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.     

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 image biofeedback for voice disorder patients

Laryngeal image biofeedback (LIB) is a new therapeutic technique for selected patients with abnormal vocal production. In particular, patients with false vocal fold phonation or psychogenic aphonia/dysphonia who have failed traditional voice therapy have been found to respond to LIB. The apparatus and procedure used for this technique are presented along with suggested criteria for patient selection.     

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.     

The dystonic larynx

“Spastic Dysphonia” or spasmodic dysphonia has been shown to be a focal laryngeal form of dystonia. Review of our 2556 cases of dystonia and 562 cases of laryngeal dystonia reveals similar male/female ratio, Jewish/non-Jewish ratio, family history, EMG data, and percent focal, segmental and general cases to be the same. Patients with the adductor form have a staccato, jerky, squeezed, labored, hoarse or groaning voice. In the abductor form, patients have a breathy, effortful voice with aphonic, whispered segments of speech. Compensatory forms may confuse the diagnosis. Fiberoptic videostroboscopy, EMG, and voice spectrograms are very useful for diagnosis.     

Clinical Characteristics and Voice Analysis of Patients With Mutational Dysphonia: Clinical Significance of Diplophonia and Closed Quotients

The aim of this study was to investigate the acoustic and electroglottographic characteristics of patients with mutational dysphonia before and after voice therapy. The clinical records of 15 patients with mutational dysphonia were reviewed, and their voice recordings were analyzed with the help of the Lx Speech Studio program (Laryngograph Ltd, London, UK). After voice therapy combined with the manual compression method, the subjects' voices lowered in pitch and improved in quality. In addition, we classified the mutational dysphonia into four categories according to the presence of diplophonia and closed quotients. The most common type among the categories was characterized by a bimodal distribution of fundamental frequency (diplophonia), accompanied by a low closed quotient (falsetto voice) at high frequencies. However, the results also showed that mutational dysphonia cannot be generalized as always having a falsetto voice, as shown in other types. The effect of therapy was different for each type, and those cases with both diplophonia and a non-trained falsetto voice could be treated more readily. Consequently, the diplophonia and closed quotient, which were easily analyzed using Lx Speech Studio program, are important factors in the classification of mutational dysphonia. Identification of these characteristics may affect treatment choices, facilitate monitoring of the efficacy of therapy, and aid in estimating prognosis.     

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.     

Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy

A combined-modality treatment program consisting of botulinum toxin injection (Botox) and voice therapy was used to treat 17 subjects diagnosed with adductor spasmodic dysphonia (ADD SD). Ten subjects with ADD SD served as the control and were given Botox only. Voice therapy after Botox injection was directed toward reducing the hyperfunctional vocal behaviors, primarily glottal overpressure at voice onset and anterior-posterior squeezing. The results indicated that subjects who underwent combined-modality treatment maintained significantly higher mean airflow rates for significantly longer periods. Moreover, there was a carryover effect in these patients when they received Botox only. Adductor spasmodic dysphonia is treated most effectively when intrinsic laryngeal muscle spasms are reduced or eliminated by Botox injection and extrinsic hyperfunctional vocal behaviors are treated with voice therapy     

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.     

Longitudinal Effects of Botulinum Toxin Injections on Voice-Related Quality of Life (V-RQOL) for Patients with Adductory Spasmodic Dysphonia

Adductory spasmodic dysphonia is a focal dystonia of laryngeal muscles. Patients with this disorder typically have severe vocal difficulties, with significant functional, social, and emotional consequences. There is no widely accepted cure for this condition, however, botulinum toxin injections of the thyroarytenoid muscles are considered by most voice clinicians to be the state of the art treatment. Based on extensive experience treating patients for adductory spasmodic dysphonia, we feel that traditional means of voice assessment do not adequately measure either the disease severity or the treatment outcomes. That is, listening to or acoustically analyzing limited phonatory samples does not capture the functional, social, and emotional consequences of this disorder. These consequences will be reflected in a patient's voice-related quality of life (V-RQOL). Using a validated voice outcomes instrument, the V-RQOL Measure, the purpose of this study was to quantify longitudinal changes in the V-RQOL of patients with adductory spasmodic dysphonia who are undergoing botulinum toxin injections. Twenty-seven consecutive new patients presenting with dysphonia to our institution during an 18-month period were diagnosed with adductory spasmodic dysphonia, and treated patients were evaluated prospectively using the V-RQOL Measure. Results indicated that (1) V-RQOL was initially very low for these patients, (2) botulinum toxin injections improved it significantly for each injection cycle studied, and (3) the magnitude of the treatment effect appears to change across injections.     

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.     

Botulinum toxin in the treatment of recalcitrant mutational dysphonia

Mutational falsetto is the failure of the normal drop in vocal pitch at puberty. Voice therapy almost always achieves an appropriate pitch; however, in cases of failure, surgical treatment has also been recommended. We report a case of a 47-year-old man with an above-average fundamental frequency and a thin voice quality in the absence of any signs of androgen insufficiency. Laryngeal examination revealed atrophy of the vocalis muscle. Voice therapy was unsuccessful in achieving a stable voice. Injection of 15 units of botulinum toxin into each cricothyroid muscle initially resulted in aphonia, but the voice returned by 1 week. Average fundamental frequency was 84 Hz at 1 week, 104 Hz at 1 month, and 100 Hz at 1 year. We hypothesize that mutational dysphonia is an habitual dysfunction of the voice with inappropriate activation of the cricothyroid muscle and disuse of laryngeal adductor muscles. Temporary deactivation of the cricothyroid muscle enforces adoption of a more appropriate vocal mechanism. Botulinum toxin as an adjunct to voice therapy should be considered before surgical alteration of the glottis in patients with recalcitrant mutational falsetto.     

Vocal stability in functional dysphonic versus healthy voices at different times of voice loading

Functional (nonorganic) dysphonia is often characterized by vocal instability. The purpose of the prospective study was to examine whether there is a difference in vocal instability of functional dysphonic voices compared with healthy ones, this means whether electroglottographic perturbation values differ (1) between healthy and dysphonic voices and (2) between two subgroups of the dysphponic voices (hpertonic and hypotonic dysphonic voices). Twenty-three patients with hypertonic functional dysphonia, 9 with hypotonic functional dysphonia and 31 healthy nonsmokers, were each examined electroglottographically before (Ex 1), immediately after (Ex 2), and 1 hour after (Ex 3) voice loading. Perturbations of frequency, amplitude, quasi-open-quotient, and contact-index were calculated from the EGG signal. At all three times of examination, hypertonic dysphonic voices showed higher perturbations than healthy voices, and they had higher perturbations than hypotonic dysphonic voices before and 1 hour after voice loading. Hypotonic dysphonic voices showed higher perturbations than healthy voices only 1 hour after voice loading. Voice loading induced different reactions in dysphonic voices: Some voices showed increased perturbations, and others exhibited normal or even decreased perturbation immediately after voice loading. Examination of electroglottographic-derived perturbations immediately after voice loading seems not to be useful. Differentiation of hypertonic and hypotonic dysphonic voices was possible with an estimated sensitivity of 88.9% and a specificity of 87.0% by using the sum of the amplitude-perturbation and the quasi-open-quotient-perturbation measured before voice loading.     

Botulinum Toxin Therapy for Abductor Spasmodic Dysphonia

Botulinum toxin has been widely accepted as an effective therapy for controlling the symptoms of adductor spasmodic dysphonia (ADSD). Reported experience with botulinum treatment for abductor spasmodic dysphonia (ABSD) has been less impressive. Factors that may impair outcomes for ABSD include differences in the pathophysiology of ADSD and ABSD and limitation of maximal dose from airway restriction with posterior cricoarytenoid muscle (PCA) weakness. We report our experience with botulinum injection of the PCA with an asymmetric dose escalation protocol, based on clinical observations that in ABSD, abductor spasms are often stronger on one side, usually the left. The nondominant side was injected with 1.25 units. Dominant side dose began at 5 units, with step-wise increments of 5 units per week until one of three endpoints was reached: Elimination of breathy voice breaks, complete abductor paralysis of the dominant side, or airway compromise. Fourteen of 17 patients achieved good or fair voice, with dominant-side doses ranging from 10 to 25 units. Exercise intolerance limited PCA dose in two patients. One patient had persisting breathiness that improved with medialization thyroplasty. Asymmetric botulinum toxin injection into PCA muscles can suppress abductor spasm in patients with ABSD, but breathiness may persist, because of inadequate glottal closure.     

Vocal Fold Mucosal Tears: Maintaining a High Clinical Index of Suspicion

Vocal fold mucosal tears have been discussed in the literature rarely, although they are not uncommon clinically. Disruptions in the epithelium usually follow trauma that may result from voice abuse and/or misuse, coughing, and other causes. A high index of suspicion is necessary to avoid missing vocal fold mucosal tears, and strobovideolaryngoscopy is indispensable in making the diagnosis. A brief period of complete voice rest is the standard of care and appears to be helpful in avoiding adverse sequelae and advancing the healing process, but there are no scientific studies to confirm its efficacy. Mucosal tears may heal completely or may be followed by the development of vocal fold masses, scar, and permanent dysphonia.     

Nonorganic Habitual Dysphonia and Autonomic Dysfunction

The present study was designed to test the hypothesis that there is a relation between nonorganic habitual dysphonia and subjective experience of dysfunction of the autonomic nervous system (neurovegetative lability). Eighty-three patients (65 women and 18 men) with a nonorganic voice disorder and a matched control group answered a questionnaire of 46 questions. One question replicated in different terms and six nonrelevant questions point out that the inquiry forms were answered in a consistent way. It appears that female patients in all age categories with a nonorganic habitual dysphonia report significantly more autonomic symptoms and complaints than healthy controls. This hypothesis cannot be confirmed for the male subgroup.     

Statistical analyses of electromyographic activity in spasmodic dysphonic and normal control subjects

Heterogeneity in the quality and task sensitivity of vocal symptoms in the spasmodic dysphonia (SD) population contributes to controversy as to whether this is a single disorder or two disorders with different etiologies (neurogenic versus psychogenic). Perceptual and acoustic assessments of vocal symptoms are inadequate to resolve this controversy. However, myoelectric events are intimately proximal to the source of vocal disruption and may be informative. The present report employs statistical modeling of quantitative amplitude measures of electromyographic activity recorded from thyroarytenoid to examine neuromotor bases of vocal symptoms in SD. Consideration of perceptual ratings of the quality and task sensitivity of vocal symptoms in the context of statistical models provides support for the conclusion that the range of vocal symptoms identified as SD represents a single, neurogenic disorder.     

Abnormal soft palate posturing in patients with laryngeal movement disorders

Laryngeal movement disorders (LMDs), including spasmodic dysphonia and essential voice tremor, have been described as focal disorders affecting the muscles of the larynx. Little reference has been made to possible hyperfunction of supralaryngeal structures and/or palatal involvement. Videonasolaryngoscopic examinations of 83 patients with LMDs revealed a significantly high incidence of abnormal soft palate posturing (84%). Further associations and implications are presented.     

Voice handicap index change following treatment of voice disorders

Outcome measurements of voice disorders is an important new area for both the evaluation of voice-disordered patients and evaluation of treatment efficacy. The Voice Handicap Index (VHI) measures the patient's perception of the impact of his or her voice-disorder. The VHI was used in this study to measure the changes of the patient's perception following treatment for four different voice disorders. The VHI showed a significant change following treatment for unilateral vocal fold paralysis, vocal cyst/polyp, and muscle tension dysphonia. Results of this paper indicate that the VHI is a useful instrument to monitor the treatment efficacy for voice disorders.     

The Relationship Between Dysphonia and Sinusitis: A Pilot Study

Though some clinicians believe chronic sinusitis is associated with dysphonia, studies confirming such a relationship are not available. This pilot study investigated vocal characteristics of chronic sinusitis patients compared to those of nonsinusitis patients. Nineteen male patients were evaluated in a single-blind, nonrandomized, prospective study at a Department of Veterans Affairs Medical Center. After candidates for the experimental and control groups were thoroughly screened [nasal and laryngology examinations, sinus computed tomography (CT) scan, history], 10 chronic sinusitis patients were assigned to the experimental group, nine patients without chronic sinusitis were assigned to the control group. Visi-Pitch analysis of their speech evaluated fundamental frequency, intensity, and perturbation. The evaluator described voice quality and vowel prolongation. Videostroboscopic examination evaluated glottic closure, supraglottic activity, vocal fold edge, amplitude, mucosal wave, and nonvibrating portion. Visi-Pitch analysis and vowel prolongation for each group was compared using an independent t-test. The average fundamental frequency mean was 113.43+/-32.75 Hz for the control group and 112.29+/-19.71 for the experimental group. This study established methods and parameters to determine if a relationship between chronic sinusitis and dysphonia actually exists. It did not establish a relationship between these entities, possibly due to the small sample size enrolled in the study, but determined that 126 subjects would be necessary to achieve significant results.