Table 5

Treatment of functional articulation disorders

Domains of interventionExamples of possible strategies
Education and explanatory
  • Reassurance regarding nature of symptoms and good prognosis for resolution.

  • General principles already discussed as for functional voice and fluency including their understanding of diagnosis, the rationale for current diagnosis.

  • Education about how we actually speak vs how we think we speak for example, we do not necessarily pronounce words according to spelling.

Symptomatic
  • Reduction of excessive musculoskeletal tension in speech and non-speech muscles often associated with articulation: in head, neck, shoulders, face and mouth.

  • Where there is functional facial weakness, spasm, or trismus, collaborative treatment with physiotherapy or occupational therapy may be helpful.

  • Eliminate secondary or accessory movements which may involve the patient doing something differently, which acts as a distraction, later to be faded out as speech normalises.

  • Focusing on normal movements and sounds, distracting from abnormal sounds, etc.

  • Dual tasking while speaking as form of distraction.

  • Invite non-speech articulation such as singing.

  • Introduce skills in ‘mindfulness’ during oromotor tasks as a way of maintaining focus on easy, smooth movements where possible.

  • Slow speech down or elongate a sound rather than building tension around it, which can be explained as ‘resetting the system’.

  • Use nonsense words or syllable repetitions as way to demonstrate potential for ‘normal‘ function.

  • Advance communication with higher cognitive linguistic content in hierarchical fashion (similar to the strategies for functional voice and stuttering).

  • Redirect patient focus on speech to other topics, monitoring if speech improves and in which contexts.

  • If functional voice or fluency problems are also present the treatment of a single communication problem may result in resolution of all communication symptoms.

Psychological
  • Attention to psychosocial issues as for other symptom groups.

  • Address cognitive features related to locus of control, executive function, abnormal illness beliefs, hypervigilance to bodily functions, etc.

  • Help person gain insight into the positive changes in articulation, and how they are achieving more normal control over speech movements.

Psychological
  • Counselling by the speech and language professional in relation to psychological and life stresses contributing to symptoms.

  • Education about the physiology of anxiety, the anxiety arousal curve, and the importance of avoiding avoidance.

  • Treatment of any comorbid or secondary psychiatric disorder for example anxiety, depression, phagophobia.

  • Cognitive Behavioural Therapy strategies may be useful. Identify and challenge:

    • Beliefs and cognitions, for example, ‘food will stick in my throat’ ‘I will choke and die’.

    • Self-reported sensations, for example, ‘My throat feels tight and narrow’ ‘Food is sticking there and won’t move’.

    • Maladaptive behaviours, for example, avoidance of solids, withdrawing from others, eating in isolation.

  • Self-directed attention, for example, preoccupations with throat sensations ‘Chewing is hard, swallowing is difficult’.

  • Recommend positive self-statements during the swallow such as ‘my throat feels easy’, ‘this swallow is easy’.

Medical
  • Provide information and advice to reduce acid reflux. Signpost for appropriate medical management of acid reflux and/or post nasal drip if present.

  • Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants or low-dose amitriptyline may be helpful for globus.