity: Symptoms that are more severe than would be expected from any identified structural injury or lesion 1
• Suggestibility: Symptoms become more prominent when being discussed or focused upon 1
• Inefficient movement patterns: Struggle behaviors including overmouthing, facial contortions, excessive effort in breathing, neck and shoulder tension, and shifts in body posture 1

Underlying Biopsychosocial Framework

Predisposing Vulnerabilities

The condition typically develops in individuals with:

• Psychological traits: Neuroticism, stress reactivity, emotional inhibition, low self-esteem, or perfectionism 1
• Previous functional symptoms: History of other medically unexplained symptoms 1
• Adverse life events: Significant stress or poor relationships 1
• Biological vulnerabilities: Pre-existing conditions affecting the nervous system, respiratory system, or head and neck 1

Precipitating Mechanisms

Common triggers include:

• Physical events: Injury, surgery, viral infection affecting respiratory tract, or choking incidents with persistent belief something is caught in the throat 1
• Psychological dilemmas: Ambivalence over expressing negative emotions, conflict over "speaking out," sense of entrapment, or anticipation of difficult encounters 1
• Interpersonal stress: Significant adverse life events occurring around symptom onset 1

Perpetuating Factors

What keeps symptoms ongoing:

• Fear-avoidance behaviors: Perception that voice use or swallowing are dangerous or harmful 1
• Hypervigilance: Excessive self-monitoring and hypersensitivity to subtle changes in sensation 1
• Illness beliefs: Belief that symptoms are due to damage or disease, with symptoms becoming part of personal identity 1
• Medical uncertainty: Lack of clear diagnosis leading to excessive reliance on unreliable information sources 1

Critical Differential Diagnosis Considerations

This is NOT a diagnosis of exclusion made by ruling out everything else—it is made by identifying positive clinical features. 1 However, functional disorders can be comorbid with structural or neurological disease (termed "functional overlay"), requiring careful differentiation of which symptoms have a functional basis versus structural cause. 1

Essential Rule-Outs Based on Presentation Context

If the person has altered mental status or confusion, do not assume functional etiology without excluding:

• Hepatic encephalopathy (though normal ammonia has strong negative predictive value) 1, 2
• Alcohol intoxication or withdrawal 1
• Drug-related causes including benzodiazepines, opioids, gabapentin 1
• Infections (spontaneous bacterial peritonitis, pneumonia, urinary tract infection) 1
• Metabolic disorders (hypoglycemia, diabetic ketoacidosis, electrolyte abnormalities) 1
• Structural brain lesions (intracranial hemorrhage, subdural hematoma) 1
• Seizures or post-ictal states 1

If presenting with vague or poorly defined complaints, recognize that uncertainty about symptom significance and resulting fear are primary drivers of healthcare seeking behavior. 3 The medical history must translate vague complaints into precise symptoms, as poorly defined symptoms lose diagnostic discriminative power. 4

Management Approach

Communication Strategy

The explanation provided to the patient is therapeutically critical. 1 Explain that:

1. Brain-gut/brain-body communication is bidirectional: The brain sends and receives frequent messages to/from the body, usually dampening signals so they remain outside conscious awareness 1

2. Normal communication can go awry: Substantial life stress, strong negative emotions, inadequate sleep, inflammation, or infection can disturb this system, causing the brain to perceive sensations more strongly and send inappropriate signals 1

3. Symptoms are real, not imagined: Behavioral and psychosocial factors may exacerbate symptoms but are generally not the causes—most health problems are multifactorial 1

4. The brain can help reduce symptoms: Specialized psychological treatment (CBT, gut-directed hypnosis) and certain medications can make the brain less sensitive to input, regardless of whether the brain is actively contributing to symptom generation 1

Treatment Framework

Multidisciplinary approach involving speech-language pathology (for communication/swallowing symptoms) and behavioral health:

• Address perpetuating factors: Target fear-avoidance, hypervigilance, catastrophic thinking, and maladaptive illness beliefs 1
• Behavioral interventions: Stress management, sleep hygiene, physical activity, and adaptive coping strategies 1
• Psychological therapy: CBT or other evidence-based approaches for functional disorders 1
• Symptom monitoring: Use valid scales to measure treatment response 5

Common Pitfalls to Avoid

• Do not tell the patient "it's all in your head": This invalidates their experience and damages the therapeutic relationship 1
• Do not normalize or dismiss symptoms: Provide explanation and probable prognosis while acknowledging symptom reality 5
• Do not focus exclusively on one symptom: Most patients have multiple symptoms that should be addressed comprehensively 5
• Do not delay appropriate referral: Early introduction of behavioral health consultation improves acceptance and outcomes 1

Prognosis

Symptoms improve in weeks to several months in most patients, but become chronic or recur in 20-25% of cases. 5 Serious causes that are not apparent after initial evaluation seldom emerge during long-term follow-up. 5