Singing Without Speaking: A Unique Case of Psychogenic Speech and Voice Disorder in an Adolescent

Abstract

Psychogenic voice disorder, often a manifestation of conversion disorder, is characterized by a sudden impairment of voice following a stressful event or other psychological cause. This case report presents a patient with a psychogenic voice disorder featuring the atypical ability to sing despite losing conversational voice. Few case reports exist on psychogenic speech and voice disorders, and no cases in the current literature examine the loss of conversational voice with preservation of singing voice. In this case, the patient experienced sudden onset stuttering which progressed to complete loss of voice in all settings while retaining the ability to sing. Despite extensive medical, psychiatric, and speech-language evaluations, including psychotherapy and speech therapy, the symptoms persisted, highlighting the diagnostic and treatment challenges in psychogenic voice disorders. This case underscores the complex interplay between psychological stressors and physical symptoms in psychogenic voice disorders, and highlights the lack of effective, evidence-based therapies for psychogenic voice disorders.

Case History

We present the case of a 16-year-old female with no known psychiatric history who presented to the child and adolescent psychiatry outpatient clinic for loss of conversational voice. She initially presented to the emergency department after her parents noted a one-day history of intermittent tremor in her hands and “drawn out” speech with progression to complete word omission and near constant stuttering. Prior to presentation, she was noted to have a mild upper respiratory infection which had been treated symptomatically. Complete neurological exam, laboratory studies, and CT brain without contrast did not reveal any evidence of an acute cause for the patient’s altered speech and tremor. She received a dose of IV midazolam and was discharged with a prescription for as needed hydroxyzine.

Further evaluation by outpatient neurology revealed that her stuttering began after performing in the marching band at her first home football game. After the game, she noted pauses and breaks in her speech pattern which progressively worsened over the next 24 hours and prompted her visit to the ED. After she was discharged from the ED, she endorsed having trouble “getting words out,” although she denied having difficulties with mental word finding. She continued to have constant stuttering of waxing and waning severity. Notably, she denied having any dysphonia, stuttering, or word production issues when singing. She continued to have an intermittent tremor which was notably worse in band class. Review of systems was negative for headaches, sinusitis, infections, and decreased concentration, although positive for intermittent lightheadedness, intermittent tinnitus, and difficulty falling asleep. Physical examination was unremarkable aside from a fine low amplitude high frequency postural tremor in the hands bilaterally and 3 café au lait spots on her chest and abdomen. Neurology determined that there was minimal suspicion for a specific neurological etiology for her symptoms and suspected that her tremor and speech concerns were related to underlying anxiety and stress. Therefore, they continued her current treatment with buspirone 5 mg BID and recommended follow-up with psychiatry and speech language pathology.

Upon evaluation by outpatient child and adolescent psychiatry one year later, she was found to have no known psychiatric history, learning difficulties, or developmental delays. She had exhibited strong academic performance, had friendships with other adolescents her age, and was very involved in her school’s band. Her parents noted increased stress and tension within the household due to a recent episode of major depression in the patient’s sister. Initial assessment of the patient in the office revealed a new progression to total lack of verbal communication. The parents estimated that this lack of verbal communication began approximately 5–6 months after she first presented to the ED with speech abnormalities. The patient had since begun communicating through a text to speech application and was unable to engage in verbal conversation. Through text, she stated that she had “squeaked out a few words” in the past couple of months and described a “tug of war with my brain” over getting words out. She also noted that she could still sing songs because she didn’t have to think about the words. Her parents stated that she had a desire to engage in verbal communication but felt unable to do so. The patient denied concern regarding the potential impact her loss of verbal communication could have on her education, relationships, and future employment.

Symptomatology

The patient reported some anxiety and noted ruminative thought processes, constant worrying, nervousness, and fear of something bad happening. She also noted having racing thoughts with decreased sleep. She denied having any obsessive thoughts or behavioral compulsions, although she would repeat stories or phrases in her head until they sounded right and would engage in repetitive behaviors, often swinging for hours at a time. She denied feeling depressed or hopeless. On mental status exam, she appeared comfortable and well-groomed, did not have any abnormal movement, was aphonic, described her mood as “pretty good” using a voice software, and had a positive affect which was congruent to her mood. Although she was aphonic, thoughts communicated using a voice software were linear, logical and goal directed. She did not appear to have any delusions or hallucinations, and was oriented to person, place, time, and situation. She had limited insight and fair judgment.

Diagnosis

Psychiatric assessment revealed likely diagnoses of generalized anxiety disorder (GAD), autism spectrum disorder (ASD), and psychogenic speech and voice disorder (PSVD).

Treatment

Treatment was increased to escitalopram 20 mg daily with a plan to cross taper to fluoxetine for higher efficacy if there was no evidence of improvement after 4 weeks. Several strategic interventions were recommended, including encouragement of verbal communication and non-response to non-verbal communication with the goal to have the patient utilize her singing voice to communicate.

At her one-month psychiatry follow-up, the patient reported insignificant change in her speech difficulties. She felt unable to speak and continued to use a text to talk application for communication. She expressed little interest in practicing her speech. The family and patient agreed to cross taper to fluoxetine as the next step in treatment.

Discussion

Psychogenic speech and voice disorders (PSVDs) are characterized by a variety of vocal abnormalities that cannot be explained by an organic physical or neurological cause.¹ PSVDs manifest as a diverse array of vocal and phonetic abnormalities, including sudden onset aphonia, hoarseness, breathlessness, stuttering, or production of a foreign accent.² PSVDs appear to affect women more than men, and onset is often preceded by a traumatic or stressful event.³ Although PSVDs may occur in isolation, they are often seen in patients with other psychogenic movement disorders (PMDs), including tremors, tics, dystonia, and gait abnormalities among others.⁴ In a study of 182 patients receiving care at the Baylor College of Medicine Movement Disorders Clinic, 30 (16.5%) of these patients were found to have a concurrent psychogenic voice disorder with stuttering (16 patients, 53.3%) and speech arrest (4 patients, 13.3%) being the most commonly identified manifestation.⁴ Key features and differentiators of PSVDs from other organic vocal disorders include suggestibility, diminished symptoms with distraction, varied symptom severity, and denial or indifference to vocal abnormalities.² Treatment of PSVDs has emphasized a multidisciplinary approach to care with incorporation of psychotherapy, pharmacotherapy, and voice therapy.^3,5 The current state of research in PSVDs leave much to be explored regarding the etiology, diagnosis, and treatment of these unique disorders.

In this case, we describe a case of a psychogenic speech and voice disorder (PSVD), a functional voice disorder in which no neurological or laryngeal dysfunction can be identified.¹ Psychogenic aphonia and other PSVDs have been described in the literature as a feature of conversion disorder which often occurs after a traumatic or stressful event.⁶ Previous case reports and case series have identified stuttering, aphonia, hoarseness, and foreign accent syndrome (FAS) as the most common presenting features of the disorder.² In this unique case of PSVD, the patient initially presented with slowed speech and stuttering with progression to near total aphonia with preservation of vocal function when singing. Her presentation was most consistent with a PSVD given that comprehensive work-up was negative for an acute or organic cause of her tremor and dysphonia, and her symptoms were not characteristic of other speech disorders, such as selective mutism, since her dysphonia was not context or situation dependent.⁷

Previous case reports of psychogenic dysphonia, a specific category of PSVDs, report that symptoms are often acute in onset and triggered by a traumatic life event.^2,3 As a potential manifestation of conversion disorder, PSVDs may evolve as a response to a trauma and may further limit other’s knowledge of the trauma due to the lack of verbal communication and non-disclosure of the event. Two cases of psychogenic dysphonia in the literature demonstrated that neither patient recounted the traumatic event until achieving improvement or resolution of their dysphonia.⁸ In the case presented in this report, the patient’s symptoms began shortly after a non-specific stressful event at marching band practice. Although her parents were capable of providing contextual details about the rigor and demand of her marching band practice, the patient herself did not provide specific details regarding the potentially traumatic inciting event. Additionally, the relationship between the event and the preservation of the patients’ musical voice requires further exploration. Interestingly, the preservation of her singing voice supports that the patient exhibited a PSVD that is more complex than a psychogenic dysphonia. Perhaps unique to the circumstances leading up to the loss of her conversational voice, the preservation of her singing voice suggests that she may have valued her musical abilities more than her ability to communicate with others through conversation.

In this case report, we identified a case of PSVD where the patient presented with complete loss of conversational speech and total preservation of her ability to sing. Dissimilar to cases of psychogenic dysphonia, the patient never experienced hoarseness or foreign accent syndrome. Although the patient exhibited both stuttering and aphonia, the prolonged duration of her aphonia with conversational speech was most consistent with a PSVD, not a psychogenic dysphonia.

Treatment of psychogenic dysphonia and other PSVDs has historically focused on treating the underlying causes of the disorder. In the case of our patient, we felt that treating the patient’s underlying anxiety with both pharmacologic and non-pharmacologic approaches would lead to the greatest improvements given the functional nature of her disorder. We additionally advised the patient to continue follow-up with a Speech-Language Pathologist (SLP) for voice therapy. Our patient exhibited mild incremental improvements with treatment of her anxiety. Although our patient saw improvements after up titrating to 30 mg dose fluoxetine for treatment of her underlying anxiety, a previous case report of a psychogenic dysphonia in a 32-year-old male demonstrated evidence of disorder resolution following treatment with sertraline 100 mg daily and regular voice therapy.³ Although the role of selective serotonin reuptake inhibitors (SSRIs) remains poorly defined, treatments that emphasize the role of voice therapy have been cited in multiple case reports.^3,9 Reports have described how voice therapy encourages patients to utilize their non-communicative voice (coughing, sneezing, laughing) to increase voice production with the goal to transition to word production and conversational voice.³ A review of cases of child and adolescent psychogenic aphonia found that evoking a basic laryngeal tone by digital manipulation and cough reflex were the most effective treatment methods.⁹ Additional treatment options explored in a study of 23 patients with psychogenic aphonia revealed that treatment using directive and biofeedback therapies to re-evoke the psychological awareness of the condition was successful in some patients. However, several patients relapsed despite treatment.¹⁰

In conclusion, we report a unique case of psychogenic speech and voice disorder in an adolescent female who exhibited complete loss of conversational speech and total preservation of her singing voice. Perhaps unique to the potentially traumatic marching band event, this patient’s case underscores the complex nature of the relationship between trauma, anxiety, and the development of PSVDs. In this case, we also tried various pharmacologic treatments and ultimately developed a multidisciplinary approach to treatment.