Free Health Essays - Compare two approaches to therapy in relation to the management of psychogenic dysphonia/aphonia.
Emotional stress has been recognised as a trigger to vocal disorders for a number of years, although the cause had not been identified until recent research established a link between the sensory cortex and the motor cortex, involving the anterior cingulate cortex in the brain. Aronson, however, amongst others, recognised the extreme sensitivity of the laryngeal muscles to emotional stress, a factor he attributed to “virtually all psychogenic voice disorders” (Aronson, 1990: 121; Morrison et al, 1983: 303 – 306; also Butcher et al, 1993).
The Journal of Voice (01/09/2003) has defined psychogenic dysphonia as a condition in which an individual’s loss of voice cannot be attributed to a “structural or neurological pathology…and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder”. Symptoms often start as the result of a virus infection, often attributable to a bout of laryngitis. The Journal of Voice clarifies, however, that psychogenic dysphonia often occurs “in close proximity to emotionally or psychologically taxing experiences, where ‘conflict over speaking out’ is an issue” (Baker, 2003).
It would appear to be related to traumatic stress syndrome and can transpire long after the trauma actually happened. This is not always the case, however. The Journal of Voice actually reports a situation in which a patient had undergone a modified thyroplasty for unilateral vocal fold paresis and developed psychogenic dysphonia as a result. However, many non-organic symptoms also present in psychogenic dysphonia, with a number of designations, such as ‘muscle tension’ or ‘muscle misuse disorders’. Aronson (1990) however defines psychogenic as being:
“a voice disorder which is broadly synonymous with a functional one but has the advantage of stating positively, based on an exploration of its causes, that the voice disorder is a manifestation of psychological disequilibrium such as anxiety, depression, personality disorder or conversion reaction, to the extent that normal volitional control of the phonation is lost” (Page 121).
The affecting factors often involve the thyro-arytenoid muscles in the larynx, either the adductor muscle or its corresponding abductor muscle. However, the sympathetic nervous system provides the link, although the specific area through which speech is controlled is found within the motor cortex of the brain, known as Broca’s area (Hudson, 2000: 153). The activity, however, according to Allman et al, is generated from the anterior cingulated cortex, together with the structures within the basal root ganglia and connections within the cortices (Allman et al, 2001)
This was recognised by MacDonald et al (2000), who also noted that the lateral frontal and parietal areas were linked, establishing a correlation with strategic control of body placement. The research recently published by Washington University established that the anterior cingulate cortex was responsible for the relationship between this strategic control and the autonomic nervous system and could be responsible for individuals’ responses of a highly emotive characteristic (Brown, Washington University, 2005), similar to that observed by Freud, Janet and Allonson, amongst others. This phenomenon was revealed through functional magnetic resonance imaging which showed that cognitive division within the autonomous nervous system was able to inter-react with transmissions from the motor neurones giving a physical response, whilst an excessive sensory response was also noted which, according to Wilbarger and Wilbarger, resulted in increased emotional stress (2002, Page 335).
DISCUSSION
Aronson (1990), building on the research of Morrison et al (1983), acknowledged the psychological nature of psychogenic dysphonia, but suggested that “the extrinsic and intrinsic laryngeal muscles are exquisitely sensitive to emotional stress, and their hyper-contraction is the common denominator in virtually all psychogenic voice disorders” (Page 121). This was later confirmed through research by Butcher, Elias and Raven (1993). Due to the psychogenic nature a number of clinicians suggest that therapy needs to incorporate psychological profiling and recognition of personality traits whilst involving therapeutic management (House, 1987; Butcher et al, 1987; Gerritsma, 1991; White et al, 1997; Roy et al, 1997; and Millar et al, 1999). The Journal of Voice also include the possibility that “hysterical personality structure, and the notion of conversion reaction as the primary psychological process…[and]…embrace a psychodynamic view” (Baker, 2003).
This psychodynamic observation was first introduced by Traube, then Freud and Brener during the 19th Century and later developed, during the 1920s by Janet, with Freud’s research being considered the definitive work in respect of psychodynamic theory. Butcher et al (1993) observed that:
“the Freudian view of the aetiology of hysterical conversion disorders has been more influential than any other in shaping our understanding of this condition”, [i.e. psychogenic dysphonia].
Freud recognised ‘hysterical conversion reaction’ [relating that to hysterical females] and ‘unacceptable impulse theory’ as both being a contributing factor to the later named psychogenic dysphonia, but, in his time, attributed to ‘transmutation of energy’ in which a patient could avoid emotional conflict through a lack of awareness. This concept has been confirmed as the result of the recent research at Washington University (Brown, 2005).
Conversion reaction was studied by Ziegler and Imboden who interpreted it as a “symbolic expression of an internal conflict or threatening idea” (1962, p. 279 to 287). Aronson, whose definitive work on the classification of psychogenic dysphonia included muscle tension disorders and conversion reactions, concurred with this suggestion (Aronson, Peterson, and Litin, 1966, pp. 115 and 127), although the psychodynamic theoretical concept is no longer in vogue due to evidence elicited from later research (Journal of Voice, 01/09/03).
Voice Therapies
Aronson’s Massage Model
Stemple (1993) has recognised five different voice therapies, the psychosocial facet relevant for this essay, addressing underlying problems that could have caused the dysphonia. Professor Werning, from the Department of Otolaryngology, University of Florida considers that “a multimodal approach is frequently essential, since many of these voice disorders have psychogenic overlay” (Werning, 2004). Aronson, meanwhile, maintains that virtually all psychogenic conditions can be relieved by “manoeuvring the patient’s laryngeal and hyoid anatomy to promote greater vocal tract relaxation and to lower the position of the larynx”, acknowledging the psychogenic factor but insisting that “the common denominator” is the hypercontraction of “the extrinsic and intrinsic laryngeal muscles” and providing gentle massage to assist these muscles in releasing their spasm (Aronson, 1985).
Aronson’s particular model is known as ‘manual laryngeal muscle tension reduction procedure’ (Roy and Leeper, 1993). Other clinicians, such as Dr Morrison, Dr Roy, and Dr Lieberman, have all adopted this technique with varying degrees of success. Dr Lieberman qualified as a Doctor of Osteopathy and he utilises a “deep massage technique for the larynx”. Massage begins at the hyoid bone, involves the thyroid cartilage and then “the larynx is moved from side to side as well as downward, and various types of rotary and other movements are used”.
This approach has been acknowledged by some very eminent professors to be extremely successful in alleviating muscle tension that is the result of psychogenic dysphonia and, due to the comparatively easy method of applying this technique, a personal view would suggest this should be the first attempt at treatment prior to psychological intervention. It would be suggested that only if this method failed to improve the condition should the psychological approaches be attempted.
Psychological Approach to Therapy
Aronson has also been responsible for developing a method of psychosocial interview that involves cognitive behavioural therapy and has been described as suitable for all types of functional voice disorders. This method has been utilised, in the UK, by Professors Butcher, Elias, and Raven correlating “psychotherapy methods with traditional voice therapy methods for patients with stress-related voice disorders”. The concept behind cognitive behavioural therapy is the perceived link with an individual’s thought processes, i.e. irrationally negative thoughts giving rise to depressive disorders.
The intention is to encourage these patients to focus on these though processes with behavioural therapy “strengthening desired behaviours through…’classical’ and ‘operant’ conditioning”. When related to voice disorders the clinician attempts to re-focus an individual’s awareness onto the “thought patterns surrounding voice problems” using specific strategies to alter negative behaviour. Some clinicians incorporate hypnotherapy with this approach in an attempt to relax the patient.
There do appear to be a number of drawbacks to this approach, one of which is the implication that, in the absence of any obvious pathological disorder, the patient must be suffering from a functional problem. Whilst this is probably correct, the clinician needs to be in a position to identify underlying problems during an initial assessment. Some pathological problems fail to make themselves immediately obvious, especially if the condition is related to disease elsewhere in the body, such as a patient who has developing lung cancer yet to be diagnosed and who is brought to the awareness of the clinician due to their distress at loss of voice (Massey, 2005).
This might be a single instance where a diagnosis could be incorrect due to the medical profession looking in the wrong place, resulting in the patient being treated for psychogenic dysphonia that is, in fact, the result rather than the cause. However if, at assessment, it is clear the patient is depressive, stressed or suffering anxiety it has been shown that both cognitive therapy and rational-emotive therapy can be very successful, improving the thought processes, improving the depression or anxiety which, in turn, reduces the muscle tension that is the cause of the dysphonia. (http://www.ncvs.org/ncvs/library/pubs/vv/vocologyguide.pdf).
Symptomatic Voice Therapy
Whilst at first sight this therapy might appear to be a superficial amelioration, Miller and Thompson (2003) observe that two-tone exercises, focusing on tonal resonance, enable a patient to distinguish between different tones, establishing the link with the primary auditory cortex which needs to be invoked before speech itself may become possible. Hudson (2000, Page 153) reports that the sound waves associated with speech are picked up within the cochlea, which is attached to the auditory nerve, then relayed to Broca’s area in the motor cortex, after which it is transmitted to the primary motor cortex which provides the muscle contractions necessary to emit any required sound.
Through research it is now known that damage to Broca’s area results in speech showing severely slurred words unable to be formed properly, although impairment of language is unaffected, whilst Wernicke’s area, which is known to be responsible for loss of language comprehension when damaged, lies within the junction of the parietal and temporal lobes. Damage to this area results in words being characteristically put together into an incomprehensible format.
Symptomatic voice therapy has been recognised as an approach suitable for patients with psychogenic dysphonia but it is an approach which involves the co-operation and education of the patient. These methodologies, the most famous of which involves the Lee Silverman technique, are directly suited to modifying specific speech characteristics with techniques used to achieve the most appropriate behavioural patterns, as seen in Boone’s technique (Boone, 1983). The desired behaviour is identified then, using an incrementally more difficult facilitating technique, the voice is re-stabilised. All the hierarchical techniques are fairly similar and may be quantified, with an especial focus on calibrating the voice, their ethos relating specifically to the normal physiological production of speech as described below.
CONCLUSION
Voice therapies incorporating a holistic approach (see Green & Mathieson, 2001) can often be particularly effective when used to minimise the effects of psychogenic dysphonia. Utilising the soothing effects of massage with counselling and vocal exercises might improve an individual’s sense of well-being. To be effective, treatment would need to be repeated over a period of weeks although particular instances of psychogenic dysphonia, such as that associated with adductor spasms in the muscles associated with speech due to anxiety, when used in conjunction with the symptomatic therapies, appears to be a particularly efficient form of relief for a sufferer.
However, whilst various approaches are advised as being suitable for assisting those patients with psychogenic dysphonia, the individual therapy might not be appropriate for some individuals. The symptomatic approach requires the co-operation of the patient, yet many depressed individuals may have little desire to co-operate due to their state of mind. The massage technique may be inappropriate through lack of suitably trained clinicians, whilst the indirect technique, which has not been discussed here through constraints on space, creates a number of problems in itself, regardless that, for a patient who might be anxious, stressed or depressed, the expectations attached to this route might be totally unacceptable, or even incongruous.
In terms of advantages, the easiest technique to adapt for general use, depending on the availability of practitioners, would be the massage model. Apart from releasing the tension in the muscles gentle massage can provide relief from stress and result in the patient becoming more relaxed generally. It does not, however, removed the causes of the anxiety, but it is debatable whether therapy could remove the cause of a person’s anxiety. Some individuals are more comfortable than others when being counselled and, in those private individuals who are opposed to counselling, there must be some question over whether this technique would be effective.
For maximum impact, and endorsed by many clinicians, would be a combination of gentle or deep massage, a number of sessions of cognitive behavioural therapy spread across a number of sessions, together with corresponding sessions of symptomatic voice therapy which, between the different techniques might achieve a holistic improvement in a patient’s perception of themselves and a mechanical improvement in the utilisation of their voice and its resonance.
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