ISSN: 2643-4059 Clarós et al. Int J Depress Anxiety 2019, 2:015 DOI: 10.23937/2643-4059/1710015 Volume 2 | Issue 2 International Journal of Open Access Depression and Anxiety REVIEW ARTICLE Psychogenic Voice Disorders Literature Review, Personal Ex- periences with Opera Singers and Case Report of Psychogenic Dysphonia in Opera Singer Pedro Clarós1*, Agata Karlikowska1,2, Astrid Clarós-Pujol1, Andrés Clarós1 and Carmen Pujol1 1Clarós Clinic Barcelona, Spain 2Scholarship Clarós Clinic, Cracow, Poland Check for *Corresponding author: Pedro Clarós, Clarós Clinic Barcelona, Spain, ORCID: 0000-0002-7567-0370 updates others do not perceive it as abnormal [2]. Abstract The point of this article is to make a diagnosis of psycho- Organic speech or voice disorder has structural or logical voice disorders easier by reviewing germane to the neurological components that cause the speech distur- subject literature. Current view on terminology, classifica- bance (e.g. vocal nodules, polyps, hematoma of vocal tion, clinical manifestation and underlying psychological folds, structural changes in the larynx due to aging, vo- background of this rare condition is given. Secondly our aim cal tremor, spasmodic dysphonia, or paralysis of vocal is to asses prevalence ratio of psychological voice disor- ders in a group of 1520 professional opera singers-people folds, among others). with the most challenging voice effort among professional On the contrary, a functional speech disorder is a voice users. Our findings contradict common belief of high occurrence rate of this disorder among opera singers. Cha- voice impairment that is caused by underlying psycho- racteristics of this professional group are discussed and a logical process with no organic pathology (or a non-se- short example case report is described. Based on literature vere one which doesn’t justify the intensity of the findings and authors personal experience we propose an symptoms) of the vocal folds not associated with neu- outline of an assessment protocol when psychological voice rological illness, or if the vocal folds lesions are secon- disorder is suspected. The importance of multidisciplinary diagnosis involving laryngologist, psychologist, speech the- dary to the functional disorder. rapist and possibly a psychiatrist is pointed out. This group could be divided into two subgroups of Keywords pathologies: Muscle tension voice disorder (MVD) and Psychological voice disorders, Opera singers, Psychogenic psychogenic voice disorder (PVD) [3]. dysphonia, Psychogenic aphonia, Multidisciplinary diagno- Muscle tension voice disorder (also called hyperfun- sis ctional voice disorder) is a phonation impairment which develops over time due to psychological process which Introduction causes disbalance of phonatory muscles. Examination A voice disorder is diagnosed when quality of voice, reveals: Excessively effortful, forced voice during all loudness or pitch of sound is insufficient for communi- types of sound, as well as rare phonatory breaks and cation or inappropriate for person’s age, gender or cul- involvement of the false vocal folds which can in extre- tural background [1]. me cases lead to ventricular phonation. There are two subtypes of MTVD: with no pathology to the vocal folds According to American Speech-Language-Hearing (MTVD1) or with secondary, developed overtime or- Association (ASHA) voice disorder is also present when ganic changes (MTVD2) such as vocal nodules, contact the patient is having concerns about his voice even if ulcers or polyps due to muscle hyperactivity. This arti- Citation: Clarós P, Karlikowska A, Clarós-Pujol A, Clarós A, Pujol C (2019) Psychogenic Voice Disorders Literature Review, Personal Experiences with Opera Singers and Case Report of Psychogenic Dyspho- nia in Opera Singer. Int J Depress Anxiety 2:015. doi.org/10.23937/2643-4059/1710015 Accepted: September 13, 2019: Published: September 15, 2019 Copyright: © 2019 Clarós P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Clarós et al. Int J Depress Anxiety 2019, 2:015 • Page 1 of 6 • DOI: 10.23937/2643-4059/1710015 ISSN: 2643-4059 cle focus is on the psychogenic voice disorders group. overactivity which in extreme cases may lead to ventri- Psychogenic voice disorder (PVD) is a voice impairment cular phonation. Muscle misuse may lead to quick vo- (foremost dysphonia or aphonia) caused by pathological cal fatigue and weak voice [1]. Patient often presents psychological process with absence of organic structu- himself as very anxious, agitated with untypical facial ral or neurological pathologies. It’s main characteri- expression, excessive face movements. Typically he or stics include: Existence of symptom incongruity as the she may be experiencing increased stress level or sup- patient would manifest severe dysphonia but preserve pressed anger, sometimes poor sex identification or non-verbal sounds of vegetative behavior, such as cou- suffer from dysthymia/depression [9]. Other associa- ghing, laughing, or crying with normal glottic closure ted somatoform pathologies can be: Habitual cough or and reversibility of the voice pathology [4]. We present hyperventilation syndrome. Globus sensation is very review of literature alongside with an interesting case of common and can be reported by the patient as inability psychogenic dysphonia in opera singer. of swallowing, foreign object sensation or even dysp- nea. The diagnosis should be confirmed by psychologi- Different Clinical Presentations of PVD cal and speech therapy assessments. Occasionally PVD Presentations of psychogenic voice disorders may may resolve spontaneously, it more commonly remains include different symptoms and with myriad of under- for longer periods, sometimes for months, or even for lying psychological disorders causing them they form a years. In most cases it is alleviated with one voice the- very heterogeneous group. rapy session; however, it is important to include longer psychological treatment. Even after successful therapy One of the most common manifestations of PVD is reoccurrences are common and may appear couple of dysphonia or aphonia. The disorder can be explained times in the future [10]. that an individual who doesn’t have sufficient ways of coping with stress or difficult life situations may lose vo- Other type of PVD is puberphonia or mutational fal- luntary voice control because of intrinsic and extrinsic setto which can appear either in an adult male or ado- laryngeal muscles imbalance. lescent boy for an unusually long period of time. In this condition the voice characteristics are: High-pitched Recent belief is that this disequilibrium could be (usually a full octave or more above the normal pitch) caused by either a conversion reaction where psycho- asthenic, breathy, falsetto voice which can be intermit- logical problem is ‘converted’ into a somatic manifesta- tent by a normal voice [1]. tion, or high level of emotional distress due to difficult life events or psychological conflicts for example over Some authors believe that other rare manife- fear of expressing negative emotions [5]. stations may be: A foreign accent syndrome which means developing foreign speech prosody without In psychogenic dysphonia, voice quality is deterio- actually changing geographical surroundings; and rated, voice may be rough, breathy, asthenic, low or childish voice in adults, where voice is usually of hi- high pitched and hoarse or strained, less commonly di- gher pitch, and childlike pattern, with no other than plophonia may be present (two different tones). Apho- psychological reasons [11]. nia usually presents itself as an asthenic or normal whi- sper or rarely as a total inability to produce sound [6]. Mutism or selective mutism disorder is characte- Patient usually preserves ability of normal glottic closu- rized by the fact that the patient usually just mouths re during cough. Individual may also present normal or words without actually making attempt of using voice better phonation accidentally, involuntarily when he or when patient with elective mutism consciously chooses she doesn’t realize it. Like mentioned before this may not to speak in some domains but can normally speak occur during coughing or making other vocal, non-ver- in others [12]. bal sounds for example crying or even gurgling water Another type of pathology, marked out only by [7]. Patient may also find counting or singing easier than some of the authors, is psychogenic adductor spasmo- conducting a conversation. dic dysphonia (ADSD). Voice presentation resembles The course of PVD can be highly variable, usually the neurological ADSA and could be strained or asthenic, onset is sudden, but it can also develop gradually over with frequent or irregular phonatory breaks, sometimes hours or days. In this type of disorder episodes of nor- a voice tremor may be present [1]. mal voice can occur intermittent with dysphonia depen- ding on the patient’s emotional attitude [8]. Most commonly Found Psychological Traits Studies about psychogenic implication in the patho- On examination of the larynx by an ENT (with vi- genesis of psychogenic voice disorders reveal significant deo-laryngoscopy or laryngo-stroboscopy) PVD may depressive symptoms, elevated stress level, anxiety and present itself as anterior or posterior constriction of adjustment disorders as well as eating