Clinical Linguistics & Phonetics, April–May 2006; 20(2/3): 157–162 An atypical case of Foreign Accent Syndrome Clin Linguist Phon Downloaded from informahealthcare.com by National Dong Hwa University on 03/15/14 For personal use only. JACK RYALLS, & JANET WHITESIDE Department of Communicative Disorders, University of Central Florida, Florida, USA (Received 27 June 2004; accepted 12 November 2004) Abstract A new case of Foreign Accent Syndrome is described. This American woman presented with a British- or Australian- sounding accent after stroke, which resulted in a lacunar infarct in the left internal capsule. The atypical etiology and apparent changes in lexical use are described. It is hypothesized that an abnormally tense vocal tract posture may account for phonetic changes in vowel quality and a higher average fundamental frequency. Keywords: Foreign Accent Syndrome, speech changes, stroke Introduction In some rare cases, patients who have sustained neurological damage can end up with a perceived foreign accent termed ‘‘Foreign Accent Syndrome’’ (Whitaker, 1982). This syndrome does not result from previous experience with a second language, and typically persons with this adult acquired speech disorder have never even visited the country of their perceived accent. This rare neurological disorder offers a unique opportunity for insight into the representation and control of speech production in the human brain. Pick (1919) is usually attributed with the first description of Foreign Accent Syndrome (FAS), although Whitaker (1982) states that Marie described an aphasic patient with an Alsatian accent in 1907. The most widely known case of FAS is the patient described by Monrad-Krohn in 1947 (Monrad-Krohn, 1947; Ryalls & Reinvang, 1985). Kurowski, Blumstein, and Alexander noted less than 15 published cases in the literature in 1996. But Aronson (1980) reviewed 12 cases in the literature, and another 13 cases seen at the Mayo Clinic under the term ‘‘pseudoforeign accent’’. Moen (2000) has published an overview of cases to date, as well as theoretical underpinnings. Coelho and Robb (2001) present a new case and consider three models of FAS. Dankovicova, Gurd, Marshall, McMahon, Stuart-Smith, Coleman, and Slater (2001) present a detailed case study of an English woman who had a Scottish-sounding accent. None the less, it is obvious that FAS is quite a rare phenomenon, probably since most speech impairments resulting from neurological insult have much more deleterious effects on speech such as aphasia or dysarthria. New cases are likely to shed further light on this Correspondence: Jack Ryalls, Department of Communicative Disorders, PO Box 162215, University of Central Florida, Orlando, Florida 32816-2215 USA. E-mail: rya.lls@mail.ucf.edu ISSN 0269-9206 print/ISSN 1464-5076 online # 2006 Taylor & Francis DOI: 10.1080/02699200400026900 158 J. Ryalls, & J. Whiteside rare phenomenon. Furthermore, cases that differ from typical descriptions of FAS may be most likely to extend our understanding. With this in mind, a new case of FAS with some ‘‘atypical’’ features is presented below. Clin Linguist Phon Downloaded from informahealthcare.com by National Dong Hwa University on 03/15/14 For personal use only. Case history TN, a 57-year-old Caucasian female, presented with right–sided paralysis and loss of speech. She was a native speaker of American English with a High School education. Her most recent employment was for a foundation for medically fragile children, which she had also established. She had also worked in the music and publishing industries. There was no prior medical history of vascular disease, heart disease, diseases associated with a hypercoagulable state, or the taking of drugs with a known association with ischemic cerebral disease. Several medical authorities believe that platinum leeching from a ruptured breast implant may have been involved in the medical tableau. Such an etiology has not been previously reported for FAS. Over the following 2 months, the hemiplegia significantly improved. Speech recovered, but with an associated foreign (British or Australian) accent. MRI examination had revealed a small, circumscribed lacunar infarct in the left internal capsule. Figure 1 displays MRI results and the lesion is circled. Although she had only lived in the United States, people constantly asked TN where in England she was from, or whether she came from Australia. In fact, the patient presented with all four of the cardinal symptoms outlined by Whitaker (1982), who suggested the term ‘‘Foreign Accent Syndrome’’: (1) the accent is considered by the patient, by acquaintances, and by the investigator, to sound foreign; (2) it is unlike the patient’s native Figure 1. MRI display with left hemisphere appearing on the left side. The small lacunar infarct in the left internal capsule is circled. Clin Linguist Phon Downloaded from informahealthcare.com by National Dong Hwa University on 03/15/14 For personal use only. Foreign Accent Syndrome 159 dialect before cerebral insult; (3) it is clearly related to central nervous system damage (as opposed to an hysteric reaction, if such exist); (4) And there is no evidence in the patient’s background of being a speaker of a foreign language (i.e., this is not like cases of polyglot aphasia)’’ (pp. 196, 198). TN had only very short interactions from people from England and Australia. She responded negatively when questioned whether she watched British or Australian television shows. Before her stroke, TN described her speech as having a ‘‘New York accent’’, since she had lived in New York City the greater portion of her adult life. An audio recording of her speech from before the stoke reveals that not only is her accent very different, but she had a much lower fundamental frequency and a different voice quality as well—both of which the patient had also described. Fundamental frequency measures of several sentence productions from this premorbid recording were below 150 Hertz, while her fundamental frequency measures were mostly above 200 Hertz when she reproduced these same utterances. This higher fundamental frequency suggests increased longitudinal tension on the vocal folds, or perhaps the lower fundamental frequency before the stroke was the result of years of sustained smoking. As is typically the case in FAS, there were some differences in exactly which accent was perceived by different listeners. Yet, in this case, all listeners heard the accent as either British or Australian. In other words, while most patients with FAS are ‘‘heard’’ by listeners as having different foreign language influenced accents, TN was heard to be a native speaker of English, simply not a speaker of ‘‘American English’’. Ingram, McCormack, and Kennedy (1992) describe a case of FAS who lost her native Australian accent and was subsequently perceived by listeners not be a native speaker of Australian English and the present case is very similar to the English woman who ended up with a Scottish accent presented by Dankovicova et al. (2001). We can speculate that her accent was not altered enough to cause listeners to perceive the influence of a foreign language, but merely a foreign accent. Different British listeners describer her accent variously as ‘‘from Sussex’’, ‘‘cockney’’, or ‘‘Yorkshire’’. There are several features of this case that are ‘‘atypical’’ for FAS. The first atypical feature is the etiology and the second is the higher fundamental frequency of her voice. The other atypical feature of TN is that she also employs some British-sounding expressions as well. Her listeners first pointed out these ‘‘Briticisms’’ to her, and she was not aware of this change in word usage. For example, she referred to an ‘‘elevator’’ as a ‘‘lift’’, and to a mother as ‘‘mum’’ instead of the more American ‘‘mom’’. These apparently British lexical uses are curious, and there is no readily obvious explanation for this atypical component of the patients’ FAS. Are they the result of semantic paraphasias or circumlocutions typical of aphasic speakers? Patients with aphasia are known to sometimes produce circumlocutions when they experience word-finding difficulties (Goodglass & Wingfield, 1997). Although the patient’s speech is extremely fluent, she still describes word-finding difficulties. Perhaps these ‘‘Briticisms’’ are subconscious lexical choices that the patient has adapted over the past 3 years she has presented with FAS. They may stem in part from an effort on the part of the patient to make her word usage fit with her pronunciation; all in an effort to consolidate her changes into a new acceptable and ‘‘believable’’ personality. The patient describes that people sometimes accused her of lying when she told them that she was not from England. She related how it became easier for her to allow people to believe that she was from England, rather than attempting to explain that her accent was the result of a stroke. But she insists that her altered word usage is not under her conscious control. 160 J. Ryalls, & J. Whiteside Clin Linguist Phon Downloaded from informahealthcare.com by National Dong Hwa University on 03/15/14 For personal use only. Aphasia and cognitive-linguistic tests The subject was seen at the University of Central Florida Communication Clinic. She responded to a Voice Handicap Index (Jacobson et al., 1997), which is a question and answer tool designed to quantify the disability that a voice disorder is causing. Although developed for voice disorders, we thought it might be useful in understanding the subject’s perception of her foreign accent. Her answers revealed a very minimal amount of handicap mostly in psycho-emotional and social aspects of communication. The subject was tested for her ability to change word stress patterns, since part of the difference between an American and a British accent has to do with which syllable gets stressed. She could successfully distinguish noun-verb pairs, which are distinguished by which syllable gets accentuated such as ‘‘I wanted to record the record onto cassette tape’’. She could also repeat words with the syllable stress on the wrong syllable such as ‘‘put the emPHÁsis on the wrong sylLÁble.’’ Although somewhat informally tested, we believe the patient has very good command of prosody. Her speech has appropriate intonation contours. TN was also tested informally for her knowledge of British expressions on two different occasions by means of questions specifically designed for this purpose. We are not aware of specific tests for knowledge of British expressions, so we had to develop our own. An example question was ‘‘In the United States we say ‘baby stroller’, but what do they say in England?’’ She could only provide correct British equivalents for three out of ten such items on the first test, and four out of 20 items on the second test. Informal testing of other native Americans on these same items revealed similar scores. A native British speaker produced nine out of ten items correct on the first test and 18 out of 20 items on the second test. This admittedly informal testing supports our contention that she does not have a greater than the average American’s command of British expressions. Portions of the Boston Diagnostic Aphasia Examination, Third Edition (BDAE; Goodglass, Kaplan, & Barresi, 2002) were administered. In response to the Cookie Theft picture description, the subject used subclausal, single clause and multi-clause utterances. There were no instances of agrammatic deletions. Her Complexity Index was 1.54. Her narrative writing of the picture also yielded multi-clauses with appropriate detail and references. In addition, the Boston Naming Test was administered in its entirety. She named 56/60 pictures accurately, without cues, which placed her above the mean for her age. Although she reported, ‘‘it takes longer, sometimes, to think of words’’, she stated she does the New York Times crossword puzzles. Furthermore, she reported no difficulty with reading comprehension. Additionally, the Design Generation subtest of the Cognitive Linguistic Quick Test (CLQT: Helm-Estabrooks, 2001) was administered to measure executive functions. Her performance was at the criterion level for her age. This task required mental flexibility, working memory skills, and self-monitoring. Lastly, the Word Association subtest form the Arizona Battery for Communication Disorders of Dementia (Bayles & Tomoeda, 1993) was presented to assess her ability to learn new information (working memory integrity). Her performance exceeded her age criterion, as she was able to recall ten items with Free Recall and the remaining items when given the cue. In summary, the subject did not present a profile of aphasia. A cursory examination of cognitive processes yielded performance within her expected age range. Discussion On the basis of their case and a review of the literature Kurowski et al. (1996) concluded that FAS is distinct from Broca’s aphasia. Although the results of their case study Clin Linguist Phon Downloaded from informahealthcare.com by National Dong Hwa University on 03/15/14 For personal use only. Foreign Accent Syndrome 161 supported a characterization of a ‘‘generic’’ foreign accent, these authors noted that the constellation of phonetic features varies between cases, ‘‘challenging the notion that a general prosodic disturbance is the sole underlying mechanism in FAS’’ (p. 1). They noted that: ‘‘All cases had some prolongation of speech, in either vowel production, word duration, excessive pausing between words, or long latencies of speech onset. All cases may have had some abnormality of tone of the vocal tract—excessive tension or laxity’’ (p. 23). Graff-Radford, Cooper, Colsher, and Damasio (1986) and Ingram et al. (1992) also implicate abnormally tense vocal tract postural setting in their studies of FAS. Based on our auditory impressions of this patient’s speech, we feel that she is experiencing a greater than normal tension of the vocal tract posture which may explain the perception of her speech as having a ‘‘British’’ or ‘‘Australian’’ accent on the part of listeners. There are differences in vowel quality that may be accounted for by this change in vocal tract posture. The fact that the patient now has a higher overall average fundamental frequency may also be a result of the increased tension of the vocal folds. Acknowledgements We would like to thank Professor Jennifer Gurd for referring this case to our attention, and to Drs. J. F. Bubinak and S. Norris for their assistance in describing the medical case history. References Aronson, A. (1980). Clinical Voice Disorders: An Interdisciplinary Approach. New York: Theime Publishing. Bayles, K., & Tomoeda, C. (1993). The Arizona Battery for Communication Disorders of Dementia. Tucson, AZ: Canyonlands Publishing. Blumstein, S., Alexander, M., Ryalls, J., Katz, W., & Dworetzky, B. (1987). On the nature of the foreign accent syndrome: A case study. Brain and Language, 31, 215–244. Coelho, C., & Robb, M. (2001). Acoustic analysis of Foreign Accent Syndrome: An examination of three explanatory models. Journal of Medical Speech-Language Pathology, 9, 227–242. Dankovicova, J., Gurd, J., Marshall, J., MacMahon, M., Stuart-Smith, J., Coleman, J., & Slater, A. (2001). Aspects of non-native pronunciation in a case of altered accent following stroke (foreign accent syndrome). Clinical Linguistics and Phonetics, 15, 195–218. Goodglass, H., & Wingfield, A. (1997). Word-finding deficits in aphasia: Brain-behavior relations and clinical symptomatology. In H. Goodglass, & A. Wingfield (Eds.), Anomia: Neuroanatomical and Cognitive Correlates. 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