PSYCHOGENIC VOICE DISORDERS: some terms

compiled by Alexander Massey at FREE YOUR VOICE


What is a psychogenic voice disorder?

"... a manifestation of one or more types of psychologic disequilibrium, ... that interfere with normal volitional control over phonation" [Aronson, A.E. (1990) Clinical voice disorders: an interdisciplinary approach, Third edition, Thieme, New York, p.121]. (Also sometimes referred to as non-organic, functional or psychosomatic voice disorder).

Psychogenic voice disorders are distinguished from other vocal dysfunction by the fact that, though the symptoms or secondary characteristics are physical or 'organic', the origins of the problem are psychological rather than physical. Care must be taken to ensure there is not a physical cause (e.g. viral infection, allergy, neurological disease).

Examples of psychogenic causes of vocal problems are chronic anxiety states, stress, depression, intrapersonal and interpersonal problems (often dating back to unresolved emotional and psychological issues from childhood), and trauma.

Dysfunction in one's voice, with the attendant heightened problems of communication, reactions of rejection or embarassment in others at the sound of one's voice, can lead to further distress, frustration and depression, as well as a sense of isolation, compounding the emotional problems which led to the original voice disorder.


Glossary (disorders and related terms)

Childlike/infantile speech in adults: this is related to, but not synonymous with, puberphonia. In addition to immature speech and/or language patterns (including indistinct articulation, lisped 's', or defective 'r'), the habitual pitch is often higher, there is an open, 'young' facial expression, cherubic smiling, and demure head movements, bodily postures and gestures. In emotional terms, the person often avoids the responsibility or relating to others as an adult, preferring to elicit protective behaviour from others through perceived helplessness. Unlike puberphonia, where simple physical re-education is the key, treatment of this condition usually requires a significant period of psychotherapy.

Contact ulcer: voice is characterised as low pitched, hoarse and grating; can arise from sudden traumatic yelling. Classic profile is a middle-aged male, tense, driven personality, often under chronic stress, lawyer, doctor, actor, salesman, teacher, minister; explosive speech stress patterns, sharp/abrupt glottal attack, excessively low voice pitch level, restricted pitch variability; complains of discomfort/pain deep in neck, tickle in the throat, urge to clear throat, lump in the throat, aching or dryness. Therapeutic intervention usually focuses on the person finding a higher vocal pitch acceptable (rather than being e.g. 'unmanly'), eliminating the hard glottal attack, and techniques to reduce the overloud quality.

Conversion aphonia: involuntary whispering despite a basically normal larynx. Onset can be sudden or gradual. Conversion disorders can sometimes be triggered by organic disorders, such as colds or flu, fatigue or exhaustion. Common symptoms are discomfort, pain or tightness in the larynx, neck and upper chest. People with this condition often have characteristics similar to those with conversion muteness. Psychotherapy is often recommended.

Conversion dysphonia: often a 'catch-all' term for a voice that behaves unreliably; usually hoarseness of some kind is present, and the voice my vary from high to low pitch, loud to soft, breathiness to clear/normal, falsetto breaks etc. unpredictably. People with this condition have characteristics similar to those with conversion muteness or conversion aphonia.

Conversion mutism (muteness): a condition where the person "neither whispers nor articulates, or may articulate without exhalation" (Aronson); the proof that this is a conversion disorder is that the person is able to cough normally (indicating the ability to phonate). Common characteristics of people with the disorder are chronic stress, indifference to the symptom, immaturity and dependency, neurotic life adjustment, and mild depression. Often there is evidence of "1) a breakdown in communication with someone important to that person 2) a conflict between not allowing oneself to express anger, fear, or remorse verbally 3) Fear or shame standing in the way of expressing feelings via conventional speech and language." (Aronson)

Conversion voice disorders: any loss of voluntary control of the voice as a consequence of psychogenic causes. Typically, people with conversion disorders are often convinced the problem is organic although the specific physical symptoms cannot be traced to organic disease, and the condition enables the person to avoid feeling or expressing emotions directly.

Globus symptom: distiguished from the 'lump in the throat' that many people feel at times of strong emotion when it is temporarily impossible or inappropriate to express the feeling, this is a condition which is persistent and recurring. The person may frequently attempt to clear the throat or swallow. Often relieved when the person has been able to weep, perhaps in the safe, confidential company of someone else, although there could be any number of unexpressed emotions other than sadness.

Iatrogenic illness: any illness induced by the actions of a clinician or someone providing treatment. Aronson is categorical: 'to advise patients with organic, and particularly psychogenic, voice disorders to whisper or remain mute for days or weeks is the worst advice that can be given a patient with a voice disorder.' Whispering is a very inefficient use of voice, and, if sustained for any length of time, wearing on the vocal mechanism. To advise anything but the briefest voice rest to a person with a voice disorder reinforces their mistaken belief that they cannot phonate, and can lead to a secondary voice disorder through nonuse of the muscles of phonation. In addition, the distress, depression and sense of isolation that can result through the inability to communicate with one’s voice can be enormous, leading to further psychological damage.

Laryngitis: any disorder associated with the larynx, often manifesting in temporary symptoms of hoarseness or even complete voice loss.

Larynx: houses the vocal cords and is situated in the throat, observable as the 'Adam's apple'.

Musculoskeletal tension disorders: This is a family of disorders associated with excessive musculoskeletal tension originating in emotional stress, and showing principally as hypercontraction of muscles in and around the larynx (leading to its elevation). The person will often describe pain radiating to ear, sternum and mid-chest. In addition, hand manipulation of or pressure on the larynx will result in discomfort or pain. These disorders may occur with or without secondary laryngeal pathology. Those with secondary laryngeal pathology (i.e. those which display physical abnormality) include vocal nodules and contact ulcers.

Psychogenic adductor spastic dysphonia: intermittently strained voice, or complete voice arrests brought on by psychologic stress.

Puberphonia (mutational falsetto): "failure to change from the higher pitched voice of preadolescence to the lower pitched voice of adolescence and adulthood" (Aronson). The sound of the voice is usually high-pitched, "weak, thin, breathy, hoarse, and monopitched, giving the overall impression of immaturity, effeminacy and passiveness" (Aronson). Sometimes there has been resistance to 'growing up' for some reason; even when this is overcome, the person may not have learned to use the muscles differently with physical maturation, in which case this must be taught. Once arrest of physical growth has been ruled out, and the commitment of the person to make the transition to adult voice has been established, the change can be rapid. Emotional resistance to the change is rare, and the focus is usually on physical re-education.

Sternum: the lowest point where the ribs meet at the front of the body.

Ventricular folds: also known as the 'false vocal folds'; situated just above the true vocal folds.

Vocal folds: also known as the vocal cords. These vibrate during phonation.

Vocal nodule: small white, or grayish protuberance on vocal fold as a result of haemorrhage. Usually results from high pitch use of voice, such as in singing or screaming. Voice characterised as breathy, husky or foggy. In adults, common personality traits are: talkative, socially agressive, tense, acute or chronic interpersonal problems that generate tension, anxiety, anger or depression. Usually the first and immediate treatment response is to advise complete vocal rest (i.e. total silence) for a short period (24 hours or so). Recovery of basic vocal function can be rapid under these circumstances; however, to regain proper vocal function and prevent a repeat of the condition, vocal re-education is usually necessary (focusing on breathing and longer vowels), combined (depending on the individual) with some psychotherapeutic work around the (predisposing, precipitating and perpetuating) psychogenic factors.


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