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, contd

• 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,
contd

• 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 theres 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

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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

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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-disor
  ders.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
  pathologists role in managing stress related
  voice disorders (2003). Retrieved April 6,
  2003, from http//www.londonspeech.com/article7.h
  tm