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This is a combination of a very common symptom, difficulty focusing, concentrating or being "in the moment", and a less specific and possibly less frequent one, difficulty speaking audibly and clearly at some times but not at others. The list of potential causes, as is often the case when illnesses or problems first present themselves, is fairly long, but the most likely possibilities are generally benign and treatable, even if the symptoms are worrisome, and appropriate specialists have apparently been consulted with no specific findings being apparent, which makes some of the more worrisome possible causes less likely.

A form of anxiety, which can often have intermittent symptoms and may simulate almost any kind of medical or neurological disorder, is a strong possibility, as are to a lesser extent some other conditions of physical cause that are classified with the psychiatric disorders; some of these have been appropriately brought up in some of the other posts, such as obsessive compulsive disorder, avoidant personality disorder and a form of depression in which physical symptoms may be more prominent than depressed mood. Sometimes the key to identifying anxiety or mood disorder is the presence of some of their symptoms at times in the past, or the history of these disorders in the family.

The normal examination of the vocal cords makes many disorders of speech and vocalization unlikely, but there are some which are intermittent in occurrence and without apparent abnormality of the throat and larynx. Spasmodic dysphonia is the name sometimes given to intermittent spasm or incoordination of the muscles involved in vocal cord positioning that control the volume and character of speech; there is often no sign of vocal cord abnormality in between the attacks, and the condition is sometimes associated with some movement disorders like torticollis, which is spasmodic contraction of some of the muscles of the neck, or with anxiety disorders, and will sometimes respond to some of the same treatments as anxiety or torticollis.

The sudden onset or descent of these symptoms suggests some kind of attack, and episodes of disorientation, altered consciousness or behavior and difficulty communicating or remembering might represent complex partial or temporal lobe seizures. Migraine is another cause of episodic symptoms and, although there do not appear to be characteristic headaches associated with these spells, there are forms of migraine in which confusion and dysphasia, or interference with the production or understanding of language, are the paramount and sometimes the only symptoms. A variety of other neurological disorders can produce episodic problems of this kind, ranging from multiple sclerosis to a brain tumor to a cyst in the third ventricle of the brain that can cause intermittent obstruction to the flow of cerebrospinal fluid and acute enlargement of the ventricles with these and other neurological symptoms. This list should not cause consternation, because all of these possibilities, or at least the last group, are very infrequent and the key words here are "other symptoms" in addition to the kind that have been described. There may be a family history of migraine, and people with confusional migraine may remember headaches at other times or have a history of migraine precursors, like cyclical abdominal pain or fainting in childhood.

Some general medical causes need to be considered, and there was a brief suggestion from the period of sushi avoidance that there might have been some relationship between the symptoms and diet. Difficulties with concentration and expression are quite consistent with the neurological manifestations of hypoglycemia, and more people have relative hypoglycemia, in which symptoms are related to the rate at which blood sugar shoots up and crashes downward after eating (or not), than the kind of hypoglycemia s, that we usually think about, in which symptoms are caused by a profoundly low blood sugar level. There are a few other potential medical explanations, including levels of calcium or magnesium and thyroid function, that are less likely in an otherwise healthy young person but might still be thought about.

These symptoms seem to replicate the effects of marijuana smoking in past years, and paranoid and anxious states are among the bad effects of long-term marijuana use. It is in general possible that further smoking of marijuana on an occasional basis could now recreate some of the effects of earlier heavier use, so stopping any remaining use of marijuana, or for that matter any other drugs, would be a good idea if that is relevant. Alcohol could also be a trigger, as well as nicotine or caffeine if used to any significant degree, and a form of anxiety brought on by substance use has recently been distinguished from the other anxiety disorders by the American Psychiatric Association. A few weeks without alcohol, nicotine or caffeine might clarify their relationship if any to the symptoms, and would be a healthy thing to do in any event.

A visit to the primary-care physician is a good idea, because a longer discussion may elicit some of these clues from past and family history, and sometimes findings on neurological examination, even slight ones, may be a clue to some of the more remote neurological explanations. Blood tests will likely have a low yield, but measuring blood sugar in the fasting state or two hours after eating sometimes shows a predisposition to hypoglycemia. A CT or MRI scan may be needed down the road to look for some of the neurological causes, and there are means of evaluating vocal cord function that allow laryngologists to identify intermittent spasm, but these are best deferred until later. The simplest approach might be to stop caffeine, nicotine, alcohol, marijuana if still an issue and any other potential rest and lifestyle factors pending a talk with the general practitioner, then take his or her advice from there.

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