Disturbanceso theMind

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Published on February 5, 2008

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III. Disturbances of the Mind: III. Disturbances of the Mind A. Psychologically-Based Disorders: A. Psychologically-Based Disorders “Although the larynx is a well-organized and stable biological structure with complex neurological control, its vulnerability to changes in an individual’s emotional or psychological state makes it an excellent barometer of mental and psychological stability” (Case, 1991, p. 187) A. Psychologically-Based Disorders: A. Psychologically-Based Disorders Under emotional stress, the biological functions of the larynx are usually not affected, but the phonatory function may well be. The person may be unable to speak, or to hide/mask his/her emotional state. Whether the emotional state is one of fear, anger, or happiness, the human voice generally communicates the condition. A. Psychologically-Based Disorders: A. Psychologically-Based Disorders Vocal symptomatology produced under emotion or stress is normal and experienced by everyone. However, in some individuals, the vocal effect is the standard, rather than a temporary reflection of heightened emotion. A. Psychologically-Based Disorders: A. Psychologically-Based Disorders Psychogenic voice disorders occur when vocal control over pitch, loudness, quality, or resonance is disrupted by psychological disequilibrium. A laryngoscopic examination reveals essentially normal structures, but the voice function is abnormal. A. Psychologically-Based Disorders: A. Psychologically-Based Disorders Such disequilibrium can result from: unrealistic fear, anxiety, depression, anger, unresolved conflicts, personality abnormalities, psychosexual confusion, conversion reactions, interpersonal relationship disruptions, poor self-confidence, puberty adjustment difficulties, as well as Major neuroses and psychoses. A. Psychologically-Based Disorders: A. Psychologically-Based Disorders To qualify as a psychogenic voice disorder: One or more of the psychological factors/conditions must be present; The voice is affected fairly constantly—not just during episodes of extreme emotion. An otolaryngologist has determined that there is no structural or physical basis for the disorder. 1. Conversion Voice Disorders: 1. Conversion Voice Disorders A conversion voice disorder is created by anxiety, stress, depression, or interpersonal conflict. It has symbolic significance for that conflict, and enables the person to avoid facing the memory, situation, or conflict. The onset of the voice disorder is almost always associated with some emotional conflict or traumatic event. 1. Conversion Voice Disorders: 1. Conversion Voice Disorders Onset of vocal symptoms are usually quite sudden with many patients relating the disorder to symptoms of a cold or flu accompanied by a sore throat. Conversion voice disorders come in many forms: muteness, aphonia, and less dramatic forms of dysphonia such as breathiness, hoarseness, falsetto pitch breaks, and continuous falsetto. They are more common in women than men. a. Conversion Muteness: a. Conversion Muteness Conversion muteness is the most extreme and incapacitating limit of conversion voice disorders. The patient is unable to whisper or even articulate. The patient usually enters a room with notebook and pencil in hand to communicate. They are unaware that they are revealing through involuntary coughing or throat clearing their normal vocal capacity. a. Conversion Muteness: a. Conversion Muteness Common findings in such cases are chronic stress, primary and secondary gain (conscious or unconscious payoff), indifference to their symptoms, other manifestations of conversion, poor sexual identification, suppressed anger, immaturity, dependency, neurotic life adjustment, and mild/moderate depression. Common in the histories of all patients with conversion muteness is the following set of characteristics: a. Conversion Muteness: a. Conversion Muteness A conflict between wanting and not allowing oneself to express anger, fear, or remorse verbally; A breakdown in communication with someone important to that person; and Fear or shame standing in the way of expressing feelings via conventional speech and language. b. Conversion Aphonia: b. Conversion Aphonia Conversion aphonia refers to involuntary whispering despite a basically normal larynx. It encompasses a variety of whispers, including pure or noiseless; harsh, sharp, or piercing; intermittent high pitched squeaks and squeals; and moments of normal voice. The sharpness of the whispering indicates that the intrinsic laryngeal muscles are in a state of hypercontraction even though the VFs are prevented from approximating. The entire laryngeal-hyoid sling is held high in the neck and is difficult to move manually in any direction. b. Conversion Aphonia: b. Conversion Aphonia Most patients with conversion aphonia have had previous episodes of aphonia or dysphonia that have spontaneously cleared. Onset can be sudden, within seconds or minutes, or over a period of hours, beginning first with hoarseness that turns into aphonia. Conversion aphonias and dysphonias are often triggered by colds or flu, and associated laryngitis, fatigue and/or exhaustion. b. Conversion Aphonia: b. Conversion Aphonia Upon recovery from the illness, the dysphonia remains, worsening to aphonia. Discomfort, pain, and tightness in the larynx, and upper and lower neck and chest regions are common. As with conversion muteness, patients give histories of either acute or chronic emotional stress, symbolic significance of the voice loss, primary and secondary gain. c. Conversion Dysphonia: c. Conversion Dysphonia Varying degrees and types of hoarsness with and without a strained-harsh quality, high-pitched falsetto breaks, breathiness, intermittent whispering with moments of breathy and normal voice occur for the same psychodynamic reasons as muteness and aphonia. Few of these patients suffer from incapacitating psychiatric disturbances, and have usually adjusted to their anxiety or depression. Many are willing to continue as they are rather than submit to any therapy. Case A: Conversion Aphonia (Case, 1991, pp. 192-193): Case A: Conversion Aphonia (Case, 1991, pp. 192-193) RT was an 18-year-old female who was referred because of a severe voice disorder. She had been held up while working late one night as an attendant at a gas station. The robber held a knife to her throat and told her to empty the cash register. Case A: Conversion Aphonia (Case, 1991, pp. 192-193): Case A: Conversion Aphonia (Case, 1991, pp. 192-193) After she complied, he took the money, but before leaving he ran the knife across RT’s throat. She was taken to the hospital and examined for possible laryngeal damage. Only a superficial cut of external tissue was found. Case A: Conversion Aphonia (Case, 1991, pp. 192-193): Case A: Conversion Aphonia (Case, 1991, pp. 192-193) There was not laryngeal damage. Laryngoscopic examination revealed normal form and function of her vocal folds. However, RT could only produce a weak and breathy voice even three weeks after the incident. She was essentially aphonic. 1. Conversion Disorders: 1. Conversion Disorders Emotionally conditioned voice disorders are by no means rare and they require skillful professional assistance before the patient can resume control over her voice. The voice is the mirror of the soul and in these cases the loss of control of the voice shows the soul to be in disarray. If the loss of voice has allowed the patient sufficient time to reestablish mental composure, a suggestive treatment may be appropriate. 1. Conversion Disorders: 1. Conversion Disorders However the chances for recurrence are high if the causes of the stress and the resulting disarray are left untreated. In such cases the needs of the patient are best answered by an appropriate form of counseling. For SLPs, treatment should begin with building a non-threatening relationship. 1. Conversion Disorders: 1. Conversion Disorders Go over the ENT’s report to reassure the patient that there is nothing physically wrong with the larynx. Counsel the patient on how stress and tension can interfere with voluntary muscle action. Start with the vegetative sounds the client can make, e.g., cough, throat clear, yawn, sigh. 2. Psychosexual Conflict Disorders: 2. Psychosexual Conflict Disorders A voice disorder that is a sign of a conflict of sexual identification is embedded in the fabric and personality of the individual. It is not a transient sign of environmental stress, nor a means of solving unavoidable and unbearable life problems. 2. Psychosexual Conflict Disorders: 2. Psychosexual Conflict Disorders The hypothalamo-hypophyseal axis and its testicular or ovarian response determine and influence the physical, psychic and emotional sexuality of a person. In the western world, the average age of puberty is around 8 to 13 years for a girl and 9 to 14 years for a boy. In a girl, estrogen and progesterone will give her voice its female characteristics. In a boy, testosterone will give his voice its unique male character. Psychosexual Conflict Disorders a. Male : Psychosexual Conflict Disordersa. Male Androgens are the most important hormones responsible for the passage of the boy-child voice to a man’s voice, and their impact is irreversible. The angle of the thyroid lamina decreases making the thyroid prominence more acute. The vocal folds lengthen. The arytenoids become bigger and the vocal ligaments become thicker and more powerful. Psychosexual Conflict Disorders a. Male: Psychosexual Conflict Disordersa. Male The laryngeal mucosa becomes more viscous and the epithelium thickens with the formation of three distinct layers. In addition, the cricothyroid muscle broadens, becoming more powerful, and its contraction permits falsetto voice production. With the increase in the length of the male vocal folds and laryngeal apparatus, there is up to an octave drop in pitch as compared to a 3-4 semitone drop in pitch for females. 2. Psychosexual Conflict Disorders a. Male: 2. Psychosexual Conflict Disorders a. Male Also increased testosterone secretion results in maturation and increase in pulmonary capacity, the cardiovascular apparatus, hemoglobin levels, and striated muscle mass. During this time, lower pitches tend to be more stable than upper pitch ranges, and most of the active changes tend to occur within one year. 2. Psychosexual Conflict Disorders a. Female: 2. Psychosexual Conflict Disorders a. Female In females, there is little development of the thyroid cartilage or of the cricothyroid membrane. The vocal muscle thickens slightly, but remains very supple and quite narrow. The squamous mucosa also differentiates into three quite distinct layers on the free edge of the cords. The sub- and supra-glottic glandular mucosa becomes hormone-dependant to estrogens and progesterone. 2. Psychosexual Conflict Disorders a. Female: 2. Psychosexual Conflict Disorders a. Female Female pubertal voice changes are often less obvious than that of males. Their fundamental frequency drops about 3-4 semitones. However, adolescent girls' voices tend to exhibit increased breathiness or huskiness, occasional "cracking", and increased pitch inaccuracy while singing until pubertal hormone changes stabilize. Use of anabolic steroids to increase muscle performance, particularly in post-pubertal females, can have lasting virilization effects on the voice. Psychosexual Conflict Disorders c. Mutational Falsetto (Puberphonia): Psychosexual Conflict Disordersc. Mutational Falsetto (Puberphonia) A failure to change the higher-pitched voice or preadolescence to the lower pitched voice of post-adolescence is called mutational falsetto or puberphonia. The voice simply has not “broken” or is broken only incompletely in post-pubertal males with puberphonia. The voice is high-pitched, weak, thin, breathy, or hoarse, with limited pitch range. It gives the impression of immaturity, effeminacy, and passiveness. Psychosexual Conflict Disorders c. Mutational Falsetto (Puberphonia): Psychosexual Conflict Disordersc. Mutational Falsetto (Puberphonia) There is usually no anatomic or functional basis for the lack of change in pitch. The cause appears to be psychological—resistance to adult role; strong feminine self-identification; desire to maintain the childhood singing voice; embarrassment at speaking at a lower pitch. Disorders in breaking of the voice may also result from multi-factorial parameters such as hormonal mismatch, the environment, diet, and/or social life. B. Sexually-Based Disorders: B. Sexually-Based Disorders The term transsexualism was defined by Benjamin (1966) as a syndrome of sexual disorders in which the individual perceives his/her gender identity as being different from his/her sexual anatomy. In other words, transgendered individuals believe that their psychological or true gender is not congruent with their biological gender (Oates & Dacakis, 1983). B. Sexually-Based Disorders: B. Sexually-Based Disorders Most transsexuals attempt to conform to the social role specified by their biological gender, but many may seek medical and surgical treatment as well as other forms of counseling and treatment to achieve an identify they feel is their true self. Therapists, physicians, and surgeons involved with the care of transsexuals usually follow the Standards of Care established by the Harry Benjamin International Gender Dysphoria Association (HBIGDA). B. Sexually-Based Disorders: B. Sexually-Based Disorders According to HBIBDA standards, any transgendered individual who desires to undergo gender change must first begin the process with a minimum of three months of counseling. If after 3 or more months of counseling, if the individual is still committed to a course of gender reassignment, hormone treatment may be initiated. B. Sexually-Based Disorders: B. Sexually-Based Disorders The male-to-female transsexual would then begin taking some form of estrogen in order to stimulate the development of secondary female characteristics. Many male-to-female transsexuals report that passing as the feminine sex is very difficult because of the voice. They often hesitate to use the phone, talk to new people, or speak in public. They are constantly afraid of embarrassment because of a low-pitched voice. B. Sexually-Based Disorders: B. Sexually-Based Disorders Unfortunately, neither surgery nor hormone therapy will raise the pitch of the voice in the male-to-female transsexual. Once the vocal folds are thickened and lengthened during mutation and puberty, they cannot be reversed. Since hormone treatment does not alter the adult male vocal mechanism, voice change for male-to-female transsexuals must be affected behaviorally. B. Sexually-Based Disorders: B. Sexually-Based Disorders Changing speech, language, and nonverbal behaviors may ultimately be more beneficial to the transsexual than changing the pitch of the voice. Indeed, many women have low pitched voices, yet are unquestionably female (Boone, 1977). Examples prior to ( )and after tx ( ). B. Sexually-Based Disorders: B. Sexually-Based Disorders Gender differences in speech and language can be found not only in pitch, but also in intonation, resonance, loudness, articulation rate, speech quantity, word choice, syntax, vocal behaviors, body posture, and other nonverbal behaviors. The clinician can work with the transsexual on those female characteristics of speech and language that may facilitate a communication match with the desired body image. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) O.R. had been a 26-year-old male who had received hormone treatment for six months as prescribed by the Gender Identity Clinic of an urban teaching hospital. Prior to his decision for surgical reassignment surgery (SRS), he had dressed as a female off and on for years, had always felt like a female, and once was addicted to heroin as an escape from being unable to be a female. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) O.R. lived with her mother who supported her emotionally and financially. O.R. reported that she had studied music during the two years she attended college and hoped to give piano lessons to support herself after SRS. Her long range goals were to be a successful piano teacher, get married, and adopt children. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) O.R. presented herself at the diagnostic session as a female, wearing a long black wig, facial makeup, a dress, heels, and carrying a purse. It was the examiner's subjective opinion that she was a bit "overdone," but was reasonably acceptable as a female. Because of her previous heroin addiction and suspected schizophrenia, psychotherapy continued during speech and language evaluation and treatment. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Voice Examination revealed normal structure and function of a male larynx. The pitch ranged from approximately 90-350 Hertz (Hz). Habitual /i/ vowel prolongation was produced at an fo of 145 Hz and an /i/ produced in a falsetto voice was 280 Hz. Modal pitch, roughly analogous to speaking fo, on “um” averaged between 140-160 Hz. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Voice O.R.’s vocal behaviors were observed to be characterized by a female soft laugh, no harsh coughing, sneezing, throat clearing. Loudness and voice quality were appropriate in the conversational situation. The client reported that she did not speak as loudly in group situations since adopting the female gender—a reportedly female characteristic (Markel, Prebor, and Brandt, 1972). Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Prosody Other than clipping the ends of words, O.R.'s prosody was normal. She reported that she did interrupt in mixed-sex conversations—a characteristic that is more typical of males than females (Thorne and Henley. l975). Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Language Behavior O.R. did not exhibit many of the typical (Kline, l978) female syntactical or semantic patterns, such as hypercorrect grammar, tag questions, confirmation words, or polite requests. Non-Verbal Behavior 1. Body Posture:  male open leg crossing, foot movement, pelvis rolled back in walking, swinging arms, hand and arm gesturing more forceful, angular. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Non-Verbal Behavior 2. Facial: female—facial pleasantness; smiles; nods of approval. 3. Eye Contact: male--decreased eye contact. 4. Touching: male--little touching.Diagnostic conclusions O.R. did not exhibit a speech or language disorder in the traditional sense of a male speaker. However, more male than female speech and language behaviors were exhibited. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Management Goals: Goal A: Raise the modal pitch of O.R.’s voice as much as possible without creating vocal abuse or a falsetto range; Goal B: Make O.R. aware of the characteristics of speech/language that are associated with a (feminine) woman so that she may choose from these to fit her own needs. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Therapy Disposition O.R. was seen 2 hours per week for lO weeks. She returned for follow-up sessions 3 months and 6 months after the conclusion of therapy. Spectrographic measurements were made after the diagnostic session, 4th therapy session, and final therapy session. O.R.'s speech/language characteristics were informally evaluated by another certified SLP at the 4th and final sessions. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Session 1 A new vocal image was discussed in terms of its psychological desirability. The mechanics of tone focus to create forward resonance (e.g., focus the sound behind the nose) that would lead to a voice that would be perceived as higher in pitch were practiced with the “um hum” and “hello?” techniques. O.R. had an excellent understanding of the pitch/resonance issue. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Session 1 She was aware of the importance of avoiding abusive vocal habits. Although she smoked 1.5 packages of cigarettes per day, she voluntarily decided to stop smoking after the first therapy session because of its suspected lowering of pitch. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Sessions 2-4 The new resonance pattern (pitch) was monitored and attention was given to concepts of volume and breath support. O.R. began with easy words for the new pitch (/h/-words) and progressed to more difficult vowel/consonant words. Whenever she needed to establish the new pitch, she thought of a "spot" behind the bridge of her nose. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Sessions 2-4 O.R. reported that she liked her new pitch and that it made her feel more feminine. As soon as O.R. consistently used the new pitch in single words, she was ready to learn how to alter her inflection and intonation in phrases. All activities were tape recorded and replayed for O.R.'s monitoring. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Sessions 2-4 During session 3, the clinician re-introduced concepts discussed during the diagnostic session, i.e., femininity is more than higher pitch (resonance). In sessions 3 and 4, the goals included work on feminine intonation, hyperarticulation, rapid rate, and fewer interruptions during conversations. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Feminine Intonation O.R. listened to lower pitched women's voices on her home tape recorder and hummed the melody pattern of the voices (Thorne & Henley,1975). Extensive practice and monitoring of intonation were necessary with drill materials often used in foreign accent reduction. Careful selection of stimulus material enabled O.R. to develop a greater pitch range and to relay varied emotions. After those drills were mastered, the clinician and O.R. practiced role playing, using scenarios written by O.R. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Hyperarticulation O.R. and the clinician simultaneously viewed a few minutes of a well-known “soap opera” as characters seem to be ultra female or ultra male. They discussed the differences in male/female phonetic forms. O.R. practiced a quick, precise, and light pattern of articulation by using smaller jaw movements, using a higher-than-usual tongue position, and practicing word lists containing /s /, and /t /, and final consonant clusters, and slower rate. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Interruptions To decrease O.R. 's speech interruptions in male/female conversations, she was assigned to monitor her own conversation with men. She reported that she did indeed have a tendency to interrupt, but was reducing this behavior now that she was aware of it. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) O.R.'s fo was measured at the conclusion of the 4th therapy session. Her fo was between 160-180 Hz as compared to the 140-160 Hz measure at the time of the diagnosis. Subjective evaluation by a male SLP (who knew she was a transsexual) was that her voice "sounds lower than appropriate for a feminine voice." Another female SLP (who was unaware that she was a transsexual) reported that phonation was normal but that the pitch was "a bit low." Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Sessions 5-10 In these sessions, work on the previous areas was continued and the introduction of female language characteristics was begun. Some characteristics that were considered were female intensifiers, qualifiers, expletives, nonspeech vocal modifiers, pronouns, verbs, conjunctions, interjections, swear words, jokes, and word choice. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Sessions 5-10 O.R. reviewed nonverbal female behaviors of Birdwhistell (1970), including body posture and movement, hand and arm gesturing, facial pleasantness, eye contact, touching, and space. Clothing, make-up, and accessories, which are considered to be forms of nonverbal communication were also discussed. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) At the conclusion of the 10th therapy session, fo was again measured and found to be identical to the measure made after the 4th session--160-180 Hz. The same male SLP who had previously evaluated her reported that although she "appeared to be a female" she still had a low pitched voice. Interestingly, he reported, "I don't see how you can work with her--it makes me nervous." Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Follow-up sessions O.R. came back 3 months and 6 months after the conclusion of therapy. She had stabilized the new voice and exhibited most of the female speech/language characteristics covered in therapy. She reported that she still interrupted conversation in mixed sex situations. Her nonverbal communication was female and her clothing was less "overdone." Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Follow-up sessions O.R. was accepted as a female on the telephone about 50% of the time, according to her report. This was aided by the fact that she answered the telephone with her female name, and not "hello." She reported that the Gender Identity Clinic had decided that she should not yet have SRS. She was very upset that the committee did not approve her after one year. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) Case Disposition 6 months after the conclusion of therapy, O.R. received SRS from a private physician without the knowledge of the Gender Identity Clinic. According to her psychologist, she had a postsurgical psychotic episode, but has now stabilized. She is living a "marginal life" with friends and is back in psychotherapy as an outpatient at the Gender Identity Clinic. Case B. Male-to-Female Transsexual (Hooper, 1985): Case B. Male-to-Female Transsexual (Hooper, 1985) SUMMARY AND CONCLUSION This report introduces some of the sex differences in speech/language that are of benefit to a transsexual client. Although an increase in the fo of voice may be minimal in the male-to-female transsexual, many other therapy goals may be attained--including more appropriate resonance characteristics. Any therapist considering work with this population should work in cooperation with a gender identity clinic or a psychological treatment team. B. Sexually-Based Disorders: B. Sexually-Based Disorders For those of you interested in working with the transgendered population, please refer to the following article, which outlines extensive voice therapy ideas: Gelfer, M P. (1999). Voice treatment for the male-to-female transgendered client. AJSLP, 8, 201-208. Case C: Psychogenic Dysphonia (from Voice Listserv) : Case C: Psychogenic Dysphonia (from Voice Listserv) 15 year old patient has severe psychogenic dysphonia.  She has been "sick" for almost 3 years after very serious and lengthy case of mononucleosis. Has multiple present physical complaints and problems and strong co-dependency on mom (mom is home-schooling her, she will not tolerate her mom leaving tx room, etc).  She wears sunglasses due to photophobia, earplugs, and withdraws with grimace from touch. Case C: Psychogenic Dysphonia (from Voice Listserv) : Case C: Psychogenic Dysphonia (from Voice Listserv) She has gradually allowed me to do some very light-pressure digital manipulation over several sessions.  Her phonation is normal on spontaneous laughter and one spontaneous word during last tx session.  Otherwise she speaks with larynx forcibly descended and tongue retracted. Phonation characterized by very low pitch, low volume, effortful voice with vowel distortion and posterior articulation of all phonemes. Case C: Psychogenic Dysphonia (from Voice Listserv) : Case C: Psychogenic Dysphonia (from Voice Listserv) Lips are tightly rounded and there is a general facial grimace.  The only time she has normal oral-facial posture is when she gets tickled and smiles.  Over the course of 6 voice therapy sessions she has gradually been able to produce phonation during tongue trill, inconsistent with inhalation phonation with forward tongue placement, and can maintain forward tongue posture to sustain /s/ for 4-5 seconds. Case C: Psychogenic Dysphonia (from Voice Listserv) : Case C: Psychogenic Dysphonia (from Voice Listserv) She can relax lips and forehead at my request, has learned to perform Mendelsohn maneuver, but does not produce any normal volitional phonation on humming, speech, yawn/sigh, etc.  I have tried mirror work, Visipitch biofeedback without success. I have told her that her vocal cords are normal and have the ability to produce normal voice but her body is not allowing her muscles to work properly. Case C: Psychogenic Dysphonia (from Voice Listserv) : Case C: Psychogenic Dysphonia (from Voice Listserv) She has been seen by multiple M.D.'s including ENT and Neurology--all agree this is psychogenic.  She and mother have previously refused Psychiatry consult (although recent discussion between PT and mom suggests parents are willing to reconsider; patient herself is resisting).  Neurologist thinks I should tell her she will be able to talk normally in 3 days. I am hesitant to do this since I really cannot get normal voicing in tx. Case C: Psychogenic Dysphonia (from Voice Listserv) : Case C: Psychogenic Dysphonia (from Voice Listserv) I would appreciate opinions as to how to proceed with this patient. How long to continue trials of direct voice therapy with her improving on non-speech "exercises" but no generalization to speech?  She is so young that I do not want to give up on her--should I be more direct with telling her this is psychological?  How important is it to try to get mom out of tx room? Case C: Psychogenic Dysphonia (from Voice Listserv) : Case C: Psychogenic Dysphonia (from Voice Listserv) Should I discontinue tx and insist on psychiatric/psychological intervention first???  She does not appear to be ready to "give up" her speech/voice disorder.

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