The patient who didn’t know
Mrs. A was successfully treated for psychotic symptoms, but she answers all questions with, ‘I don’t know.’ What could be limiting her speech?
7 and frontotemporal8 and stroke-related9 speech disorder. Neuroimaging studies may be helpful in differentiating language disorders from psychosis. For example, evidence of lesions in the language centers of the brain is found in some cases of aphasia, and enlarged ventricles is a common finding in patients with schizophrenia. We considered all of these possibilities when evaluating Mrs. A (Table 2).
Table 1
Mrs. A’s family and personal history of ‘nerve problems’
| Childhood | Mrs. A’s mother had ‘nerve problems.’ Her father physically abused Mrs. A. She received a ninth-grade education |
| Adult life | Married at age 17, Mrs. A had her first child at age 19, second child at age 20, and third child at age 21. She never obtained employment but raised her children with her husband |
| Last 2 years | Mrs. A lived in a trailer next to the house where her husband lived with 2 of their children. Family reports Mrs. A’s ’nerve problems’ were the reason for the separation. They state they took care of her needs and made sure she took her medications |
| Last 2 months | Mrs. A was admitted to a local psychiatric facility with confusion, hallucinations, crying spells, and decreased speech. After discharge, she could perform activities of daily living, but her speech did not improve |
| Present | Mrs. A is a passenger in a motor vehicle accident that results in her husband’s death and multiple injuries to her son. She is admitted to our hospital |
What is the cause of Mrs. A’s speech difficulties?
| Possible diagnosis | Finding that ruled it out |
|---|---|
| Primary progressive aphasia | Subacute onset with rapid progression |
| Frontotemporal dementia | Inconclusive mild frontotemporal atrophy on brain MRI |
| Nonconvulsive status epilepticus | Normal EEG |
| Conversion disorder | Uncommon presentation: Mrs. A is beyond usual age of onset, and symptoms have lasted >1 month |
| Broca’s aphasia/CVA | No corresponding organic lesions on MRI |
| Factitious disorder | No motivation to assume the sick role |
| Psychotic speech | No other evidence of psychosis |
| CVA: cerebrovascular accident; EEG: electroencephalography; MRI: magnetic resonance imaging | |
TREATMENT: An abbreviated stay
A week after admission, Mrs. A is deemed medically stable. Head CT reveals a small, calcified left parietal meningioma that did not correlate with her symptoms (Table 3). Brain MRI shows mild frontotemporal atrophy that was considered inconclusive evidence for a diagnosis of frontotemporal dementia; there is no evidence of infarction, tumors, or other enhancing lesions that may have explained Mrs. A’s symptoms. A 12-lead EEG shows no abnormalities, which rules out a seizure disorder.
Neurology consult rules out concussion syndrome. Over several different evaluations, Mrs. A is noted to follow commands, perform ADLs, and walk. She is able to write her name legibly but is unable to write anything else or to perform a clock-drawing test.
A speech pathology evaluation is requested. A speech pathologist diagnoses Mrs. A with expressive aphasia—impaired ability to speak and write—with some receptive component, meaning her ability to comprehend spoken words also is impaired.
Mrs. A’s speech status does not change, and she remains unable to communicate. She is discharged 10 days after admission with scheduled outpatient follow-up.
Table 3
Findings of Mrs. A’s neurologic testing
| Test | Result |
|---|---|
| Head CT | 1-cm dural-based lesion in the left posterior parietal region |
| Brain MRI | Mild, inconclusive frontotemporal atrophy |
| EEG | Normal |
| CT: computed tomography; EEG: electroencephalography; MRI: magnetic resonance imaging | |
The authors’ observations
At discharge, it seemed likely that Mrs. A may have early symptoms of a neurodegenerative illness, such as frontotemporal dementia, or the aphasia may be a manifestation of chronic psychotic depression. We wanted to follow up with neuropsychological testing and PET scan before establishing a definitive psychiatric diagnosis and modifying the treatment plan.
Related resources
- The Academy of Aphasia. www.academyofaphasia.org.
- The National Aphasia Association. www.aphasia.org.
- Amoxicillin/clavulanate • Augmentin
- Diazepam • Valium
- Duloxetine • Cymbalta
- Escitalopram • Lexapro
- Lamotrigine • Lamictal
- Olanzapine • Zyprexa
- Ziprasidone • Geodon
- Zolpidem • Ambien
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
