Edited by: Srikantan S. Nagarajan, University of California, San Francisco, USA
Reviewed by: Katia Nemr, University of São Paulo, Brazil; Stéphane Poulin, Université Laval, Canada
*Correspondence: Peter Mariën
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This paper presents the case of a 33-year-old, right-handed, French-speaking Belgian lady who was involved in a car accident as a pedestrian. Six months after the incident she developed a German/Flemish-like accent. The patient's medical history, the onset of the FAS and the possible psychological causes of the accent change are analyzed. Relevant neuropsychological, neurolinguistic, and psychodiagnostic test results are presented and discussed. The psychodiagnostic interview and testing will receive special attention, because these have been underreported in previous FAS case reports. Furthermore, an accent rating experiment was carried out in order to assess the foreign quality of the patient's speech. Pre- and post-morbid spontaneous speech samples were analyzed phonetically to identify the pronunciation characteristics associated with this type of FAS. Several findings were considered essential in the diagnosis of psychogenic FAS: the psychological assessments as well as the clinical interview confirmed the presence of psychological problems, while neurological damage was excluded by means of repeated neuroimaging and neurological examinations. The type and nature of the speech symptoms and the accent fluctuations associated with the patient's psychological state cannot be explained by a neurological disorder. Moreover, the indifference of the patient toward her condition may also suggest a psychogenic etiology, as the opposite is usually observed in neurogenic FAS patients.
Foreign accent syndrome (FAS) is a rare motor speech disorder which causes patients to speak their native language with an accent which is perceived as non-native by speakers of the same speech community. This “non-nativeness” is the result of suprasegmental and/or segmental changes, which—according to the criteria proposed by Whitaker (
The current study focuses on psychogenic FAS. For most of the psychogenic cases reported so far, a psychogenic cause was assumed because it was not possible to unambiguously identify a neurological disorder. Some authors have discarded the idea of psychogenic FAS because of diagnostic difficulties to objectify this condition (Gurd et al.,
In little over a century—counting from the first (anecdotal) FAS description by Pierre Marie in 1907 until July of 2014—only 15 FAS cases with a presumed psychogenic origin have been reported (Critchley,
The patient gave written informed consent to report the medical data. All the tests reported below are part of the standard, clinical neurolinguistic work-up in patients with speech and language disorders at ZNA Middelheim general hospital. Speech recordings were also made to allow for better follow-up. The patient gave written consent to use recorded speech samples for the perceptual evaluation in a public environment.
SB is a 33-year-old, right-handed, monolingual French-speaking lady, originating from a village in the francophone Walloon part of Belgium near the Flemish border. She was raised in French and her parents were monolingual French-speaking Belgians. From a neurological perspective, growth and development were unremarkable. There was no family history of neurodevelopmental disorders or learning disabilities. She had always obtained normal school results and had an educational level of 12 years. She consulted the neurology department in November 2013 because of a “Dutch or German-like accent,” which she acutely developed approximately 6 months after she was hit by a car while crossing the street to deliver orders from the bakery where she worked as a saleswoman. A few months after the accident occurred, the patient mentioned an “abrupt change of personality.” She considered her behavioral change as the cause for her sudden dismissal at work. There had been serious disagreements with colleagues, customers, as well as with her line manager. She was dismissed in June 2012. It was shortly after her dismissal that she developed a foreign accent.
The accident happened in December 2011. There had been no loss of consciousness. Apart from some superficial subcutaneous hematomas in the frontal and right peri-orbital region, clinical examination on admission to the hospital was normal. CT scan of the brain and spinal cord were normal. A diagnosis of minor head trauma was made. One week later, the patient started suffering from increasingly painful headaches (possibly a post-traumatic migraine, see: Weiss et al.,
Due to the persistence of her complaints with respect to her accented speech and memory, the patient was referred to hospital for additional radiological examinations. In November 2012, she underwent a saggital T1-weighted and axial FLAIR, diffusion, SWI, proton density and T2-weighted MRI of the head, a coronal FLAIR MRI perpendicular to the axes of the left and right hippocampi, as well as an angio-MRI of the brain and 3D TOF of the circle of Willis. The qualified radiologist reported that all acquisitions were normal.
In November 2013, she consulted our department because of the persistence of the accent change and cognitive complaints (attention problems and episodes of confusion). At a linguistic level she suffered from word-finding difficulties and morphological problems related to article-noun agreement (she did not differentiate between the masculine and feminine forms of the definite article). According to her, listeners had the impression that she spoke with a Dutch accent. Her previous customers, for instance, had perceived her as a native Dutch-speaking Belgian and repeatedly asked her why she spoke French instead of “Flemish” (the Belgian variant of Dutch; see: Verhoeven,
The first neuropsychological assessments were carried out approximately 1 year after the accident in January 2012 (see Table
Intelligence | |||||
WAIS-IV | |||||
FSIQ | 105 | 100 (±15) | |||
Verbal comprehension scale | 96 | 100 (±15) | |||
- similarities | (10) | 10 (±3) | |||
- vocabulary | (9) | 10 (±3) | |||
- information | (9) | 10 (±3) | |||
Working memory scale | 112 | 100 (±15) | |||
- arithmetic | (14) | 10 (±3) | |||
- digit span | (10) | 10 (±3) | |||
Perceptual organization scale | 120 | 100 (±15) | |||
- block design | (13) | 10 (±3) | |||
- matrix reasoning | (14) | 10 (±3) | |||
- picture completion | (13) | 10 (±3) | |||
Processing speed scale | 86 | 100 (±15) | |||
- symbols | (7) | 10 (±3) | |||
- coding | (8) | 10 (±3) | |||
Attention d2-test | Attention d2-test | ||||
- Total items (Tn) | (249) | - Total items (Tn) | (242) | ||
- Total (corrected for mistakes) (Tn-F) | (246) | - Total (corrected for mistakes) (Tn-F) - Concentration (C-F2) | (242) (105) | ||
- Variation in tempo (Tn highest-Tn lowest) | (7) | - Variation in tempo (Tn highest-Tn lowest) | (10) | ||
Barrage de Zazzo (10 min.) | |||||
Fastness | (103.6) | ||||
Exactness | (11.48) | ||||
Profitableness | (239) | ||||
Executive functions Wisconsin Card Sorting Test | Executive functions Trail Making Test | ||||
Nr. of categories realized | 6 | - Test A | (52″ 38) | ||
Learning capacity | 24.25% | - Test B | (1′38″ 25) | ||
Nr. of errors | 7 (69) | ||||
Stroop | |||||
Naming | (89″) | 64.78 (±16.25) | |||
- Mistakes | 2 | 1.13 (±1.59) | |||
Reading | (39″) | 46.72 (±16.4) | |||
- Mistakes | 1 | 0.38 (±0.72) | |||
Interference | (155.8″) | 111 (±27.58) | |||
- Mistakes | 3 | 3.5 (±4.15) | |||
Flexibility | (221″) | 133.52 (±52) | |||
- Mistakes | 6 | 2.89 (±2.61) | |||
(Long Term) Memory California Verbal Learning Test | Memory | ||||
List A | (66) | 57.88 (±5.46) | WMS-R | ||
Total 1–5 | (5) | 7 (±2.37) | Attention/Concentration | (50) 70 | 100 (±15) |
List B | - mental control | (4) | 10 (±3) | ||
Free recall of A | (14) | 12.35 (±1.97) | - number series | (18) | 10 (±3) |
Cued recall A | (16) | 13 (±1.90) | - visual series | (28) | 10 (±3) |
Delayed recall A | (15) | 13 (±1.84) | Visual Memory | (66) 133 | 100 (±15) |
Cued delayed recall A | (16) | 13.59 (±1.91) | - perceptual memory | (7) | 10 (±3) |
Recognition | (16) | 14.71 (±1.40) | - associated visual pairs | (18) | 10 (±3) |
- visual reproduction | (41) | 10 (±3) | |||
Verbal Memory | (42) 74 | 100 (±15) | |||
- logical memory | (26) | 10 (±3) | |||
- associated verbal pairs | (16) | 10 (±3) | |||
Global Memory | (108) 86 | 100(±15) | |||
Delayed Recall | (74) 91 | 100 (±15) | |||
- logical memory | (11) | 10 (±3) | |||
- associated visual pairs | (12) | 10 (±3) | |||
- associated verbal pairs | (14) | 10 (±3) | |||
- visual reproduction | (16) | 10 (±3) | |||
Language Boston Naming Test (/60) | (53) |
A full scale IQ (FSIQ) of 105 was found with a significant discrepancy of 24 IQ-points between the verbal (96) and performance IQ level (120). All subtest scores were within the normal range. Executive function (mental flexibility, frontal problem solving) was tested by means of the Stroop and the WCST. She obtained a normal result on the WCST, but depressed scores on the Stroop with slowed processing in the color naming condition (Z-score = −1.5 SD), interference condition (Z-score = −1,6 SD), and flexibility condition (Z-score = −1.7 SD). Tests measuring sustained visuo-motor and selective attention (d2-test in 2012/2014 and the “test de barrage de Zazzo”) were performed at a slow pace. Scores for total items treated for the d2-test (2012: Z = −3.08 SD; 2014: Z = −2.44 SD) as well as the total items corrected (2012: Z = −2.94 SD; 2014: Z = −2.20 SD) were in the pathological range. As shown by the CVLT, verbal memory was intact, the patient obtained borderline results for the “total recollection” (5 trials) of List A (Z-score = −1.49 SD). On other subtasks of the CVLT she obtained normal results (+1 SD: Cued recall A, Delayed recall A, Cued delayed recall A, Recognition).
In 2014, a significant discrepancy between a very superior visual memory index (= 133) and clinically deficient verbal memory index (= 74; −1.7 SD) was found on the WMS-R. As reflected by a general attention index of 70 (−2 SD), the WMS-R tasks scores were in the deficient range. The Trail Making Test (part A and B) disclosed low average visual search (< pct. 10) and mental flexibility (pct. 20). Sustained visuo-motor attention scores were within the defective range. Performance on the BNT was normal. Overall, the data for the test session in 2014 were in line with the results obtained in 2012.
The psychodiagnostic assessment consisted of an interview with an experienced clinical psychologist (LDP), which was followed some time later by a session during which the patient was asked to respond to a series of standardized questionnaires. These questionnaires were completed at the hospital, without the help of the examiner. Testing included the Minnesota Multiphasic Personality Inventory-2 (MMPI-2: Butcher et al.,
Furthermore, symptom validity and self-presentation tests were carried out by means of the List of Indiscriminate Psychopathology (LIPP: Merten and Stevens,
During intake the patient gave evidence of disinhibition which mainly manifested itself as laughing without reason, Witzelsücht and inappropriate comments. The patient was reticent and maintained a (psychologically immature) defensive attitude throughout the entire interview. Her thoughts were preoccupied by frustration about her own situation. The interview was dominated by her feelings concerning her increased impulsiveness, aggressiveness and apathetic demeanor vis-à-vis her family, former boss, and colleagues. The examiner noticed that a topic which rendered her frustrated led to an emotional breakthrough during which she lost the “Dutch/Flemish-like” accent. The patient's interview contained numerous contradictions (e.g., stating at first that she was a very lively, out-going person, but when asked later what she did during the day, she answered that she sat in a chair as all personal contact bored her and conversations with others—even friends—were too difficult and tiring). The description of her emotional and family life remained superficial and prosaic. The interview revealed increasing relational problems. The relationship with her husband left her “unaffected” and relationships with friends, family and relatives were unstable, marked by serious rows in which she responded unpredictably.
She confirmed egocentric and narcissistic tendencies. It was not possible to detect signs of perceptual aberration or other florid psychotic symptoms. A few weeks after the interview, a series of standardized psychodiagnostic tests were administered. Symptom validity and self-presentation tests, such as the List of Indiscriminate Psychopathology and the Supernormality Scale, did not yield indications for (conscious or unconscious) manipulation. Personality testing indicated a wide, undifferentiated personality disturbance. Interestingly, scores on both narcissism measures (NPI and PNI) were at most extreme upper ends, which is consistent with her answers during the clinical interview. A thymic disturbance and affective lability were objectified (APA,
A post-morbid speech sample was recorded in November 2013. It consisted of 5 min of video-recorded spontaneous speech, which was selected from an interview with the patient. In this interview she talks about her accent change and her relational and professional problems. This sample consisted of 644 words (including filled pauses). The patient also provided two (short) pre-morbid speech samples consisting of 43 and 26 s of conversational speech dating from April and July 2011, i.e., approximately half a year before the accident. When comparing pre- and post-morbid speech samples a number of striking differences were found. The first one was a very strong trilling aspect when realizing the uvular [R]. The trill is too excessive for French, and is more typical of the one in German and some regional variants of Dutch (36/644). According to Van de Velde and Van Hout, (
On the suprasegmental level, speech rate and articulation rate were particularly slow (speech rate: 2.67 syll/s, articulation rate: 3.813 syll/s). Avanzi et al. (
Grammar was perceived to be more simplistic than would be expected from a native-speaker of French. Sentences were perceived to be very short. At the morphosyntactic level the patient omitted the article “le” (1/644) as well as “de” in “là
The foreign accent of the patient was assessed by a listening panel who listened to speech stimuli of the patient that were mixed with those of a native speaker of French and three non-native speakers with a clear foreign accent. The listening panel was required to rate the degree of foreignness and they were asked to identify the mother tongue of each of the speakers. The ratings provide additional support for the diagnosis of FAS, whereas the accent attribution gives an indication of whether naive listeners are able to perceptually identify the mother tongue of native (including the FAS patient) and non-native speakers of French. Furthermore, there was an interest to investigate whether there would be any differences between the FAS patient, the true non-native speakers and the native speaker of French.
Thirty students of French linguistics were recruited at the Université Libre de Bruxelles (ULB) in Brussels (age: 16–24, mean age: 20 years, 12 male and 18 female) and they were asked to rate the degree of “foreign-ness” of five speakers and to determine their native language. The students had no formal experience with speech and language pathology.
The stimuli for this experiment were taken from the intake interview, in which the patient explains what had happened to her (accident), and elaborates on her relational and professional problems. From this interview, 6 words, 3 phrases, and 6 sentences were chosen (see also: Dankovičová and Hunt,
The speakers in this experiment were the FAS patient and four control speakers (Table
FAS | F | 33 | Belgium | French | _ |
Control 1 | F | 36 | Belgium | French | _ |
Control 2 | F | 48 | Belgium | Dutch (Flemish) | B2 |
Control 3 | F | 27 | United States of America |
English/Dutch (Netherlands) | B2 |
Control 4 | F | 35 | Russia | Russian | A2+/B1 |
The perception experiment contained a total of 75 stimuli, i.e., 15 stimuli × 5 speakers. Each presentation block consisted of one stimulus read by the five different speakers. The order of the speakers differed for each block (in pseudo-random order). The stimuli were separated by a 15 s. pause to provide time for listeners to record their judgments. Total duration was 26 min. 26 s. The stimuli were played to the listeners in open field at their institution. The instructions to the test were given orally to the listening panel, but they were also able to read them. Raters provided demographic information (age, gender, country of origin, time in Belgium—if not born here, mother tongue, and other spoken languages including an indication of proficiency) in a short questionnaire. For the experiment, they were asked to first rate the “foreign-ness” of the speaker on a scale from 1 to 7. This scale is to be interpreted as a continuum ranging from “definitely
The data were processed statistically in SPSS version 22 (IBM Corp.,
Table
FAS | 3.791 | 4.000 | 2.318 | 1.000 | 7.000 | 6.000 | 5.000 |
French | 6.098 | 7.000 | 1.675 | 1.000 | 7.000 | 6.000 | 1.000 |
Dutch (Be) | 3.138 | 3.000 | 2.161 | 1.000 | 7.000 | 6.000 | 4.000 |
English/Dutch (Nl) | 3.011 | 2.000 | 2.219 | 1.000 | 7.000 | 6.000 | 4.000 |
Russian | 1.407 | 1.000 | 0.913 | 1.000 | 7.000 | 6.000 | 0.000 |
Application of the Kolmogorov-Smirnov test indicated that the data were not normally distributed (Kolmogorv-Smirnov:
FAS | 450 | 322.88 | 145294.50 | 43819.500 | 145294.500 | −15.497 | 0.000 |
French | 450 | 578.12 | 260155.50 | ||||
FAS | 450 | 487.20 | 219240.00 | 84735.00 | 186210.00 | −4.326 | 0.000 |
Dutch(Be) | 450 | 413.80 | 186210.00 | ||||
FAS | 450 | 494.07 | 222331.50 | 81643.500 | 183118.500 | −5.154 | 0.000 |
English/Dutch(Nl) | 450 | 406.93 | 183118.50 | ||||
FAS | 450 | 587.61 | 264424.50 | 39550.500 | 141025.500 | −17.102 | 0.000 |
Russian | 450 | 313.39 | 141025.50 | ||||
French | 450 | 606.39 | 272845.00 | 31100.00 | 132575.000 | −18.728 | 0.000 |
Dutch(Be) | 450 | 294.61 | 132575.00 | ||||
French | 450 450 | 604.38 | 271972.00 | 32003.000 | 133478.000 | −18.576 | 0.000 |
English/Dutch(Nl) | 450 | 296.62 | 133478.00 | ||||
French | 450 | 659.11 | 296598.00 | 7377.000 | 108852.000 | −25.523 | 0.000 |
Russian | 450 | 241.89 | 108852.00 | ||||
Dutch(Be) | 450 | 459.37 | 206717.50 | 97257.500 | 198732.500 | −1.059 | 0.290 |
English/Dutch(Nl) | 450 | 441.63 | 198732.50 | ||||
Dutch(Be) | 450 | 558.65 | 251391.50 | 52583.5 | 154058.500 | −13.864 | 0.000 |
Russian | 450 | 342.35 | 154058.50 | ||||
English/Dutch(Nl) | 450 | 547.76 | 246494.00 | 57481.000 | 158956.00 | −12.628 | 0.000 |
Russian | 450 | 353.24 | 158956.00 |
A correspondence analysis was performed to get a two dimensional image of the strength (distance) of the associations between rating and speakers, based on frequency counts (Table
FAS | 118 | 62 | 40 | 42 | 45 | 50 | 93 | 450 |
French | 18 | 15 | 21 | 10 | 34 | 41 | 311 | 450 |
Dutch(BE) | 165 | 59 | 51 | 38 | 51 | 33 | 53 | 450 |
English/Dutch(NL) | 183 | 62 | 47 | 35 | 36 | 22 | 65 | 450 |
Russian | 349 | 53 | 27 | 11 | 8 | 1 | 1 | 450 |
Active margin | 833 | 251 | 186 | 136 | 174 | 147 | 523 | 2250 |
It appeared that only 50% of the raters (
French | 61 | 214 | 39 | 35 | 4 |
Spanish | 21 | 0 | 8 | 33 | 19 |
Italian | 21 | 1 | 7 | 10 | 32 |
Portuguese | 5 | 0 | 0 | 2 | 22 |
Romanian | 4 | 0 | 0 | 0 | 3 |
Dutch | 46 | 5 | 120 | 63 | 25 |
English | 8 | 0 | 10 | 19 | 16 |
Danish | 0 | 0 | 1 | 0 | 0 |
Norwegian | 0 | 0 | 1 | 0 | 0 |
German | 10 | 0 | 20 | 23 | 5 |
Luxembourgish | 0 | 0 | 1 | 0 | 0 |
Greek | 1 | 0 | 0 | 1 | 2 |
Polish | 8 | 0 | 0 | 10 | 27 |
Russian | 3 | 2 | 2 | 7 | 64 |
Slavic | 1 | 0 | 0 | 0 | 1 |
Chinese | 1 | 0 | 0 | 0 | 0 |
Japanese | 3 | 0 | 1 | 2 | 0 |
Vietnamese | 0 | 0 | 0 | 1 | 0 |
Asian-sounding accent | 1 | 0 | 0 | 1 | 0 |
Hungarian | 0 | 0 | 1 | 1 | 1 |
Estonian | 1 | 0 | 0 | 0 | 0 |
Lithuanian | 0 | 0 | 0 | 1 | 0 |
Turkish | 0 | 0 | 0 | 0 | 0 |
Basque | 0 | 1 | 0 | 0 | 0 |
Unidentifiable | 30 | 2 | 14 | 16 | 4 |
TOTAL | 225 | 225 | 225 | 225 | 225 |
In general, the FAS patient was less often identified as “French” (
Interestingly, the accent stratification was most diverse for the FAS patient (16 different mother tongues were associated with her stimuli). For the other speakers, the number of attributed accents was: English/Dutch(Nl): 15; Russian: 13; Dutch (Be): 12; and French: 5. Equally interesting to note is that the accent of the FAS patient could not be identified in 30 items: this is considerably more often than for the other control speakers: French: 2; Dutch (Be): 14; English/Dutch (Nl): 16; Russian: 1.
This article discusses the case of a patient who developed FAS in the absence of demonstrable damage to the central nervous system. No structural damage was visible on repeat CT and MRI of the brain. Repeat neurological and neurophysiological examinations were normal. An in-depth psychodiagnostic work-up was carried out (a) to confirm the existence of psychological issues and (b) to identify a possible psychiatric disorder. Unfortunately, testing did not reveal a clearly delineated disorder on either axis I or II of the DSM-IV-TR (APA,
First, the accent diminished whenever there was a psychological breakthrough during the clinical interview (Avbersek and Sisodiya,
Second, there was a correspondence between the culmination of disputes with her line manager, which ultimately led her dismissal, and the onset of the accent: both occurred approximately 6 months after the accident.
Third—and related to prior argument—the increased emotional lability and hysteric symptoms may have been reinforced by the adverse life events that had marked her life in rapid succession: the car accident, the accent shift, the dismissal, and the relational problems. According to Avison and Turner (
The patient had repeatedly complained about (sustained) attentional and amnestic problems, as well as slow cognitive processing. These complaints were confirmed by neuropsychological test results: the patient demonstrated impaired processing on the cognitive tasks appealing to working memory, attention, and executive function. These complaints have been noted regularly in psychogenic FAS patients (Poulin et al.,
In the case of our patient the profile seems mostly consistent with a post-concussion cognitive syndrome after a minor head trauma. The objectively attested cognitive deficits and the negligence of the cognitive complaints after prior examinations might also have contributed to the development of the FAS.
On a linguistic level, the patient's speech was characterized by the realization of the uvular R with a marked, atypical trill and occasionally, she deleted phonemes. Furthermore, the patient spoke at a very slow speech rate and had a speech rhythm that was qualified as stress-timed, whilst French is a syllable-timed language (Grabe and Low,
Some speech characteristics might have been consistent with the impression of a Dutch or German accent. However, results of the listening experiment suggest that the patient was perceptually situated midway between a true non-native speaker of French and a native speaker of French. This finding is in line with what has been found in the experiments of Di Dio et al. (
Remarkably, the patient did not seem bothered by the accent change at all. Nevertheless, there were clear problems at the cognitive-behavioral and psychological level (mentioned above). Moreover, she was not keen to be treated for the condition. Rather, she wanted to show off with it. She did not seem to be overtly concerned about her symptoms. This is unlike what is mostly seen in neurogenic patients, who are emotionally and psychologically affected by FAS (Miller et al.,
Patient coping strategies, psycho-emotional and -social implications have generally been underreported in the literature about both psychogenic and neurogenic FAS (for neurogenic patients: Munson,
Only a handful of putative psychogenic FAS cases have been described in the literature and many researchers have been hesitant to conclude to an underlying psychogenic etiology. Although it is hard to provide evidence for a direct causal link between the psychological factor in play and FAS, ample evidence exists that the FAS symptoms (and their course) in this patient are of a psychogenic nature: (1) clear absence of (visible) neurological damage or clinical evidence for a neurological disorder, in conjunction with (2) the presence of psychological and psychiatric factors, (3) the timing of the onset of the accent change, (4) the atypical and fluctuating symptom course, (5) irregular and incredible morphological mistakes occurring in a short sample of spontaneous speech, and the fact that (6) the patient was unconcerned by the change of accent. As most of the psychogenic FAS cases were published in the last decades, reports of cognitive-behavioral deficits such as the ones displayed by current patient are becoming increasingly important with a view to the development of the proper therapeutic approaches for this psychogenic FAS population.
Acquisition of data: SK, LDP, and PM. Analysis and interpretation of data: SK, JV, RJ, LDP, RB, and PM. Drafting the manuscript: SK and PM. Critical manuscript revision: all authors. Critical revision of reviewed manuscript: SK, JV, and PM. Final manuscript approval: SK and PM on behalf of all authors.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
1In English, the term elision is sometimes used as a synonym for deletion (e.g., Miller et al.,
2In this recently published article, another case of psychogenic FAS is presented. The patient suddenly lost her accent during a temper tantrum.