BrazJOtorhinolaryngol.2014;80(6):497---502
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
www.bjorl.org
ORIGINAL
ARTICLE
Psychogenic
dysphonia:
diversity
of
clinical
and
vocal
manifestations
in
a
case
series
夽
,
夽夽
Regina
Helena
Garcia
Martins
∗,
Elaine
Lara
Mendes
Tavares,
Paula
Ferreira
Ranalli,
Anete
Branco,
Adriana
Bueno
Benito
Pessin
FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulistaJúliodeMesquitaFilho(UNESP),Botucatu,SP,Brazil
Received24January2014;accepted22July2014 Availableonline16September2014
KEYWORDS
Voicedisorders;
Clinicalpsychology;
Psychopathology; Psychotherapy
Abstract
Introduction:Psychogenicdysphoniaisafunctionaldisorderwithvariableclinical manifesta-tions.
Objective: Toassesstheclinicalandvocalcharacteristicsofpatientswithpsychogenic dyspho-niainacaseseries.
Methods:The study included28 adult patients with psychogenicdysphonia, evaluatedat a Universityhospitalinthelasttenyears.Assessedvariablesincludedgender,age,occupation, vocalsymptoms,vocalcharacteristics,andvideolaryngostroboscopicfindings.
Results:28patients(26womenand2men)wereassessed.Theiroccupationsincluded: house-keeper(n=17),teacher(n=4),salesclerk(n=4),nurse(n=1),retired(n=1),andpsychologist (n=1).Suddensymptomonsetwasreportedby16patientsandprogressivesymptomonsetwas reportedby12;intermittentevolutionwasreportedby15;symptomdurationlongerthanthree monthswasreportedby21patients.Videolaryngostroboscopyshowedonlyfunctionaldisorders; nopatienthadstructurallesionsorchangesinvocalfoldmobility.Conversionaphonia,skeletal muscletension,andintermittentvoicingwerethemostfrequentvocalemissionmanifestation forms.
Conclusions: In this caseseries ofpatients with psychogenic dysphonia, the mostfrequent formofclinicalpresentationwasconversionaphonia,followedbymusculoskeletaltensionand intermittentvoicing.Theclinicalandvocalaspectsof28patientswithpsychogenicdysphonia, aswellastheparticularitiesofeachcase,arediscussed.
© 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.
夽 Pleasecitethisarticleas:MartinsRH,TavaresEL,RanalliPF,BrancoA,PessinAB.Psychogenicdysphonia:diversityofclinicalandvocal
manifestationsinacaseseries.BrazJOtorhinolaryngol.2014;80:497---502.
夽夽
Institution:UniversidadeEstadualPaulistaJúliodeMesquitaFilho(UNESP),Botucatu,SP,Brazil.
∗Correspondingauthor.
E-mail:rmartins@fmb.unesp.br(R.H.G.Martins).
http://dx.doi.org/10.1016/j.bjorl.2014.09.002
498 MartinsRHetal.
PALAVRAS-CHAVE
Distúrbiosdavoz;
Psicologiaclínica;
Psicopatologia; Psicoterapia
Disfoniapsicogênica:diversidadedeapresentac¸õesclínicasevocaisdeumasériede
casos
Resumo
Introduc¸ão:Disfonia psicogênicaéum distúrbio vocalfuncionalcomdiversasmanifestac¸ões clínicas.
Objetivo:Apresentarascaracterísticasclínicasevocaisdeumasériedepacientescomdisfonia psicogênica.Tipodeestudo:estudodesérie.
Método: Foramincluídos28pacientesadultoscomdisfoniapsicogênicaatendidosemum Hos-pital Universitário. Parâmetros analisados: sexo, idade, profissão, sintomas, características vocais,eachadosvideolaringoestroboscópicos.
Resultados: 28pacientes(26mulheresedoishomens).Profissão:domésticas(n=17), profes-sor(n=4),vendedor(n=4),enfermeiro(n=1),aposentado(n=1)epsicóloga(n=1).Sintomas de inicio súbito reportados por 16 pacientes e progressivo por 12; curso intermitente dos sintomas foi reportado por 15 pacientes. A durac¸ão dos sintomas acima de 3 meses foi referidopor21pacientes.Avideolaringoestroboscopiaidentificouapenasalterac¸õesfuncionais (nenhum paciente apresentou lesões estruturais ou de mobilidade das pregas vocais). Principais apresentac¸ões da disfonia psicogênica: afonia de conversão, tensão músculo esqueléticaequebradesonoridade.
Conclusões:Nestasériedecasosdepacientescomdiagnósticodedisfoniapsicogênicaaforma deapresentac¸ãoclínicamaisfrequentefoiaafoniadeconversão,seguidapelatensãomúsculo esqueléticaesonoridadeintermitente.Discutimososaspectosclínicosevocaisde28pacientes comodiagnósticodedisfoniapsicogênicaeasparticularidadesdecadacaso.
©2014Associac¸ãoBrasileira deOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicadopor ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Thesomatizationofemotionaldisordersthroughthevoice,
termedpsychogenicfunctionaldysphonia,hasbeen known
for years.1,2 This diagnosis is not always evident during
the first contact with the patient; part of the difficulty lies in the different manifestations of this voice disor-der. Additionally, patients tend to avoid discussing their emotional conflicts, even when repeatedly questioned, reflectinganinitialresistancetotheassociationofthe phys-icalsymptoms withemotional issues. Anotherproblem in confirming the diagnosis of psychogenic dysphonia is the need toexcludeother diseases that may manifest similar vocal symptoms, such asacute infectious diseases, vocal cord paralysis, spasmodic dysphonia, and neuromuscular diseases.3---5
Inpsychogenicdysphonia,familyorprofessionalconflicts areoften identified.The respiratorycontrol, vocal inten-sity,vocalrange,vocalresonance,fundamentalfrequency, articulation,andvelocityandintonationofspeechmaybe impaired.1,3Inmostcases,morethanonevocalparameteris altered,eitherpermanentlyornot.Theonsetofvocal symp-tomsrelatedtopsychogenicdysphoniaisusuallysuddenand canbeaccuratelydescribedbythepatient.4The intermit-tentnatureofpsychogenicdysphoniaisthemostprevalent formofevolution,inwhichperiodsofnormalvoicealternate withperiodsofaphoniaordysphonia.2---6Thesefluctuations invocal emissionsaregenerallyobservedin thefirst min-utesof themedicalconsultation,leadingthe physicianto thediagnosis.
Considering the diversity of clinical manifestations displayed by patients with psychogenic dysphonia, the exchangeofinformationamonghealthprofessionalsinorder tofacilitatediagnosisisvaluable.Thisstudyaimedto ana-lyzethediversityofclinicalandvocalpresentationsinacase seriesofpatientsdiagnosedwithpsychogenicdysphonia.
Methods
Thisprospectivestudyincludedadultpatientsofboth gen-ders, aged >20 years, with a diagnosis of psychogenic dysphoniatreatedintheOutpatientClinicsofVoice Disor-dersinauniversityhospital,from2002to2014.The child and adolescent populationswere excluded. Patientswere continuouslyenrolledinthestudy,andafterdiagnosis confir-mationwasobtainedthroughamultidisciplinaryassessment byanotorhinolaryngologist,psychologist,andspeech ther-apist.Allpatients completedthestandardizedassessment protocol for voice disorders in the clinic and underwent a videolaryngostroboscopy, aswell asspeech therapy and psychologicalevaluations.
The videolaryngostroboscopy wasalways performed by thesameotorhinolaryngologistandauthoroftheresearch, using a rigid telescope (70◦, 8mm; Asap --- Germany) or
Psychogenicdysphonia 499
These examinationsassessed thepresence oflaryngeal lesions,secretions,mucosal colorand vocal foldmobility, presenceofglotticcleft,presenceofabnormalmovements, andbehavior of thevestibularfolds duringphonation and inspiration (tension, hyperconstriction). These tests were complemented by laryngostroboscopy (stroboscopic light source --- Endo-Stroboscopel Model; Atmos --- Germany), assessing theamplitude, symmetry, synchronism,and fre-quencyofmuco-undulatorymovement,aswellastheglottal closureandopeningstage.
The following parameterswere recorded:gender, age, occupation, characteristics,duration andevolution of the vocal symptoms, videolaryngostroboscopy findings, and vocalemissionpresentation.
The diagnosis of psychogenicfunctional dysphonia was establishedinpatientswhohadvocal symptoms accompa-nied by normal videolaryngoscopy results, displayingonly inadequate functional motor dysfunctions used as phona-toryadjustmentsandsuspectedpsycho-emotionaldisorder associatedwiththepictureofdysphonia,2,3confirmedinthe psychologicalandspeechtherapyassessments.Patientswith recentreportsofrespiratoryinfectionsorother comorbidi-tiesassociatedwiththecurrentpictureofdysphoniawere assessedandexcluded.
Afterdiagnosiswasconfirmed,themultidisciplinary ther-apy(psychotherapyandspeechtherapy)wasinitiatedinall patients;thedurationofthetherapy variedfromthreeto sixmonths,withremissionofdysphoniaatvaryingintervals for each patient,together withgreater psycho-emotional stability in the all cases whoreceived psychotherapeutic support.Allpatientswerefollowedupforfourtosixmonths inoutpatientclinicsafterdischargefrompsychologicaland speechtherapy,andpresentednosymptomrecurrence dur-ingthisperiod.
Theclassificationusedtocharacterizethetypeofvocal emissionwasthatofBehlau2:conversionaphonia,divergent useofregister,falsettovoice,intermittentvoicing,skeletal muscletensionsyndrome,vestibulardysphonia,dysphonia duetofixedbasalregister,psychogenicspasmodicdysphonia byadduction,anddysphoniaduetoparadoxicalmovements of the vocal folds. Patientswithorganic laryngeal lesions andwithdoubtfuldiagnoseswereexcluded.Theprojectwas approvedbytheResearchEthicsCommitteeofthe Univer-sidadeEstadualPaulistaJúliodeMesquitaFilho(Plataforma BrasilNo.18033313.6.0000.5411).
Results
Table 1 summarizes the parameters assessed in the 28 patients included in the study. Of the 28 patients diag-nosed with psychogenic dysphonia, aged 26---78 years, 26 were women and twowere men. Sudden symptom onset was reportedby a large number of patients (n=16), and symptom durationlongerthanthreemonthswasreported by21patients,andintermittentevolutionofdysphoniaby 15.Regardingoccupation,thevastmajorityofpatientswere housekeepers (n=18). The most frequent types of vocal presentationwereconversionaphonia(n=17),intermittent voicing(n=5),andmuscle-skeletaltension(n=5).
Atthevideolaryngostroboscopyassessment,allpatients hadnormalvocalfolds,withnostructurallesionsormobility
alterations.Vestibularfoldhyperconstrictionwasidentified infivepatientsduringphonationandanteroposterior trian-gularglotticcleft.Amongpatientswithconversionaphonia, fivehadanteroposterior glotticcleft. All patientsshowed remissionofvocal symptomsand betterpsycho-emotional controlafterspeechtherapyandpsychologicaltreatment. Nopatientshowedsymptomrecurrenceduringthefollow-up period.
Discussion
Psychogenic dysphonia is considered a functional voice disorder,astherearenostructurallaryngeallesionsor neu-rologicalalterations directly related tothe evident vocal symptoms.2,3,6Psychogenicdysphoniahasbeennotedtobe highlypredominantinwomen,2---5aswefoundinthisstudy (26:2). Especially today, with the significant contribution of women to householdbudgets, the stress and demands of both domestic and professional tasks can be partially responsiblefortheincreasedutilizationofpsychologicand psychiatricconsultationsamongwomen.5
Inthisstudy,mostpatientswerehousekeepersandonly fourpatients wereteachers.Manyauthors,however,have emphasizedthehighincidenceofpsychogenicdysphoniain teachers,oftenrelatedtoprofessionaloverload,asmanyof themoftenworktwoshifts.7
In psychogenic dysphonia, psycho-emotional and psy-chosocialdisordersareusuallyidentified,includinganxiety, distress,depression,conversionreaction(including dyspho-nia),personalitydisorders,andinterpersonalconflictsinthe family or professional environment.2,3,8 The predominant agegroup is between 30 and 50 yearsof age, the period ofprofessionalactivityofhighestintensity,asweobserved inthisstudy.Psychogenicdysphoniaisrareinchildrenand adolescents,andwhenitoccurs,itisusuallyrelatedtothe traumaofsexualabuseordeathofacloserelative.9
Videolaryngoscopicexaminationsinpsychogenic dyspho-nia do not identify organic laryngeal lesions; however, functionaldisordersareusually present duringphonation, suchastremors,vocalfoldadductionintension,ventricular phonation with hypercontraction and constriction, glottic cleft,andparadoxicalmovementsofthevocalfolds.Thus, thevideolaryngoscopicassessmentisnotalwayscapableof differentiatingpsychogenicdysphoniafromotherfunctional dysphonias and stroboscopic, electromyography evalua-tions, as well as acoustic vocal and auditory-perceptual measures,becomeimportant.10---12
Theauditory-perceptualandvocalanalysesdisclose diffi-cultyinmaintainingthestabilityofphonationduetolackof controlofthelaryngealmuscles.Otherfindingsarevarying degreesofmusculoskeletaltensionandbreathiness.The lat-terisoftenobservedinphonationwithglotticinsufficiency, andconstitutesa valuableresource tominimizethe glot-ticcleft;however,ithasalsobeenobservedinpsychogenic dysphoniaandmayresultinventricularphonation.
500
Martins
RH
et
al.
Table1 Clinicalfeatures,videolaryngoscopicfindings,andtypeofvoiceemissioninpatientswithpsychogenicdysphonia.
Case Gender Age Symptom onset
Profession Symptomduration Symptom evolution
Videolaryngoscopy Typeofvoiceemission
1 F 25 Progressive Housekeeper >6m Permanent Absenceofstructurallesions, hypercontractionofvestibularfolds. Anteroposteriortriangularglottic cleft
Conversionaphoniaand musculoskeletaltension
2 F 26 Sudden Teacher Between3mand6m Permanent Absenceofstructurallesions,normal mobility,stretchedvocalfolds
Falsettovoice
3 F 26 Progressive Housekeeper >6m Permanent Absenceofstructurallesions,normal mobility,anteroposteriorglotticcleft
Conversionaphonia
4 F 28 Sudden Housekeeper Between1mand3m Intermittent Absenceofstructurallesions,normal mobility
Intermittentvoicing
5 F 31 Sudden Housekeeper >6m Intermittent Absenceofstructurallesions, hypercontractionofvestibularfolds Anteroposteriortriangularglottic cleft
Intermittentvoicingand musculoskeletaltension
6 F 35 Sudden Housekeeper >6m Permanent Absenceofstructurallesions,normal mobility
Divergentuseofregister
7 F 37 Sudden Teacher >6m Permanent Absenceofstructurallesions,normal mobility,anteroposteriorglotticcleft
Conversionaphonia
8 F 39 Sudden Housekeeper >6m Intermittent Absenceofstructurallesions,normal mobility
Intermittentvoicing
9 F 40 Sudden Nurse Between1mand3m Intermittent Absenceofstructurallesions,normal mobility,anteroposteriorglotticcleft
Conversionaphonia
10 F 40 Progressive Salesclerk Between1mand3m Intermittent Absenceofstructurallesions, hypercontractionofvestibularfolds Anteroposteriortriangularglottic cleft
Conversionaphoniaand musculoskeletaltension
11 F 40 Progressive Housekeeper Between1mand3m Intermittent Absenceofstructurallesions,normal mobility
Conversionaphonia
12 F 40 Progressive Housekeeper >6m Intermittent Absenceofstructurallesions,normal mobility
Conversionaphonia
13 F 41 Sudden Housekeeper >6m Permanent Absenceofstructurallesions,normal mobility,anteroposteriorglotticcleft
Conversionaphonia
14 F 42 Sudden Teacher Between3mand6m Permanent Absenceofstructurallesions,normal mobility
Conversionaphonia
15 F 42 Progressive Housekeeper >6m Intermittent Absenceofstructurallesions,normal mobility
Intermittentvoicing
16 F 50 Sudden Housekeeper >6m Intermittent Absenceofstructurallesions,normal mobility
Conversionaphonia
17 F 50 Progressive Salesclerk >6m Permanent Absenceofstructurallesions,normal mobility
Psychogenic
dysphonia
501
Table1(Continued)
Case Gender Age Symptom onset
Profession Symptomduration Symptom evolution
Videolaryngoscopy Typeofvoiceemission
18 M 55 Sudden Salesclerk Between3mand6m Intermittent Absenceofstructurallesions,normal mobility
Psychogenicspasmodic dysphonia
19 F 56 Progressive Salesclerk >6m Intermittent Absenceofstructurallesions,normal mobility
Divergentuseofregister
20 F 56 Progressive Teacher >6m Intermittent Absenceofstructurallesions, hypercontractionofvestibularfolds Anteroposteriortriangularglottic cleft
Conversionaphoniaand musculoskeletaltension
21 F 58 Progressive Housekeeper >6m Intermittent Absenceofstructurallesions,normal mobility
Conversionaphonia
22 F 59 Progressive Salesclerk >6m Intermittent Absenceofstructurallesions,normal mobility
Conversionaphonia
23 F 62 Sudden Psychologist Between1mand3m Permanent Absenceofstructurallesions,normal mobility,anteroposteriorglotticcleft
Conversionaphonia
24 F 64 Sudden Housekeeper Between1mand3m Permanent Absenceofstructurallesions,normal mobility
Conversionaphonia
25 F 68 Sudden Housekeeper Between1mand3m Permanent Absenceofstructurallesions,normal mobility
Psychogenicspasmodic dysphonia
26 F 68 Sudden Housekeeper >6m Permanent Absenceofstructurallesions,normal mobility
Intermittentvoicing
27 M 72 Progressive Retired Between3mand6m Intermittent Absenceofstructurallesions,normal mobility
Psychogenicspasmodic dysphonia
28 F 75 Sudden Retired >6m Permanent Absenceofstructurallesions, hypercontractionofvestibularfolds Triangularglotticcleft
anteroposterior
502 MartinsRHetal.
also be found in inflammatory acute laryngitis and vocal
fold paralysis, thus not exclusively associated with
emo-tional disorders, confirming the importance of including
suchinformationintheclinicalhistory.Theseauthors
con-ductedastudy of40 patientsdiagnosed withpsychogenic
dysphonia and a group of patients with acute infectious
laryngitis andfound nodifferencein thepattern of vocal
emissionbetween the groups, demonstratingthe need to
takeintoaccounttheclinicalhistoryandphysical
examina-tion.
BaderandSchick13 emphasizethefrequentdelayinthe
diagnosisofpatientswithpsychogenicdysphonia, culminat-inginmisdiagnosisandmistreatmentincludingunnecessary drugs, such as antibiotics. Reiter et al.14 emphasized the importance of a multidisciplinary approach in the treatment of these patients. Those authors studied 40 patientswithpsychogenicdysphoniaandthetreatment ben-efits(speechtherapyand/or psychotherapytherapy)were assessedthroughthevoicehandicapindex(VHI)protocols. Inthisgroupofpatients,70%reportedimprovementor res-olutionof vocal symptoms; however,only 37.5% accepted andunderwentpsychotherapy.
When speech therapy was used alone, only 12.5% of thepatientsreportedvocal symptomimprovement.Inthe present study, the multidisciplinary approach is believed tohave been thekeytosuccessandgoodevolution inall patients.Treatment isdifficult, strenuous,andprotracted inpatientsresistanttopsychotherapy,requiringeffort, dis-cipline,anddeterminationbybothpatientandtherapist.2 Sudhir et al.15 and Baker16 reinforced the importance of a multidisciplinary approach in psychogenic dyspho-nia, emphasizing that it is important to understand the complexassociationbetweenneuropsychological, intrapsy-chological, and interpersonal behaviors that affect these patients.
Conclusion
In this case series of patients diagnosed with psy-chogenic dysphonia, the most frequent form of clinical presentation was conversion aphonia, followed by mus-culoskeletal tensionand intermittentvoicing. Considering thediversityinclinical andvocalpresentation ofpatients withpsychogenic dysphonia, a multidisciplinary approach (otorhinolaryngologic and psychologic, combined with speech therapy) is crucial to achieve a good outcome in thesepatients.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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