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Abstract
Foreign accent syndrome (FAS) is a rare disorder where the affected person speaks in an accent that the listener perceives as foreign. Although most cases have left hemisphere lesions, some may be functional. We describe a case of functional FAS and present a video of her speech. We identify characteristics that help to distinguish functional from structural cases. These include preceding motor disturbances causing the maladaptive speech response, inconsistencies in accent production, the adoption of unusual mannerisms in speech and the speech disturbances being transient and reversible. We conclude that FAS is a complex disorder encompassing both functional and structural causes.
- Foreign Accent Syndrome
- Functional Neurological Disorder
- Psychogenic
- Conversion DIsorder
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Introduction
Foreign accent syndrome (FAS) is a rare disorder where the affected person speaks with an accent different from the their usual native tongue.1 It may occur either in isolation or with other deficits, including apraxia, aphasia or dysarthria. Some authors consider that the acoustic process gives rise to the accent; most cases appear to result from a deficit in linguistic prosody,2 the ‘melody’ of speech. The huge variation among cases gives little consensus about its nature.3 FAS is often linked to left hemisphere lesions but here we report a patient with features suggesting ‘functional’ or ‘psychogenic’ FAS.
A functional neurological disorder has symptoms that are demonstrably internally inconsistent and incompatible with structural disease.4 Other terms include psychogenic, non-organic, somatoform or conversion disorder.4 While functional motor disorders have well-characterised positive signs, functional FAS is uncommon and its clinical characteristics are not well known. We propose characteristics that may help to distinguish functional FAS from a neurogenic disorder.
Case description
A 59-year-old Scottish woman presented with a new foreign accent following facial trauma. She was previously well with no neurological, psychiatric or relevant medical problems. She had tripped and struck the left side of her face and head, losing several front teeth. There was no loss of consciousness, amnesia or immediate neurological deficit. Her CT scan of head was normal but MRI scan of brain showed an area of right occipital white matter high signal; this was thought to be consistent with a perinatal event and not relevant either to the head injury or the current presentation. She was admitted for observation but became distressed by her experiences in hospital. The missing teeth affected her speech but there was no change in accent.
One week later she underwent a dental repair under local anaesthetic. Soon afterwards she began to experience delayed post-traumatic stress symptoms, including repeated flashbacks of the accident and its aftermath in hospital, nightmares, poor concentration and a cyclical mood disturbance. She felt more hesitant with her speech, and her family noticed that she was speaking in a foreign accent. Before the accident she had spoken with a typical Edinburgh accent but she now sounded Scandinavian or German (see online supplementary video) although different people placed it differently. There was no dysarthria and apart from occasional minor errors when repeating phrases such as baby hippopotamus (‘baby hittopotomas’), her language was otherwise clear and fluent. There was no difficulty with initiation of speech. Syntax remained mainly intact, although at times she missed out conjunctions in her sentences such as ‘and’ and ‘to’, giving her speech a telegraphic sound.
Our patient has given consent for publication of an online video which accompanies this article.
Other neurological and cognitive examinations (Addenbrooke's Cognitive Assessment) were normal. In answer to the question ‘who was the female Prime Minister in the 1980s?’ she replied ‘Angela Merkel’. She also used German words, for example, ‘ya’ instead of ‘yes’. She described a sense of altered identity and that her thought processes were more ‘black and white’, with a poor tolerance for uncertainty. She identified this as one perception of a ‘German’ stereotype (neither the patient nor the authors, one of whom is German, agree with or endorse this stereotype!).
Her accent was mostly consistent but on two occasions she temporarily reverted back to her normal accent for a few hours on each occasion. She could imitate a ‘posh English’ accent as well as an Irish accent, indicating voluntary control of prosody.
We diagnosed functional FAS and explained this to her. We suggested to her that the change in speech was triggered by the dental injury that had caused a change in the ‘software’ of her speech and produced a new speech ‘habit’ in the context of associated psychological trauma from the accident, but that there was no evidence of brain injury. We prescribed citalopram and propranolol, with speech therapy and psychotherapy. Cognitive behavioural therapy was key in establishing a model of how the accent may result from a conditioned response to the initial injury. Of particular importance was the discussion of the role that her anxiety might have played in the cause of the syndrome and also in its maintenance—both on a physiological level in terms of anxiety-triggered muscle tension of speech muscles and on a psychological level with a perception of changed identity, feelings of dependence, decreased levels of activity and deterioration in mood and confidence. An important element of therapy was to challenge a ‘vicious circle’ in which her accent reinforced her altered identity and vice versa. Working on these factors in conjunction with speech therapy appeared to provide a basis for improvement. Her speech improved and transiently returned to normal after therapy, but she continued to have periods of foreign accent speech (see Figure 1 and online supplementary video 1).
Discussion and conclusion
FAS was first described in 1907 by the French neurologist Pierre Marie; he reported a Parisian patient who started speaking French with an Alsatian accent when recovering from a subcortical left hemisphere stroke. There have since been over 60 reported cases, with most associated with left hemisphere lesions such as stroke or traumatic brain injury.5 Blumstein and Kurowski3 proposed that the syndrome results from damage to the dominant language (usually left hemisphere) speech output motor system affecting the primary motor cortex and either its cortico-cortical connections or its cortico-subcortical projections.
There have been nine cases in which the authors suggested a functional or alternatively psychological disorder as the cause. Functional speech disorders exist in many forms, including stuttering dysfluencies, speech substitutions as well as defects in prosody of speech that could come in the form of a foreign accent.6 Critchley described a patient who developed a Welsh accent following post-traumatic neurosis after a car crash.7 Others have described functional FAS as psychogenic or conversion disorders.8–10 For example, Verhoeven et al9 reported a Dutch patient who developed a French accent, along with a bizarre gait following a traffic accident. Reeves et al11 ,12 reported four patients with normal brain imaging who developed FAS following psychosis and whose speech gradually returned to baseline as their psychosis improved. Finally, Gurd et al13 described a case of FAS in a patient whose speech deficit did not correlate with the neurological abnormality and suggested a mixed organic and functional cause.
This patient's functional FAS showed some features that help to differentiate a functional from a structural cause, based on the published literature and our own experience (see table 1). She showed variability in her accent, as well as some stereotyped linguistic and behavioural features associated with the accent. Her ability to imitate other accents successfully was particularly important in establishing that prosody pathways were essentially intact. Her new speech appeared soon after a dental injury that affected the sound of her speech, in keeping with a maladaptive conditioned response to the initial injury, as can be the case for other functional motor disorders.14
Features of functional foreign accent syndrome
In September 2013, the BBC screened a documentary ‘The woman who woke up Chinese’, featuring a woman from Plymouth, UK, who developed a Chinese accent.15 She, and one other patient in the programme, had symptoms reportedly triggered by migraine without an identifiable brain lesion and some features similar to those in table 1. FAS may be more often related to a functional disorder than previously thought.
As with all functional disorders, clinicians should remember that some patients might have both a disease process and a functional disorder. Motor speech production disorders can easily be mistaken for functional disorders, in part because they share features such as intersentence and intrasentence variability. On the other hand, patients with small lesions undercutting the posterior left frontal lobe can have features that suggest functional overlay. Therefore, it can be difficult to disentangle mechanisms and it is not always appropriate to make clear dichotomies between functional and structural conditions. Some cases in the literature described as neurogenic FAS may have a degree of functional disorder, perhaps explaining the difficulties in locating their neural correlates.
Acknowledgments
We thank Moira Little (Speech Therapist) and the patient for their help and consent to publication. We thank Dr Michael O'Sullivan for helpful reviewer comments.
References
Footnotes
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed. Reviewed by Michael O'Sullivan, Cardiff, UK.
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