What is the most accurate diagnosis for a patient with sudden loss of expressive speech, preserved comprehension, and a history of psychological trauma, who is not consciously producing these symptoms?

Functional Neurologic Symptom Disorder

The most accurate diagnosis is functional neurologic symptom disorder (conversion disorder), as this patient demonstrates sudden loss of expressive speech with preserved comprehension and reading/writing abilities—a pattern of internal inconsistency that is incompatible with structural neurological disease and represents a positive clinical sign of functional disorder. 1

Diagnostic Reasoning

Why This is Functional Neurologic Symptom Disorder

The clinical presentation contains positive diagnostic features that establish this as a functional disorder rather than requiring exclusion of other conditions 1:

• Internal inconsistency: Loss of expressive speech while maintaining intact comprehension, reading, and writing abilities is neurologically implausible for any structural lesion 1
• Sudden onset in the context of significant psychological trauma history (recurrent victimization, state custody) represents a classic predisposing vulnerability 1
• Intermittent command-following suggests variability in symptom expression that is characteristic of functional disorders 1
• The preserved ability to read and write while unable to speak expressively demonstrates symptom inconsistency with any recognized neurological localization 1

Why Not the Other Diagnoses

Acute ischemic stroke is excluded because:

• No stroke syndrome produces isolated expressive speech loss with completely preserved reading and writing 2
• Broca's aphasia affects both spoken and written expression 2
• The internal inconsistency of symptoms is incompatible with structural brain lesions 1

Malingering is explicitly excluded by the question stem stating symptoms are not consciously produced 1

Factitious disorder is also excluded as the patient is not consciously producing symptoms 1

Somatic symptom disorder requires excessive thoughts, feelings, or behaviors related to somatic symptoms causing significant distress or functional impairment, but does not explain the specific neurological symptom pattern of speech loss 1

Clinical Context and Risk Factors

The patient's history of recurrent victimization and state custody represents predisposing psychosocial vulnerabilities documented in functional communication disorders 1:

• Adverse life events and trauma are recognized predisposing factors 1
• Stress and poor relationships contribute to functional symptom development 1
• However, the absence of clear psychological trauma should never discount a functional diagnosis—not all patients with functional disorders have identifiable stressors 1

Management Approach

Make a positive diagnosis immediately based on the internal inconsistency rather than waiting to exclude all possible structural causes 1, 2:

• Explain that symptoms are real, the diagnosis is not mysterious, and demonstrate the positive clinical signs to the patient 2
• Provide written materials and acknowledge the problem seriously 2
• Reduce excessive musculoskeletal tension in head, neck, shoulders, face, and mouth 2
• Use dual tasking while speaking as distraction from dysfluent patterns 2
• Redirect patient focus from speech mechanics to conversational content 2

Address comorbid psychological conditions concurrently as depression and anxiety significantly worsen outcomes and prevent maintenance of treatment gains 2:

• Treat comorbid depression first or concurrently with SSRIs or low-dose amitriptyline 2
• Refer to mental health professionals for structured CBT or acceptance and commitment therapy 2
• Evaluate psychosocial stressors including relationship conflicts, workplace stress, and trauma history 2

Common Pitfalls to Avoid

• Do not delay diagnosis waiting to exclude every possible structural cause—functional disorders can be diagnosed positively based on clinical features 1, 2
• Do not focus exclusively on speech symptoms while ignoring depression or anxiety, as this leads to treatment failure and relapse 2
• Do not provide communication aids that perpetuate avoidance patterns—encourage direct communication without technological supports 2
• Do not probe injudiciously about trauma if history is not forthcoming, as this can undermine the therapeutic relationship 1