The term ” aphonia ” in translation from Greek means “absence of sound”, the definition “psychogenic” indicates the peculiarities of the origin of the disorder, its connection with psychotrauma. This disorder is also called functional, inorganic, hysterical aphonia, as opposed to the disappearance of the voice as a result of diseases of the larynx. The prevalence is significantly higher among girls and women. Epidemiological indicators grow during periods of socio-economic crises; in Russia, the maximum number of patients was registered in the early 1990s and in 1998. Recently, cases of morbidity among adolescents have become more frequent, which is probably associated with an increasing information load.

Loss of voice occurs as a reaction to stress. The causes of the development of the disorder are always individual, but researchers have identified a predisposing basis – constitutional features, character traits, as well as a number of triggers – events that trigger pathological processes. Thus, the risk of psychogenic aphonia is increased in the presence of the following factors:

• Low adaptive abilities . The inability to withstand stress is due to innate psychophysiological characteristics. A neurotic response to changing external conditions is characteristic of individuals with an unstable type of higher nervous activity (choleric, melancholic).
• Hysteroid type of character . Psychogenic loss of body functions – dumbness, blindness, deafness, paralysis – occurs subconsciously. This type of mental protection is characteristic of people of a hysterical nature.
• Interpersonal conflicts . The impossibility of productive resolution of disagreements provokes the activation of mental protection – the loss of the ability to conduct a dialogue. An example of such a situation could be a quarrel with a spouse, lack of parental attention, loss of a job.
• Frustration of needs . The inability to get what you want is sometimes manifested by a subconscious protest – aphonia. The immediate cause of the disorder is a lack of attention from others (husband, lover, parent), insufficient recognition in professional activities, and business failures.

The pathogenetic basis of psychogenic aphonia is a combination of three factors: a neurotic background, a triggering situation (psychotrauma), and fixation of incorrect voice formation as a pathological conditioned reflex. From the point of view of psychology, this disorder is considered as a variant of a hysterical reaction. Loss of the ability to speak is a subconscious mechanism that allows the patient to avoid responsibility in a difficult situation and at the same time attract the attention and care of other people.

At the level of physiological processes, psychogenic aphonia is explained by the emergence in the cerebral cortex of a focus of transcendental inhibition in response to a strong stimulus (experiences of fear, anger, frustration). An imbalance in neurotransmission disrupts the regulation of voice production. Discoordination of impulses from the cerebral cortex to the muscles of the larynx occurs. Preservation of a sonorous cough, crying, laughter confirms the absence of pathology of the vocal apparatus.

According to the mechanism of development and the nature of the course, two types of psychogenic aphonia are distinguished: the first arises suddenly and is quickly eliminated by correctly selected methods of psychotherapy , the second is formed gradually – from attacks to a permanent lack of voice – and requires long-term periodic training to restore voicing. By the nature of physiological disorders, two forms of the disorder are also distinguished:

• Hypofunctional aphonia . Most common. When examining the larynx, good mobility of the larynx is determined. Fonation movements are accompanied by a decreased tone of the internal muscles, as a result of which the gap remains. Treatment focuses on activating the vocal folds.
• Hyperfunctional aphonia . The mobility of the laryngeal walls is preserved. During phonation, the folds close too tightly due to increased muscle tone. The therapy is focused on relaxing the vocal apparatus.

The disorder is manifested by the complete loss of a sonorous voice when trying to verbal communication. Patients communicate using whispering speech. In rare cases, the normal voice is replaced by an excessively high, “squeaky” voice. The habitual laughter, crying (sobbing), coughing, phonation when yawning and sneezing persist. Many patients, just as before the disorder, cry out in fear or surprise. Violation of the motor function of the larynx is manifested by discoordination of speech breathing, articulation and voice formation – patients try to sound speech, but are unable to control the movements of the vocal apparatus, the duration and depth of inhalation and exhalation during conversation.

Possible violations of the sensory function of the speech apparatus. In such cases, patients complain of increased sensitivity in the larynx, discomfort – perspiration, pain, tingling, tingling. A change in secretion is manifested by a feeling of squeezing, the presence of a foreign body in the throat . In addition, neurological and mental symptoms develop: headaches, weakness, unstable mood background, irritability, tearfulness, depression , insomnia .

In the absence of corrective and psychotherapeutic assistance, it is possible to increase the symptoms of aphonia up to psychogenic or hysterical mutism, when patients lose not only the ability to speak sonorously, but also to communicate with others in a whisper, using non-verbal means of communication. The socio-psychological complications of the disorder are depression, an increase in isolation, a limitation of direct communication, a decrease in interest and success in studies, professional activity. The longer aphonia lasts, the more massive and prolonged therapy is needed to eliminate it.

Most often, patients turn to an otolaryngologist for diagnosis, since organic diseases of the larynx, leading to loss of voice, are more common than psychogenic aphonia. After excluding ENT pathology, the examination is carried out by a phoniatrist , as well as a psychiatrist or psychotherapist . The full range of procedures includes:

• Collecting anamnesis . In the course of the survey, complaints, the nature and duration of the manifestation of symptoms are ascertained. The otolaryngologist clarifies the presence of signs characteristic of infectious, inflammatory, tumor diseases (hypothermia, fever, cough, pain). The psychiatrist asks about cases of neurotic disorders earlier, about the impact of stressful, traumatic situations before the loss of voice.
• Laryngoscopy . The larynx is examined using special mirrors. With aphonia, the normal mobility of the vocal folds is determined when inhaling (opening) and exhaling (closing), various changes in tone during phonation. The doctor also palpates the larynx and neck, if he suspects an infectious disease, directs it for laboratory tests (blood culture, mucosal smear). To exclude tumor pathologies, instrumental procedures are prescribed ( X-ray , MRI of the larynx ).
• Psychological research of personality . At the final stage of diagnostics, complex personality questionnaires are used: SMIL, Eysenck’s test, Cattell’s 16-factor questionnaire, and others. Additionally, projective techniques are used – drawing tests, tests of color choices, interpretation of situations. Psychogenic aphonia is characterized by the identification of hysterical traits (demonstrativeness, egocentricity, emotional instability ), an increased level of neurotization.

The tactics of therapy are determined individually, depending on the prevalence of increased or decreased muscle tone of the larynx, the severity of neurotic experiences, depression. Various specialists are involved in corrective and therapeutic measures: phonologists (phoniators), speech therapists, psychologists, psychotherapists. The work is carried out in three directions:

• Neuro-linguistic programming . The basis of the techniques in this direction is distraction and reliance on sound sound when laughing, crying, coughing. In the classroom, patients learn to move from available sounds, such as “hum”, to more complex ones. The technique of drawing according to Cheveleva is used, cutting out figures with pronunciation, pronouncing words after emotional and physical stress.
• Voice and breathing exercises . Classes with a phonologist have a good effect in treating the disorder. Deep and shallow breathing techniques are used with fixation of tension and / or relaxation in the larynx region. Of the vocal exercises, the most common is the removal of sound “into a mask” (from sound to word), soundless phonation, singing, soft, aspirated and hard attack.
• Psychoanalysis . In the presence of hysterical features and a deep subconscious conflict, aphonia can be eliminated through psychoanalysis sessions . Understanding and acceptance by the patient of the triggered protective mechanisms of the psyche allows finding resources for actualizing and overcoming repressed experiences. Psychotherapy is long-term, but the result is persistent, relapses are extremely rare.