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.     

The neural circuitry of conversion disorder and its recovery

Little is understood about neural networks associated with conversion disorders. This case study reports the first investigation of the neural circuitry associated with the recovery of chronic conversion disorder. A patient with a four year history of hysterical mutism was assessed with functional MRI (fMRI) during a vocalization task, and then provided psychotherapy that attempted to reduce motivational factors that maintained mutism. The patient resumed full speech, and was readministered the fMRI vocalization task. Vocalization during mutism and following recovery of speech resulted in increases in speech-related networks, including the inferior frontal gyrus (IFG), middle frontal, and supplementary motor area of the frontal cortex, temporal and parietal cortices, and also in the primary and sensory motor regions. Following speech recovery but not during mutism, the IFG was correlated positively with the anterior cingulate cortex and negatively with the amygdala. This pattern suggests that during the conversion disorder there was impaired connectivity between speech networks and networks that regulate anxiety.     

Laryngeal anesthetization for the treatment of acquired disfluency: a case study

The subject of this case study is an adult who became severely disfluent after a motor vehicle accident in which he did not suffer significant injuries. His disfluency persisted for 4 months notwithstanding a short trial of speech therapy. Hyperfunctional phonation subsystem disturbances were identified on follow-up evaluations. Laryngeal anesthetization was achieved via a transcutaneous lidocaine injection. The patient improved dramatically within 15 min of the procedure. More than 18 months later, he has retained normal speech fluency without any additional post-injection intervention. Theoretical discussions are rendered to help interpret this treatment outcome. EDUCATIONAL OBJECTIVES: The reader will be able to describe (1) the laryngeal movements and adjustments commonly associated with stuttered speech; (2) the speech dysfunctions a patient evidenced following a motor vehicle accident; and (3) the author's treatment rationale for resolving the patient's speech disorder.     

Disorganization and Individual Psychotherapy for Schizophrenia: A Case Report of Metacognitive Reflection and Insight Therapy

Despite being a characteristic symptom of schizophrenia, implications for therapy with persons experiencing prominent disorganization have received less attention in the psychotherapy literature than have other aspects of the disorder. As such, formal thought disorder may be viewed largely as a barrier to effective participation in therapy. In contrast, though, a range of writers from varied traditions have stressed that this feature of schizophrenia is meaningful and improved coherence of speech is an important and viable component of treatment and recovery. This paper suggests that an emergent integrative psychotherapy, metacognitive reflection and insight therapy (MERIT), may be well-suited for work with persons experiencing disorganization symptoms. A brief overview of MERIT is provided, followed by a case report of an 18-month course of therapy with a man with severely disorganized speech.     

A Micro-Process Analysis of Functional Analytic Psychotherapy's Mechanism of Change

This study sought to clarify the micro-process of Functional Analytic Psychotherapy (FAP) by using the Functional Analytic Psychotherapy Rating Scale (FAPRS) to code every client and therapist turn of speech over the course of successful treatment of an individual meeting diagnostic criteria for depression and histrionic personality disorder. Treatment consisted of cognitive behavioral therapy alone followed by the addition of FAP techniques in a unique A / A + B design. In-session client behavior improved following the shift to FAP techniques, and micro-process data suggested that client behavior was effectively shaped by in-vivo FAP procedures. These results support FAP's purported mechanisms of change and highlight the advantages of utilizing molecular coding systems to explore these mechanisms.     

旋律语调疗法及其对失语症的临床应用

失语症是当今人类面临的一个重要的健康问题。旋律语调疗法被认为是治疗失语症的有效手段之一。传统旋律语调疗法强调严格的程序和材料,改编版本则依据患者情况进行调整,二者均能提高失语症者的自发言语产生、言语复述以及命名等能力。研究还表明,旋律语调疗法不仅能提高失语症者相关脑区的激活水平,而且也能通过影响失语症者的相关神经结构改善其言语功能。未来研究需要进一步确定该疗法的干预机制及其对汉语失语症的适用性。     

Multidisciplinary assessment and diagnosis of conversion disorder in a patient with foreign accent syndrome

Multiple reports have described patients with disordered articulation and prosody, often following acute aphasia, dysarthria, or apraxia of speech, which results in the perception by listeners of a foreign-like accent. These features led to the term foreign accent syndrome (FAS), a speech disorder with perceptual features that suggest an indistinct, non-native speaking accent. Also correctly known as psuedoforeign accent, the speech does not typically match a specific foreign accent, but is rather a constellation of speech features that result in the perception of a foreign accent by listeners. The primary etiologies of FAS are cerebrovascular accidents or traumatic brain injuries which affect cortical and subcortical regions critical to expressive speech and language production. Far fewer cases of FAS associated with psychiatric conditions have been reported. We will present the clinical history, neurological examination, neuropsychological assessment, cognitive-behavioral and biofeedback assessments, and motor speech examination of a patient with FAS without a known vascular, traumatic, or infectious precipitant. Repeated multidisciplinary examinations of this patient provided convergent evidence in support of FAS secondary to conversion disorder. We discuss these findings and their implications for evaluation and treatment of rare neurological and psychiatric conditions.     

Motor initiation and execution in patients with conversion paralysis

Motor initiation and motor execution in four patients with conversion paralysis were investigated in a non-affected motor modality (speech). In line with the hypothesis of dissociated control in conversion disorder [Cognit. Neuropsychiatry 8 (1) (2001) 21] motor initiation, but not response duration, was expected to be impaired. The motor initiation times (reaction time: RT) and motor execution times (response duration: RD) were compared on four RT-tasks that required the production of a verbal response: a simple choice RT-task, a mental letter rotation task, and an implicit and an explicit mental hand rotation task. Because conversion disorder is expected to primarily involve an impairment in the initiation of movement, we expected the following task characteristics to uniquely affect RT and not RD: type of instruction (implicit versus explicit instructed imagery), angle of rotation, and target arm (affected versus non-affected arm). The results indeed showed the task characteristics to significantly affect the participants' RT and not their RD. It was concluded that conversion paralysis is associated with a specific impairment in the explicit initiation of processes with a spatial and motor component.     

��If This is What I��m ��Meant to be������: The Journeys of Students Participating in a Conversation Partner Scheme for People with Aphasia

The development of speech language therapy students into clinicians is an area of increasing interest as educators focus on how knowledge, skills and attitudes are taught and learnt within the profession. The personal journeys of students through experiences of service learning have potential to further our understanding of the impact of civic engagement on the student experience and their learning. This paper explores the journeys of first year speech and language therapy students through a Thematic Analysis of reflective letters written by students to themselves at the beginning and completion of a service learning module. Analysis demonstrates development of interpersonal and preclinical skills as well as an understanding of attitudes and values inherent in the social model of disability. The skills and attitudes developed by the students through participation in the Conversation Partner Scheme are consistent with social model principles that support therapists to fully address the long-term, real life needs of clients with aphasia (the acquired communication disorder that frequently follows stroke). The interface between the social model of disability and the role of service learning in nurturing the attitudes and values which underpin this model are explored.     

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.     

Systems-Centered Therapy: A Protocol for Treating Generalized Anxiety Disorder

The systems-centered short-term therapy protocol was adapted and applied in three single case studies with generalized anxiety disorder (GAD) patients in a ten-session individual treatment over a two week period. All three subjects showed substantial improvement and no longer met diagnostic criteria post-treatment. Changes were maintained at follow up both six months and one year later. These results are promising and suggest the importance of further research on SCT as a viable, alternative treatment for generalized anxiety disorder.     

Speech pathology student clinician attitudes and beliefs towards people who stutter: A mixed-method pilot study

PurposeStuttering is a disorder of fluency that extends beyond its physical nature and has social, emotional and vocational impacts. Research shows that individuals often exhibit negative attitudes towards people who stutter; however, there is limited research on the attitudes and beliefs of speech pathology students towards people who stutter in Australia. Existing research is predominantly quantitative; whereas this mixed-method study placed an emphasis on the qualitative component. The purpose of this study was to explore the attitudes and beliefs of final year Australian speech pathology students towards people who stutter.MethodsThis mixed-method study applied the Public Opinion Survey of Human Attributes – Stuttering (POSHA-S) and semi-structured interviews to gather data from final year speech pathology students from a major university in Australia.Principal resultsThe overall qualitative findings identified that final year Australian speech pathology students exhibit positive attitudes towards people who stutter. The results also illustrated the role of education in influencing attitudes of students as well as increasing their confidence to work with people who stutter.Major conclusionThis research revealed that Australian final year speech pathology students exhibit positive attitudes towards people who stutter. They displayed an understanding that people who stutter may have acquired traits such as shyness as a response to their personal situation and environment, rather than those traits being endemic to them. Results also suggested that education can play a role in creating confident student clinicians in their transition to practice, and positively influence their attitudes and beliefs.     

Henry Freund: 1896–1982

Dr. Henry Freund was one of the foremost authorities on stuttering in Europe, and his contributions on the psychology of the disorder continued after emigrating to this country. He was a neurologist and psychiatrist, as well as a speech pathologist. He died in 1982, and in this posthumous paper he describes his career and personal experiences, while undergoing therapy from the most famous European speech pathologists of his time. He also offers some cogent comments about current therapies and future needs.     

Cognitive impairments and disordered speech in schizophrenia: thought disorder, disorganization, and communication failure perspectives

This article posits that basic cognitive impairments in schizophrenia are more highly related to speech disorder measured as communication failures than speech disorder measured as thought disorder or disorganization. The author tested 47 schizophrenia patients and 36 control participants for sustained attention, sequencing, and conceptual sequencing ability. Their speech was also rated for communication failures, thought disorder, and conceptual disorganization. Attention and sequencing impairments, examined hierarchically, explained a substantial 38% of the variance in the communication measure of speech disorder but little of the variance in formal thought disorder or conceptual disorganization. The author concludes that (a) impairments in attention and sequencing abilities contribute substantially to schizophrenic communication failures, and (b) it is important to consider lower level cognitive "3rd variables" when examining higher level cognitive associates of speech disorder.     

Fabricated Illness: Working within the Family System to Find a Pathway to Health

The term medically unexplained symptoms refers to a clinical presentation where the child's symptoms and impairment cannot be explained by any known organic pathology, and may include conversion disorders, somatoform pain disorders, factitious disorder, and factitious disorder by proxy. In this case study, we present our treatment of a 9‐year‐old girl with a 2‐year history of medically unexplained abdominal cramping and vaginal discharge. During the 9 months that we worked with this family, we were never able to clarify in our own minds the source of the child's symptoms—that is, who was responsible for their induction or who was the instigator or maintainer of the exaggerated symptoms. Nor did we come to fully understand the function of the symptoms in the family system. Our case report does not answer either of these questions. Instead, we describe how we worked with the family despite the ongoing ambiguities as to why the symptoms were occurring and who was inducing them. The functional outcome was disappearance of symptoms, return to full school attendance, and improved parenting behavior.     

Does the right hemisphere take over after damage to Broca's area? the Barlow case of 1877 and its history

In 1877 Thomas Barlow, a London physician, published a remarkable case of functional recovery of speech following brain damage. It involved a 10-year-old boy who had lost his speech, regained it, and lost it again before he died from a disorder that affected his heart and produced embolisms that subsequently affected other organs, including his brain. Examination of the boy's brain revealed two focal regions of softening; one that affected Broca's area and the left facial-motor area, and another, which occurred weeks later, in the homologous regions of the right hemisphere. Although Barlow was most concerned with motor deficits, others at the turn of the century began to cite this case as strong evidence that the corresponding region of the right hemisphere can take over speech functions for Broca's area on the left. Whether this case really provides good support for functional takeover or vicariation theory is critically evaluated in the light of contemporary research, including PET scan studies involving damage to Broca's speech region.     

Converting between word and syllable counts in children's conversational speech samples

Several authors have suggested that it is possible to convert between word and syllable counts for basic clinical measurements such as the frequency of speech disfluencies or speaking rate in conversational speech samples. Based primarily on results from adults' speech samples, proposed conversion factors have averaged approximately 1.5 syllables per word. Because children produce fewer multisyllabic words than adults, this conversion factor is probably not appropriate for children's speech samples. This study sought to develop a more accurate conversion factor for children's speech by comparing syllable and word counts in spontaneous speech samples produced by 50 children, age 3 to 5. Analyses revealed an average ratio of 1.15 syllables per word, which was consistent across different subjects, across subject groups (children who stutter and children who do not stutter) and also, somewhat surprisingly, across age groups (3-year olds, 4-year olds, and 5-year olds). Results suggest that this constant conversion factor of 1.15 can be used to convert between word and syllable with sufficient precision to allow clinicians to compare their data to published guidelines and benchmarks about childhood stuttering.     

A case of acquired aphasia and convulsive disorder: some linguistic aspects of recovery and breakdown

Among the cases of acquired aphasia and convulsive disorder several children are reported to have experienced more than one aphasic period. We present such a case in more detail, with emphasis on some characteristics of spontaneous speech. The occurrence of paraphasias, and in particular of neologisms, appeared to be associated with language recovery and breakdown. At the beginning of the period of recovery, a rapid and total disappearance of neologisms was observed, while only literal paraphasias remained. A period of language breakdown was preceded by the return of neologisms. The process was not influenced by drug therapy.