Functional Speech and Swallowing Difficulties

Functional speech and swallowing difficulties are problems with talking, voice or swallowing where symptoms are real and often disabling, but tests do not show structural damage to the brain, throat, vocal cords or oesophagus.

They are usually understood as part of Functional Neurological Disorder (FND) – a condition where the functioning of the nervous system is disrupted, even though its structure appears normal on scans and examinations.

People may develop sudden stuttering, slurred or whispered speech, lose their voice completely, or feel a persistent “lump in the throat” and difficulty swallowing, despite normal investigations.

At The Royal Buckinghamshire Hospital, we support adults with functional speech, voice and swallowing symptoms as part of complex neurological and FND presentations, using multidisciplinary inpatient neurorehabilitation to help people regain confidence and function.

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What Are Functional Speech and Swallowing Difficulties?

Functional speech and swallowing difficulties happen when the automatic control of the muscles needed for speaking or swallowing stops working smoothly, even though the underlying structures are intact.

Examples include:

• Sudden onset of stammering or stuttering
• Slurred speech that fluctuates or appears in certain situations
• Whispered or very quiet speech, sometimes called functional dysphonia or aphonia
• A feeling of tightness or strain in the voice
• Difficulty swallowing food, drink or tablets, or a sense that swallowing “will not start”
• A constant feeling of a lump in the throat (globus sensation)

These symptoms are not produced deliberately. They reflect changes in how the brain is controlling and coordinating speech, voice and swallowing, often in the context of stress, illness or other FND symptoms.

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Causes and Contributing Factors

There is no single cause. Functional speech and swallowing symptoms usually arise from a combination of factors:

• Stress, anxiety or low mood
• High voice demands or prolonged talking (for example, teaching, call-centre work, singing)
• Recent illness or injury, including respiratory infections or other neurological symptoms
• Previous episodes of choking, severe coughing, or frightening symptoms
• Attention and worry focused on the throat, voice or swallowing
• Other FND symptoms, such as functional limb weakness, gait disorder, seizures or cognitive problems

In functional voice disorders, the larynx and vocal cords often look structurally normal, but the muscles may be over-tense or poorly coordinated, leading to symptoms like muscle tension dysphonia, functional dysphonia or aphonia.

In functional swallowing difficulties, investigations may not show narrowing, obstruction or neurological damage, but the person can still feel stuck, hesitant or unsafe when they swallow. This may be described as functional dysphagia or globus.

Importantly, these symptoms are not “imagined” or faked – they are genuine difficulties linked to how the nervous system is functioning.

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Symptoms of Functional Speech and Swallowing Difficulties

Functional Speech and Voice Symptoms

Common speech and voice changes include:

• Sudden stammering or stuttering, sometimes appearing after a stressful event or illness
• Slurred or slowed speech, which may vary with fatigue or emotional state
• Whispered, very quiet or breathy voice (aphonia / dysphonia)
• Voice that sounds strained, tight or effortful, often worse with prolonged talking
• Speech that breaks up under pressure, but may improve when distracted or singing
• Needing to “push” the voice out, leading to throat discomfort or fatigue
• Feeling that words are “stuck” or that it is hard to get speech started

These symptoms can be highly variable – sometimes improving in relaxed situations and worsening when the person feels anxious, observed or under time pressure.

Functional Swallowing Symptoms

Functional swallowing problems may present as:

• A sensation of a lump in the throat (globus pharyngis)
• Feeling that swallowing will not start, even though the muscles are capable of moving normally
• Hesitation, or needing several attempts to swallow
• A feeling that food or drink sticks in the throat despite normal tests
• Worry about choking, even when objective risk is low
• Symptoms that fluctuate, and may be worse when tired, anxious or focusing closely on swallowing

Most people with functional swallowing difficulties do not have significant aspiration (food going into the airway) on investigation, but it is important that any swallowing problem is properly assessed to check safety.

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How Are Functional Speech and Swallowing Difficulties Diagnosed?

Diagnosis usually involves a team approach, including a neurologist and/or ENT specialist, and a Speech and Language Therapist (SLT).

The assessment may include:

• A detailed history of symptoms, including onset, triggers and variability
• Examination of the mouth, throat and larynx – often with laryngoscopy for voice problems
• Assessment of speech clarity, fluency, voice quality and communication
• For swallowing: clinical swallowing assessment and, where indicated, tests such as videofluoroscopy or FEES to check swallow safety
• Neurological assessment to look for signs of structural brain disease or other neurological conditions
• Review of investigations (MRI, CT, endoscopy, blood tests) already performed

Functional speech and swallowing difficulties are diagnosed positively, not just because tests are normal. Clinicians look for typical patterns, for example:

• Symptoms that fluctuate with attention, context or emotional state
• Features that do not match a single nerve, brain or muscle lesion
• Evidence that the person can use the muscles effectively in some situations (for example, coughing strongly, singing or swallowing in a different context)
• Absence of progressive worsening typical of degenerative neurological disease

Before confirming a functional diagnosis, serious causes of dysphagia or voice change – such as stroke, neuromuscular disease or cancer – must be appropriately excluded.

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Treatment and Management

There is no single pill that “switches off” functional speech and swallowing symptoms. Evidence and expert consensus support a rehabilitation approach led by Speech and Language Therapy, often combined with psychological and physiotherapy input.

Speech and Language Therapy (SLT)

SLT plays a central role in:

• Explaining the diagnosis – that symptoms are real but arise from altered function, not structural damage
• Helping to normalise muscle use for voice and swallowing through targeted exercises
• Working on breath support, posture and muscle tension in the neck and larynx
• Teaching strategies for clearer speech, easier voice production and safer, more comfortable swallowing
• Using techniques such as graded practice, desensitisation and biofeedback where appropriate

For voice symptoms, therapy may include voice exercises, laryngeal relaxation, posture work and behavioural change to reduce strain and overuse.

For swallowing, SLT may:

• Guide pacing, posture and texture modification (only if needed)
• Support a gradual return to usual foods and drinks, where safe
• Address fear of choking and reduce over-reliance on very soft or limited diets
• Help shift focus away from intense self-monitoring towards more automatic swallowing

Psychological Therapies

Psychological input does not imply symptoms are “all in the mind”. It focuses on how thoughts, emotions and attention influence muscle tension and automatic control.

Therapy may involve:

• Cognitive Behavioural Therapy (CBT) or other approaches to:
  • Reduce catastrophic thoughts about choking or losing one’s voice
  • Address avoidance behaviours, such as avoiding eating with others or speaking in public
  • Manage anxiety, trauma or low mood linked to symptoms
• Techniques to shift attention outward, away from constant monitoring of the throat or speech

Multidisciplinary Rehabilitation

Because functional speech and swallowing symptoms often occur alongside other FND features, pain, fatigue or dizziness, many people benefit from team-based rehabilitation, including:

• Neurophysiotherapy – to address posture, breathing patterns, balance and movement
• Occupational therapy – for fatigue management, daily routines and confidence in social and work situations
• Neuropsychology / psychology – as above
• Medical review to optimise medication, sleep and physical health

With clear explanation and consistent rehabilitation, many people see significant improvement in function and quality of life, even if occasional symptoms persist.

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Functional Speech and Swallowing Difficulties and FND

Speech, language and swallowing symptoms are now recognised as well-established manifestations of Functional Neurological Disorder, although they remain relatively under-researched compared to other FND presentations.

They may occur:

• On their own, as the main problem
• Alongside other FND symptoms, such as:
  • Functional limb weakness or gait disorder
  • Dissociative (non-epileptic) seizures
  • Functional visual symptoms
  • Functional cognitive symptoms (“brain fog”)
  • Chronic pain and fatigue

Because of this overlap, management is often most effective when delivered within a broader FND-informed rehabilitation programme, rather than in isolation.

You can read more on our dedicated pages:

• Functional Neurological Disorder (FND) – Conditions & Symptoms
• Functional Neurological Disorder – Inpatient Rehabilitation – Rehab Centre

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How We Can Help at The Royal Buckinghamshire Hospital

At The Royal Buckinghamshire Hospital, we support adults with functional speech, voice and swallowing difficulties in the context of:

• Functional Neurological Disorder (FND)
• Complex neurological conditions (such as stroke, neuroinflammatory disease, traumatic brain injury) with functional overlay
• Persistent symptoms affecting communication, eating, drinking, social interaction and work

Our consultant-led inpatient neurorehabilitation programmes typically include:

• Speech and Language Therapy
  • Detailed assessment of speech, voice and swallowing
  • Individualised therapy to improve clarity, ease of voice and confidence in eating and drinking
  • Education and strategies for patients and families
• Neurophysiotherapy and Occupational Therapy
  • Work on posture, breathing patterns and physical conditioning
  • Support with fatigue, pacing, daily routines and graded return to activities
• Clinical Psychology / Neuropsychology
  • Understanding and managing the functional diagnosis
  • Addressing anxiety, trauma, low mood and health-related worry
  • Supporting self-management and long-term coping strategies
• Medical Oversight
  • Review of previous investigations and diagnoses
  • Liaison with referring ENT, neurology, gastroenterology or community SLT teams
  • Advice on onward referrals and follow-up after discharge

Programmes are goal-led and time-limited, with a clear plan for continuing rehabilitation with local services where needed.

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When to Seek Urgent Medical Help

This page provides general information and does not replace individual medical assessment.

You should seek urgent medical help (999 / emergency department) if you or someone else experiences:

• Sudden onset difficulty swallowing with:
  • Choking, inability to clear the airway or breathe
  • Repeated coughing and suspected aspiration
  • Sudden chest pain or severe breathlessness
• Sudden speech difficulties with:
  • New weakness, facial drooping or arm/leg weakness
  • Sudden loss of vision or double vision
  • Sudden severe headache unlike anything before

These symptoms may indicate stroke or other serious conditions and must be assessed immediately.