The Mysterious Foreign Accent: While Treating Ms. D for a Suspected Psychotic Disorder, You Learn She Has Developed a Foreign Accent. What Could Be the Cause of This Unusual Symptom?

CASE Disruptive and withdrawn Police bring Ms. D, age 33, to our psychiatric facility because of violent behavior at her group home. When confronted for alledgedly stealing, she became upset, fought with a housemate, and spat. Six months before coming to our facility she was admitted to a private hospital for psychotic disorder, not otherwise specified (NOS) where she was mute, refused all food and medications, lay in her room, and covered her face with a sheet when someone tried to talk to her. Ms. D denies having depressive symptoms, sleep disturbance, racing thoughts, thoughts of hurting herself or others, or auditory or visual hallucinations. She complains of poor appetite. Ms. D denies a history of mental illness and says she is not taking any medication. She is upset about being hospitalized and says she will not cooperate with treatment. We cannot obtain her complete psychiatric history but available records indicate that she has 1 previous psychiatric hospitalization for psychotic disorder NOS, and has received trials of haloperidol, lorazepam, diphenhydramine, escitalopram, ziprasidone, and benztropine. Her records do not indicate the dosages of these medications or how she responded to pharmacotherapy. During her mental status exam, Ms. D is well dressed, covers her hair with a scarf, has no unusual body movements, and responds to questions appropriately. She describes her mood as "okay" but appears upset and anxious about being in the hospital. She exhibits no overt psychotic symptoms and does not appear to be responding to auditory hallucinations or having delusional thoughts. Her cognitive function is intact and her intelligence is judged to be average with impaired insight and judgment. However, she speaks with a distinct accent that sounds Jamaican; otherwise, her speech is articulate with normal rate and tone. When we ask about her accent, Ms. D, who is African American, does not disclose her ethnicity and seems to be unaware of her accent. We did not question the authenticity of her accent until after we obtained collateral information from her family. What is your differential diagnosis? a) bipolar disorder NOS b) substance-induced psychosis c) brief psychotic disorder d) psychotic disorder NOS e) delusional disorder The authors' observations Based on the available information, we make a provisional diagnosis of psychotic disorder NOS and Ms. D is admitted involuntarily because of concerns about her safety. She is reluctant to accept any treatment and receives an involuntary probate commitment for 90 days. At admission, Ms. D is evasive, guarded, secretive, and at times hostile. Her physical examination reveals no signs or symptoms of focal neurologic deficits. Laboratory testing, including urine toxicology, is unremarkable. She refuses an MRI. Later testing reveals a critical ammonia level of 143 [micro]g/dL, warranting an axis III diagnosis of asymptomatic hyperammonemia. HISTORY Paranoia and delusions Ms. D says she was born and raised in a southern state. She reports that she was born to an Egyptian mother who died during childbirth; her father, who is white, was an ambassador stationed abroad. Ms. D attended school until the 11th grade and was married at age 19 to a Secret Service agent. She says she has a son who was kidnapped by her husband's enemies, rescued by paying ransom, and currently lives with his grandfather. Ms. D is paranoid and fears that her life is in danger. She also believes that she has gluten sensitivity that could discolor and damage her hair, which is why she always keeps a scarf on her head for protection. Through an Internet search, we find articles about Ms. D's son's kidnapping. The 7-year-old had been missing for weeks when police found him with his mother in safe condition in another state, after Ms. D called her mother to ask for money and a place to stay. …