Etiology and treatment of psychogenic voice disorder:Results of a follow-up study of thirty patients

It is generally accepted that psychogenic voice disorder (PVD) is aresult of psychosocial stress; however, systematic studies of etiological factors in this condition are few. Furthermore, although immediate effects of therapy are estimated to be good, relapses are frequent, and the long-term effects of therapy are not known. The present prospective and longitudinal study on 30 patients was thus focused on possible etiological factors, the course of therapy, and the long-term results of therapy for PVD. The results indicate that interpersonal conflicts related to family and work are of basic importance in precipitating this condition. PVD is interpreted as a specific disorder of verbal emotional expression. Our therapy model in which vocal exercises are performed, together with training of communicative skills, seems rewarding. Relapses were not reported in 88% of the patients during the followup period of 1.9-8.4 years after therapy.     

A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia

Forty-five patients diagnosed as having nonorganic dysphonia were assigned in rotation to 1 of 3 groups. Patients in group 1 received no treatment and acted as a control group. Patients in groups 2 and 3 received a program of indirect therapy and direct with indirect therapy, respectively. A range of qualitative and quantitative measures were carried out on all patients before and after treatment to evaluate change in voice quality over time. Results revealed a significant difference between the 3 treatment groups in the amount of change for the voice severity, electrolaryngograph, and shimmer measurements and on ratings provided by a patient questionnaire (P<0.05). However, other measures failed to show significant differences between the 3 groups. Most of the patients (86%) in group 1 showed no significant change on any of the measures. Some patients in treatment group 2 (46%) showed significant change in voice quality. Fourteen out of 15 patients (93%) in treatment group showed significant changes in voice quality.     

Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.     

Functional assessment of patients with spasmodic dysphonia

Assessment of function in patients with spasmodic dysphonia is necessary to confirm diagnosis, plan therapy, predict response, and assess effectiveness of treatment. This task is difficult because symptom severity fluctuates, the test environment is artificial, and the objective parameters used to measure vocal function may not adequately reflect the handicap experienced by the patient. Available methods for assessing these patients are reviewed and the utility of each considered, particularly in managing patients with botulinum toxin therapy. Assessment should include a battery of tests, including subjective perceptual ratings and direct physical measurements.     

Psychogenic dysphonia: Peeling back the layers

Resolution of psychogenic dysphonia is often quick and effortlessfor client and therapist alike. In such instances, the therapeutic interventions are simple and straightforward, insights are reached without difficulty, and once normal voice has been established, resumption of dysphonia or other psychosomatic symptoms rarely occurs. Sometimes, however, psychogenic dysphonia is extremely difficult to overcome, requiring considerable time, effort, and determination on the part of the client, coupled with confident, skilled persistence and psychotherapeutic insight from the therapist. In such cases one feels a sense of working through many complex layers before obtaining satisfactory voice or reaching an understanding of the psychogenic factors that precipitated onset and/or maintenance of the dysphonia.

Two cases that illustrate this involved process of peeling back the layers are presented. For resolution of severe psychogenic dysphonia, the therapist must be able to recognize and establish the complex relationship between the neurophysiological, intrapsychic, and interpersonal levels of function as they affect the client's voice and person, as a whole. This work requires considerable courage and skill on the part of the therapist to question, explore, change direction, and select alternative approaches. It is important that the problem can be resolved with a depth of understanding which is relevant for the client, and with due attention to the social context and wider systems of which he or she is a part.     

The Value of Laryngeal Electromyography in the Evaluation of Laryngeal Motion Abnormalities

SUMMARY: Laryngeal electromyography (EMG) functions routinely as a prognostic tool in the evaluation of vocal fold paralysis, as a guide for therapeutic injections into the laryngeal muscles, and more recently as an assessment tool in the evaluation of vocal fold paresis. This study investigates the clinical utility of laryngeal EMG as a diagnostic aid in the evaluation of movement disorders of the larynx in patients complaining of dysphonia. A retrospective chart review of all laryngeal EMGs performed at a tertiary laryngology referral center over a 13-month period was performed. All laryngeal EMGs were performed to evaluate laryngeal motion abnormalities in dysphonic patients. Thirty-seven laryngeal EMGs were completed during this study period. Analysis of the data revealed that the medical treatment plan changed as a result of findings on laryngeal EMG in 10/37 patients (27.0%); laryngeal EMG guided and/or confirmed the course of treatment in 12/37 patients (32.4%) and did not change the treatment plan in 15/37 patients (40.5%). Laryngeal EMG is a useful diagnostic tool that, in this study, contributed significantly to and helped guide the evaluation and management of motion disorders in the larynx of dysphonic patients.     

The Prevalence of Childhood Dysphonia: A Cross-Sectional Study

There is only very limited information on the prevalence of voice disorders, particularly for the pediatric population. This study examined the prevalence of dysphonia in a large cohort of children (n = 7389) at 8 years of age. Data were collected within a large prospective epidemiological study and included a formal assessment by one of five research speech and language therapists as well as a parental report of their child's voice. Common risk factors that were also analyzed included sex, sibling numbers, asthma, regular conductive hearing loss, and frequent upper respiratory infection. The research clinicians identified a dysphonia prevalence of 6% compared with a parental report of 11%. Both measures suggested a significant risk of dysphonia for children with older siblings. Other measures were not in agreement between clinician and parental reports. The clinician judgments also suggested significant risk factors for sex (male) but not for any common respiratory or otolaryngological conditions that were analyzed. Parental report suggested significant risk factors with respect to asthma and tonsillectomy. These results are discussed in detail.     

Use of acupuncture for the treatment of adductor spasmodic dysphonia: a preliminary investigation

Ten subjects with adductor spasmodic dysphonia participated in a study examining the effects of an acupuncture treatment protocol on their voice disorder. Treatment consisted of eight sessions, and it was designed and performed by two physicians certified in acupuncture. Voice characteristics were evaluated pretreatment and posttreatment using the CSL Motor Speech Profile (MSP), Unified Spasmodic Dysphonia Rating Scale, and Voice Handicap Index (VHI). Subjects also answered a posttreatment questionnaire regarding their experience. Significant pretreatment and posttreatment differences occurred for some MSP measures. Significant differences were found on all three subtests of the VHI, and the average total scores pretreatment and posttreatment differed by 17 points (considered significant according to VHI standardization). Seven of 10 subjects reported improvements in voice production, although expert raters did not detect perceptual changes in voice quality. Possible reasons for the discrepancies between objective measures and self ratings, and implications for further research, are discussed.     

A comparison of injection techniques using botulinum toxin injection for treatment of the spasmodic dysphonias

The benefit duration and side effects following effective treatment of spasmodic dysphonia or voice tremor using botulinum toxin injection were studied following 477 open trial unilateral or bilateral injections provided to 178 patients. A comparison of unilateral and bilateral injections in male and female patients with adductor spasmodic dysphonia demonstrated an increased benefit duration following unilateral injections in women, longer periods of breathiness in men than in women following bilateral or unilateral injections, and a trend for reduced benefit durations following repeated treatments using bilateral injections. Outcomes were similar in the adductor spasmodic dysphonia and vocal tremor groups following thyroarytenoid injection while benefit durations were reduced and side effects lasted longer in patients with abductor spasmodic dysphonia following cricothyroid injections. Long-term benefit > 1 year occurred in 12.3% of patients following injection.     

Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia

In a previous study, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. This could not be confirmed for the male subgroup. The present study is to corroborate and nuance this observation by investigating larger groups, and to determine if, after voice therapy, the number of autonomic symptoms and complaints-particularly those ones that have no obvious relation to voice function-decreases. It is a prospective study with a matched control group; 184 patients with nonorganic dysphonia and 126 normal controls answered a questionnaire of 46 questions with 3 subsets and a consistency control. One hundred and one patients received functional voice therapy and completed the questionnaire before and after treatment. A matched control group of 42 normal subjects also filled in the questionnaire two times, with an interval of about 6 months. Neurovegetative symptoms and complaints-voice related and not related-are reported in highly significant excess by patients (especially but not exclusively females) with habitual nonorganic voice disorder. After therapy, there is a highly significant reduction in the number of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than healthy controls (even less). The number of neurovegetative symptoms and complaints connected with voice function is also strongly reduced in patients after therapy, but remains in significant excess when compared with controls.     

The aging adult voice

Advancing age produces physiologic changes that may alter voice. Some of these changes are inevitable; others may be avoidable or reversible. In addition, many treatable medical conditions may cause voice changes similar to those of aging. It is essential that all voice care providers be familiar with the expected changes of aging, and be alert to reversible conditions that may adversely affect phonation and be mistaken for presbyphonia.     

Current and Emerging Concepts in Muscle Tension Dysphonia: A 30-Month Review

The modern theory of hoarseness is that there are multifactorial etiologies contributing to the voice problem. The hypothesis of this study is that muscle tension dysphonia is multifactorial with various contributing etiologies. METHODS: This project is a retrospective chart review of all patients seen in the Voice Speech and Language Service and Swallowing Center at our institution with a diagnosis of muscle tension (functional hypertensive) dysphonia over a 30-month period. A literature search and review is also performed regarding current and emerging concepts of muscle tension dysphonia. RESULTS: One hundred fifty subjects were identified (60% female, 40% male, with a mean age of 42.3 years). Significant factors in patient history believed to contribute to abnormal voice production were gastroesophageal reflux in 49%, high stress levels in 18%, excessive amounts of voice use in 63%, and excessive loudness demands on voice use in 23%. Otolaryngologic evaluation was performed in 82% of patients, in whom lesions, significant vocal fold edema, or paralysis/paresis was identified in 52.3%. Speech pathology assessment revealed poor breath support, inappropriately low pitch, and visible cervical neck tension in the majority of patients. Inappropriate intensity was observed in 23.3% of patients. This set of multiple contributing factors is discussed in the context of current and emerging understanding of muscle tension dysphonia. CONCLUSIONS: Results confirm multifactorial etiologies contributing to hoarseness in the patients identified with muscle tension dysphonia. An interdisciplinary approach to treating all contributing factors portends the best prognosis.     

Effects of voice therapy on the voice range profiles of dysphonic patients

In a group of chronically dysphonic patients, a voice range profile, or phonetogram, was recorded before and after receiving voice therapy and again 3 months later. The voice range profiles took a wide variety of shapes. Therefore, only measures that did not depend on a smooth contour could be used to describe changes before and after therapy. The main effect of voice therapy was an enlargement on the side of low frequency and low intensity.     

Psychogenic spasmodic dysphonia: A case study with expert opinions

Spasmodic (spastic) dysphonia (SD) is considered by some to be a neurologic syndrome and by others a symptom complex of multiple etiologies, neurologic and psychogenic. A case of a 26-year-old female psychiatric nurse with psychogenic SD (PSD) is presented. The dysphonia was alleviated within one session of voice therapy. Psychogenic etiology was established by the author, based on three diagnostic criteria—symptom incongruity, symptom reversibility, and symptom psychogenicity. Seven nationally recognized voice experts listened to audio-recorded samples of the patient's pre- and posttherapy voice during conversational speech. The experts agreed that the dysphonia was psychogenic and characterized it as staccato-like speech, effortful phonation, and interrupted flow of speech; six characterized it with intermittent voice arrests (voice stoppages); five with hoarse-harsh voice; and four with waxing and waning, strained-strangled phonation. These are often described as salient features of SD. Nevertheless, the experts disagreed among themselves as to whether the dysphonia was characteristic of SD and should be labeled as such. The author argues that as long as the voice characteristics and pathophysiologic findings that constitute SD are not well delineated, and as long as the diagnosis of SD is based on symptoms alone, patients with psychogenic or poorly understood voice disorders are likely to be misdiagnosed with organic (neurologic) SD and thus subjected to undue medical treatment. The author also argues that the debate over the etiology of SD can be resolved if SD is considered a neurologic syndrome, PSD a nonorganic phonatory disorder that mimics the syndrome, and if the voice symptoms and pathophysiologic characteristics of SD are well defined and agreed on.     

Laryngeal adduction in resonant voice

The primary question in this study was whether subjects with nodules and subjects with healthy larynges would produce “resonant voice” with a similar laryngeal configuration. A second question regarded whether the electroglottographic closed quotient (EGG CQ) could be used to noninvasively distinguish resonant from other voice types. Twelve adult singers and actors served as subjects, including 6 persons with healthy larynges and 6 persons with nodules. Performers were used as an attempt to maximize token validity and stability. Subjects produced repeated tokens of resonant, pressed, normal, and breathy voice during sustained vowels. Laryngeal adduction was directly estimated using blinded, ordinal, visual-perceptual ratings based on videoscopic views of the larynx. EGG CQs were further calculated based on separate trials. The perceptual ratings indicated that subjects in both groups produced resonant voice with a barely adducted or barely abducted laryngeal configuration that was distinct from configurations for pressed and breathy (but not normal) voice. Previous literature suggests that this configuration may be relevant in many cases of voice therapy (I). Average CQs distinguished resonant from pressed voice, but inconsistently distinguished resonant from breathy voice. Further CQs were reliably different across healthy subjects and subjects with nodules. Thus, the utility of this measure to noninvasively estimate resonant voice may be limited, particularly without ongoing subject-specific calibration procedures.     

Spectral pattern recognition of improved voice quality

The self-organizing map (a neural network) was applied to the spectral pattern recognition of voice quality in 34 subjects: 15 patients operated on because of insufficient glottal closure and 19 subjects not treated for voice disorders. The voice samples, segments of sustained /a/, were perceptually rated by six experts. A self-organized acoustic feature map was first computed from tokens of /a/ and then used for the analysis of the samples. The locations of the samples on the map were determined and the distances from a normal reference were compared with the perceptual ratings. The map locations corresponded to the degree of audible disorder: the samples judged as normal were overlapping or close to the normal reference, whereas the samples judged as dysphonie were located further away from it. The comparison of pre- and postoperative samples of the patients showed that the perceived improvement of voice quality was also detected by the map.     

Laryngeal adduction in trillo

Acoustic, glottographic, and videolaryngoscopic analyses were made of trillo, a vocal ornament described as the rapid repetition of a single note. This vocal gesture, performed by a trained singer, was studied for variations in laryngeal adduction, fundamental frequency, and acoustic amplitude characteristics. Results suggested that trillo was produced with alternating abduction/adduction of the vocal folds, and fundamental frequency tended to be lower during the relatively more abducted portions of the utterance.