When a duck is not a duck: non-organic bases for aphasia and dementia

Abstract

ABSTRACTBackground: There are numerous reports in the literature describing cases of non-organic speech and language disorders. Most reports do not contain specific diagnoses (other than a “psychogenic” disorder); however, establishing which of the many psychogenic disorders are at play may be important for management and prognosis. This paper is inspired by 10 patients who presented to speech–language pathology (SLP) services with speech, language and/or cognitive impairments incongruent with organically based disorders. Non-organic symptoms are neurological complaints thought to be incompatible with recognised neurological or medical conditions. The patients, discussed here, presented with abnormal speech (stuttering, backward speech), language (aphasia) and/or cognition (dementia) that were ultimately reconciled in the psychiatric context.Aims: The aim is to provide empirical and clinical evidence that supports multidisciplinary assessment of patients who present with speech, language and cognitive impairments that do not seem to have a clear organic basis. The clinical data are discussed in the context of “non-organic” disorders and include exploration of relevant assessment and management issues.Methods and Procedures: Clinical files of 10 patients diagnosed with psychogenic disorders were retrospectively reviewed and evaluated on several factors contributing to their profiles. They included analysis of speech, language, neuroimaging, social and medical histories and psychological stressors reported by each patient.Outcomes and Results: Based on assessment results, a number of psychiatric conditions were identified, including conversion, factitious disorder, malingering and Ganser syndrome. Performance on language and cognitive tests was inconsistent with neurological disorders. Each patient appeared to be dealing with some sort of emotional conflict (e.g., unexpected obligation to take care of disabled parents or returning to an extremely stressful workplace). While those with the diagnosis of malingering, factitious or conversion disorders did not show imaging abnormalities, patients with abnormal imaging were initially diagnosed with Ganser syndrome and were found on a follow-up assessment to exhibit signs suggestive of behavioural variant fronto-temporal dementia.Conclusions: The literature suggests that as many as 30–60% of patients with seemingly non-organic symptoms end up with a neurological diagnosis that explains their initial somatic complaints, a proportion large enough to treat all non-organic disorders seriously. In addition to SLP, successful management of somatic communication disorders requires a multidisciplinary approach and an understanding that they may represent an alternative mode of communicating socially unacceptable feelings or thoughts. Additionally, regardless of questionable veracity of presenting symptoms, presence of abnormal neuroimaging findings should raise concerns of a neurodegenerative disorder.