Speech Disorders in Adults Psychogenic

The human communication system is vulnerable to changes in the individual's emotional or psychological state. Several studies show the human voice to be a sensitive indicator of different emotions (Aronson, 1991). Psychiatrists routinely evaluate vocal (intensity, pitch), prosodic (e.g., rhythm, rate, pauses), and other features of communication to diagnosis neurotic states (Brodnitz,

1981). Speech-language pathologists also consider the contributions of psychopathology in the evaluation and management of acquired adult speech disorders (Sapir and Aronson, 1990). This is important because depression and/or anxiety are common in stroke, traumatic brain injury, and progressive neurological disease (Giannoti, 1972). Depression frequently occurs after a laryngectomy and may interfere with rehabilitation efforts (Rollin, 1987). Individuals subjected to prolonged stress may speak with excessive tension in the vocal mechanism. When misuse of the vocal apparatus occurs for a long period of time, it can lead to the formation of vocal fold lesions (e.g., nodules) and long-term dyspho-nia (Aronson, 1991; Case, 1991). One of the responsibilities of the speech-language pathologist is to determine if and how psychogenic components contribute to acquired speech disorders in adults secondary to structural lesions and neurological disease to enhance differential diagnosis and to plan appropriate intervention (Sapir and Aronson, 1990).

In general, some degree of psychopathology is present in most acquired adult speech disorders. It is reasonable that persons who previously communicated normally would be affected psychologically when their ability to communicate was disrupted. In such cases, psychopa-thology (e.g., depression and anxiety) contributes to and possibly exacerbates the speech disorder, but it is not the cause of the disorder. Therefore, while the speech-language pathologist must be alert to the role of psy-chopathology in assessment and management of these cases, these disorders are not "purely" psychogenic in nature.

Purely psychogenic speech disorders, the subject of this chapter, are rare in clinical practice. With psycho-genic speech disorders, the communication breakdown stems from a conversion disorder. Conversion disorders are included within a larger family of psychiatric disorders, somatoform illnesses. These tend to be associated with pathologic beliefs and attitudes on the part of the patient that results in somatic symptoms. The American Psychiatric Association (1987) defines a conversion disorder as "an alteration or loss of physical functioning that suggests a physical disorder, that actually represents an expression of a psychological conflict or need." An example might be a woman who suddenly loses her voice because she cannot face the psychological conflict of a spouse's affair. Here the symptom (voice loss) constitutes a lesser threat to her psychological equilibrium than confronting the husband with his infidelity. A partial list of psychogenic speech disorders includes partial (dys-phonia) or complete (aphonia) loss of voice (Andersson and Schalen, 1998), dysarthria (Kallen, Marshall, and Casey, 1986), mutism (Kalman and Granet, 1981), and stuttering (Wallen, 1961; Deal, 1982). There are a few reports that indicate patients can also develop psycho-genic language disorders, specifically aphasia (Iddings and Wilson, 1981; Sevush and Brooks, 1983) and dyslexia and dysgraphia (Master and Lishman, 1984). Reports of psychogenic swallowing disorders (dyspha-gia) also exist (Carstens, 1982).

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