Editorials

Functional dysphonia

Not "hysterical" but still seen mainly in women

Last year at the Glasgow Royal Infirmary over 190 new patients presented with 
dysphonia (hoarseness) and were referred to speech and language therapists for 
voice therapy. Extrapolation from these data suggests that up to 40000 such 
patients are referred and treated annually in Britain. A substantial proportion 
suffer from functional dysphonia, in which there is neither a structural 
abnormality of the larynx (such as a vocal cord polyp, nodule, or papilloma) nor 
paralysis. As with most functional somatic symptoms, women are considerably 
overrepresented, in some series by a factor of eight.

Functional dysphonia is a diagnosis of exclusion. It may be confirmed only after 
specialist examination of the larynx by an otolaryngologist, which means that 
otolaryngologists see large numbers of patients with functional dysphonia in 
their outpatient practice. Traditional teaching dictates that hoarseness should 
remain "unexplained" for only three weeks, especially in smokers.

General practitioners, however, are aware that laryngeal cancer is rare and 
found predominantly in older patients. Therefore, because most patients with 
functional dysphonia are young or middle aged adults who are otherwise healthy, 
roughly 40% are diagnosed presumptively as having laryngitis and receive a trial 
of antibiotic treatment before being seen as hospital outpatients.

There are two particular problems in diagnosis. The presenting symptom of 
altered voice quality is subjective, both for the patient and for the clinical 
observer. Secondly, as with many putative functional symptoms, dysphonia forms 
part of a range from a barely noticed variant of normality to a major life 
disability.

Broadly speaking, there are two types of functional dysphonia: disorders of 
hypofunction, with inadequate apposition of the vocal cords; and hyperfunctional 
dysphonia, in which accessory laryngeal muscles are used in voicing (this 
reaches its most extreme variant--dysphonia plicae ventricularis--in middle aged 
men who recruit the false cords in phonation). The disorder may also be 
classified according to the amount of residual phonation present: completely 
mute ("hysterical aphonia"), continually whispered speech, intermittently 
phonated "whispered" speech, or continually phonated speech. Rare variants of 
functional dysphonia include puberphonia or mutational falsetto, in which the 
voice retains an inappropriately high and monotonous quality into adulthood, 
and spasmodic dysphonia, which was long held to be of psychogenic origin but in 
recent years has been thought to be a focal dystonia.

Aetiology and treatment

The role of psychosocial factors in the aetiology of functional dysphonia 
remains in doubt. Early psychodynamic explanations of hoarseness as a conversion 
symptom1 have given way to a search for characteristic personality traits.

Dysphonic patients are more introverted and score higher on neuroticism scales 
than controls. This may be a non-specific personality diathesis shared with at 
least one other functional otolaryngological syndrome, globus pharyngis.

Conversely, there is evidence that the environmental stressor may be a specific 
type of interpersonal difficulty: when the Bedford College life events and 
difficulties questionnaire was administered to a cohort of dysphonic patients 
54% reported a recent life event involving "conflict over speaking out," 
compared with only 16% of a female control group. In a study which used 
structured psychiatric interviews a third of 71 patients with functional 
dysphonia received diagnoses of mood, anxiety, or adjustment disorders.

Evidence that very few patients have personality disorders corrects an 
earlier influential report suggesting that most people with functional dysphonia 
have a "hysterical flavour."

Historical treatments of functional dysphonia included applying "stimulating" 
sprays to the vocal cords or electric currents to the cervical muscle or giving 
oral quinine, arsenic, or strychnia. Modern conventional treatment is speech 
therapy, which often includes training in relaxation. A recent British survey 
showed that speech therapists tend to acquire their psychological skills 
haphazardly, often after qualifying, and confirmed that voice therapy is far 
from standardised. Nevertheless, in the only controlled prospective trial 
reported to date, patients given a course of direct voice therapy which aims to 
improve voice production through vocal rehabilitation exercises showed a 
significantly greater return to normal voice functioning than untreated 
controls. Indirect therapy (which aims to improve patients' knowledge and 
awareness of the causes of voice disorder) produced intermediate results. 
In patients who fail to respond to conventional voice therapy, additional 
psychological support with a cognitivebehavioural approach has been advocated.11 
In the minority of subjects with hyperfunctional dysphonia, results equivalent 
to those achieved with relaxation therapy are claimed for a laryngeal 
electromyelographic biofeedback technique. Good results are also claimed for 
massage of the laryngopharyngeal area. Neither approach, however, has been 
compared with a placebo or no treatment.

In psychosomatic medicine functional dysphonia provides a paradigm of the shift 
from intuition to objectivity. There has been progress in defining the disorder 
objectively; assessing the aetiological role of organic, psychological, and 
social factors; understanding the degree of accompanying psychiatric 
disturbance; and characterising the key therapeutic elements and effectiveness 
of speech therapy. None of these has been solved definitively. Even less is 
known about the prime mystery of this and other functional somatic 
syndromes--namely, the fact that most of the sufferers are women.

Janet A Wilson, Ian J Deary, Shonagh Scott, Kenneth MacKenzie