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With 意思 being いし{HL} (頭高型) and 疎通 pronounced そつう{LHH}, I think I've only heard 意思疎通 pronounced いしそつう{HLLHH}, but since middle-low is not a pitch accent pattern, I'm starting to doubt my ears (which quite frankly fail me more often than they serve).

Also complicating the issue is 意思表示, despite its morphological resemblance to 意思疎通, seems to be いしひょうじ{LHHHLL}.

So it seems the only possible explanation is 意思表示 is taken as a whole word, but 意思疎通 isn't? 意思疎通 does appear quite commonly though. Or am I hearing it wrong?

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I hear both いしそつう【HLLHH】 and いしそつう【LHHHL】 commonly. I believe 意思疎通 is a lexicalized compound, but middle-low is not an uncommon pattern at least in 四字熟語:

  • 意志薄弱 いしはくじゃく【HLLHHHH】
  • 支離滅裂 しりめつれつ【HLLHHH】
  • 春夏秋冬 しゅんかしゅうとう【HHLLLLHHH】
  • 因果応報 いんがおうほう【HLLLHHH】
  • 森羅万象 しんらばんしょう【HLLLHHHH】

Some are even more complicated:

  • 切磋琢磨 せっさたくま【HLLHLL】
  • 一蓮托生 いちれんたくしょう【LHHHLHHHH】

On the other hand, 意思表示 is always いしひょうじ【LHHHHL】. I don't know why.

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