Catatonic Speech Disturbance
This is a family of unusual qualities that speech can take on in catatonia, distinct from disturbances of the content or structure of thought itself. It includes strange or stilted delivery that can make the patient sound unfamiliar with their own native language, unusual intonation such as speaking in falsetto, staccato or nasal speech, and a strangled vocal quality (Wurgstimme). Some patients whisper continuously, appearing to be responding to hallucinatory voices, while others remain silent and expressionless, staring at the speaker without any reply.
This has traditionally been noted for its resemblance to the strange, stilted speech quality seen in motor aphasia of neurological origin, another example of how catatonic signs can echo patterns seen in primarily neurological conditions.
Also known as
- Wurgstimme
- German for 'strangled voice': an unusual, strangled vocal quality seen in some patients with schizophrenia, which may reflect a mannerism or an underlying delusion.
Recognition features
- Strange, stilted delivery, so that the patient may sound unfamiliar with their own native language despite fluent vocabulary and grammar
- Unusual intonation patterns: falsetto tone, staccato rhythm, or a nasal quality to speech
- A strangled vocal quality (Wurgstimme), which may reflect a mannerism or may be related to an underlying delusional belief
- Continuous whispering, sometimes suggesting the patient is responding to hallucinatory voices, or complete, expressionless silence despite apparently attending to the speaker
Eliciting it at interview
- Listen closely to the quality, rhythm, and intonation of speech, not just its content, noting any strangled, staccato, nasal, or falsetto qualities
- Where continuous whispering is observed, consider and ask directly about possible hallucinatory experiences that may be driving it
- Distinguish silent, expressionless staring from mutism due to negativism (active refusal to speak) by considering the whole clinical picture, including the patient's apparent attentiveness and any other catatonic signs present
Distinguishing features
- Differs from thought disorder such as schizophasia, in which the disturbance lies in the structure and coherence of thought itself, whereas this concerns the quality and delivery of speech, which may otherwise be structurally normal
- Differs from talking past the point, in which the content of answers is characteristically approximate or oblique, whereas catatonic speech disturbance concerns vocal quality and delivery
- Whispering suggestive of responding to hallucinatory voices should be distinguished from ordinary quiet speech by the apparent presence of a one-sided, absorbed quality to the whispering
Common misconceptions
- That unusual speech quality in catatonia always reflects thought disorder; the content and structure of speech may be entirely intact even when its delivery sounds strange or strangled
- That silence and staring in catatonia always mean the patient is unaware or unresponsive; some patients who remain silent are nonetheless clearly attending closely to what is being said
Related phenomena
Talking Past the Point (Vorbeireden) · Negativism
Practice this
A patient speaks with a strange, stilted delivery and an unusual falsetto intonation, sounding almost unfamiliar with his own native language, despite using entirely fluent vocabulary and correct grammar. What is this? · Asked what colour the sky is, a patient answers, in a completely normal speaking voice, "green," and asked what colour grass is, answers "blue," with every answer showing clear understanding of the question but consistently and noticeably wrong. Before revealing the answer: is this catatonic speech disturbance? · A patient's speech sounds unusual. Before revealing the answer, decide what distinguishes catatonic speech disturbance from talking past the point. · You suspect a patient shows catatonic speech disturbance. Before revealing the answer, decide how you would assess for this. · Explain why continuous whispering in a catatonic patient is worth exploring further rather than dismissing as an odd mannerism.
Illustration
A patient with catatonic schizophrenia speaks in an oddly strangled, effortful voice throughout the assessment, as though forcing each word out through a narrowed throat, and pauses periodically to whisper rapidly under his breath before resuming eye contact with the interviewer, apparently unaware of how unusual this pattern sounds.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 8, 'Motor Disorders'.