Psychogenic voice disorder refers to a voice disorder that is a manifestation of some confirmed psychological disequilibrium (Aronson, 1990). In its purest form, the psychogenic voice disorder is not associated with structural laryngeal changes or frank central or peripheral nervous system pathology. It is asserted that the larynx, by virtue of its neural connections to emotional centers within the brain, is vulnerable to excess or poorly regulated musculoskeletal tension arising from stress, conflict, fear, and emotional inhibition (Case, 1996). Such dysregulated laryngeal muscle tension can interfere with normal voice and give rise to complete aphonia (i.e., whispered speech) or partial voice loss (dysphonia). Although numerous theories have been offered to explain psychogenic voice loss, the precise mechanisms underlying such psychologically based disorders have not been fully elucidated (see functional voice disorders for a review). Despite considerable controversy surrounding causal mechanisms, the clinical voice literature is replete with evidence that symptomatic voice therapy for psychogenic disorders can often result in rapid and dramatic voice improvement (Koufman and Blalock, 1982; Aronson, 1990; Milutinovic, 1990; Carding and Horsley, 1992; Roy and Leeper, 1993; Gunther et al., 1996; Roy et al., 1997; Andersson and Schalen, 1998; Carding, Horsley, and Docherty, 1999; Stemple, 2000). The following discussion considers voice therapy techniques aimed at directly alleviating vocal symptoms without specific attention to the putative psychological dysfunction underlying the disorder.

Before symptomatic therapy is begun, the laryngological findings are reviewed with the patient, and he or she is reassured regarding the absence of any structural laryngeal pathology. An explanation of the problem is then provided by the clinician. While the specific approach and emphasis vary among clinicians, the discussion typically includes some explanation of the untoward effects of excess or dysregulated muscle tension on voice production and its probable link to stress, situational conflicts, or other psychological precursors that were identified during the interview. The confident clinician provides brief information regarding the therapy plan and the likelihood of a positive outcome.

Because excess or dysregulated laryngeal muscle tension is frequently offered as the proximal cause of the psychogenic voice disorder, many voice therapies including yawn-sigh resonant voice therapy, visual and electromyographic biofeedback, chewing therapy, progressive relaxation, and circumlaryngeal massage aimed at reducing or rebalancing such tension (Boone and McFarlane, 2000). Prolonged hypercontraction of laryngeal muscles is often associated with elevation of the larynx and hyoid bone, with associated pain and discomfort when the circumlaryngeal region is palpated. Aronson (1990) and Roy and Bless (1998) have described manual techniques to determine the presence and degree of laryngeal musculoskeletal tension, as well as methods to relieve such tension during the diagnostic assessment and management session. Circumlaryngeal massage is one such treatment approach. Skillfully applied, systematic kneading of the extralaryngeal region is believed to stretch muscle tissue and fascia, promote local circulation with removal of metabolic wastes, relax tense muscles, and relieve pain and discomfort associated with muscle spasms. The hypothesized physical effect of such massage is reduced laryngeal height and stiffness and increased mobility. Once the larynx is “released” and range of motion is normalized, proportional improvement in voice is said to follow. Improvement in voice and reductions in pain and laryngeal height suggest a relief of tension (Roy and Ferguson, 2001). In a similar vein, Roy and Bless (1998) also recently described a number of manual laryngeal reposturing techniques that can stimulate improved voice and briefly interrupt patterns of muscle misuse. These brief moments of voice improvement associated with laryngeal reposturing maneuvers are immediately identified for the patient and reinforced. Digital cues can then be faded and the patient taught to rely on sensory feedback (auditory, kinesthetic, and proprioceptive) to maintain improved laryngeal positioning and muscle balance. Any partial relapses or return of abnormal voice during the therapy process can be dealt with by reassurance, verbal reinstruction, or manual cueing. Once the larynx is correctly positioned, recovery of normal voice can occur rapidly.

Certain patients with psychogenic dysphonia and aphonia appear to have lost kinesthetic awareness and volitional control over voice production for speech and communication purposes, yet display normal voicing for vegetative or nonspeech acts. For instance, some aphonic and severely dysphonic patients may be able to clear the throat, grunt, cough, sigh, gargle, laugh, hum, or produce a high-pitched squeak with normal or near-normal voice quality. Such preserved voicing for nonspeech purposes represents a clue to the capacity for normal phonation. In symptomatic therapy, then, the patient is asked to produce such vocal behaviors. The goal of these voice maneuvers is to elicit even a brief trace of clearer voice so that it may be shaped toward normal quality or extended to longer utterances. These efforts follow a trial-and-error pattern and require the seasoned clinician to be constantly vigilant, listening for any brief moments of clearer voice. When improved voice is elicited, it is instantly reinforced, and the clinician provides immediate feedback regarding the positive change. During this process, the patient needs to be an active participant and is encouraged to continually self-monitor the type and manner of voice produced. Once this brief but relatively normal voice is reliably achieved, it is shaped and extended into sustained vowels, words, simple phrases, and oral reading. When this phase of intervention is successful, the patient is then engaged in casual conversation that begins with basic biographical information and proceeds to brief narratives, and then conversation about any topic and with anyone in the clinical setting. If established, the restored voice is usually maintained without compensatory effort and may improve further during conversation. Finally, the clinician should debrief the patient regarding the cause of the voice improvement, discuss the patient's feelings about the improved voice, and review possible causes of the problem and the prognosis for maintaining normal voice.

Certainly, direct symptomatic therapy for psychogenic voice disorders can produce rapid changes; however, in some cases voice therapy can be a frustrating and protracted experience for both clinician and patient (Bridger and Epstein, 1983; Fex et al., 1994). The rate of improvement during therapy for psychogenic voice disorders varies. Patients may progress gradually through various stages of dysphonia on their way to normal voice recovery. Other patients will appear to experience sudden return of voice without necessarily transitioning through phases of decreasing severity (Aronson, 1990). Because there are few studies directly comparing the effectiveness of specific therapy techniques, not much is known about whether one therapy approach for psychogenic voice disorder is superior to another. Although signs of improvement should typically be observed within the first session, some patients may need an extended, intensive treatment session or several sessions, depending on several variables, including the therapy techniques selected, clinician experience and confidence in administering the approach, and patient motivation and tolerance, to mention only a few.

The anecdotal clinical literature suggests that the prognosis for sustained removal of abnormal symptoms in psychogenic aphonia or dysphonia may depend on several factors. First, the time between the onset of voice problem and the initiation of therapy may be important. The sooner voice therapy is initiated following the onset of the voice problem, the better the prognosis. If months or years have elapsed, it may be more difficult to eliminate the abnormal symptoms. Second, the more extreme the voice symptoms, the better the prognosis for improvement. Aphonia and extreme tension, according to some authorities, may be easier to modify than intermittent or mild dysphonia. Third, if significant secondary gain is present, this may interfere with progress and contribute to a poorer treatment outcome. Finally, if the underlying psychological triggers are no longer active, then normal voice should be established quickly and improvement should be sustained (Aronson, 1990; Duffy, 1995; Case, 1996; Colton and Casper, 1996). As a caveat, however, the foregoing observations have rarely been studied in any objective manner; therefore they are best regarded as clinical impressions rather than factual statements.

The long-term effectiveness of direct voice therapy for psychogenic voice disorders also has not been rigorously evaluated (Pannbacker, 1998; Ramig and Verdolini, 1998). Most clinicians report that relapse is infrequent and isolated, yet others report more frequent post-treatment recurrences. Of the few investigations that exist, the results regarding the durability of voice improvement following direct therapy are mixed (Gunther et al., 1996; Roy et al., 1997; Andersson and Schalen, 1998; Carding, Horsley, and Docherty, 1999). It should be acknowledged that following direct voice therapy, only the symptom of psychological disturbance has been removed, not the disturbance itself (Brodnitz, 1962; Kinzl, Biebl, and Rauchegger, 1988). Therefore, the nature of psychological dysfunction needs to be better understood. If the situational, emotional, or personality features that contributed to the development of the psychogenic voice disorder remain unchanged following behavioral treatment, it would be logical to expect that such persistent factors would increase the probability of future recurrences (Nichol, Morrison, and Rammage, 1993; Andersson and Schalen, 1998). Therefore, in some cases, post-treatment referral to a psychiatrist or psychologist may be necessary to achieve more enduring improvements in the patient's emotional adjustment and voice function (Butcher, Elias, and Raven, 1993; Roy et al., 1997).

In summary, psychogenic voice disorders are powerful examples of the intimate connection between mind and body. These voice disorders, which occur in the absence of structural laryngeal pathology, often represent some of the most severely disturbed voices encountered by voice pathologists. In an experienced clinician's hands, direct symptomatic therapy for psychogenic voice disorders can produce rapid and remarkable restoration of normal voice. Much remains to be learned regarding the underlying bases of these disorders and the long-term effect of direct therapeutic interventions.

See also functional voice disorders.