Functional aphonia, conversional aphonia, psychogenic aphonia, acute sudden voice loss, hysterical aphonia….They all are names for the same disorder. In school, I learned that functional aphonia was when a person lost his or her voice and couldn’t figure out how to speak again despite trying. In clinical experience, I have found that many factors can contribute to functional aphonia, not all clients are “malingerers” and it takes skill, patience and experience to separate these malingerers from those truly in need of voice therapy.
With this diagnosis, many insurance companies deny at the hint of anything functional. They see “functional” and read it as the patient is “choosing” not to speak. It doesn’t help that some patients receive secondary gain from this disorder and “milk it for all it is worth.” This may sometimes be the case, but for most functional aphonics, this disorder is something they cannot recover from without intervention. It usually occurs following an illness (such as an upper respiratory infection) or following a traumatic or emotional occurrence. It may even develop as a result of fear.
Before speech therapy was seen as an appropriate intervention technique, psychogenic aphonia was treated in very odd ways. One way was essentially “suffocating” the patient to evoke a vocal cry of alarm. Other treatments included using electricity, grabbing the tongue, water torture or cocaine applied to the laryngeal mucosa. Yikes…None of my therapy techniques include any of these thankfully.
The first functional aphonic patient I ever saw was by observation only. She was a young woman who had a child at home. Being a single mom, she worked at a very demanding job where she had to use her voice all day. She was receiving voice therapy fully paid for by her insurance company, and her job was giving her time off for short term disability. Each time she would come for a session, we made progress and she was able to find a wonderful and resonant target voice. The next time she would come in, the voice would be whispery and diminished again. It made me wonder if she was just using the time off for whatever personal reason, but the struggle in each session to achieve a normal sounding voice was all too real.
A memorable functional aphonia patient I saw was in a hospital where I worked. He had not been intubated, and I spend most of the evaluation trying to figure out if he was faking or not. Malingerers are out there… The more I found out about his family and the emotional trauma of what brought him to the hospital, the more I realized that the trauma itself had changed how this man functioned in every way, including how he spoke. It took 3 sessions before he even made a noise, but through semi-occluded vocal tract exercises with a straw in a cup of water, we were able to bring him into a complete and normal speaking voice in no time.
This population can be difficult to treat because, like most voice cases, no “one” treatment will work all the time. I have compiled a list of tricks and tips to help any SLP treating a functional aphonic achieve that “light bulb” moment.
- Bubbles in a cup. Begin with water in a cup, 1/3 of the way full or so. Have the patient place the straw in the water and blow air until bubbles are seen. This gives the patient visual feedback that air is indeed flowing. Next, have the patient begin to hum this way. Sometimes the distraction of the cup, the vibration of the bubbles and the noise made is all that is necessary to get phonation to occur again.
- Gargle. If the patient is appropriate and not an aspiration risk (i.e. not bedbound or on a ventilator), get some warm salt water, or plain water to gargle.
- Raspberries or tongue trills. These semi-occluded vocal tract exercises are based on the same scientific idea as straw phonation, but these easy productions may be the key for some patients.
- Laughing. Get out your joke book here. Sometimes all that is needed is good old-fashioned joking around. Some YouTube videos can be used as well. I like this old superbowl commercial about herding cats. It’s hysterical.
- Being silly. Act out some lines from a play in ridiculous accents or at different tempos.
- Masking. If you have headphones with some white noise you want to use, great! If you are interested in a more budget friendly and quick trick, crinkle paper towels or plastic next to both ears while having the patient attempt to phonate.
- Technology. Use your phone or a small recording device to record the patient making these noises. Sometimes patients will not even believe it is really them in the recording, so videos are the next step here.
Laryngeal Reposturing (ideas from Nelson Roy) can also be helpful in these cases. The book, Exercises for Voice Rehabilitation, shows this nicely in detail, but it is best learned from a practicing clinician.
Make sure you are utilizing negative practice in your sessions because the quicker the patient regains the ability to reorganize his or her own kinesthetic framework for phonation, the quicker the patient can get back to a normal life.
-ATVC
References:
Kollbrunner, Juerg; Menet, Anne-Dorine; Seifert, Eberhard. Psychogenic aphonia: No fixation even after a lengthy period of aphonia. Swiss Med Weekly, 2010,; 140(1-2):12-17.
Stemple, Glaze & Klaben. Clinical Voice Pathology: Theory and Management, Fourth Edition. Plural Publishing, 2010.
Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.
