SPEECH IMPAIRMENT

Managing Functional Neurological Disorder (FND) with Speech Impairment

Speech impairment is a common but often misunderstood symptom of Functional Neurological Disorder (FND). It can include mutism, stuttering, slurred or slowed speech, difficulty finding words, or voice changes. These symptoms are real, involuntary, and not a reflection of cognitive ability or intoxication.

Types of Speech Difficulties in FND

Common Presentations:

• Functional Mutism: Inability to speak, sometimes intermittent

• Stuttering or Word Blocks: Disrupted speech flow

• Slurred or Slow Speech: Difficulty with articulation or pacing

• Voice Changes: Whispery, strained, or absent voice

• Word-Finding Difficulty: Trouble retrieving words or names

Associated Features:

• Brain fog or cognitive fatigue

• Facial dystonia or jaw tightness

• Dissociation, emotional stress

• Co-existing aphonia, tremors, or facial weakness

Management Strategies

1. Speech and Language Therapy (SLT)

• Tailored to functional causes

• Focus on:

  • Breath control and vocal cord relaxation

  • Gradual reintroduction of speech (sound > syllable > word)

  • Augmentative communication support

  • Cognitive communication therapy (for brain fog overlap)

2. Communication Aids

• Use alternative methods when speech is difficult:

  • Text-to-speech apps (e.g., Proloquo, TD Talk)

  • Whiteboards or notebooks

  • Prewritten flashcards for common needs

  • Pointing charts or picture boards

• Keep aids accessible at all times

3. Pacing and Speech Rest

• Avoid forcing speech during flares

• Use quiet cues or gestures to conserve energy

• Schedule rest breaks throughout the day

4. Mental Health and Trauma Support

• Speech issues may be worsened by stress, trauma, or dissociation

• Trauma-informed CBT or ACT

• EMDR if trauma is a root cause

• Address anxiety around speaking or social fear

5. Education and Validation

• Speech symptoms are real and reversible with time/support

• Educate family and professionals to avoid misinterpretation

• Reaffirm that difficulty speaking does not mean:

  • Intoxication

  • Intellectual disability

  • Lack of understanding

Flare-Up Management (Loss of Speech)

• Communicate in advance that speech may become impaired

• Use prewritten cards ("I'm currently unable to speak")

• Provide a quiet environment and avoid rushing responses

• Reintroduce speech gradually after rest (humming, vowels, etc.)

• Avoid frustration or pressure to “snap out of it”

When to Escalate

• Sudden onset with other stroke-like symptoms

• Loss of swallowing function or risk of choking

• Inability to communicate basic needs with no backup method

Communication Support for Others

• Ask if the person can communicate nonverbally

• Offer paper, phone, or signal-based systems

• Speak slowly and clearly, one idea at a time

• Avoid interrupting or correcting stuttering

• Be patient—wait time is critical

Care Team Involvement

• Speech and Language Therapist (SLT): Core support

• Neurologist: Confirm diagnosis, rule out stroke or structural causes

• Psychologist: Address stress, trauma, and performance anxiety

• Occupational Therapist: Assistive communication tools

• Primary Care Provider: Coordinate care and monitor comorbidities

FND-related speech impairment is a reversible, functional condition that responds well to support, pacing, and communication tools. Patience and validation make a profound difference.