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What is the mechanism of discrepancy between cued vs. spontaneous performance in the context of heightened emotion? Pontine CVA.

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I am a speech pathologist. I have a 45 y.o male patient s/p pontine CVA and locked-in. He uses software to communicate. He is unable to volitionally produce any phonation/voicing or oral-motor postures, however when he is extremely agitated/frustrated he spontaneously produces excellent phonation and attempts to produce words during these times of anxiety are close enough to target that untrained ear could discern the distorted phrase "I want" because he was able to perform oral motor movement/articulate during his vocalizations. What is the mechanism of this marked discrepancy between cued (no oral motor movement or phonation) vs. spontaneous performance in the context of heightened emotion? The same is true for elevated mood - while he is unable to demonstrate any lip retraction on cue, I have seen him suddenly smile widely and demonstrate strong voice during spontaneous laughing. He presents like severe non verbal oral apraxia & apraxia of phonation but again this CVA is isolated to brainstem (pontine) area so I don't understand this clinical presentation. I don't believe he is malingering because of the oral motor groping behaviors and evident frustration he evidences during cued/on command tasks. Thank you, D
Posted Thu, 12 Apr 2012 in Brain and Spine
Answered by Dr. Shiva Kumar R 7 hours later
Hello and thank you for the query.

Your question is a good one and I will try to provide you with some information and recommendations regarding what is going on.

It is well known in Neurology that some times stress and emotions can bring out some of the things which is not done by the patients routinely.
The classical example is in a person who is suffering from "parkinsonism". When you ask him to walk or run we see his gait is low, short stepped and refuses to run. But when there is an emergency situation like fire in the house or a snake you can see them running like a normal person.

So I personally feel something like this must have happened in your patient. No one knows the exact reason for such behavior. You are also right in saying that it is not an apraxia.

But I feel it is a good sign and creates scope for continuing the current treatment.

I thank you again for submitting your query. I hope my response was both helpful and adequate. If you have any additional questions I would be happy to address them.

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