[Psychogenic Aphonia - Succesfull Multiprofessional Treatment of a 13-Year-Old Girl - A Case Report]. / Psychogene Aphonie ­ erfolgreiche multiprofessionelle Behandlung eines 13-jährigen Mädchens ­ ein Kurzbeitrag aus der Praxis.

Psychogenic Aphonia - Succesfull Multiprofessional Treatment of a 13-Year-Old Girl - A Case Report Psychogenic aphonia is a rather rare disorder with a point prevalence of 0.4 %. It appears more frequently in females than in males. There are only few reports in the scientific literature about children affected by psychogenic aphonia. The diagnostical and therapeutical approach must be multimodal. The case reported here describes a 13 year-old girl with a psychogenic aphonia, the course of her illness und the efforts of treatment until full recovery of voice and speech.

Dexmedetomidine-assisted drug interviews: an observation in psychiatric setting.

Drug-assisted interviews are an effective tool in the management of various psychiatric illnesses where psychopharmacological, as well as routine psychological interventions, do not prove beneficial. These have most commonly been done by using barbiturates and benzodiazepines that have given favourable results for a long time. However, they carry the risk of respiratory depression and difficulty in maintaining the plane of sedation where the patient is amenable to interviewing. In our experience of drug-assisted interviews with two patients we used intravenous dexmedetomidine, which is being used in anaesthesia practice for conscious sedation or sedation in the intensive care unit. We found dexmedetomidine to be superior to thiopentone in achieving a level of conscious sedation where the patients were amenable for an interview, with no significant adverse events and faster post-anaesthetic recovery.

Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study.

PURPOSE: To measure patient-reported change of mood, communication-related quality of life, and general health status with return of voice among mechanically ventilated tracheostomy patients admitted to the intensive care unit (ICU). MATERIALS AND METHODS: A prospective observational study in a tertiary ICU was conducted. Communication-related quality of life was measured daily using the Visual Analogue Self-Esteem Scale. General health status was measured weekly using the EuroQol-5D. RESULTS: Aspects of communication self-esteem that significantly improved with the return of voice were ability to be understood by others (P = .006) and cheerfulness (P = .04), both with a median difference from before to after return of voice of 1 on the 5-point scale. Return of voice was not associated with a significant improvement in confidence, sense of outgoingness, anger, sense of being trapped, optimism, or frustration. Reported general health status did not significantly improve. CONCLUSIONS: Return of voice was associated with significant improvement in patient reported self-esteem, particularly in being understood by others and in cheerfulness. Improved self-esteem may also improve quality of life; however, further research is needed to confirm this relationship. Early restoration of voice should be investigated as a way to improve the experience of ICU for tracheostomy patients.

[Psychogenic aphonia. A challenging diagnosis?]. / Psychogene Aphonie. Eine schwierige Diagnose?

BACKGROUND: Based on clinical experience in the treatment of psychogenic aphonic patients, the study aimed to analyse the time interval between symptom onset and diagnosis using concrete data and to identify the cause of delayed diagnosis. PATIENTS AND METHODS: The medical records of 14 patients (all female) with psychogenic aphonia first diagnosed at the ENT department of the Saarland University Clinic were evaluated in a retrospective study. RESULTS: The time interval between symptom onset and the diagnosis of psychogenic aphonia ranged from 1 to 32 weeks, with a mean time interval of 9 weeks. In addition to all patients consulting an ENT specialist, additional diagnostic procedures (primarily imaging) were performed in 6 of 14 patients before the correct diagnosis was made. In all, 13 patients had previously undergone some form of therapy, 11 of these receiving antibiotic treatment. CONCLUSIONS: The study confirms that unnecessary instrument-based"over-diagnosis", as well as ineffective treatment attempts lead to significant delays in the diagnosis of psychogenic aphonia and hence delays in the initiation of causal treatment.

Affective temperament in women with functional aphonia.

OBJECTIVES: The aim of the present study was to assess the affective temperament in women with functional aphonia. STUDY DESIGN: Cross-sectional. METHODS: Forty-one women with functional aphonia underwent an examination of affective temperament by means of the Temperament Evaluation of Memphis, Pisa and San Diego Autoquestionnaire. RESULTS: Compared with the reference group, women with functional aphonia show significantly higher rates of depressive and anxious temperament. CONCLUSIONS: The results of the present study are concordant with the previous findings, indicating elevated levels of depressive and anxious symptoms in aphonic patients. Implications for the therapy of functional aphonia as well as considerations for further studies are discussed.

[Hysterical mutism]. / Le mutisme hystérique.

BACKGROUND: Conversion disorders comprise many clinical pictures, including hysterical mutism. Hysterical mutism has emerged as a clinical entity that remains difficult to diagnose, and whose treatment is poorly codified. Hysterical mutism is a disorder of the vocal function without changing the integrity of the body, resulting in loss of voice. Identified at all times, hysterical mutism entered the medical field in the late nineteenth century, under the direction of Jean-Martin Charcot (Salpêtrière School). Since then, although the disorder has emerged as a clinical entity, it remains little known. METHOD: A systematic review of the literature. We performed electronic literatures search of relevant studies using Medline, SUDOC, and BIUM. Search terms used were mutism, functional aphonia, conversion disorder, hysteria. RESULTS: The epidemiology of hysterical mutism is difficult to assess. The first limitation is the lack of consensensual diagnostic criteria. An estimate of its frequency may be advanced through registries consultation of otolaryngology-head and neck surgery. Through a literature review, emerges a rare disorder, about 5% of functional dysphonia. The sex-ratio is in favour of women. Regarding age of onset of disorder, functional aphonia mainly concerns adults with an average around the age of 30-40 years. The onset of the disorder typically involves a sudden onset and a recent stressful event. The duration of the disorder is difficult to specify. It appears that this dysfunction is rapidly reversible and that the majority of patients are in remission of this disorder within three months. The recurrence of dysfunction seems to be frequent. The existence of psychiatric comorbidity did not appear to be the rule. The natural history of this disorder is not known making it tricky to evaluate the efficiency of therapeutic approaches. CONCLUSION: Today the term hysterical mutism does not appear as an entity in either international classification. It belongs to the category of conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Identified as a medical entity described by the school of the Salpêtrière, this disorder has raised little interest. The medicalization of the condition remains difficult because of the importance of stigma associated with it, which contributes to the rejection rather than support of patients with mutism. To better understand this disorder and improve the care of patients who suffer, renewed interest is warranted.

[Assessment of degree of psychological health involvement in pre-laryngectomized patients]. / Valoración del grado de afectación sobre la salud psíquica en el paciente prelaringectomizado.

INTRODUCTION AND OBJECTIVE: Several authors have found increased anxiety in patients the day before an intervention and its correlation with anxiety levels the post-operative period. In this study, we determined a number of problems to which patients who underwent total laryngectomy often objected: the tracheostomy, being left without a voice and it being an aggressive, major surgery. Our objective was to assess the degree of anxiety and fears of the patient prior to total laryngectomy. MATERIAL AND METHODS: We compared 2 groups of 20 patients who underwent operation for total laryngectomy and for other ENT pathologies. On the day before the operation, we collected demographic and medical data and administered the Spanish versions of the Folstein Mini-Mental State Examination (MMSE) and the Goldberg General Health Questionnaire (GHQ-28). We also investigated whether the patients had any fear or fear of surgery and what that fear was. RESULTS: Completion of the MMSE revealed cognitive impairment in only one patient. We subsequently conducted the GHQ-28 and found psychological distress in 20-25% of our cases. When the different fears in both groups were compared by X(2), the results were not statistically significant. CONCLUSIONS: Total laryngectomy causes the loss of oral communication and impairs self-image, contributing to a strong emotional reaction. It is essential to have effective rehabilitation, which considers all aspects of health-sickness, such as the recovery of spoken language, social aspects and the psychological characteristics, vital for proper comprehensive patient management.

Afonia com etiologia desconhecida: relato de caso / Aphonia with unknown etiology: a case report

Introdução: A afonia de conversão é definida como a perda total da voz, é uma doença rara que acomete frequentemente as mulheres. O diagnóstico é clínico, pois não há alterações nas estruturas laríngeas. Objetivo: Descrever um caso de afonia de conversão, atendida em um hospital público no Centro-Oeste do Brasil. Relato do Caso: Paciente de 32 anos, sexo feminino, com queixa de afonia há dois dias, sem outros sintomas aparentes. Os exames não revelaram alterações nas estruturas laríngeas e/ou extralaríngeas. As etapas do atendimento foram descritas desde a consulta inicial até a recuperação da paciente. Comentários Finais: É importante considerar os aspectos psicoemocionais que envolvem os pacientes com alterações vocais, uma vez que os mesmos podem originar ou alterar os sintomas e comprometer o prognóstico da doença.

Introduction: The conversion aphonia is defined as the total loss of voice, is a rare disease that often affects women. The diagnosis is clinical, because there are no changes in the laryngeal structures. Objective: To describe a case of conversion aphonia, seen in a public hospital in the Midwest of Brazil. Case Report: Patient 32 years old female, complaining of hoarseness for two days without other apparent symptoms. The examinations revealed no changes in the laryngeal structures and / or extra laryngeal. Stages of care have been described since the initial consultation to the recovery of the patient. Final Comments: It is important to consider the psycho-emotional aspects involving patients with voice disorders since they may cause or modify the symptoms and affect the prognosis.

Psychogenic aphonia: no fixation even after a lengthy period of aphonia.

BACKGROUND: Although psychogenic aphonia is considered to be a conversion disorder, aphonic patients are primarily treated symptomatically. This is because it is considered of overriding importance to elicit a voice quickly to avoid fixation of the aphonia. The aim of this study was to show that, for patients exhibiting the symptom of voicelessness, not eliciting the voice immediately will not lead to a permanent aphonia. METHODS: Between February 2000 and May 2006, aphonia was diagnosed in 22 patients. Effects of short-term psychodynamic psychotherapeutic intervention and voice therapy were studied in a follow-up of three years, on average. RESULTS: Twenty one patients recovered their voices; 6 even before their first medical examination, 13 after an average of 12 weeks and 2 patients after 2 and 3 years respectively. One patient who has been in psychiatric therapy for years, as a result of having suffered serious abuse, failed to regain her voice. CONCLUSIONS: Even after a lengthy period of aphonia a complete recovery of the voice function is possible in nearly all cases. Countertransference phenomena in therapists are discussed as the possible reason why they usually decide on treatment aimed primarily at dealing with the symptoms.

Retrospective study of 116 patients with non-organic voice disorders: efficacy of mental imagery and laryngeal shaking.

OBJECTIVE: To report the short- and long-term results of two techniques (mental imagery and manual shaking of the larynx) in patients with non-organic dysphonia or aphonia. DESIGN: Retrospective review of patient records, plus follow-up survey (questionnaire). SETTING: Academic teaching hospital. PATIENTS: One hundred and sixteen patients with moderate to severe non-organic dysphonia or aphonia. OUTCOME: Cure (i.e. normal voice) and improved voice quality, judged by clinicians and patients. RESULTS: One hundred (86 per cent) of the 116 patients were cured. Ninety-four (81 per cent) patients regained their normal voice within one therapy session. The follow-up survey revealed that 43 of the 87 (49 per cent) patients who responded had not had a relapse since therapy ended. Of those patients suffering relapse, 15 successfully applied mental imagery in order to retrieve their voice, compared with three patients who applied shaking of the larynx. CONCLUSION: Mental imagery, combined if necessary with manual therapy, is an effective therapeutic technique in patients with non-organic voice disorders.

Marked depression and anxiety in patients with functional dysphonia.

The etiology of functional dysphonia is still unclear, but psychological factors are assumed to play an important role . The purpose of this report is to investigate the impact of depression and anxiety in functional dysphonia. Sixty-one patients with functional dysphonia were screened for additional psychiatric disorders (besides 300.11) by a clinical psychiatric interview. They were then compared with healthy controls, matched by age, sex and occupation, with respect to self-reported symptoms of depression, generalized anxiety, and specific anxiety concerning health. The patients had significantly higher scores than the controls in depressive symptoms, in the symptoms of nonspecific and general anxiety, and in the symptoms of specific anxiety concerning health. Fifty-seven percent of the patients also fulfilled DSM-IV criteria for a mood disorder, an anxiety disorder, or an adjustment disorder. Multivariate analysis of covariance, performed to correct for the influence of co-morbid psychiatric diagnoses on self-rated symptoms of depression and anxiety, confirmed significant differences between patients and controls in the symptoms of depression and specific anxiety concerning "somatic complaints." Both symptoms of depression and anxiety should be taken into consideration in the diagnostic as well as the therapeutic process of patients with functional dysphonia.

[Cognitive-behavioral therapy of conversion aphonia]. / Kognitivno-bihejvioralna terapija konverzivne afonije.

Although a common disease, conversion disorder still calls attention in the clinical practice. A case of conversion disorder, diagnosed as a psychogenic aphonia that persisted for a week, was reported in this paper. A 21-year-old woman developed symptoms after breaking off a long-lasting relationship with her boy-friend. History revealed that she was introvert with high neuroticism and communication problems. Cognitive-behavioral therapy was used. After the positive reinforcement in the therapy of her aphonia, assertion training for the development of communication skills was performed. In the end, cognitive restructuring was used to prevent relapse in regard to her actual life situation of being a refugee preparing for immigration to Australia.

A comparative study of psychological aspects of recurring and non-recurring functional aphonias.

The present study is based on the hypothesis that patients with recurrent attacks of aphonia differ from those with non-recurring attacks of aphonia in their anxiety levels, social assertiveness and stress-coping strategies. A comparison was made between 21 women with recurring aphonia and 19 women with non-recurring aphonia with respect to these three factors. Seventeen healthy women served as volunteers. Compared to patients with non-recurring aphonias, patients with recurring aphonias exhibited a significantly higher level of anxiety and significantly more respect for social norms and codes of propriety. Their coping was also characterized by a higher escape tendency. Patients with recurring aphonias also reported a significantly higher number of problems in their private lives within the preceding 5-year period. In therapy patients should be encouraged to reflect upon a possible rigidity toward social norms and better understand fears regarding conflicts in personal relationships.

Psychological processes in psychogenic voice disorder.

Using Freud's hysterical conversion model as a basis for reviewing the psychological features in psychogenic voice disorder, this paper describes research findings which show that individuals with this condition are not usually suffering from severe psychopathology but tend to be women who are experiencing high levels of stress (commonly associated with interpersonal relationship conflicts, low self-esteem, the burden of responsibility and feelings of powerlessness), and have above-average musculoskeletal tension as well as difficulties in voicing their feelings or views. The review indicates that the psychoanalytic interpretation of psychogenic voice loss continues to have relevance. However, it is suggested that in most cases Freud's hysterical conversion model should be reformulated, reducing the core focus to unconscious conflicts, repression, denial and secondary gains, in order to emphasise the psychosocial causes and maintenance of intrapsychic conflict and physical dysfunction. It is also suggested that a reformulated psychoanalytic interpretation of psychogenic voice loss has a lot in common with a cognitive-behavioural conceptual model. A psychoanalytic approach may be valuable when focused on early trauma and repressed experiences or feelings, whereas cognitive-behavioural treatment strategies, such as stress management and assertiveness training, appear to be particularly relevant in this condition. The paper concludes by briefly considering some areas of future research.

Treatment of hysterical aphonia with hypnosis and prokaletic therapy.

A patient with chronic refractory hysterical aphonia was treated by prokalesis (challenge) and hypnosis within a psychotherapeutic relationship. A temporary remission was achieved but this was followed by subsequent relapse. This report illustrates the therapeutic effectiveness of prokaletic techniques. It also emphasises that these potent interventions are unlikely to achieve abiding change unless they are applied within the context of a longer-term relationship with a clinical team.

[Psychogenic aphonia; an effective and rapidly treatable conversion]. / Psychogene afonie; een goed en snel behandelbare conversie.

Psychogenic aphonia is a conversion symptom which is quite annoying to the patient. This article concentrates on the treatment of psychogenic aphonia. The literature contains only few articles on this subject. We present in detail a very efficient way of treatment with directive and biofeedback aspects. Central to the treatment is a direct approach of the symptom, based on the idea that due to the time factor the aphonia has become dissociated from the unconscious psychological conflict. The treatment starts with a double cough so that the vocal chords close. At the same time the ear, nose and throat specialist looks with the laryngoscope and corrects directly which gives an optimal learning effect. In 1988 and 1989, 23 patients were treated with this method. The duration of the aphonia varied from two weeks to two years. In eight of the patients the aphonia recurred. Patients were treated for a total of 45 episodes of aphonia. In all cases the voice returned within an hour.

Short-term strategic treatment in traumatic conversion reactions.

The therapists applied the strategic approach in four cases that demonstrate a variety of traumatic and conversion reactions. The therapists accepted the definition of the problem as presented by the patients or their families at the overt level, and were able to treat the conversion symptoms. At the latent level, however, there were additional system-focused goals. In the first stage, the therapists strove to understand the inner world and cultural background of their patients, their dynamics and the circumstances surrounding the event that led to the conversion reaction, or the traumatic significance of the event when it was a posttraumatic conversion. It was then possible to develop a strategy for treatment and to decide which treatment techniques were appropriate. The therapists created situations that encouraged change and pushed the patients to abandon the symptom. This therapy model is composed of behavioral and paradoxical techniques based on the understanding of the dynamic material and cultural content.

Aphonia due to paramedian thalamo-subthalamic infarction. Remarks on two cases.

We describe two patients in whom CT brain scans imaged paramedian thalamo-subthalamic infarcts in the territory of the thalamo-mesencephalic arteries. Such infarcts give rise to a complex syndrome marked by disturbances of consciousness and of eye movement and neuropsychological disorders, including attentional, memory and, more rarely, language deficits. A loss of voice volume may accompany aphasic disturbances but is exceedingly rare in isolation. In the cases described the aphonia, total but transient, was the only language disorder. The physiopathological mechanisms involved in aphonia are complex and controversial.