A Case of Spastic Dysphonia

 This case history was published in 1988. I have updated it with footnotes indicated by bracketed letters. The cause of spastic dysphonia, now more commonly called “spasmodic dysphonia,” remains unknown. There has been a shift away from offering a variety of theories as to causality to focusing on neurobiology--the cells of the nervous system and how they mediate behavior. Studies indicating a genetic basis also now appear frequently in scientific journals. The standard of treatment now involves injections of botulinum.

General Discussion

Spastic dysphonia is a rare condition affecting speech. All aspects of normal phonation are altered including volume, pitch, inflection, fluency, rate, and rhythm.  In typical cases, the voice  is  hoarse  with  a tense, strained, and tight quality. Impaired individuals suffer greatly and are severely limited in their ability to communicate, even on the telephone. Depression, progressive withdrawal, and isolation are common.

The cause of this disorder, as with virtually every human ailment, remains a medical mystery [A]. Some clinicians have descriptively termed the condition "laryngeal stuttering" emphasizing the  similarities between the glottal symptoms of spastic dysphonia and  the oral ones of the stutterer (1).  Surgeons postulate the cause to be a "neurohormonal imbalance" that involves the basal ganglia in the central nervous system. The consequences of this involvement are thought to be ultimately manifested peripherally in the throat  through the extrapyramidal  motor system. Among the psychological speculations, the psychoanalytic theory of the neurosis explains the  physical disorder as a manifestation of a deeply rooted emotional conflict.

Unfortunately, because currently accepted theories lack any appreciation of the underlying disordered energetic functioning,  current medical treatments remain necessarily mechanistic and  pragmatic. They include: speech therapy, surgery, drug therapy,   hypnosis, and psychotherapy. Drug therapy is of no avail. Hypnosis has rarely provided lasting relief. Speech therapy also is frankly   described as rather disappointing even in the hands of highly skilled therapists with extensive experience in treating the problem (2). [B]  Psychoanalysis, even with its insight and affective abreaction associated with ideas, is ineffective because the "release can rarely  be brought about  in such intensity as would bring about the desired [physical] result" (3).

In recent years, some selected cases have been afforded symptomatic relief with surgical intervention. There is, however, a significant degree of recurrence, hoarseness, and other voice  changes  as a complication  of surgery. In this approach, one of the recurrent laryngeal nerves is severed, permanently paralyzing a vocal cord, thereby relieving its spastic contraction and the mechanical cause of the hindered speech [C]. It is no surprise to the student of orgonomy, however, that the individuals with this condition usually exhibit facial grimacing and tic-like contractions of the neck and shoulder muscles.

Spastic dysphonia is, in fact, a conversion hysteria [D]. Only with the application of Reich's energetic principles can the functional identity of psyche and soma come into sharp focus and the disorder be understood. Only then is it possible to offer sound, effective treatment. This is illustrated in the following case presentation.

Case History

Olivia is a 38-year-old, married housewife, the youngest of three children, who sought treatment three and a half years ago because of a yearlong history of progressive and almost complete loss of speech. What began as hoarseness with some cracking of her voice worsened to the point where she could barely make herself understood.  The sounds she could produce were breathy, strained, and squeaky, and she spoke by breathing in “like whistling in." She could, however, scream out, especially the word "No." She was also able to laugh out loud and talk while crying. Her overall physical  health was excellent, and she never had previous psychiatric  treatment.  She attended college, enjoyed music, art, and gardening, and was clearly a bright and very sensitive woman. Married 15 years, her relationship with a decent, sensitive, and supportive husband was solid. Her first sexual relationship was with him. Their sex life was not especially satisfying for her and was sometimes endured with resentment. Without formal profession at the time of initial consultation, she worked as a housewife raising her three young children, ages two, three, and seven.

Although Olivia was unaware of any prior difficulty speaking, a friend reported speech problems dating back as much as ten years. Olivia felt her loss of voice coincided with anxiety over her daughter's starting kindergarten. Episodes of anxiety gave way to full-blown panic, especially when near a school. She feared the teachers' criticism of her child and of herself as the mother. She was also terribly afraid that her daughter would be perceived as emotionally damaged--proof positive she was a bad mother. "When she started school, it triggered what I felt at her age--now I can find my panic in her situations."

The more she told of what she felt and experienced as a child, the clearer it became that her present inability to speak was the consequence of a lifelong emotional battle. She was able, for the longest time, to bravely cope and maintain an outward appearance of calm, peacefulness, serenity, and sweetness. This was, however, no longer possible. Her defensive structure was breaking down, and the contraction  of her throat, a weak point in her structure, was an attempt to contain her overwhelming fear and anxiety. With her daughter's entry to school as the final straw, she literally began to hold her breath, waiting to be accused, judged, and sentenced. She said, "This is how I always felt inside — now everybody can see it."

She felt herself becoming progressively more numb, more closed to herself and others, with  increased frequency of anxiety attacks and extended periods of severe depression marked by alterations in vegetative functioning and self-reproach.  She castigated herself for having been a mean, horrible mother and, finding herself  acting like her parents toward her children, provoked terrible guilt. Anger, rarely felt, was directed at her children and husband and only provoked more guilt.

Course of Treatment

In her first session, Olivia was tense and very apprehensive, but tried to maintain a calm and composed exterior. She was moderately slim and of above average height with small breasts in comparison to her hips. Her eyes revealed her underlying fear and sadness but were mobile, and the pupils were not dilated. The face was held and stiff. The jaw could not be moved passively and her neck, predictably, was heavily armored, especially in the deep musculature. The jaw and throat were visibly tense and strained when she attempted to speak.  Overall armoring was, otherwise, moderate. Her pelvis could be moved passively. She was able to hit and kick with some force, albeit without feeling, and able to shout out fairly well. She could hardly speak. Her voice, clearer or even quite normal at times of emotional expression, encouraged me greatly, and I felt optimistic orgone therapy could be helpful.

Based upon her past and present functioning, her character, and the distribution of armoring, a  diagnosis was made of a hysteric with an oral repressed block.

The initial phase of treatment lasted about a year, and she came to feel secure in a situation free of judgment. Initially, she literally could not relax enough to just breathe. She was frightened to be on the couch, scared to speak up, and felt like a child. She was also acutely aware of my presence and always afraid she was not doing things "right"' on the couch. ⁽¹⁾ 

⁽¹⁾ It is interesting to speculate to what extent the two sides of the body are associated with gender identification: the right being masculine and the left feminine. On the couch the patient's side closest to me, her right side, has always felt less alive than her left. Also, in establishing the diagnosis of spastic dysphonia, the surgeon anesthetized her right vocal cord (releasing the inhibited father side?), allowing her to speak clearly.

This was in large part a paternal transference reaction and mirrored  her contemporary relationships with those she saw as authority figures. Her father was domineering, controlling, cruel, and physically violent. He was unpredictable and explosive; she never knew what to expect. In therapy, too, she feared how I might react.

The biophysical work began with breathing and vocalization. Persistent encouragement to make sounds produced an initial loosening of both the cervical and thoracic segments. Unfocused rage was released from the throat and chest, respectively, with piercing  screams and moderately forceful hitting. Manual compression of the chest brought immense relief, "as if a weight was being lifted," with easing of superficial holding and greater contact with sadness from both the distant past and the present. Initially, her perception  of emotions  and physical  sensations  were disconnected, and it was necessary to bring her into contact with not only that she was feeling but also what she was feeling. She said, "Your giving ʻpermissionʼ and demanding that I express myself began to break up the mass; I began to feel my physical being. I had been so cut off from my body and the  physical release made me feel looser,  freer, and more limber." She was inhibited about her body and afraid to express feelings. Early in treatment she felt always on guard, "except for when an emotion was more powerful than my inhibition.

Because her ocular segment was not her weakest point, it was safe to begin by mobilizing lower segments of armoring. However it was not long before the holding in her face and the sadness and fear in her eyes became considerably more prominent. Direct work on the scalp and pressure on the orbital notches — combined with facial movements and ocular mobilization — brought her in contact with these repressed emotions. Fear was expressed by having her open her eyes wide and scream out in terror. Occasionally, deep pressure on the posterior cervical muscles helps relieve holding and sometimes elicits feeling states from the past. Gagging at home and on the couch has been helpful.

Olivia is well into the long middle phase of  treatment and fairly well conducts the biophysical aspect of her sessions herself, requiring  little outside intervention. She recognizes her tendency to avoid beginning to breathe by talking too much, and she still needs to be encouraged to open her eyes and scream out in fear. She is now able to release rage quite well from the upper four segments.

Prior to therapy, she rarely, if ever, felt anger in her daily life. Within a few sessions, however, she came in contact with the repressed hate long held toward her parents. She also recalled the long-buried feelings she had as a child with impressions flooding back of having been alone  and without friends. She had been raised abroad, separated from neighbors, isolated in a house with grounds. She never spoke up at home and had no memory of talking. She could not ever recall having had any of the normal, everyday verbal interchange children have with their parents. No one ever asked her opinion, and there were no discussions, not even arguments.

She was brave in the face of her anxiety and timidity, but because she was a hysteric, I knew she was always ready to take flight. I was careful not to push her beyond tolerable limits. Notwithstanding, she held true to form and voiced, from time to time, her desire to try to function without therapy. Her ability to speak was improving, and she felt stronger  and wanted to stand on her own two feet. This was a position difficult to argue against, but I told her she was running away and let her go. Her return depended on the following facts: Negative transference feelings had been aired regularly; she had not yet reached an energetically stable position; her anxiety would be bothersome; and her drive to become well would override her fears  and again force her back into treatment. She always returned.

She continued to show steady progress. Her running away abated. She experienced and expressed more easily the long repressed rage toward her parents, was able to look about and feel terror, and was able to cry a bit with feelings of sadness and deep sorrow. This she said is, "not for the adult me so much but for the dearest little girl that I was. There was no one loving me and watching over me."

Because the armoring was laid down by unceasing, inhibiting parental attitudes and not by discrete events, specific memories were few: moments of profound desolation; her father's physical cruelty  to  her brother and mother; and the horror of reexperiencing these events with the terror she and her brother felt. Recollections come not in the form of pictures, but as realizations, as if her body was  remembering. "There have been no isolated memories of the pain  of  not being able to voice my opinion, desires, feelings — that  memory is more like a continuum, a constant something that always was."

With the loosening up of her ocular segment, she was able to see the world about her much more clearly. She realized for the first time how disturbed and contactless her mother really was, withholding her love to force acquiescence and obedience. She began to link present-day guilt feelings with those she felt as a child with her mother. Until a recent visit, Olivia never fully realized her mother maintained effective control using guilt. Suddenly, it all became so clear. The message to Olivia was always, "You are the one to save me and make  me happy." She refused to cooperate in this dynamic and has greater  contact with the hate she harbored for so long. She began to express this pent-up rage. It requires but time until this murderous fury can be discharged with full intensity. It will only be then that she will be relieved of her own guilt feelings for having been such a "bad" mother.

Discussion

Olivia has progressed steadily and her voice has been restored. She is more aggressive, tolerates her anxiety, and is now working and planning to return to school. She is less plagued by depression and no longer immobilized by anxiety. Her existence is not the life and death struggle it was, and the nameless terror is all but gone. Sex has improved. Decisions are made without the terrible fear that some punishment lies in store if she chooses wrongly, and there is less constant guilt that colored so much of her life.

There is also new confidence, as she speaks up for herself. She has a better understanding of how she became so verbally repressed and traces it back to the authoritarian and restrictive atmosphere at home. She says, “I heard language mostly used as a directive, a way to control and inhibit." Interestingly, her use of language is changing, too: "I have more and more really nice thoughts and ones that I feel like speaking. I notice my language — the actual use of words, my vocabulary—has flowered and filled in. I am still in the process of developing my own style, and I listen to others who use words easily and consciously pick up phrases. My thoughts run more smoothly and flow now, and my mind seems to work faster."

Her relationship with her parents has shifted, and she challenges them to relate to her; her relationship with her children and husband has changed for the better. She is more the mother and less the child.

Summary

In terms of traditional symptomatic medical treatment, the outcome of this therapy would be considered a remarkable success without resorting to irreversible surgical intervention. It is a tribute to the depth of the goals of orgone therapy that what would be considered a cure by traditional medicine is but one step in the process of restoring the organism to health. Olivia still has quite some way to go to reach the end stages of therapy. She appears to have the drive necessary to push on.  Whether she will ever  achieve orgastic potency  cannot  be  predicted, but there appears nothing to prevent her from moving  ever forward in that direction.  Her cervical segment must be watched carefully as it is her most vulnerable point. The treatment of this case of spastic dysphonia illustrates particularly well the functional identity of soma and psyche, and the value of medical orgone therapy in reversing this biopathic condition.

REFERENCES

1. Brodnitz, F. S.: "Spastic Dysphonia," Annals of Otorhinolaryngology (2pr. 1): 210-4, March-April 76:85.

2. Bridger, M. W. and Epstein, K.: "Functional Voice Disorders, A Review of a 109 Pa tients." The Journal of Laryngology and Otology, Vol. 97 (12): 1145-8, December, 1983.

3. Reich, W.: Character Analysis, 3rd enlarged edition. New York: Orgone Institute Press, 1949.

4. Aminoff, M. J., Dedo, H. H., and lzdebski, K.:  "Clinical Aspects of Spasmodic Dysphonia," Journal of Neurology, Neurosurgery, and Psychiatry, 41, 361-365, 1978.

ADDED REFERENCES

[A] Ladlow, CL , in the Journal of Neuroscience, 2011 Jan 19;31(3):793-7 indicates that the puzzlement as to the cause of spasmodic dysphonia (as it in now termed) is no less today than when this article was published in 1988.  He writes, “Little is known about its [spasmodic dysphonia] origins; it is classified as a focal dystonia secondary to an unknown neurobiological mechanism that produces a chronic abnormality of laryngeal motor neuron regulation during speech.” He goes on to state, “Research is needed to address the basic cellular and proteomic mechanisms that produce this disorder to provide intervention that could target the pathogenesis of the disorder rather than only providing temporary symptom relief.”

[B]  Silverman, EP, et al, in the Journal of Voice, 2011 Feb 2, concluded from their study that was designed to determine the effect of voice therapy after initial botulinum toxin type A (BTX-A) injections for ADSD that: “For participants in this investigation, undertaking voice therapy did not appear to exert significant beneficial effects on the variables of interest.” These were “vocal quality of life from the Voice-Related Quality of Life (V-RQOL) scale, acoustic measures of vocal instability, and perceptual ratings of voice quality.”

[C] Today, botulinum toxin  injections into the thyroarytenoid muscles are the treatment of choice for adductor spasmodic dysphonia (ADSD). It has replaced the older procedure that involved cutting or crushing of the recurrent laryngeal nerve. Novakovic D, Waters HH, DʼElia JB, Blitzer A, in their article “Botulinum toxin treatment of adductor spasmodic dysphonia: longitudinal functional outcomes.” (Laryngoscope, 2011 Mar;121(3):606-12.) indicate the results their study: “A total of 133 patients treated continuously between January 2006 and January 2009 with an individuated regime (dose, pattern, and schedule) were included. Of 1,457 treatments, 50.9% experienced some breathiness. Mean VHI [voice handicap index] improvement was 9.6%. Mean PNF [percentage of normal function] improvement] was 30.3%. There was correlation between the two scales. Dysphagia to liquids was reported after 14.2% of treatments.” They go on to report: “A total of 28.5% of treatments were followed by initial functional decline.” It is apparent from this report, and others, the benefits of the botulinum injections approach are limited. There are significant adverse effects, and in many there is a decline in improvement following each series of injections.

[D] This diagnosis is in keeping with Freudʼs belief that anxiety is converted into physical symptoms. It was largely reserved for conditions where neurological symptoms, such as paralysis and blindness, present in patients without a definitive neurologic cause. From Reichʼs perspective, spastic dysphonia develops as a result of an energetic contraction (secondary to repressed emotions) that occurs in early life. Over time this contraction becomes chronic, producing actual physiologic (structural) changes.