FAS can result from lesions in brain areas involved in speech production, including precentral gyrus, premotor mid-frontal gyrus, left subcortical prerolandic gyrus, postrolandic gyri, and left parietal area.4 Most FAS cases are secondary to a structural lesion in the brain caused by stroke, traumatic brain injury, cerebral hemorrhage, or multiple sclerosis.2 There are a few cases in the literature of acquired foreign accent with psychogenic etiology in patients with schizophrenia and bipolar disorder with psychotic features.5
TREATMENT: Combination therapy
Based on Ms. D’s unstable mood, irritability, delusional beliefs, and paranoid ideas, we start divalproex, 500 mg/d titrated to 1, 750 mg/d, and risperidone, 3 mg in the morning and 4 mg at bedtime.
The unit psychologist evaluates Ms. D and provides individual psychotherapy, which is mainly supportive and psychoeducational. Ms. D gradually becomes cooperative and friendly. She is not willing to talk about her accent or its origin; however, as her psychiatric symptoms improve, her accent gradually diminishes. The accent never completely resolves, but reduces until it is barely noticeable.
The authors’ observations
Ms. D’s foreign accent was more prominent when she displayed positive psychotic symptoms, such as delusions and disorganized thinking, and gradually disappeared as her psychotic symptoms improved. Ms. D’s case was peculiar because her accent was 1 of the first symptoms before her psychosis fully manifested.
How are FAS and psychosis linked?
Language dysfunction in schizophrenia is common and characterized by derailment and disorganization. Severity of language dysfunction in schizophrenia is directly proportional to overall disease severity.6,7 Various hypotheses have suggested the origin of FAS. In patients with FAS secondary to a neurologic disorder, a lesion usually is found in the dominant brain hemisphere, but the cause is not clear in patients with psychosis who have normal MRI findings. One hypothesis by Reeves et al links development of FAS to the functional disconnection between the left dorsolateral prefrontal cortex (DLPFC) and the superior temporal gyrus (STG) during active psychosis.5 In normal speech production, electric impulses originate in the DLPFC and are transmitted to STG in Wernicke’s area. From there, information goes to Broca’s area, which activates the primary motor cortex to pronounce words. In healthy individuals, word generation activates the DLPFC and causes deactivation of the bilateral STG.8 In schizophrenia, the left STG fails to deactivate in the presence of activation of the left DLPFC.9 Interestingly, STG dysfunction is seen only during active phase of psychosis. Its absence in asymptomatic patients with schizophrenia and bipolar disorder10,11 suggest that a foreign accent-like syndrome may be linked to the functional disconnection between the left DLPFC and left STG dysfunction in patients with active psychosis.5
Performing functional neuroimaging, including positron-emission tomography, functional MRI, and single-photon emission computed tomography, of patients with FAS could shed more light on the possible link between FAS and psychosis. In a case report of a patient with bipolar disorder who developed FAS, MRI initially showed no structural lesion but a later functional imaging scan revealed a cerebral infarct in the left insular and anterior temporal cortex.2
One of the limitations in Ms. D’s case is the lack of neuroimaging studies. For the first few weeks of her hospitalization, it was difficult to communicate with Ms. D. She did not acknowledge her illness and would not cooperate with treatment. She was withdrawn and seemed to experience hysterical mutism, which she perceived as caused by extreme food allergies. Later, as her symptoms continued to improve with pharmacologic and psychotherapeutic interventions, neuroimaging was no longer clinically necessary.
OUTCOME: Accent disappears
As Ms. D improves, psychotherapy evolves to gently and carefully challenging her delusions and providing insight-oriented interventions and trauma therapy. As her delusions gradually start to loosen, Ms. D reveals she had been physically and emotionally abused by her husband.
At discharge after 90 days in the hospital, Ms. D’s symptoms are well managed and she no longer shows signs of a thought disorder. Her thinking is clear, rational, and logical. She demonstrates incredible insight and appreciation that she needs to stay in treatment and continue to take divalproex and risperidone. Her delusions appear to be completely resolved and she is focused on reuniting with her son. Many of her previous delusions appear to be related to trauma and partly dissociative.
Ms. D contacts the psychologist several months later to report she is doing well in the community, staying in treatment, and working on legal means to reunite with her son. No trace of any foreign accent is detectable in her voice.