Table 3

Treatment of functional voice disorders

Domains of interventionExamples of possible strategies
Education and explanatory
  • A key part of treatment is clear explanation of the nature of the disorder (see box 4 for helpful phrases) and the rationale for the diagnosis.

  • Review the laryngoscopy examination and/or images together with the patient. It is particularly important to explain that ‘abnormal movements’ and similar remarks in written reports reflect reversible habitual movements and not irreversible structural abnormality, as patients may misunderstand the implications of such phrases.

  • Explain that voice disorders can result from excessive muscle tension which may prevent normal speech but does not represent an irreversible or uncontrollable abnormality and that it can brought under their control.

Symptomatic Natural, reflexive, or instinctive behaviours usually accompanied by sound:
  • Cough and clear the throat (allowing voice to be present if possible).

  • Yawn followed by a sigh (as if with genuine relief).

  • Whimper sounds (as if a small distressed animal such as a kitten) or invite extremely high-pitched voice.

  • Grunt or groan (as if in pain, shifting posture, lifting a heavy item).

  • Comfort moaning sounds (associated with pleasure, eating something delicious).

  • Gargling with a firm sound (first with water then simulated without water

  • Pretend to be snoring.

  • Use slow easy onset with prolonged speech sounds such as /mmyyy-mmuumm.

  • Phonation on inhalation while maintaining a very relaxed body.


Playful pre-linguistic vocal sounds that we might enjoy with a young child:
  • Blow raspberries while voicing.

  • Phonate with a rising and falling scale blowing the lips like a horse.

  • Move finger rapidly in between the lips shaped for ‘ooh’ with a falling inflection from high to low (you are so cute).

  • Pat the lips with hand while phonating (gentle affectionate tone as if to infant).

  • Gently pat the patient’s back while they sigh out ‘ah’ (as if with comfort).

  • Patient pats own chest firmly while sighing ‘ah’ (with a sense of comfort or relief).

  • Siren quietly down the scale using nasal sounds such as /m/ /n/ or /ng/.

  • Produce a low-pitched glottal fry at the very bottom of the vocal range.

  • Giggle or laugh (as if in absolute delight).

  • Hold a tube of paper to the lips, phonate ’ooh’ and notice sensation of lips vibrating.

  • Sing rising and falling scale on tongue trill with firmly voiced consonant, for example, ‘drr’.


Automatic phrases and utterances with minimal communicative responsibility
  • Respond with short ‘Mm mm’ ‘Okay’ ‘Uh huh’ (as in response to question).

  • Count and recite days of the week, sing ‘Happy Birthday’ or favourite song.


Physical and or postural manoeuvres:
  • Reposturing/repositioning/lowering of the larynx including circumlaryngeal massage with concurrent vocalisation. It is important to clearly explain and check with the patient before touching their neck.

  • During these manoeuvres, patient may be asked to phonate gently on an open vowel such as /ah/, nasal sounds such as /mm/, or to glide down the scale from high to low on a /whooo/, which will often facilitate a tentative squeak, an uncertain pitch break from falsetto phonation into modal voice, or a brief sound resembling their normal voice. For some it may even prompt more irregular phonation, so the therapist needs to reassure the patient that different stages of dysphonia may be heard as it returns to its normal pitch, quality and function.

  • Postural manipulations such as phonating while bending over or while leaning back and looking at the ceiling.


Redirection of attentional focus:
  • Bubble blowing into water with vocalisation.

  • Large body movements such as jumping, shaking out body while make ‘shivering noises’ facilitates redirection and release.

  • Invite patient to communicate and interact while walking along, inside or outside the clinical setting, against the noise of traffic.

  • Use of amplification or headphones to alter or enhance auditory feedback.


Use of electroglottography (EGG) and electromyography as forms of laryngeal biofeedback which may also serve to redirect attention.
Psychological
  • Communication counselling attending to predisposing, precipitating and perpetuating issues related to onset and maintenance of voice symptoms.

  • Identify and gently address patterns of avoidance of speaking or excessive dependence on aids to communication.

  • Identify any social or other phobic anxiety, that is, of speaking in particular situations. Support to increase exposure (and so reduce anxiety) to feared situations. In some cases collaborative work with, or onward referral to, mental health professionals for structured psychotherapy (eg, CBT) may be helpful.

  • CBT, cognitive–behavioural therapy.