Understanding Functional Cognitive Disorders

Speech therapy often addresses the tangible evidence of a stroke, a traumatic brain injury, or a progressive neurological disease. But what happens when a patient is experiencing significant cognitive, speech, or swallowing difficulties, yet all the typical diagnostic tests come back normal?

This is where the concept of Functional Neurological Disorder (FND) comes into play. FND is a "rule-in" diagnosis, meaning it's diagnosed based on the presence of positive clinical signs and symptoms rather than purely by excluding other conditions. For speech-language pathologists (SLP) and other therapists, identifying FND involves assessing several key features. These can include: symptom variability, distractibility of movements or symptoms, suggestibility (where symptoms may change or improve with suggestion), overly effortful patterns of movement, atypical or inconsistent speech errors, rapid improvement or resolution of symptoms (often seen in response to specific therapeutic techniques or suggestion), and a sudden onset often without a clear neurological event or cause readily identifiable through standard imaging or testing." 

These disorders can be incredibly frustrating for both the individual experiencing them and their loved ones. They represent a genuine and often debilitating breakdown in how the brain sends and receives signals. The “hardware” is fine, but the “software” is not.

Functional Cognitive Disorder

Imagine knowing you know a word, but it just won't come to you. Or feeling like your thoughts are happening in slow motion, even though your brain scans are clear. This is the reality for many individuals experiencing FCD.

What it involves:

• Memory difficulties
• Attention and concentration problems
• Slowed processing speed
• Executive function challenges
• Word-finding difficulties

How can a speech-language pathologist help? As SLPs, we play a vital role in assessing FCD. Our therapy often focuses on:

• Strategies
• Environmental modifications
• Nervous system regulation techniques
• Pacing and energy management
• Education and validation

Functional Speech Disorder

For someone with functional speech disorder, the ability to articulate words or produce smooth, fluent speech can become unexpectedly challenging. This isn't due to muscle weakness or a primary voice box issue, but rather a disruption in the neurological pathways responsible for speech production.

What it involves:

• Dysphonia (voice changes)
• Stuttering
• Slurred or strained speech
• Intermittent mutism
• Irregular articulation patterns

The SLP's role: Our assessment carefully rules out other speech disorders. Our interventions may include:

• Respiratory and phonatory exercises
• Articulation exercises
• Pacing and rhythm strategies
• Biofeedback
• Education

Functional Dysphagia

Eating and drinking are fundamental to life and social interaction. For individuals with functional dysphagia, this basic task can be difficult, even though physical examination and instrumental tests like videofluoroscopy or FEES show no structural abnormalities or typical neurological swallowing deficits.

What it involves:

• Sensation of a "lump in the throat": Often the primary symptom, even when no lump exists.
• Difficulty initiating a swallow: Feeling like one no longer knows how to swallow.
• Food "getting stuck" in the throat: Despite appropriate swallow on imaging.
• Pain or discomfort during swallowing: Without inflammation or injury.
• Fear of choking: Leading to avoidance of certain foods or textures.
• Weight loss or nutritional deficiencies: Due to avoidance or difficulty eating.

The SLP's role: Functional dysphagia requires a thorough evaluation to rule out other causes. Our therapy is often focused on:

• Swallowing rehabilitation: Exercises to improve oral motor control and coordination.
• Sensory retraining: Addressing altered sensations in the throat to normalize swallowing perception.
• Cognitive behavioral techniques: To address anxiety and fear related to swallowing.
• Dietary modifications: In some cases, temporary texture modifications may be helpful, but the goal is to return to a regular diet.
• Mindfulness and relaxation: To reduce muscle tension in the throat and manage anxiety.
• Education and reassurance: Crucial for validating the patient's experience and empowering them to regain control.

A multidisciplinary approach is often key to successful management of FND. We frequently collaborate with neurologists, psychologists, metabolic care providers, physical therapists, and occupational therapists to provide holistic and comprehensive care. Furthermore, patient education regarding factors that can influence symptoms – such as sleep, nutrition, stress, mental health, pain, and sensory function – forms a significant portion of our treatment. 

Learn more about speech therapy at CHI Health or discuss with your primary care provider.