A 20-Year-Old Man Who Stopped Speaking

James Robert Brasic, MD, MPH


July 31, 2017


The patient in this case has autism spectrum disorder (ASD) complicated by progressive catatonia; he has had persistent facial tics after treatment with a dopamine receptor–blocking drug demonstrated degenerative changes in nerve and muscle biopsies at age 18 years and 8 months.

Malingering is a situation in which a person falsely and intentionally reports medical or psychological symptoms[1]; no basis for the symptoms is found upon careful evaluation. Usually, malingering is produced to avoid an unwanted situation (eg, going to school, going to jail) or to gain desired benefits (eg, disability payments). The patient in this case wanted to go to school, and multiple abnormalities were found upon examination and laboratory testing, confirming the presence of neurologic bases for his symptoms.

Conversion disorder is a condition in which a person reports symptoms consistent with a neurologic illness.[2] In conversion disorder, the signs and symptoms occur within the voluntary parts of the neuromuscular system (eg, an inability to use one's right arm or hand). Careful examination demonstrates no evidence of a physical basis for the symptoms. Conversion disorder resembles malingering, with the presence of reported symptoms and the absence of examination findings. Malingering represents a situation in which the person deliberately reports symptoms they know to be false. On the other hand, in conversion disorders, the patient reports symptoms that the patient believes are real. In other words, in conversion disorders, the person is not deliberately reporting fabricated symptoms. The key to understanding the underlying basis of the symptom is that an unconscious conflict is converted into a physical symptom. Conversion disorders may occur after environmental stresses, including physical or sexual abuse.[3] An amobarbital interview may possibly reveal the underlying conflict. Again, the examination findings confirmed a neurologic basis in this case.

Cessation of speaking can occur in many conditions. Selective mutism refers to a situation in which a person can speak but does not talk under certain circumstances. Some children may be fearful at school, so they never talk while there but speak freely at home. Selective mutism typically occurs when children enter school.[4] They may readily speak at home. The absence of speech at school may reflect high anxiety. Thus, selective mutism may represent an anxiety disorder. This can be a form of social anxiety or social phobia, in which the person anticipates or fears the ridicule of others. The opposite condition may occur when silence at home may reflect an emotional or behavioral situation.[5] An example may be a child who has a parent with an alcohol problem. When that parent drinks, whatever the child says is followed by physical punishment and abuse; thus, that child learns the prudence of silence. The patient in this case did not speak at home or at school after he stopped talking. He never spoke under any circumstances. Although anecdotal case reports describe people who resumed talking after many years of silence, this patient has not displayed that behavior. Also, the abnormal physical and laboratory findings suggest that his silence reflects a degenerative disorder of the nervous system.

Schizophrenia is a disorder that typically presents in adolescence or young adulthood, characterized by the presence of hallucinations, perceptions of stimuli absent in the environment, and delusions/fixed false beliefs. Schizophrenia may manifest itself in youth with numerous soft neurologic findings. Auditory hallucinations are the most common perception in schizophrenia. Catatonia can occur with untreated schizophrenia. However, electroconvulsive treatments typically relieve symptoms of catatonia and schizophrenia. This patient demonstrated no response to them.


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