Psychogenic Voice Disorders

Presented bySara PanianASC 823C

April 17, 2003

“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

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)

Psychogenic Causes of Voice Problems

Chronic anxiety states

Stress

Depression

Intrapersonal & interpersonal problems

Trauma

Qualifications for Psychogenic Voice Disorders

One of the previous factors or causes listed must be presentVoice must be affected fairly consistentlyNo organic cause can account for the disorder

Types of Psychogenic Voice Disorders

Conversion Aphonia

Conversion Dysphonia

Puberphonia/Mutational Falsetto

Conversion Muteness

Conversion Aphonia

Involuntary whispering despite a normal larynx

Gradual or sudden onsetCan be triggered by an organic disorderPsychotherapy often recommended

Approximately 80% of patients with conversion aphonia are female (Aronson, p. 144)

Conversion Dysphonia

Characterized by an unreliable voiceUnpredictable pitch, amplitude, etc.Examples:

breathy normal qualityhigh low pitchloud soft voice

Many of these patients have adjusted to their anxiety or depression

Some may prefer to continue as they are without voice therapyOthers truly want a better voice

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)

Puberphonia/Mutational Falsetto

Failure to change from higher-pitched voice of preadolescence to lower-pitched voice of adolescence and adulthood (Aronson, p. 146)

Characteristics:WeakThinBreathy HoarseMonopitched

Laryngeal capability of producing normal low-pitched voice is present

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

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

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.

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.

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 disorderLet 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

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)

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”

Therapy Techniques

The steps to normal communication:Coughing, throat-clearing, etc.Prolongation to phonated vowels with coughProduction of all vowelsMonosyllabic wordsAny wordSimple phrases Oral readingSimple conversationConversation with anyone about anything in the clinic settingGeneralization to everyday communication

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)

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,

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