Auris Nasus Larynx 40 (2013) 470–475

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Auris Nasus Larynx

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Long term outcome of psychogenic voice disorders

Rudolf Reiter *, Dieter Rommel, Sibylle Brosch
Department of Otolaryngology Head and Neck Surgery, Section of Phoniatrics and Pedaudiology, University of Ulm, Frauensteige 12, 89075 Ulm, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To evaluate different therapy for psychogenic voice disorders.
Received 19 September 2012 Methods: Epidemiological data, organic and psychological symptoms, therapeutic options and outcome
Accepted 24 January 2013 were prospectively analyzed in 40 consecutive patients with psychogenic voice disorders. Their voice
Available online 14 February 2013
was evaluated by subjective means and self assessment (voice handicap index) and an organic or
functional disorder was excluded by videolaryngostroboscopy. Additionally, a detailed psychological
Key words: examination and exploration were made. Every patient received intensive voice exercises with
Voice handicap index
biofeedback by a phoniatrician and counseling by a clinical psychologist. Following this, therapy options
Psychogenic voice disorder
Psychotherapy
of psychotherapy or a combination of psychotherapy and voice therapy were given. After an interval
Voice therapy (average 16 months) from first contacting our section, every patient was asked to complete a
questionnaire about their therapies and quality of voice.
Results: Patients had previously received insufficient voice therapy or antibiotics. The psychological
examination detected psychological disorders as a basic problem. Overall, in 70% of patients there was
either an improvement or resolution of voice problems. For all patients psychotherapy or a combination
of voice therapy and psychotherapy was recommended, but only accepted in 37.5%. In all cases, when
psychotherapy in combination with speech therapy took place, it was successful, whereas speech
therapy alone provided improvement only in 12.5%.
Conclusion: Psychogenic voice disorders are often misdiagnosed, leading to inadequate therapy.
Psychotherapy (often in combination with voice therapy) was most effective also in the long term, but is
often not accepted by patients. Voice therapy alone had a poor success rate.
ß 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Psychogenic voice disorders are often missed, leading to
inadequate therapy [1,2]. Diagnosis is characterized by absence
of an organic or functional laryngeal disorder combined with voice
abnormalities (aphonia/dysphonia), whereas laryngeal sound
unrelated to communicative behavior (e.g. cough) is not [1–4]. A
lack of adduction of the vocal folds during phonation is observed,
but normal movement and complete closure of the vocal folds
during coughing is present [5]. Patients with psychogenic voice
disorders often show an acute onset and reveal a history of stress-
related problems [6–8]. The voice disorder may be a manifestation
of psychological disequilibrium such as anxiety, depression,
personality disorder, somatization, conversion reaction (cogni-
tive-behavioral-conversion) or conflicts (e.g. in the field of their
own health with a new diagnosis such as cancer and in the field of
business, money or partnership), to the extent that normal
volitional control of phonation is lost [1–4,7,9]. According to
* Corresponding author at: Tel.: +49 731500 59705; fax: +49 731500 59702.
E-mail address: rudolf.reiter@uniklinik-ulm.de (R. Reiter).
Sapir, patients with psychogenic voice disorders met the following
criteria: (a) the onset of the voice disorder was linked to a
psychologic stimulus such as stressful life event or interpersonal
conflict (symptom psychogenicity), they show (b) symptom
incongruity, and (c) symptom reversibility with short-term voice
therapy and/or through psychotherapy is observed [10].
Differential diagnoses of psychogenic voice disorders are aging
voice with voice complaints in patients over 65 years in 58% with
the most common diagnosis being vocal atrophy with incomplete
glottic closure in 25% [11,12]. Furthermore Parkinson’s disease
(PD) [13] and muscle tension dysphonia caused by increased
tension of the (para)laryngeal musculature compensating an
underlying organic disease, e.g. upper airway infections with
cough are etiologies for incomplete closure of the vocal folds [14–
16]. Additionally hyperfunctional voice disorder often shows
incomplete vocal fold closure and can be either the cause or
consequence of psychological problems [16–18]. Gastroesophage-
al reflux or laryngopharyngeal reflux are often associated with
voice disorders, too [11,16,19].
Patients with psychogenic voice disorders are primarily treated
symptomatically in order to re-establish the voice quickly and
avoid fixation. This acute therapy is often done by phoniatricians

0385-8146/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved.
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 R. Reiter et al. / Auris Nasus Larynx 40 (2013) 470–475
and/or speech therapists with intensive voice exercises e.g.
initiating the voice by coughing or clearing the throat. Speech
therapists also treat patients with psychogenic voice disorders by
direct (vocal function and resonance voice exercises) and indirect
voice therapy (relaxation and breathing exercises) [5,20–23].
A psychotherapeutic approach using counseling may be a useful
approach, particularly in refractory cases [3,7,20,24,25]. Where
psychogenic voice disorder is thought to be a conversion reaction,
symptom orientated voice therapy in combination with cognitive-
behavioral therapy might be a promising therapy option [4,26,27].
Additionally, biofeedback approaches (e.g. means visual endo-
scopic feedback of the larynx findings) may be successful [5,28].
But in all these cases little information exists about long term
success and high relapse rates are observed [1,21–25].
In this study we wanted to investigate epidemiological data,
organic and psychological symptoms assessed by a phoniatrician
and clinical psychologist, respectively. Therapy options (counsel-
ing, biofeedback and intensive voice exercises – psychotherapy,
especial cognitive behavior therapy – psychotherapy in combina-
tion with voice therapy, especial direct voice exercises and indirect
relaxation techniques) and long term outcome of patients with
psychogenic voice disorders were prospectively evaluated.
2. Materials and methods
We included 40 consecutive patients with a psychogenic voice
disorder who visited the Section of Phoniatrics and Pedaudiology
from February 2009 to April 2011 in this prospective study. The
diagnosis psychogenic voice disorder, caused by a severe
underlying psychological problem, was made by a phoniatrician
and clinical psychologist according to the criteria of Sapir. The
onset of the voice disorder was linked to a psychologic stimulus
such as stressful life event or interpersonal conflict (symptom
psychogenicity) and symptom incongruity was observed. The
symptoms should be reversible with short-term voice therapy and/
or through psychotherapy.
The medical history contained information about voice
impairment, dependence on voice, profession, associated medical
conditions and treatment. At first presentation voice quality was
evaluated by a phoniatrician when the patient read a standard text
and rated by roughness R, breathiness B, and hoarseness H (RBH)
scale: RBH were scored from 0 to 3 points (0 = normal, 1 = mild,
2 = moderate, 3 = severe/highly) [29]. Self assessment of their
voice-related quality of life was done by the German version of the
voice handicap index. The overall voice handicap index score (raw
score) can be used to grade subjective handicap from no handicap
[raw score, 0–14], mild handicap [raw score, 15–28], moderate
handicap [raw score, 29–50] to severe handicap [raw score, 51–
120] [30].
In addition, the phoniatrician made a videolaryngostroboscopic
vocal fold examination (90 degree endostroboscope 5052, Wolf,
Hamburg) and documented these findings (rpSzene1, Rehder,
Hamburg). Additionally a detailed psychological examination and
exploration of biographic history, psychosocial symptoms and
functions were made by a clinical psychologist. This included the
evaluation of the following items: social network, stressors,
contentment at the working place and mental disorders (according
to World Health Organization ICD-10 classification of mental and
behavioral disorders) [31].
The psychogenic genesis of the disorder was explained to the
patients with the aid of videolaryngoscopic findings by the
phoniatrician as a kind of biofeedback method. Organic findings
(e.g. inflammation, paralysis, tumors or atrophy of the vocal folds)
were excluded and a lack of adduction of the vocal folds during
phonation is observed, but normal movement and complete
closure of the vocal folds during coughing [5]. All patients were
471
immediately given an intensive voice therapy (e.g. initiating the
voice by coughing or clearing the throat) with the aim of recovery
by the phoniatrician. Afterwards counseling was undertaken. In
this procedure the linkage between the underlying psychological
problem and psychogenic voice disorder was explained to the
patients by the clinical psychologist.
Additionally, a recommendation for further therapy was made
by the clinical psychologist and the phoniatrician: psychotherapy
alone or a combination of psychotherapy and voice therapy, if
intensive voice therapy in combination with biofeedback and
counseling failed. A blinded randomization group placement was
not pursued, as we thought that all patients needed psychotherapy
as the most effective basic therapy approach, because all our
patients had an underlying psychological problem. The psycho-
therapeutic intervention was made in the form of a cognitive
behavior therapy that includes a reflection of the biographical
history and analysis of current relationship conflicts. The voice
therapy included direct voice therapy approaches (vocal function
and resonance voice exercises) and indirect voice therapy (sensory
awareness, relaxation and breathing exercises). Voice and psycho-
therapy were performed by different therapists, who were not
employed in our section. Psychotherapy and voice therapy started
simultaneously and the sessions were about equally distributed.
A follow up was made at an average of 16  8 months [range 6–
32 months] after the last visit to our section by contacting the patients
with a questionnaire containing the following items: (a) What is your
actual quality of your voice? No – mild–moderate–severe handicap.
(b) How often did you experience an event of psychogenic voice
disorder after the visit in our section? Never, if yes, how often? (c)
What therapy did you receive? None, antibiotics, antipsychotic drugs,
voice therapy, psychotherapy, combination of psychotherapy and
voice therapy. Additionally self assessment of the voice was again
done by the patients with the VHI questionnaire. Statistical data
analysis was performed with the Wilcoxon signed-rank test for
checking significant differences of the parameters between before
and after therapy (SPSS 19, IBM, NY). The study was approved by the
local Ethics Committees at the University of Ulm.
3. Results
3.1. Demographic data
Thirty four of the 40 patients were women (85%) with a mean
age of 39.2  15.9 years, (range 20–85 years, only one women was
older than 60 years).
A history of (mental) disorders was noted in 27.5% (11 out of
40). Four had a depression, four mental stress, two phobia and one
bullying. A history of acute laryngitis/rhinitis/bronchitis immedi-
ately before the onset of the psychogenic voice disorder was noted
in 16 out of 40 patients (40%) (Table 1). An occupational history
was taken: about one third of them had professions with a high
demand on the voice (businessmen and businesswomen, students
Table 1
Number of patients with associated medical conditions are listed in Table 1.
Associated medical conditions Number
of patients
Laryngitis/rhinitis/bronchitis 16
Oncological disease 1
Reflux 10
Asthma 3
Depression 4
Mental stress 4
Bullying 1
Phobia 2
472 R. Reiter et al. / Auris Nasus Larynx 40 (2013) 470–475

Table 2 Table 4
Number of jobs/occupation of the patients are listed in Table 2. The number of patients with their organic complaints at presentation is listed in
Table 4.
Occupation Number of patients
Organic complaints at presentation Number
Businessman/businesswomen 12
of patients
Nursery nurse 3
Student/trainee 6 Dysphonia/aphonia 40
Pensioner 7 Headache 11
Housewife/retired housewife 2 Vertigo 8
Manufacturer 6 Tinnitus 1
Unemployed 4 Dyspnea 5
Globus pharyngeus 12
Chest pain 9
Abdominal pain 9
Pain of the musculoskeletal system 14
Sleep disturbance/burnout 10
and nursery nurses, Table 2). 28 out of 40 reported a dependence Throat cleaning 1
on their voice for their job or social life.

3.2. Characteristics of the current disorder/complaints at presentation

All patients complained about recurrent voice problems (18
dysphonia, 10 aphonia and 12 both). The results of the auditory
perceptive voice assessment was in mean roughness 2.4  0.7 [1–
3], breathiness 2.8  0.5 [2,3] and hoarseness 2.8  0.4 [2,3]. The
majority of patients had VHI scores in the severe range (Table 3). Eight
patients alone suffered from just a voice disorder without coexisting
symptoms. Additional symptoms like chronic pain (80%), globus
pharyngeus (30%) and sleep disturbance/burnout (25%) were
observed (Table 4). Recurrent coughing was not observed at all.
Mean number of complaints was 3.6  2.7 and ranged between
1 and 11.
The voice symptoms developed suddenly within one day in 23
patients and gradually within a week in 17 patients. The duration
of the symptoms was a few hours in one patient, several days in 20
and several weeks or months in 19 patients. Former voice
impairment was observed in 28 out of 40 patients before (3 once,
16 up to 10 times and 9 more than 10 times).
3.3. Diagnosis
Eighteen patients were referred by a general practitioner, 17 by
an ENT specialist and 5 by a specialist for pulmonary disease.
Psychogenic voice disorders had been established in 2 out of 40
patients prior to referral to this particular clinic. Further diagnoses
were functional dysphonia (9/40) and acute laryngitis (16/40). No
diagnosis was available for the rest of the patients.
3.4. Previous diagnostics and therapy
The period from first symptoms to diagnosis was on average
22.7  15.3 months [range 2–48 months]. Before attending our
section the patients had already contacted a mean of 2.7  0.9
specialists [range 1–6]. A videolaryngostroboscopy had been per-
formed in 17 cases, an examination of the lungs in 10 cases, of the
thyroid gland in 8 cases and X-ray examination of the lungs in 2, a
gastroscopy in 3 and a psychological examination only in 1 case
before. The number of diagnostic investigations was 2.8  1.1 [1–5].
Prior diagnostic workup revealed asthma in 3 out of 40 and
gastroesophageal reflux/laryngopharyngeal reflux in 10 out of 40
(Table 1).
Most (28/40, 70%) of the patients had had voice therapy before
(mean 27.2  10.2 sessions, range 10–50 sessions) or antibiotics (12/
40, 30%). Detailed information is given in Table 5. Mean number of
therapies was 1.1  0.9 [1–4].
3.5. Videolaryngostroboscopy
In contrast to prior diagnostic organic findings (e.g. inflamma-
tion, signs of reflux, tumors or atrophy of the vocal folds),
functional impairment was excluded by the videolaryngostrobo-
scopic examination at first presentation. We saw an activation of
the supralaryngeal sphincter, a lack of adduction of the vocal folds
and absent mucosal waves during phonation in 25/40 cases, but
normal movement and complete closure of the vocal folds was
observed during coughing in all patients.
3.6. (Psychological) diagnosis
The psychological examination detected problems in every
patient in the categories partner/family (n = 17), job (n = 17),
health (n = 14), financial problems (n = 8) and spare time (n = 2). An
average of 2.4  1.2 categories were affected. All of our patients with
a psychogenic voice disorder had an underlying psychological
Table 5
The number of therapies that took place before presentation is listed.

Table 3 Previous therapy Number

Voice handicap index score self assessment is listed in Table 3 at presentation and of patients
after in average 16.0 months [range 6–32 months] after therapy. The overall voice None 7
handicap index score (raw score) can be used to grade subjective handicap from no Antibiotics 12
handicap [raw score, 0–14], mild handicap [raw score, 15–28], moderate handicap Antiphlogistics 8
[raw score, 29–50] to 3 (severe handicap [raw score, 51–120]. Antipsychotic drugs 3
Inhalation corticoid 3
Handicap, raw score Number of Number of
Antazida 4
patients at patients
Voice rest 2
presentation included at
Voice therapy (relaxation, breathing and voice exercises)
16 months
(18 Cases, mean 35  5 sessions a 45 min, 28
follow up
1 or 2 week sessions, mean 22  3 months),
No handicap [0–14] 0 15 10 cases were not specified.
Mild handicap [15–28] 2 9 Psychotherapy (psychoanalytic therapy)
Moderate handicap [29–50] 9 11 (3 cases, mean 20  5 sessions a 45 min, mean 5  2 months) 3
Severe handicap [51–120] 29 5 Combination of psychotherapy and speech therapy 0
 R. Reiter et al. / Auris Nasus Larynx 40 (2013) 470–475 473

Table 6
Therapy recommendation, acceptance and outcome after in mean 16 months (range 6–32 months) are listed (cr = completely resolved, I = improved, u = unchanged). All
patients received intensive voice exercises and biofeedback by the phoniatrician and counseling by the clinical psychologist.

Therapy options Recommendation accepted Outcome [after

average 16 months]

Counseling, biofeedback and 0 17 cr: 3 out of 17

intensive direct voice exercises alone i: 9 out of 17
u: 5 out of 17

Direct voice therapy (vocal function and 0 8 cases i: 1 out of 8

resonance voice exercises) and indirect (mean 18  6 sessions a 45 min, 1 or u: 7 out of 8
voice therapy (relaxation and breathing exercises) 2 week sessions mean 12  4 months)
Psychotherapy 24 6 cases cr: 4 out of 6
(cognitive behavior therapy) (mean 24  4 sessions a 45 min, 1 or i: 2 out of 6
2 week sessions mean 8  4 months)
Combination of (in)direct voice and psychotherapy 16 9 cases cr: 8 out of 9
(cognitive behavior therapy) (mean 19  6 sessions a 45 min, 1 or i: 1 out of 9
2 week sessions mean 11  4 months)
Psychotherapy and voice therapy started
simultaneously and the sessions were
about equally distributed
Overall 40 40 cr: 15 out of 40
i: 13 out of 40
u: 12 out of 40

problem to a severe degree: 15 (38%) somatic symptoms, 13 (33%)
burnout, 4 (10%) anxiety disorder and 4 (10%) depression.
3.7. Therapy and outcome
Immediately after intensive voice therapy, biofeedback and
counseling the voice recovered in 24 cases (60%). Detailed
recommendation, acceptance and outcome of further therapy
are shown in Table 6.
Long term results showed that overall in 70% (28/40) the voice
resolved or became better for at least 16.0  8 months [range 6–32
months]. The mean voice handicap index fell significantly from
68.0  17 (severe handicap) to 26.5  12 (mild handicap) (p = 0.03,
Fig. 1, Table 3). In detail, complete recovery of the voice (voice
handicap index < 15) was observed in 15/40 (37.5%) patients and
improvement also in 13/40 (32.5%), but 12 (30%) remained dysphonic
with no change. These 12 patients had not received any psychothera-
py. Out of 40 patients, 9 reported about one event, 12 about more than
one event [range 2–5] of dysphonia and 4 about dysphonia that
occurred recurrently after contacting our section.
Psychotherapy was recommended for all patients, 24 of these
alone and 16 of these in combination with voice therapy, but only
six started psychotherapy (cognitive behavior therapy) alone. In all
six cases cognitive behavior therapy was successful (p = 0.02): four
out of six patients have recovered completely and two improved.
Combination of cognitive behavior therapy and voice therapy
really took place in nine. Out of them eight resolved completely
and one improved (p = 0.008).
Voice therapy alone was not recommended, but took place in 8
patients, because these patients declined psychotherapy. Patients
who received voice therapy alone (with the focus relaxation,
breathing and voice exercises) did not improve significantly
(p = 0.55): only improved in 1 out of these persons (12.5%), the rest
remained unchanged. No one recovered completely. Seventeen
patients did not accept any additional therapy, except intensive
voice exercise and biofeedback by a phoniatrician and counseling
by the clinical psychologist at first presentation. In 70.5% this was
sufficient (17.6% complete remission and 52.9% improvement for
at least 6 months, Fig. 1).
4. Discussion
Although psychogenic voice disorders are very rare we were
able to include 40 patients. Most of them (85%) were female, as
found before [1].
4.1. Differential diagnosis
Organic or functional impairment was excluded in the
videolaryngostroboscopic examination. We saw an activation of
the supralaryngeal sphincter or an inappropriate adduction during
phonation, but normal movement and complete closure of the

Fig. 1. Mean voice handicap index score with standard deviation before (gray) and 16  8 months [range 6–32 months] after (white) overall therapy, speech (voice) therapy,
psychotherapy and combination of voice and psychotherapy. A significant improvement was observed for psychotherapy (p = 0.02) and combination of voice and psychotherapy
(p = 0.008), whereas no significant improvement was seen for voice therapy alone (p = 0.55).
474 R. Reiter et al. / Auris Nasus Larynx 40 (2013) 470–475
vocal folds during coughing as described before [5,9]. However
psychogenic voice disorders are often misdiagnosed. Differential
diagnoses are an acute laryngitis, functional dysphonia, especially
hyperfunctional voice [16,17] and muscle tension dysphonia
caused by increased tension of the (para)laryngeal musculature
compensating an underlying organic disease, e.g. upper airway
infections with cough as etiolgies for incomplete closure of the
vocal [14,16] and aging voice [1,11,12,20].
The mean age of the patients was 39.2 years, (range 20–85
years) with only one woman being older than 60 years, indicating
that the diagnosis aging voice was not obvious. Patients with
Parkinson disease in which vocal fold bowing can occur [13] were
not included. A previous history of gastroesophageal reflux/
laryngopharyngeal reflux or asthma sometimes associated with
voice disorders, disturbances and changes [11,16,29] was found in
10 and in 3 patients, respectively. However these patients were
treated sufficiently with antacids, lifestyle changes or steroids and
signs of reflux or symptoms like recurrent coughing were not
observed at all at presentation in contrast to examinations before.
A history of acute laryngitis was found in up to 50% [1,3,20], but
in patients with psychogenic voice disorders in our group it was
only 40%. The consequence can be inappropriate treatment with
antibiotics or inhalation, as was seen in 22/40 (55%) [1].
Patients with functional dsyphonia also show a general trend
toward elevated levels of anxiety, depression and somatic com-
plaints. If these underlying features remain unchanged after the
voice therapy, it is expected that such factors would increase the risk
of future recurrences, although patients with functional disorders
are usually treated effective and rapidly with symptomatic voice
therapy [32–34]. Our patients however were all examined by a
trained clinical psychologist in advance. All of them had a severe
underlying psychological problem that was according to Sapir linked
to the onset of the psychogenic voice disorder [10].
4.2. Causes
It is thought that psychogenic voice disorders are a result of
acute or chronic psychosocial stress [8,24] as explored by the
clinical psychologist before onset of the psychogenic voice disorder
in 38% of our patients, although only 17.5% showed a psychological
strain at first presentation in our section. In a former study up to
54% of the women had experienced a difficulty or event which
involved conflict before onset of dysphonia 12 months before [1],
but in many cases it was not able to link a specific life event to the
onset of the psychogenic voice disorder [3].
4.3. Underlying psychological disease
In our group everybody had a psychological disease as a basic
problem confirmed by a clinical psychologist with the voice
disorder as the main symptom. The prevalence of somatic
symptoms (38%) was much higher in our study population
compared to the prevalence in the general population in Germany
(11%), whereas depression and anxiety disorders were about the
same [24,35]. About one third of our patients had a burnout
syndrome, but prevalence data for this problem are not available
yet [36]. The psychological examination detected problems of the
patients mainly in the categories partner/family, job and health. It
is well known that social stress related to interpersonal relations
in family, work, and/or other social activities accounts for most
common external frustration is associated with psychogenic voice
disorder [1,3,22,24]. In particular, interpersonal conflicts related
to family and work is of basic importance [3,7]. Additional
symptoms like chronic pain were observed in 80% of our patients,
which is much higher than in the general population (18%
prevalence) [37].
Multiple organic complaints were also reported before in
patients with psychogenic voice disorder. More than 75% of the
patients with psychogenic voice disorders had additional psycho-
somatic functional disturbances, e.g. anorexia nervosa, bulimia
nervosa, migraine and diffuse abdominal complaints in their
histories [3,21]. Especially patients with a high number of anxiety,
somatizations and problems in their private lives report about
recurrent periods of aphonia [8].
4.4. Therapy and outcome
Fifty-five percent of our patients had inadequate treatment of
an inflammation before, which is well known [1,22,38].
According to the literature different approaches for treatment
of psychogenic aphonia/dysphonia exist: immediate symptomatic
intensive voice therapy by a phoniatrician or speech therapists for
recovery of the voice during the first, counseling [1,3,21–23],
treatment of the underlying psychic causes [7,20] and combina-
tions [3,7,24,25]. But in all these cases little information exists
about long term success or relapse.
In accordance with the literature, in 70% the voice resolved or
improved overall [1]. A therapy option is counseling by a
phoniatrician or clinical psychologist alone, but relapse rates
can be up to 80% [1,21,24,25,38]. Visual feedback techniques are
known to be sufficient therapy options for voice disorders, too [28].
In a study where 68 phoniatricians participated immediate
symptomatic intensive voice therapy by a phoniatrician was
preferred. Psychotherapy was later not always considered neces-
sary [20]. It was recently observed in a Polish study of 500 patients
with psychogenic aphonia that the voice recovered in 82% after
symptomatic vocal exercises (e.g. phonation, relaxation and
respiration exercises) during the first day, but there was no
further information about the duration of the success. The others
required ongoing vocal therapy and concurrent psychotherapy
[23]. Interestingly in 12 out of 40 patients intensive voice exercises
with visual feedback of the laryngostroboscopic finding and
therapeutic counseling restored the voice in our patients. In some
cases this might be a therapy option alone.
However, in a case of psychogenic dysphonia it was recently
shown that speech therapy may be limited, when psychogenic
voice disorders occur in combination with other psychologic
diseases [22]. For all our patients psychotherapy was recom-
mended, but only 15/40 started this. In all cases cognitive behavior
therapy was successful, whereas only 1 out of 8 patients who
received voice therapy alone improved. Also voice therapy (which
had taken place before in 28 out of 40 patients), had no positive
effect. The high failure rate of voice therapy might reflect
inadequately trained clinicians and speech therapists or inade-
quate therapy technique(s). In our patients voice therapy
techniques of 18 cases could not be exactly specified.
Phoniatricians and speech therapists may often not have the
expertise of clinical psychologists to treat patients with severe
psychogenic voice disorders and therefore help by a clinical
psychologist is required [38]. It is known that the therapy of
psychogenic voice disorders is often insufficient and it may take up
to 7 years until patients with a psychological disorder and
psychogenic voice disorders as a symptom are treated by a
specialist, e.g. clinical psychologist [1,38]. In our patients the
period from first symptoms to diagnosis of psychogenic voice
disorder was on average 22.7 months.
When psychotherapy in the form of cognitive behavior therapy
was given to our patients it was successful and no relapse was
observed within 16 months. The combination of direct and indirect
voice therapy and cognitive behavior therapy was particularly
successful. It is known that the symptom orientated voice therapy
in combination with psychotherapy in form of cognitive behavior
 R. Reiter et al. / Auris Nasus Larynx 40 (2013) 470–475
therapy for psychogenic voice disorders as a conversion reaction is
a promising therapy option [4,27]. Psychoanalytic or cognitive-
behavioral treatment strategies, such as stress management and
assertiveness training, appear to be particularly relevant in these
cases [39]. In cases with insufficient success ongoing vocal therapy
a concurrent psychotherapy is required [23,32]. Kollbrunner et al.
stated that voice therapy alone was only an alternative for patients
with psychogenic voice disorders, who refuse psychotherapeutic
intervention [5].
In our patients, who were all examined by a trained clinical
psychologist and who had dysphonia as a symptom of a severe
underlying psychological disease, the 12 patients who did not
receive any psychotherapy were not cured. This may be because a
majority of patients are likely to be averse to psychological
treatment, even though it would likely be successful [24].
As a limitation it is important to know that this study does not
hold the weight of a randomized trial. The patients were offered a
choice of therapies and then selected which they preferred – as a
result, the study outcome may have been influenced by a selection
bias – e.g., certain patients may be more or less likely to elect
psychotherapy, and as a result be more or less likely to engage in
therapy and make progress under this treatment modality.
A further limitation of our study was that the evaluation of the
voice after an interval (average 16 months) from first presentation
was only done by a questionnaire and the voice handicap index, so
we had to rely on subjective evaluation of the voice that might
differ from an evaluation in our section.
Unfortunately no information about training and experience in
treating patients with psychogenic voice disorders of the speech-
language pathologists and psychologists are available, which
might influence the success of the therapy of this specific problem.
5. Conclusion
Psychogenic voice disorders are often not known to patients,
physicians and speech therapists leading to late diagnosis and
often inadequate therapy (e.g. voice therapy alone). These patients
often have a severe underlying psychological problem. Therefore
patients with a suspected psychogenic voice disorders should be
examined by a clinical psychologist. Psychotherapy (especially
cognitive behavior therapy, often in combination with voice
therapy) was most effective also in long term, but is often not
accepted by the patients.
Conflict of interest
All authors disclose any financial and personal relationships with
other people or organizations that could influence (bias) their work.
Acknowledgement
We thank Mr John Bennett FRCS for critically reading this
manuscript.
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