Psychogenic Stuttering and Other Acquired Nonorganic Speech and Language Abnormalities

Archives of Clinical Neuropsychology 27 (2012) 557–568 Case Report Psychogenic Stuttering and Other Acquired Nonorganic Speech and Language Abnormalities Laurence M. Binder1,*, Jack Spector2, James R. Youngjohn3 1 Department of Neurology, Oregon Health and Science University, Beaverton, OR 97005-4771, USA 2 Baltimore, MD, USA 3 Scottsdale, AZ, USA *Corresponding author at: Department of Neurology, Oregon Health and Science University, 4900 SW Griffith Drive, Ste 244, Beaverton, OR 97005-4771, USA E-mail address: (L.M. Binder). Accepted 30 April 2012 Abstract Three cases are presented of peculiar speech and language abnormalities that were evaluated in the context of personal injury lawsuit or workers compensation claims of brain dysfunction after mild traumatic brain injuries. Neuropsychological measures of effort and motivation showed evidence of suboptimal motivation or outright malingering. The speech and language abnormalities of these cases probably were not consistent with neurogenic features of dysfluent speech including stuttering or aphasia. We propose that severe dysfluency or language abnormalities persisting after a single, uncomplicated, mild traumatic brain injury are unusual and should elicit suspicion of a psychogenic origin. Keywords: Forensic neuropsychology; Head injury; Traumatic brain injury; Malingering/symptom validity testing; Aphasia Possible psychogenic explanations for neuropsychological test abnormalities or symptoms can include malingering and factitious disorders, suboptimal or variable effort, and psychiatric conditions such as depression, anxiety, somatization, or conversion disorder. A variety of methods and measures have been designed to assess the possibility that suboptimal motivation or deliberate production of wrong answers might explain neuropsychological test score abnormalities. These measures include forced choice measures of recognition memory such as the Portland Digit Recognition Test, Test of Memory Malingering, Victoria Symptom Validity Test, and the Word Memory Test (WMT); forced choice measures of visual perception and vocabulary found in the Validity Indicator Profile; and measures of perceptual speed and accuracy including the b Test and Dot Counting. In addition, quantitative indexes of efforts have been applied to neuropsychological measures originally designed to assess cognitive and motor abilities. For example, low scores on Reliable Digit Span, computed from conventional administration of Digit Span, low scores on recognition memory trials of the Rey Auditory Verbal Learning Test (Rey AVLT) or California Verbal Learning Test—Second Edition (CVLT-2), and improbable abnormalities in manual dexterity, strength, and tactile sensation have yielded markers of poor effort (Boone, 2007; Larrabee, 2007, 2012). There are few guidelines in the literature for distinguishing between psychogenic and neurogenic types of speech and language disorders. Indeed, Seery (2005), a speech and language pathologist, noted that both acquired neurogenic stuttering and acquired psychogenic stuttering had features in common. Both psychogenic- and neurogenic-acquired stuttering disorders had sudden onset and occurred throughout utterances rather than only at the initiation of utterances, as in developmental stuttering. Seery noted that variability of dysfluency was not diagnostic of feigning. However, the lack of improvement in, easier speech conditions, such as speaking in unison, shouting, and speaking while finger tapping, was consistent with malingering. Nonmalingerers were also expected to improve when performing automatic speech tasks such as counting to 10 or reciting the days of the week. Another speech and language pathologist, Duffy (2001), observed that telegraphic and infantile grammatical constructions and physical grimacing and “struggle behavior” was consistent with malingered dysfluent speech. # The Author 2012. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: . doi:10.1093/arclin/acs051 Advance Access publication on 11 July 2012 558 L.M. Binder et al. / Archives of Clinical Neuropsychology 27 (2012) 557–568 The neuropsychological literature on the assessment of motivation includes the scant discussion of methods for distinguishing between genuine versus psychogenic or feigned speech and language abnormalities. In contrast, with the extensive neuropsychological literature on psychogenic abnormalities and effort and motivation in other areas of functioning published in the last two decades, we found only two published neuropsychological case studies of psychogenic speech and language abnormalities. Axelrod (2009) reported two cases of minor head injury seen for litigation purposes that likely had psychogenic causation of speech and language abnormalities. The first case was a woman with many nonorganic features that began many months after a minor head injury. In contrast to fluent speech in a prior neuropsychological evaluation, Axelrod observed incorrect combinations of present and past tense in the same sentences. Her speech was intermittently telegraphic and consistently slow and monotonic, and her language sometimes did not convey coherent information. On a forced-choice measure of motivation to remember, she performed significantly worse than chance, and on the WAIS-R her prior post-injury Verbal IQ of 85 fell to a Verbal IQ of 52. The second case involved serious eye injury but no serious brain injury. This woman spoke haltingly during the evaluation but fluently immediately afterwards. Speech comprehension was also much improved when she was observed later. Testing of motivation to remember was consistent with deliberate production of incorrect answers. Axelrod concluded that the presentations of both cases were implausible. In another case that occurred after a mild head injury in the context of litigation for personal injuries (Cottingham & Boone, 2010), the examinee initially had abnormalities in articulation, expression, and comprehension of oral language that later evolved into a foreign accent syndrome. Her history of longstanding, unexplained medical problems led to diagnoses of somatization and conversion disorders. Failure on some measures of efforts left the authors unable to exclude the possibility of intentional feigning of deficits or malingering. With so little available neuropsychological literature describing speech and language abnormalities of psychogenic origin, we felt that analysis of case material would prove informative. The cases presented here were adults in litigation seeking monetary damages in personal injury lawsuits or workers compensation claims referred for independent forensic neuropsychological evaluations to the private practices of the authors. In all cases, brain injuries were alleged to have resulted from relatively minor head injuries, and the examinees presented with speech or language abnormalities that were atypical of neuro (...truncated)