What is the diagnosis and treatment for a condition characterized by spontaneous speech interruptions, possibly triggered by external stimuli?

Functional Speech Disorder with Attention-Dependent Variability

This presentation is highly characteristic of a functional neurological disorder (FND) affecting speech, where the spontaneous speech that stops when someone passes by represents classic attention-dependent symptom variability—a positive diagnostic feature of functional speech disorder. 1

Diagnostic Approach

The key diagnostic feature here is the internally inconsistent pattern: spontaneous speech occurring continuously but stopping with external stimuli (someone passing by), which demonstrates that the speech mechanism itself is intact but governed by abnormally focused attention. 2, 1

Positive Diagnostic Signs to Confirm

• Symptom variability with attention and distraction is the hallmark finding—speech that changes when the patient becomes aware of being observed 1
• Inconsistent movements that vary during spontaneous conversation versus formal assessment 1
• Presence of excessive effort or struggle behaviors during speech attempts 1
• Symptoms that are internally inconsistent or disproportionate to any structural findings 1

Critical History Elements

• Sudden onset or onset following a specific stressor (upper respiratory infection, voice overuse, injury, traumatic head injury) 2
• Variability patterns: Do symptoms come and go? Are there periods when symptoms disappear completely? 2
• Exacerbating factors: Symptoms worsen with attention but may improve during automatic activities 1, 3
• Presence of other functional neurological symptoms (limb weakness, tremor, sensory disturbance) 2, 1
• Psychological stressors, trauma history, or comorbid anxiety/depression—though their absence does NOT exclude the diagnosis 2, 1

What NOT to Do

• Do NOT perform laryngoscopy unless dysphonia (hoarseness, altered voice quality) is the primary complaint 3
• Do NOT obtain CT or MRI prior to clinical assessment unless focal neurological findings are present 3
• Do NOT dismiss this as "psychogenic" or "not real"—these are genuine neurological conditions with specific positive diagnostic features requiring active treatment 1

Treatment Algorithm

Primary Treatment: Speech and Language Therapy with Motor Retraining

The American Academy of Neurology recommends implementing speech and language therapy with motor retraining as the primary treatment for functional speech disorders. 1

Core Treatment Components

• Education and explanation: Help the patient understand this is a disorder of function, not damage, with a positive prognosis 2, 1
• Symptomatic treatment strategies:
  • Use natural reflexive behaviors (speaking while lying down, dual tasks, speaking while listening to music through headphones) 3
  • Attention redirection techniques to shift focus away from speech production 1
  • Physical maneuvers that demonstrate potential for normal speech 3
• Motor retraining: Help the patient gain insight into positive changes in articulation and how they achieve more normal control over speech movements 2

Treatment Structure

• Intensive therapy with multiple sessions per week shows superior outcomes 1
• First session is crucial—anecdotal evidence suggests many patients with FND only attend one session, so make it positive and therapeutic 2
• Traditional treatment approaches used for developmental and neurological articulatory disorders may be effective 2

Addressing Psychological Factors

Psychiatric comorbidities (anxiety, depression) are common perpetuating factors that must be addressed concurrently—they do NOT preclude the diagnosis. 1

• Screen for and treat depression and anxiety disorders first or concurrently, as they prevent maintenance of treatment gains 3
• Cognitive Behavioral Therapy strategies to identify and challenge:
  • Abnormal illness beliefs and hypervigilance to bodily functions 2, 3
  • Avoidance behaviors 2, 3
  • Self-directed attention and preoccupations with speech difficulties 2
• Attention to psychosocial issues: Address cognitive features related to locus of control, executive function 2
• Counseling regarding psychological and life stresses contributing to symptoms 2

When to Refer

• Refer to mental health professionals when significant depression or anxiety is present or when psychological distress interferes with daily functioning 3
• Consider multidisciplinary collaboration with physiotherapy or occupational therapy if other functional symptoms are present 3

Common Pitfalls to Avoid

• Do NOT assume psychiatric comorbidity precludes functional disorder diagnosis—anxiety and depression are perpetuating factors, not exclusion criteria 1
• Do NOT wait for psychological insight before starting treatment—symptoms often develop after illness or injury, not major adverse life events 2
• Do NOT order extensive neuroimaging without focal neurological findings—the diagnosis is made clinically based on positive signs of internal inconsistency 1
• Do NOT use terms like "psychogenic" or "all in your head" when explaining the diagnosis—use "functional" to emphasize a disorder of function with aetiological neutrality 2

Prognosis

Functional speech disorders may resolve spontaneously or during treatment, with relatively good outcomes when treated appropriately with speech and language therapy. 2