Foreign accent syndrome is the perception by listeners that a speaker has acquired a foreign accent. It was classically described after stroke or other structural lesions of the language-dominant hemisphere, but the largest case series to date found that in the majority of self-reported cases the features were those of a functional disorder. Positive features here include variability of the accent from day to day, transient normalization with emotion, effortful and hesitant delivery, a migraine-type precipitant, normal imaging, and clustering with other functional symptoms including an entrainable tremor, chronic pain and irritable bowel syndrome.
Other functional speech presentations follow the same principles of variability and incongruity: functional dysarthria that varies with attention and may include stuttering that is inconsistent across contexts, functional dysphonia in which the voice is whispered or absent yet the cough and throat clearing are normal, showing that vocal cord adduction is intact, and globus with a normal swallow. Slow, effortful, telegraphic speech with preserved writing and comprehension is another recognized functional pattern.
Foreign accent syndrome is a rare presentation requiring detailed speech analysis, placing this item at the Subspecialty level of RITE content. Note that positive functional features were present even in some patients who had a structural lesion, so the two are not mutually exclusive.
Incorrect Answers
- B. Apraxia of speech produces consistent groping articulatory errors with effortful trial and error self-correction and is usually accompanied by aphasia and an imaging abnormality.
- C. Spastic dysarthria gives a strained strangled voice with slow speech, brisk jaw jerk and pseudobulbar affect, and does not fluctuate with mood.
- D. Adductor spasmodic dysphonia produces a strained voice with task-specific voice breaks on vowels, not an altered accent.
- E. Aphemia produces mutism or severely reduced speech output with preserved writing, and follows an identifiable dominant frontal lesion.
Testing Pearls
- Foreign accent syndrome is more often functional than structural in reported case series.
- Day-to-day variability and normalization with emotion are positive functional features.
- Normal cough with a whispered or absent voice indicates functional dysphonia.
- Functional speech symptoms usually cluster with other functional neurological symptoms.
- A structural lesion does not exclude concurrent functional speech features.
References
- Jankovic J, Mazziotta JC, Newman NJ, Pomeroy SL, editors. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022. p. 2084.
- McWhirter L, Miller N, Campbell C, Hoeritzauer I, Lawton A, Carson A, et al. Understanding foreign accent syndrome. J Neurol Neurosurg Psychiatry. 2019;90(11):1265-1269.
- Baker J, Barnett C, Cavalli L, Dietrich M, Dixon L, Duffy JR, et al. Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy. J Neurol Neurosurg Psychiatry. 2021;92(10):1112-1125.
