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Barriers to Communication: Mutism and Other Problems With Speech and Communication


The on-call evaluation of new, acute changes in speech or communication requires consideration of a broad differential diagnosis. Changes in speech and language may be caused by various psychiatric, medical, and neurologic etiologies. There are a variety of deficits in speech, ranging from dysarthria to complete mutism, that must be differentiated from pathologic changes in cerebral language areas of the brain, as seen in aphasia. The clinician’s first role is to make this distinction so that proper evaluation and treatment may be pursued.

Phone call

Questions

  • 1.

    Are there alterations in vital signs (including oxygen saturation and blood glucose)?

  • 2.

    How specifically has speech or communication changed? Describe in detail.

  • 3.

    What is the patient’s level of consciousness?

  • 4.

    What are the patient’s psychiatric, medical, and neurologic histories?

  • 5.

    What is the patient’s level of psychomotor activity? Is catatonia suspected?

  • 6.

    Did the patient recently begin or stop taking any medications (including antipsychotic medications) or undergo any procedures?

  • 7.

    Is there any suspicion of recent illicit drug use?

Orders

Have the nurse take full vital signs if not already measured (including oxygen saturation and blood glucose).

Inform RN

“Will arrive in … minutes.”

Mutism in any suspected case of psychosis, depression, or mania or acute medical illness in a patient unknown to you warrants one-to-one observation pending your arrival.

Elevator thoughts

What causes an acute change in speech or communication?

Mutism is a neuropsychiatric symptom resulting in the cessation of speech. Mutism itself is not a disease. A change in the level of alertness, impaired cerebral language centers, or impaired vocal/oral mechanisms of speech can result from many different psychiatric, neurologic, and medical disorders. See Table 16.1 .

Table 16.1
Common Psychiatric and Medical/Neurologic Causes of Mutism
Psychiatric Causes Medical/Neurologic Causes
Catatonia Cerebrovascular accidents or other brain lesions
Schizophrenia Delirium
Mania Medication/drug intoxication/drug withdrawal (corticosteroids, antipsychotics, anticholinergics, PCP, amphetamines,
crystal methamphetamine, cocaine, benzodiazepines, barbiturates, ETOH, etc.)
Depression Laryngitis
Conversion disorders Encephalitis, meningitis
Malingering Seizures
Brief dissociative episodes Endocrine disorders (myxedema, DKA, hyperparathyroidism, Addison disease)
Selective mutism Tertiary syphilis
Posttraumatic stress Neuroleptic malignant syndrome
Autism spectrum disorders Paraneoplastic syndromes (e.g., anti-NMDA receptor encephalitis)
DKA, Diabetic ketoacidosis; ETOH, ethanol; PCP, phencyclidine.

The first step in the evaluation of a communication disorder is to distinguish between disorders of speech and disorders of language. Disorders of speech include dysarthria and dysphonia. Dysarthria is a disturbance in articulation. It is caused by problems of the neuromusculature of the mouth, lips, or tongue or of the cerebral or cerebellar structures that coordinate their control. It may appear as slurred speech or as a total inability to speak in extensive cases. It may also be caused by antipsychotic medications and intoxication states. A disorder of phonation, or dysphonia, commonly presents as hoarseness, which stems from pathology of the larynx.

Disorders of cerebral language refer to impairments in symbolic communication, such as an inability to speak, understand, read, write, or repeat. These disorders are called aphasias and can include disturbances in the production of language, the comprehension of language, or both. Aphasias are usually caused by central nervous system (CNS) lesions, such as vascular accidents.

Severely affected patients may present with a near-total inability to produce verbal language, mimicking mutism. Alternatively, an aphasia that impairs language comprehension may sometimes mimic psychotic thought disorders.

Altered language in the context of a confusional state requires a work-up for delirium.

Major threat to life

  • Inadequate nutrition from catatonia

  • Disordered language from delirium, particularly with deteriorating vital signs

  • Mutism in neuroleptic malignant syndrome (NMS)

  • Aphasia from acutely evolving stroke

  • Agitation, paranoia, violence, and suicidality in severe sensory aphasia

  • Violent behavior of psychotic or manic patients coming out of catatonia

  • Violent or agitated patient with paraneoplastic syndrome (e.g., anti-N-methyl-D-aspartate [NMDA] receptor encephalitis)

  • Suicide in severely depressed patients coming out of catatonia

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