Clin. Otobryngol. 1992, 17, 225-230

Differential diagnosis and treatment of psychogenic voice disorder LUCYNA SCHALEN & K A R I N ANDERSSON Department of Logopaedics and Phoniatrics. University Hospital, Lund. Sweden Accepted for publication 5 September 1991 SCHALEN L .

ANDERSSON K.

(1992) Clin. Otolaryngol. 17, 225-230

Differential diagnosis and treatment of psychogenic voice disorder Forty consecutive patients with psychogenic voice disorder were studied prospectively to shed light on some problems of differential diagnosis met by the otolaryngologist. The females (n = 35) were on average younger than males ( n = 5) (mean age 34.5 v s 51.8 years, respectively). Although an upper respiratory tract infection preceding the voice disorder was reported by no more than 25% of the patients, as many as 40% had been treated with antibiotics on one or more occasions. Other trcatrnent and voice rest had been prescribed to a further 20% of the patients. The frequency rate of reported asthma/allergy-like symptoms (37.5) exceeded the incidence of asthmapllergy in the normal Swedish adult population. Minor laryngeal abnormalities found in 10 patients could be rejected as causative since they were inconsistent with the voice disturbance. In most of the patients ( n = 27). vocal function returned to normal or improved after voice therapy combined with counselling. Vocal abnormalities remained unchanged in three patients. The patients who required multiple therapy sessions ( n = 10) were older (mean age 48.8 years) and seemed to have more profound personal problems than the average. The findings suggest that psychogenic voice disorder may often be misdiagnosed as acute laryngitis or asthma/allergy. Restricted use of antibiotics and other drugs is to bc recommended in the treatment of benign voice disorders. Keywords psychogenic voice disorder .functional voice disorder psychogenic aphonia diagnosis therapy

Psychogenic voice disorder is taken to mean unconscious simulation of a voice disorder as a result of inability to confront or come to terms with emotional conflict, stress or personal failure.' Diagnosis is confirmed by the absence of an organic laryngeal disorder combined with voice abnormality (mutism, aphonia or dysphonia), whereas laryngeal sounds unrelated to communicative behaviour (e.g. cough) are usually normal. Although the condition is generally thought to be rare,'.' an analysis of patients referred to our department during the course of three different studies on the aetiology and treatment of acute laryngitis in adults3-' suggests that it may often be overlooked, more than 10% of patients originally diagnosed as acute laryngitis subsequently being found to have a psychogenic voice disorder. Findings in other studies also Correspondence: Dr Lucyna Schalen, Department of Logopaedics and Phoniatrics, University Hospital, S-221 85 Lund, Sweden.

psychogenic dvsphoniu

indicate the difficulties in differential diagnosis between functional disturbance and dysphonia due to an organic disorder within the speech apparatus.' Nevertheless, it is generally accepted that a correct primary diagnosis is important not only to exclude inappropriate treatment but also to avoid the patient becoming fixated to the symptoms. Good results have been obtained with intensive phoniatric therapy carried out in cooperation with a psychiatrist,' and with voice therapy using a behavioural approach.8 However, as the patient's acceptance of and response to various treatments may depend on prevailing sociocultural factors, treatment and its evaluation need to be adapted to suit the specific requirements of the population in question. The present prospective study was undertaken in order to characterize patients with a psychogenic voice disorder (PVD), to pinpoint difficulties in differential diagnosis, and to evaluate patients' attitudes to our treatment model.

225

226 L.Scha1i.n and K.Andersson

lor

Patients The study was conducted during the period January 1986 to January 1990 at the Department of Logopaedics and Phoniatrics, University Hospital, Lund. Those included were consecutive patients in whom psychogenic voice disorder - either mutism, aphonia or dysphonia - was recognized by an experienced phoniatrician (i.e. an MD specialized in disorders of voice, speech and language).

OL

Methods The history was taken at presentation, being recorded on a standardized form, updated throughout the course of treatment and completed from medical records in the case of paticnts reporting previous morbidity. Routine clinical ENT examination including mirror laryngoscopy was performed. Voice recordings were made at presentation, during the course of treatment. and at the final visit on a tape recorder (Otari M X 5050) in a sound-proofed booth with the patient reading from a standardized Swedish text (Nordiznvinden och solen). When possible, the laryngostroboscopy was video-taped for further analysis of laryngeal motility. Different therapeutic approaches were adopted, depending on the response and attitude of the patient. Functional voice therapy consisted of respiratory exercises followed by vocalization, articulation of nonsense sounds and syllables, and finally articulation of nornial spccch. In this therapy. all available sensory motor feedback mechanisms (auditory, visual, tactile) are used to reinforce the restoration of vocal function. The vocal exercises were combined with discussions of the patient’s life situation. the primary objective being to guide patients towards recognition of their own problems and to help the patients come to terms with them. In some patients, whose voices had already returned to normal at presentation, a follow-up programme was arranged with personal discussions and voicc exercises in combination.

Results GENERAL CHARACTERISTICS OF THE POPULATION A N D

11-20

21-30

31-40

41-50

61->

Figure 1. Age and sex distribution among 40 patients with psychogenic voice disorder. 0 ,Male; U, female.

PREVIOUS VOICE DISORDERS WITH MEDICAL EIISTORY

Fifty per cent of patients reported previous similar episodes of voicc disorder, an isolated episode in 6 and multiple episodes in 15. Fifteen patients (37.5% of the whole group) reported themselves to be suffering from asthma/allergy, though only 7 of them had been tested, and hyper-reactivity to house dust mite and animal epithelium documented in only 3. Respiratory sytnptoms were prevalent among the organ-related manifestations previously found in 22 of the patients (Figure 2). Ten patients reported more than one symptom and 2 underwent extensive neurological examination. Nevertheless, according to available medical records, no conclusive diagnoses had been established in any of these 22.

HISTORY OF THE ClJRRENT DISORDER

Most of the patients (n = 34) were referred after previous diagnosis or treatment failure. The duration of vocal symptoms was 1-12 months in 23 (57.5%) of the patients and 1-4 weeks in the remaining 17 (42.5%).

Table 1. Occupations among 40 patients with psychogenic voice

disorder -

SOCIAL B A C K G R O U N D

Sex and age distributions are given in Figure 1 . Most patients ( n = 35) were young females (mean age 34.5, range 1 1-64 years); distribution by decades of life up to 50 years of age was more o r less equal. The 5 males included were older (mean age 51.8, range 30-64 years). Most patients (73%) were non-smokers. Only 10% had academic professions, and many were employed in the public sector (Table I). N o more than 9 reported themselves to be dependent on voice function in their professional or social life.

51-60

Age (years)

Service Re-education School pupil Industrial worker Clerk

~

__

Academic Housewife Retired Unemployed Total

14 4 4

4 4 4 2 3 2

40

.

Psychogenic voice disorder 221

16.7 7.1

n "

Resptr

Ortho

Gostro

41.7

10.7

Neurol

ENT

Gyn

21.4

Other

Figure 2. Occurrence of symptoms related to various organs or systems in 40 patients with psychogenic voice disorder.

Both abduction and adduction of the vocal folds were normal in 22 patients at the initial laryngoscopy. In 18 patients, different patterns of abnormal activation of laryngeal motility were identified: no effort to activate the larynx, incomplete activation with approximated vocal folds without closure, and activation of supralaryngeal sphincter. Motility activation seemed to be more disturbed in patients with aphonia (Sjl2) rather than dysphonia 9/28).

No more than I 1 (12.5%) of the patients reported having had upper respiratory tract infection prior to the voice disorder. Nevertheless, of the 34 patients who had previously sought medical aid for their current disorder, as many as 17 had received antibiotics on different occasions (1-4 times) (Table 2). Other medications were antiasthmatics, often in spray form. and antitussives. Completc voice rest had also been recommended in almost all patients. Voice therapy had been attempted but had not succeeded in two patients. The onset of the voice disturbance was either gradual (unspecified period of time or several days), rapid (developing within some hours), or sudden (instant loss or alteration of voice in mid-speech or voice disturbance on awakening). In this respect there was some difference between dysphonia, developing as a rule gradually, and aphonia which more often happened rapidly or suddenly and after an upper respiratory tract infection (Figure 3).

PERSONAL CIRCUMSTANCES

Of the 40 paticnts, 22 ( 5 5 % ) agreed to discuss their personal situation. Almost all of them (n = 20) reported problems involving disturbed personal relations, within the family (n = 13) or with their workmates (n = 5), whereas only 4 reported adverse work-related factors (e.g. exposure to stress or irritative agents). Thirteen patients also expressed such existential problems as anxiety for the future, fear of unemployment, or unsatisfactory personal relations. Five patients (3 of them non-Swedish immigrants) mentioned problems of identity (e.g. as a woman or as an adult).

VOCAL ABNORMALITY A N D LAKYNGOSCOPY FIKDINGS AT PRESENTATION

Dysphonia was more common (n = 28. 5 males and 23 females) than aphonia (I? = 12 females, including two initially mute patients whose voice became normal during the mirror laryngoscopy). Laryngeal structures were evaluated in all but 2 patients in whom activation of the supralaryngeal sphincter made mirror laryngoscopy impossible. Concomitant minor structural abnormalities were found in 10 patients whose detailed characteristics are given in Table 3. Table 2. Previous consultations and treatment given to patients with or without reported upper respiratory tract infection (URTI)

THERAPY ACCEPTANCE BY THE PATIENT A N D COURSE OF THE DISORDER

Based on the number of therapeutic contacts, 3 subgroups of patients were recognized. The largest subgroup (I) ( n = 17) ceased treatment after a single visit, and another subgroup (11) ( n = 13) after 2-5 visits. The remaining patients ( n = 10) attended several ( < 25) therapeutic sessions. Patients in

Antibiotics

_ _ ~ ~ _ _ _ _

x*t

URTI No URTl

9

Total

17

33.3

Figure 3. Percentage of different types on onset of voice disorder in patients with psychogenic a, dysphonia (n = 28) and b, aphonia (n = 12). 0. Gradual; D', rapid; 8 , sudden; m, after URTI

Other drugs ~

Voice rest ~

Voice therapy

Expectancy

2 4

II 29

6

40

_____

No consultation Total

.~

5

-

-

3

2

I 6

5

3

2

7

*One patient also received voice therapy. tBranhameNu catarrhah in nasopharyngeal culture and voice symptoms for 2 days in one patient.

228

LSchulen und KAnJersson

Sex/ Pat. Age ~

Laryngeal findings ~

36

F59 F57

17

PI9

40

F23

marg. erythema

16

26 2X 31

F49 F46 1-26 F20 F38 M63

URTl before PVD

Diagnosis on referral

Voice Treatment change

Table 3. Characteristics of 10 patients with psychogenic voice disorder and concomitant minor laryngeal lesions

~

oedema voc. cord asymmetry marg. erythema nodules asymmetry oedema voc. cord no activation oedema subgl. oedema voc. cord no activation asymmetry

3

7 II

Voice symptom duration

laryngitis hoarseness

Abx 2 Abx I -

3 mo 2 mo

laryngitis phonasthenia hoarseness

ABx I cortison

D N L)-D A-N A-N A-D D-N

2 mo

hoarseness?

cortison -

A--N A-N

I mo

aphonia

Abx2 voice rest

D ~N

2 mo

hoarseness

-

D-N

3 mo 6w

*

I W

II d

4d

'Referred after telephone call to ENT clinic. tKnown asthma, voice disorder after extubation. F. Female; M, male. D, Days, w. weeks, Mo, months. A, Aphonia, D, dysphonia. Voice change, e.g. from A to D after therapy denoted by A -D. Ab. Antibiotics followed by ligure indicating number of treatments.

the last subgroup (IJJ) were o n average older. and manifested greater frequency of other psychosomatic dysfunctions (Table 4). In most cases. the patient's voice returned to normal (11 = 29) or improved, that is, aphonia converted to dysphonia or dysphonia was reduced ( n = 8). No change was noted in 3 patients, all dysphonic. Rates of improvement or rccovcry were comparable in subgroups I and JI, but were less favourable in subgroup 111 (Table 5 ) . In 28 patients (70%). thcrapeutic contact was tcrniinated by agreement between the patient and the therapist. However, 10 out of thosc 28 patients wished to ccase after a single visit or a few visits. and two (So/,)dropped o u t without explanation. Subgroup 111. treated on multiple occasions, seemed to differ froin the others since none of them wishcd to terminatc treatment prematurely.

Discussion

ii

Table 4. Characteristics of patients with psychogenic voice disorder ( n = 40) receiving single, few (2-5) or several (10-25) therapy sessions

Since psychogenic voice disorder is often underdiagnoscd, its true incidence is greater than usually reported.' The present discussion is focuscd on certain aspects of differential diagnosis. management. and the patients' attitude to voice therapy.

W H Y I S 1111: C O N D I T I O N SELDOM R E C O G N I Z E D I N

MALES?

In accordance with findings in prcvious studies,'.'.'" " our patients were typically younger females with a poor social

Table 5. Outcome of vocal behaviour in patients with psychogenic voice disorder 01 ;= 40) after single, few (2-5) and several (10-25) therapeutic sessions

Therapy occasions Voice change

Single

Few

Several ~

Single (tI =

Female: male Mean age (years) Age range (years) Asthma or allergy Other psychosom. sympt. Earlier voice disorder Aphonia : dysphonia

Few Several 17) ( n = 13) (11 = 10)

15:2

34.9 11-61

7 10

6

7.10

13:o 31.4 18-64 4 5 6

2.11

7:3 48.8 37-64 4 7 3 3:7

Normalized ( 1 1 = 29) aphonia-normal d ysphonia-normal Improved ( n = 8) aphonia-dysphonia dysphonia reduced Unchanged ( n = 3) aphonia dysphonia Total

~

I 9

I 3

0 I

I

2

I

3

0 I

0 I

0

17

13

10

6

9

I

Psychogenic voice disorder 229

support network. Generally, females seem more prone than males to voice disorders due to benign laryngeal diseases such as acute infectious laryngitis3-' o r nodules of the vocal ~ 0 r d s . lAnatomical ~ and functional differences in the voice producing organsls as well as sex-related differences in communicative behaviour may suffice to explain this female preponderance. Females may also be more predisposed to vocal fatigue, perhaps owing to social and occupational demands. Many previous studies either included no male population ( ~ 4 . ~ or ) . if present it was often insufficiently discussed. When males were included and described in any detail (e.g."), as in our study they were older than the females. It would seem that in younger males, what are in fact psychogenic voice problems may instead be interpreted as mutational disorders.I6 Although our male series is very small, the findings suggest that a psychogenic voice disorder should not be overlooked in males with persistent or recurrent dysphonia unaccompanied by manifest laryngeal disease. DIFFERENTIAL DIAGNOSIS

Psychogenic voice disorder may be difficult to diagnose and, according to the findings in our series, acute laryngitis is the most frequent alternative diagnosis. A possible source of error may be difficulty in recognizing the voice manifestations that distinguish acute laryngitis from psychogenic disorder.' Moreover, the population with psychogenic voice disorder is similar to that with acute laryngitis with respect to age, sex, smoking habits and occupational profile.' A history of infection preceding the voice disorder, of patients, may be reported in between 25%" and another confounding factor, though it is seldom possible to verify a respiratory tract infection retrospectively. Hypersensitivity in the upper respiratory airway may be another diagnostic problem. As compared with the frequency of 2.5-4.5% in the Swedish adult population (see"), as many as 37.5% of our patients reported themselves to suffer from asthmaiallergy, and 3 (7.5%) of them had histories of verified hypersensitive allergic reactions. Moreover, respiratory complaints predominated among reported psychosomatic symptoms in our series (Figure 2 ) . Hence, the present results would seem to justify a more detailed examination of the interrelationship between psychological factors and respiratory and phonatory disorders. It is common knowledge that anxiety and fear may cause hyperventilation, and may also initiate and modify the course of pseudocroup and asthma. Abnormal qualitative respiratory patterns have also been described in both functional voice disorder,'* asthma," and stridor of psychogenic origin.2nThus, in our patients asthma-like symptoms might have been attributable to the emotional imbalance. though true hypersensitivity had been confirmed in 3 patients

(7.5 YO).Central nervous involvement in hypersensitivity reactions has been suggested," an interpretation deriving support from recent evidence of the modification of allergic skin responses by emotional factors.22 In psychogenic voice disorder, defensive activation of the supralaryngeal sphincter, primarily induced by an allergic reaction, may be enhanced and persist even if it is no longer purposeful. In turn. this will give rise to the high-pitched voice often observed in patients with a psychogenic dysphonia. Concomitant minor laryngeal abnormality or motility disturbances may also cause problems in diagnosis.'." Our findings suggest that minor laryngeal abnormities may not necessarily account for all types of voice disorder; for example, in a patient with marginal vocal cord erythema, aphonia should not be considered as an 'appropriate' vocal manifestation. TREATMENT: ANTIBIOTICS, VOICE REST OR VOICE THERAPY?

As in the present study, overtreatment with antibiotics However, restricted use generally seems to be freq~ent.'.~.".~' of antibiotics is also to be recommended in acute infectious laryngitis, since any effect of such treatment would seem to be In our opinion. any medication in psychogenic voice disorder should, if possible, be avoided owing to the risk of somatization and of an adverse effect on the patient's motivation for behavioural treatment. Combined treatment with complete voice rest and antibiotics is often prescribed in voice disorders. In psychogenic voice disorder, voice rest may sometimes seem attractive as a means of providing the patient with a 'legitimate' pretext for avoiding conflict. However, since future voice problems will be prevented, the place of voice rest as a routine component in the treatment of every kind of functional vocal disorder is now recognized as being questionable. Particularly as it is hardly compatible with the activities of daily life, complete voice rest is now restricted to a few specific situations (e.g. following phonosurgery, or in order to avoid voice abuse in professional singers). In a sensitive subject, complete voice rest may even induce an iatrogenic psychogenic voice disorder, as it did in at least 4 patients in the present series. Prescription of 'common sense voice use' would thus seem more appropriate. The present results support the view that in the heterogeneous population of patients with a psychogenic voice disorder the outcome of therapy will be largely determined by the patient's attitude. Return of vocal function to normal after only a few treatment sessions occurred in 70% of the patients. Such a favourable outcome has also been reported by Since the majority of patients are persons without markedly abnormal personalities, short-term treatment is probably sufficient." On the other hand, increased attention should perhaps be paid to the minority of patients

230 L.Schal6n und K.Andersson

with deeper emotional conflicts, such as o u r 10 patients w h o underwent multiple treatment sessions. Psychiatric evaluation would seem t o he indicated in such patients, t h o u g h reluctance t o seek psychiatric care w a s a c o m m o n feature a m o n g this subgroup, as it is in most patients with a psychogenic voice disorder. Our treatment model, comprising vocal exerciscs and therapeutic counselling, seeemed t o he m o r e readily accepted by t h e patients a n d m o r e rewarding.

9

10 II

12

Acknowledgement

13

T h i s study w a s supported by T h e Swedish Society of Medicine (grant 690,'1990).

14

15

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