Selective impairment of phonation: A case study

A 47-year-old right-handed man underwent craniotomy for clipping of an aneurism at the trifurcation of the left middle cerebral artery. Subsequently, he suffered a left hemisphere CVA after which his speech and language resembled that of Broca's aphasia with accompanying apraxia of speech. Medical, behavioral, and acoustical data amassed over a period of several months indicated numerous contraindications to traditional diagnoses of Broca's aphasia, apraxia of speech, and dysarthria. Ultimately, it was determined that the patient had a selective impairement of phonation or laryngeal apraxia. This was illustrated dramatically when he was taught to use an electrolarynx which allowed him to bypass his disrupted phonatory system. Speaking with the electrolarynx, the patient communicated normally. Any semblance of Broca's aphasia disappeared. Supralaryngeal articulation was normal; apraxia of speech behaviors were absent. This case report indicates that dissociation of oral and laryngeal gestures due to brain injury is possible. Mechanisms underlying such a dissociation for this case are reviewed. The possibility of discrete center lesions in the frontal motor association area causing different types of apraxia of speech is discussed.     

Apractic agraphia in a patient with normal praxis

Most right-handed crossed aphasics are not apractic. They usually have agraphia characterized by misspellings but retain the ability to write well-formed graphemes. We describe a right-handed patient with a right parietal lesion who was aphasic and not apractic. He was unable to write any formed graphemes despite a relatively preserved ability to spell aloud. We postulate that praxis and writing are dissociated in this patient because the motor engrams for praxis were located in his left hemisphere and the engrams for writing were in his right hemisphere. In addition, he comprehended commands for limb motor activities (praxis) far better than he comprehended other speech. This suggests that in this patient the areas used to comprehend limb motor commands may be anatomically distinct from areas important in comprehending other aspects of speech.     

Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study

The paper presents a 3-year follow-up of a prospective longitudinal study of posttraumatic stress disorder (PTSD) after motor vehicle accidents (J. Abnormal Psychol., 107 (1998) 508). Participants were 546 patients who had been assessed when attending an emergency clinic shortly after a motor vehicle accident, and at 3 months and 1 year afterwards. The prevalence of posttraumatic stress disorder PTSD at 3 years was 11%. Maintaining psychological factors, i.e. negative interpretation of intrusions, rumination, thought suppression and anger cognitions, were important in predicting the persistence of PTSD at 3 years, as were persistent health and financial problems after the accident. Other predictors were female sex, hospital admission for injuries, perceived threat and dissociation during the accident, and litigation.     

On the role of the anterior cingulate cortex in phonation: A case report

A 41-year-old male patient is presented with a lesion in the anterior cingulate cortex, medial orbital cortex, and rostral striatum bilaterally and supplementary motor area on the left side. The patient first exhibited a state of akinetic mutism which lasted about 6 weeks. During this state, no volitional vocal utterances were made; there were, however, occasional groans of pain. During recovery, the mute phase was replaced by a state in which the patient could whisper but not phonate verbal utterances. About 10 weeks after the accident, phonation was restored. The speech was characterized, however, by monotonous intonation and a very low frequency of spontaneous utterances. While the frequency of spontaneous speech improved noticeably during the following months, emotional intonation remained permanently defective. A comparison of the present case with other cases from the literature as well as experimental monkey data suggest that the anterior cingulate cortex is involved in the volitional control of emotional vocal utterances.     

Virtually driving: are the driving environments "real enough" for exposure therapy with accident victims? An explorative study.

There is a small but growing body of research supporting the effectiveness of computer-generated environments in exposure therapy for driving phobia. However, research also suggests that difficulties can readily arise whereby patients do not immerse in simulated driving scenes. The simulated driving environments are not "real enough" to undertake exposure therapy. This sets a limitation to the use of virtual reality (VR) exposure therapy as a treatment modality for driving phobia. The aim of this study was to investigate if a clinically acceptable immersion/presence rate of >80% could be achieved for driving phobia subjects in computer generated environments by modifying external factors in the driving environment. Eleven patients referred from the Accident and Emergency Department of a general hospital or from their General Practitioner following a motor vehicle accident, who met DSM-IV criteria for Specific Phobia-driving were exposed to a computer-generated driving environment using computer driving games (London Racer/Midtown Madness). In an attempt to make the driving environments "real enough," external factors were modified by (a) projection of images onto a large screen, (b) viewing the scene through a windscreen, (c) using car seats for both driver and passenger, and (d) increasing vibration sense through use of more powerful subwoofers. Patients undertook a trial session involving driving through computer environments with graded risk of an accident. "Immersion/presence" was operationally defined as a subjective rating by the subject that the environment "feels real," together with an increase in subjective units of distress (SUD) ratings of >3 and/or an increase of heart rate of >15 beats per minute (BPM). Ten of 11 (91%) of the driving phobic subjects met the criteria for immersion/presence in the driving environment enabling progression to VR exposure therapy. These provisional findings suggest that the paradigm adopted in this study might be an effective and relatively inexpensive means of developing driving environments "real enough," to make VR exposure therapy a viable treatment modality for driving phobia following a motor vehicle accident (MVA).     

Young female violent death trends in the general population during the Vietnam era.

Five birth cohorts of young women who became age 20 before, during, and after the Vietnam War were selected for this study of motor vehicle accident, suicide, and homicide between ages 13 and 30. Suicide and homicide increased strongly in succeeding years (1953-1986). Motor vehicle accident rates were affected primarily by age. But age, birth cohort membership, and age x cohort interaction significantly affected suicide and homicide rates, with the 19-24-year-old age range most greatly affected. The correlation between suicide and homicide risk (r = .92) was similar to that for young males (r = .95) and suggested a common source of pathogenesis for both genders.     

A controlled evaluation of cognitive behavioural therapy for posttraumatic stress in motor vehicle accident survivors

Seventy-eight motor vehicle accident survivors with chronic (greater than 6 months) PTSD, or severe sub-syndromal PTSD, completed a randomized controlled comparison of cognitive behavioral therapy (CBT), supportive psychotherapy (SUPPORT), or a Wait List control condition with two detailed assessments. Scores on the CAPS showed significantly greater improvement for those in CBT in comparison to the Wait List and to the SUPPORT conditions. The SUPPORT condition in turn was superior (p=0.012) to the Wait List. Categorical diagnostic data showed the same results. An analysis of CAPS scores including drop-outs (n=98) also showed CBT to be superior to Wait List and to SUPPORT with a trend for SUPPORT to be superior to Wait List. The CBT condition led to significantly greater reductions in co-morbid major depression and GAD than the other two conditions. Results held up well at a 3-month follow-up on the two active treatment conditions.     

PTSD and Emotional Distress Symptoms Measured After a Motor Vehicle Accident: Relationships with Pain Coping Profiles

This study explored differences among pain patients classified as Dysfunctional, Interpersonally Distressed, and Adaptive Copers on the Multidimensional Pain Inventory with respect to PTSD symptomatology, anxiety, and depression. Eighty-five patients with pain complaints who had experienced a serious motor vehicle accident were classified into these three pain coping categories and assessed using clinician and self-report measures. Results indicated that patients classified as Adaptive Copers (n = 24) showed less PTSD symptomatology, anxiety, and depressed mood, relative to individuals classified as Dysfunctional (n = 36) and as Interpersonally Distressed (n = 25), who did not differ on these dimensions. Emotional responses during the accident (fear, helplessness, danger, perceived control, and certainty that one would die) did not differentiate the groups. Pain profiles contributed to the prediction of self-reported PTSD symptoms, controlling for state anxiety. These data suggest that pain patients with both Dysfunctional and Interpersonally Distressed coping profiles are at elevated risk for a range of posttrauma problems following a serious motor vehicle accident.     

Post-traumatic stress disorder: A congnitive-contextural approach

Most people are psychologically effected by an extreme trauma and for a significant minority the debility is long term, often expressed as post-traumatic stress disorder (PTSD). A cognitive-contextual approach is described in which the prime focus is upon teaching the client how to interact adaptively with the memory of the trauma by: a) facilitating a switch from a primarily perceptual to a more conceptual level of processing the trauma itself; and b) placing the trauma in the context of past life experiences and determining its relevance for the future. The approach is illustrated by the treatment of a PTSD diagnosed motor vehicle accident victim.     

Assessment and treatment of PTSD after a motor vehicle collision: Empirical findings and clinical observations

Individuals who experience a serious motor vehicle accident (MVA) are at increased risk for psychological problems, particularly Posttraumatic Stress Disorder (PTSD). In this article, we review the literature on PTSD among MVA survivors, with particular attention to available instruments to screen for and assess symptomatology of the disorder. Approaches to the treatment of PTSD in this population are reviewed, separated into interventions designed to prevent PTSD in unselected samples, treatment targeting individuals with Acute Stress Disorder that are designed to prevent subsequent development of PTSD, and therapy for individuals with chronic PTSD. Treatment process issues are discussed, in an effort to integrate empirical findings with clinical observations. The empirical literature suggests several approaches to treatment that have good potential outcomes, although continued work is needed to identify factors that predict treatment response, as well as augment individual-based treatment formats.     

Dysfunctional meaning of posttraumatic intrusions in chronic PTSD

The paper suggests that the negative idiosyncratic meaning of posttraumatic intrusions (e.g., 'I am going crazy') and cognitive strategies intended to control the intrusions play a major role in maintaining posttraumatic stress disorder. Two studies of 159 and 138 motor vehicle accidents survivors showed that the dysfunctional meaning of intrusions explained a proportion of the variance of the intrusion-related distress, strategies used to end the intrusions, and PTSD severity that was not explained by intrusion frequency, accident severity, or by general catastrophic thoughts when anxious. Rumination, thought suppression, and distraction when having intrusions showed substantial correlations with PTSD severity, as did avoidance of reminders of the accident. The results have implications for the treatment of chronic PTSD.     

Group Cognitive Behavior Therapy for Chronic Posttraumatic Stress Disorder: An Initial Randomized Pilot Study

Individuals with posttraumatic stress disorder (PTSD) related to a serious motor vehicle accident were randomly assigned to either group cognitive behavioral treatment (GCBT) or a minimum contact comparison group (MCC). Compared to the MCC participants (n = 16), individuals who completed GCBT (n = 17) showed significant reductions in PTSD symptoms, whether assessed using clinical interview or a self-report measure. Among treatment completers, 88.3% of GCBT participants did not satisfy criteria for PTSD at posttreatment assessment, relative to 31.3% of the MCC participants. Examination of anxiety, depression, and pain measures did not show a unique advantage of GCBT. Treatment-related gains were maintained over a 3-month follow-up interval. Patients reported satisfaction with GCBT, and attrition from this treatment was comparable with individually administered CBTs. Results are discussed in light of modifications necessitated by the group treatment format, with suggestions for future study of this group intervention.     

Paroxysmal speech disorder following left frontal brain damage

The patient was a 61-year-old female who suffered from the sudden attack of a speech disorder. The episodes of speech disorder lasted for less than 1 min, but occurred several times a day, paroxysmally. A CT revealed a low density area on the surface of the left frontal lobe and an EEG showed an abnormal wave at the frontoparietal area, more dominantly on the left. This condition was diagnosed as a kind of epilepsy. The paroxysmal speech disorder occurred very often during the 2 months after the first episode. However, with therapy using anticonvulsives and antibiotics, the condition began to improve after 4 months and disappeared completely after 6 months. It is assumed that the inflammatory change which occurred at the frontal lobe stimulated the supplementary motor area paroxysmally, and subsequently the speech disorder occurred as a kind of epilepsy.     

Group Cognitive Behavioral Treatment for PTSD: Treatment of Motor Vehicle Accident Survivors

Individual cognitive behavioral therapies (CBT) are now considered the first-line treatment for posttraumatic stress disorder (PTSD; Foa, Keane, & Friedman, 2000). As mental health reimbursement becomes more restricted, it is imperative that we adapt individual-format therapies for use in a small group format. Group therapies have a number of advantages, including provision of a natural support group, the ability to reach more patients, and greater cost efficiency. In this article, we describe the development of a group CBT for PTSD in the aftermath of a serious motor vehicle accident (MVA). Issues unique to the group treatment format are discussed, along with special considerations such as strategies to reduce the potential for triggering reexperiencing symptoms during group sessions. A case example is presented, along with discussion of group process issues. Although still in the early stages, this group CBT may offer promise as an effective treatment of MVA-related PTSD.     

Enhanced priming for trauma-related words predicts posttraumatic stress disorder

There is preliminary evidence that enhanced priming for trauma-related cues plays a role in posttraumatic stress disorder (PTSD). A prospective study of 119 motor vehicle accident survivors investigated whether priming for trauma-related stimuli predicts PTSD. Participants completed a modified word-stem completion test comprising accident-related, traffic-related, general threat, and neutral words at 2 weeks post-trauma. Priming for accident-related words predicted PTSD at 6 months follow-up, even when initial symptom levels of PTSD and depression and priming for other words were controlled. The results are in line with the hypothesis that enhanced priming for traumatic material contributes to the development of chronic PTSD.     

Cognitive behavioural and neuropsychiatric treatment of post‐traumatic conversion disorder: a case study

Conversion disorder consists of involuntary sensory or motor symptoms and deficits that cannot be explained by a general medical condition. There are several treatment options, although none has emerged as the treatment of choice. The present case study examined the effects of adding cognitive behaviour therapy to neuropsychiatric management of conversion disorder (motor subtype). The patient, a retired emergency services worker, presented with a history of intermittent episodes of speech disruption (inability to speak or difficulty speaking properly). Although episodes of speech disturbance sometimes occurred unexpectedly, they were more likely to occur under conditions of stress and fatigue, and were triggered by reminders of work‐related traumatic events. The patient was treated with pharmacotherapy and psychoeducation from a neuropsychiatrist. With the aim of improving treatment outcome, cognitive behaviour therapy was added, involving imaginal exposure to trauma memories, along with cognitive restructuring. The frequency of between‐ and within‐session speech disturbance episodes declined over the course of cognitive behaviour therapy to the point that the patient was essentially symptom‐free. Within‐session distress ratings also decreased, which suggested habituation to trauma‐related memories. This case study demonstrates how particular cognitive behaviour therapy interventions can be usefully applied to one form of conversion disorder.     

Cognitive behavioural and neuropsychiatric treatment of post-traumatic conversion disorder: a case study

Conversion disorder consists of involuntary sensory or motor symptoms and deficits that cannot be explained by a general medical condition. There are several treatment options, although none has emerged as the treatment of choice. The present case study examined the effects of adding cognitive behaviour therapy to neuropsychiatric management of conversion disorder (motor subtype). The patient, a retired emergency services worker, presented with a history of intermittent episodes of speech disruption (inability to speak or difficulty speaking properly). Although episodes of speech disturbance sometimes occurred unexpectedly, they were more likely to occur under conditions of stress and fatigue, and were triggered by reminders of work-related traumatic events. The patient was treated with pharmacotherapy and psychoeducation from a neuropsychiatrist. With the aim of improving treatment outcome, cognitive behaviour therapy was added, involving imaginal exposure to trauma memories, along with cognitive restructuring. The frequency of between- and within-session speech disturbance episodes declined over the course of cognitive behaviour therapy to the point that the patient was essentially symptom-free. Within-session distress ratings also decreased, which suggested habituation to trauma-related memories. This case study demonstrates how particular cognitive behaviour therapy interventions can be usefully applied to one form of conversion disorder.     

Effect of speech task on intelligibility in dysarthria: a case study of Parkinson's disease

This study assessed intelligibility in a dysarthric patient with Parkinson's disease (PD) across five speech production tasks: spontaneous speech, repetition, reading, repeated singing, and spontaneous singing, using the same phrases for all but spontaneous singing. The results show that this speaker was significantly less intelligible when speaking spontaneously than in the other tasks. Acoustic analysis suggested that relative intensity and word duration were not independently linked to intelligibility, but dysfluencies (from perceptual analysis) and articulatory/resonance patterns (from acoustic records) were related to intelligibility in predictable ways. These data indicate that speech production task may be an important variable to consider during the evaluation of dysarthria. As speech production efficiency was found to vary with task in a patient with Parkinson's disease, these results can be related to recent models of basal ganglia function in motor performance.     

Psychiatric disorders and motor vehicle accidents

The literature has often suggested a relationship between psychiatric illness and increased risk for motor vehicle accidents but few data exist, particularly those from prospective or case-controlled studies. The present study examined detailed accident and injury data from a large series (N = 1778) of motor vehicle crashes that included persons with diagnoses of psychiatric illnesses (n = 17); matched controls were also studied. As expected, drivers with psychiatric diagnoses used psychotropic medications more frequently than did controls. Drivers with psychiatric diagnoses did not have more frequent single-car crashes, unsafe speed or failure to yield violations, or less restraint use than did controls. Such drivers did less often drive motorcycles and tended to be less often cited for alcohol use. Implications of these results for efforts toward prevention and for further study are discussed.     

The postnatal development of the motor speech area: a preliminary study

This preliminary study follows the maturation of motor speech areas and their adjacent orofacial motor zones in the right and left hemispheres of the human infant from 3 months to 72 months of age. Quantitative studies of basilar dendrite patterns of layer 5 cortical pyramids are reported in 17 age-graded subjects. The sequence of developmental changes is characterized by early (3 month) prominence of orofacial motor zones over motor speech areas and of the right hemisphere over the left as expressed in total basilar dendritic length and the length of proximal order dendritic segments. The complex series of changes which follow appear to involve increase in number and marked increase in length of the developing distal order segments and possible shortening of the proximal segments. During a variable sequence of apparent growth spurts and resorptions, dendrite arborizations of the motor speech areas overtake and exceed those of orofacial musculature and the total length of dendrite systems on the left finally exceeds those on the right, although even in the most mature group, (42-72 months), distal segment length in the right motor speech area still exceeds that of the left. The early structural primacy of right-sided dendrite systems and the progressive shift to left-sided primacy is considered in the light of the presence of a long phylogenetic and ontogenetic history of gross anatomical asymmetry favoring the left side. The possibility that developmental patterns of the cortical macroenvironment and microenvironment may be dissociated with the microenvironment depending heavily on epigenetic factors receives support from recent data suggesting the existence of a time window or critical period during which primary language proficiency must be attained if normal lateralization of language function is to occur.