Psychogenic Voice Disorders

1. Psychogenic Voice Disorders Presented by Sara Panian ASC 823C April 17, 2003

2. “Psychogenic” vs. “Functional” • Boone & McFarlane use the term “functional” • Rationale: Most patients experience a total return of functional voice in 1-3 voice therapy sessions. • Aronson and others prefer the term “psychogenic” • Rationale: Most cases are traced to a psychological cause (anxiety, depression, etc.) • The term “functional” is ambiguous

3. Conversion Reactions • Definition: Any loss of voluntary control over normal striated muscle or over the general or special senses as a consequence of environmental stress or interpersonal conflict. • Psychogenic voice disorders originate from this psychoneurosis. (Aronson, p. 141)

4. Psychogenic Causes of Voice Problems • Chronic anxiety states • Stress • Depression • Intrapersonal & interpersonal problems • Trauma

5. Qualifications for Psychogenic Voice Disorders • One of the previous factors or causes listed must be present • Voice must be affected fairly consistently • No organic cause can account for the disorder

6. Types of Psychogenic Voice Disorders • Conversion Aphonia • Conversion Dysphonia • Puberphonia/Mutational Falsetto • Conversion Muteness

7. Conversion Aphonia • Involuntary whispering despite a normal larynx • Gradual or sudden onset • Can be triggered by an organic disorder • Psychotherapy often recommended • Approximately 80% of patients with conversion aphonia are female (Aronson, p. 144)

8. Conversion Dysphonia • Characterized by an unreliable voice • Unpredictable pitch, amplitude, etc. • Examples: • breathy  normal quality • high  low pitch • loud  soft voice • Many of these patients have adjusted to their anxiety or depression • Some may prefer to continue as they are without voice therapy • Others truly want a better voice

9. Personality and Conversion Dysphonia • According to one study, the majority of individuals with vocal nodules are extroverts, while the majority of individuals with functional dysphonia are introverts. (Roy et al., 2000)

10. Puberphonia/Mutational Falsetto • Failure to change from higher-pitched voice of preadolescence to lower-pitched voice of adolescence and adulthood (Aronson, p. 146) • Characteristics: • Weak • Thin • Breathy • Hoarse • Monopitched • Laryngeal capability of producing normal low-pitched voice is present

11. Conversion Mutism/Muteness • Most severe of conversion voice disorders • Patient makes no attempt to phonate or articulate, or may articulate without exhalation • Characteristics: • Indifference to the symptom • Chronic stress • Depression (mild to moderate) • Suppressed anger • Immaturity and dependency

12. Conversion Mutism, cont’d • Common themes in patient history: • Wanting, but not allowing oneself, to express an emotion verbally (such as fear, anger, or remorse) • A breakdown in communication with someone of importance to the patient • Shame or fear getting in the way of expressing feelings through normal speech and language

13. Identification of Psychogenic Voice Disorders • A complete medical examination should be completed to rule out any possible organic or neurologic cause for the disorder. • Flexible endoscopic evaluation reveals vocal folds adduct during coughing, laughing, etc., but not during communicative speech.

14. Identification of Psychogenic Voice Disorders, cont’d • Client is unaware that the mechanisms used for non-speech actions (coughing, throat-clearing, etc.) are the same as those used for speaking.

15. Case History • After diagnosis has been made… • Clinician will want to carefully probe deeper than during a regular case history. • Attempt to determine “cause” of disorder • Let client know that stresses or conflict in her life may be affecting her voice • Ask if there’s anything happening in her life that might be important for you to know

16. Referrals? • Immediate mental health referral may not be most effective • Client may reject referral to psychologist or psychiatrist • SLP: Lead gradually to this area and educate the client regarding the need for professional counseling (Aronson, 1990)

17. Therapy Considerations • Avoid telling the client, “You could talk if you wanted to!” • Instead, explain what is physically wrong • “…keeping vocal folds apart…” • Experiencing an inability to “get them started”

18. Therapy Techniques • The steps to normal communication: • Coughing, throat-clearing, etc. • Prolongation to phonated vowels with cough • Production of all vowels • Monosyllabic words • Any word • Simple phrases • Oral reading • Simple conversation • Conversation with anyone about anything in the clinic setting • Generalization to everyday communication

19. Iatrogenic Factor • Definition: Any illness induced by the actions of the clinician • Never tell a client with a voice disorder (organic, or especially psychogenic) to whisper or not use their voice for days or weeks! • Creates anxiety  Secondary voice disorder • Failure to use voice  Flaccidity of nonuse of vocal folds  Another dysphonia (Aronson, p. 151)

20. Deep thoughts… “If the eyes are the mirror of the human soul, then the voice is the barometer of human emotion.” Kerry Erie, M.Cl.Sc,

21. Resources • Aronson, A.E. (1985). Clinical voice disorders: An interdisciplinary approach (2nd edition). New York: Thieme Inc. • Boone, D.R. & McFarlane, S.C. (2000). The voice and voice therapy (6th edition). Boston: Allyn and Bacon. • Case, J.L. (2002). Clinical management of voice disorders (4th edition). Austin, TX: Pro-ed. • Psychogenic voice disorders (1999, April 22).Retrieved April 6, 2003, from http://www.geocities.com/Tokyo/2961/FYV-psy-disorders.htm • Stemple, J.C., Glaze, L.E., & Klaben, B.G. (2000). Clinical voice pathology: Theory and management (3rd edition). San Diego, CA: Singular Publishing. • Voice of emotion: The speech-language pathologist’s role in managing stress related voice disorders (2003). Retrieved April 6, 2003, from http://www.londonspeech.com/article7.htm