^aAdapted from Wesner et al.⁴⁰

Powell,⁴⁵ using the terminology of Rafferty, Smith, and Ptacek,⁴⁶ distinguished debilitating performance anxiety from normal apprehension or anxiety that facilitates performance. Salmon contended that anxiety per se is never helpful for performance and advocates using the term arousal to describe what others have termed adaptive anxiety.⁴⁷ Wolfe explored in depth the distinctions between facilitative (adaptive) and debilitating (maladaptive) components of performance anxiety in amateur and professional musicians.⁴⁸ She delineated some of the characteristics of the two forms of anxiety and found that professional playing experience positively correlated with more adaptive as well as less maladaptive components of anxiety.

Other work supports this notion, which recalls the Yerkes-Dodson law with the classic inverted U-curve of motor skill performance vs arousal, as both low and high levels of arousal are a detriment to performance quality, while a moderate level of arousal predicts the best result.⁴⁹

In a study of 29 professional violinists, while 83% believed that “every artist experiences some performance anxiety,” 52% agreed that “some tension aided their performance.”⁵⁰ Yet, clearly, some performance anxiety can be maladaptive. Failing to address the distinction between the facilitative and debilitating varieties confounds research on performance anxiety just as would including appropriate elevations in blood pressure during exercise as targets for antihypertensive treatment.

Definitions

Several authors^41,49,51 have declared an urgent need to define performance anxiety, if not etiologically or mechanistically, then at least operationally. The wide variety of prevalence rates reported may be partly explained by such factors as differences in sample populations (eg, Steptoe and Fidler found that anxiety is higher in students than in professional musicians⁵²), but it is also likely due in large part to the heterogeneity of terms used. The ICSOM study³⁷ asked about “performance anxiety,” the British study³⁸ used the term “stage fright,” and the OCSM survey⁴¹ included the very broad “stress related to performance.” Are these studies addressing the same thing? Beyond prevalence studies, how can intervention studies be compared if each one defines the problem differently?

Salmon⁴⁷ provided an often-quoted operational definition of musical performance anxiety: “the experience of persisting, distressful apprehension about, and/or actual impairment of, performance skills in a public context, to a degree unwarranted given the individual’s aptitude, training, and level of preparation.” Robson, Davidson, and Snell⁵³ make important distinctions between “performance anxiety” and “audition anxiety.” Many performers who have little problem or may even revel on stage in front of a large, and mostly unknown, audience may have significant anxiety during auditions. Furthermore, auditions and juries may place different aspects of the performers’ sense of self-worth, and even their very livelihood, on the line.

Brodsky⁴¹ proposed the establishment of a Diagnostic and Statistical Manual of Mental Disorders (DSM)–like system of nomenclature for “music-performers’ stress syndrome” (M-PSS), with specifiers for intensity and severity. He conceptualized a continuum of psychologically related problems of musicians, ranging from “career stress” to “tension in performance” to “performance anxiety” to “stage fright.” However, it seems that this classification system conflates intensity with chronicity and at the same time ignores issues of etiology, which may be essential in understanding a particular performer’s problem and selecting an appropriate treatment.

Yet the dilemma that Brodsky was attempting to solve is not simple and has not yet been adequately addressed in the literature. The question of how to come up with a meaningful and reproducible nomenclature while doing justice to the varieties of each individual’s experience is the essence of the task at hand. An agreed-upon nomenclature to describe performance anxiety would go a long way toward improving communication within the field of performing arts psychiatry, enhance diagnostic reliability, and provide a framework for meaningful clinical research to proceed.

Social Phobia and Performance Anxiety

The simple answer to the dilemma is to say that DSM has already solved it. Many would argue that performance anxiety as discussed here is simply a subtype of social phobia (also called social anxiety disorder). As described in the DSM-IV-TR, social phobia is a disorder characterized by marked fear of social or performance situations in which the individual is exposed to scrutiny by others and invariably becomes anxious that he or she will be humiliated or embarrassed (Table 7–2). The patient recognizes that the fear is “excessive or unreasonable,” and the symptoms lead to significant interference in daily functioning either by avoidance of the feared situation or by a degree of anxiety such that the feared situation is only endured with great distress. The anxiety may be “generalized” to multiple social domains, or it may be “specific” to one or two areas.

At face value, it appears that music performance anxiety fits the definition of a nongeneralized form of social phobia. However, some argue that performance anxiety as it manifests in the performing arts is in fact a distinct syndrome that the DSM-IV criteria for social phobia do not fully describe. Osborne and Franklin⁵⁴ noted that only 27% of those who self-report high music performance anxiety qualify for the DSM-IV diagnosis of social phobia, and Clark and Agras⁴² found that only 4% of patients with music performance anxiety had generalized social phobia.

Powell⁴⁵ explored differences between debilitating performance anxiety, generalized social phobia, and specific anxiety seems to be secondary to the fear of not being able to perform up to one’s own expectations, while in the DSM, the fear described is of scrutiny by others. Whereas in specific social phobia, patients are often ambivalent about or even actively avoidant of the feared situation, the opposite is the case in performance anxiety, where the individual is fiercely devoted to the challenge that provokes the anxiety.

Kenny⁵¹ provided an extended discussion distinguishing music performance anxiety from trait anxiety. She also argued that the DSM criteria for social phobia may be too restrictive to capture those with music performance anxiety deserving of treatment and recalled that equating music performance anxiety with existing DSM diagnoses ignores the fact that some amount of anxiety or arousal is necessary for most performers to achieve their best performance.

In this light, it is not surprising that anecdotal evidence suggests that those with music performance anxiety may not endorse the DSM criterion that the fear be “excessive or unreasonable,” which is necessary to make the diagnosis of social phobia.⁴⁹ For all these reasons, it remains unclear whether research evaluating treatments for social phobia may be rightly extended to the treatment of music performance anxiety.

Etiology

Freud’s original theories viewed anxiety as a buildup of psychic energy form either internal (instinctual) or external (traumatic) stimulation. In the 1920s, his shift from the topographical model of the mind to the structural model was accompanied by an adjustment of his understanding of anxiety. He began to describe the idea of “signal anxiety” (ie, anxiety as the reaction of the ego to a perceived danger situation and “a signal for help”).⁵⁵ This view of anxiety, as a warning signal for a dangerous situation (reviewed by Wong⁵⁶), can still be useful today in understanding performance anxiety in some patients.

Recent writings in efforts to describe the etiological and mechanistic underpinnings of performance anxiety have spanned the gamut from biological to psychological to social orientations. Sataloff, Rosen, and Levy⁵⁷ have provided a useful summary of the various approaches to understanding performance anxiety. A physiological explanation describes the sequence of events as follows: “Sympathetic activation produces physical symptoms, which the central nervous system interprets as anxiety and then reinforces with further sympathetic stimulation.”⁵⁸ Performance anxiety may be viewed as a psychophysiological feedback loop in which activation of the autonomic nervous system leads to and maintains the subjective sense of anxiety.⁵⁹

Cognitive-behavioral understandings⁶⁰ emphasize the distorted ways of thinking that lead to performance anxiety and the behaviors that reinforce them. Several authors, including Weisblatt⁶¹ and Nagel,^62,63 have drawn on a long history of psychoanalytic thought and described an approach in which anxiety is understood as arising from unconscious desires that come into conflict in the context of a performance situation. Hamilton’s book reviewed the role of narcissism in performance anxiety and the conflict a performer may feel in investing in a performance at the risk of potential loss of self-esteem.⁶⁴ Cox and Kenardy⁶⁵ focused on the impact of performance setting on anxiety, and Sternbach⁶⁶ described the social conditions of musicians as leading to a “total stress quotient” surpassing that seen in many other professions and contributing to situational anxiety on the stage.

It is critical not to forget basic differential diagnosis and to always rule out other possible causes for anxiety. A particular patient may complain chiefly of performance anxiety, while the real issue is a more pervasive underlying anxiety disorder (see below) or another psychiatric illness, such as a mood disorder. Substance abuse or withdrawal and many medical illnesses, such as metabolic or endocrine abnormalities, may also bring a patient to the clinic with anxiety as the only presenting symptom.

Many authors agree that the etiology of performance anxiety is most likely multifactorial⁵¹ and unique for each individual. This view accounts for performance anxiety’s distinctive manifestations in different performers as “loosely correlated constellation[s] of physiological, behavioral, and cognitive variables.”⁴⁷ Salmon⁴⁷ argued that the effectiveness of any intervention is depending on tailoring the treatment to address the specific mix of variables in a particular patient’s anxiety profile.

As with most other complex syndromes, the etiology of performance anxiety in a given performer is multiply determined by a combination of biological, developmental, cognitive, behavioral, and psychodynamic factors. These interact on a background of inherited predispositions, unique educational backgrounds, and individual skill levels and in the context of particular social, cultural, and situational performance environments.

Treatment of Performance Anxiety

What is known about how to best treat performance anxiety is drawn from a diffuse body of literature with significant methodological limitations. Many studies are poorly controlled, and few randomized trials exist. Not surprisingly, these inquiries include vague and varied definitions of performance anxiety, impairing the ability to generalize the findings.

It is beyond the scope of this chapter to review the entire body of literature on the treatment of performance anxiety. This has been done meticulously in Kenny’s recent paper,⁵¹ the first broad “systematic review” of the literature on this topic. This review, as well as Brodsky’s article,³⁹ also presents the major critiques of the field, some of which have been discussed here. McGinnis and Milling’s recent review⁴⁹ focuses on psychological treatments of musical performance anxiety.

Psychotherapy

Despite the deficiencies and controversies in the literature, some useful generalities may be drawn about the use of psychotherapy for performance anxiety (see descriptions of various psychotherapeutic approaches above).^49,51 Overall, cognitive and behavioral treatments appear to be effective, with various studies showing different combinations of effects on subjective anxiety, physiological parameters, and performance quality. While combined cognitive-behavioral therapies also seem to be effective, there is no evidence thus far that the combination is better than either component alone.⁶⁷

As for psychodynamic treatments, which were not included in the above reviews, Nagel,⁶³ Plaut,⁶⁸ Ostwald,⁶⁹ and Weisblatt⁶¹ all advocate psychodynamic psychotherapy as an effective treatment for performance anxiety.

Several other interventions, such as meditation, music therapy, hypnotherapy, and Alexander technique, have shown some promise, although in each case only one study has been undertaken thus far.⁴⁶

Beta-Blockers

Clinicians and research attempting to address performance anxiety with medications typically turn first to β-blockers. Nies⁷⁰ in 1986 provided a still-useful review of the clinical pharmacology of these medications for the performing arts medicine audience.

β-Blockers were first used in cardiac patients to block the effects of sympathetic activation of the heart, lowering blood pressure and reducing cardiac output. Because many of the physical symptoms of anxiety are mediated through the sympathetic nervous system, β-blockers have, over the years, become an extremely popular choice for the treatment of performance anxiety that includes somatic symptoms. Their popularity among performers is a strong testament to their effectiveness (and overall safety). However, a deeper reading of the literature reveals controversy among clinicians and researchers regarding the effects of this class of drugs on subjective anxiety and performance quality.

In his 1991 review, Nubé⁷¹ concluded that β-blockers do improve somatic symptoms of anxiety, subjects’ self-ratings of their performances, and overall jury assessment of musicality and technical quality. As such, these medications can be extremely helpful, even curative, for example, for the string player whose physical manifestations of, say, tremulousness, make him incapable of controlling his bow arm or vibrato.

However, there are some mixed data about β-blockers’ effects on subjective anxiety and on specific components of performance, such as intonation, rhythmic control, dynamics, and emotional connection to the music. Nubé wondered whether the “gains relative to the peripheral somatic side effects are worth a potential decrease” in these areas related to performance.⁷¹ Careful dose titration may be the key for some performers, based on the finding that low doses of a β-blocker improve performance whereas higher doses impair performance.⁷²

Sataloff, Rosen, and Levy⁵⁷ advised that, for singers and wind instrumentalists who require “athletic stamina,” β-blockers may not be appropriate (see also Gates et al⁷²). Given that singing is an endeavor requiring physical effort leading to a kind of exercise-induced tachycardia, suppression of this physiologically normal response with β-blockers may hinder optimal performance. Many singers in the study felt that higher doses of β-blockers were “energy-sapping.” This argument has been extended to dancers, where the obvious need for athletic endurance may be frustrated by β-blocking medications. Harris explored this “dancer’s dilemma” and cautioned that the literature on pharmacotherapy for orchestral musicians may not be generalized to dancers.⁷³

So, β-blockers may be a “double-edged sword.”⁷⁴ Nonetheless, they have undoubtedly been helpful to many performers struggling with debilitating performance anxiety. Lederman⁷⁵ clearly presents the pros and cons and advocates β-blockers as one alternative for treatment of performance anxiety if no contraindication exists. Brandfonbrener⁴³ offers a useful caution to use a test dose before the day of the big performance.

The most commonly used β-blocker for performance anxiety in clinical practice is propranolol at low doses of 10 to 20 mg 1 hour before a performance or audition. As with all other medical decisions, only when doctor and patient weigh the pros and cons of all possible treatments thoughtfully can an informed decision can be made.

In the real-world performing arts community, it is critical to recognize that many performers obtain β-blockers without a prescription. β-Blockers are not benign medications. They may exacerbate underlying conditions, such as asthma (symptoms of which may occasionally be mistaken for anxiety), or at higher doses may cause drops in blood pressure or heart rate. As with all medications, they should be used only under the care of a physician and should never be shared with colleagues. Furthermore, without a full medical evaluation, it is unknown whether the performer is suffering from run-of-the-mill performance anxiety or from another psychiatric or medical disorder that would not respond to β-blockers. Indeed, depression may be exacerbated by some β-blockers, although this association remains controversial.⁷⁶

β-Blockers are widely used for performance anxiety. In the ICSOM survey,³⁷ 27% of respondents had taken β-blockers at some point in their lifetime. Of those, 70%, nearly 1 out of 5 in the entire sample (19%), took β-blockers without a prescription. Among nondaily users, 72% took β-blockers before auditions, 52% before solo recitals, 50% before difficult orchestral performances, and 42% before concerto performances. A small but not insignificant number, 4% of occasional users, took β-blockers before every orchestral performance; this translates to 0.9% of the entire cohort of orchestral musicians or nearly 1 in 100.

Of occasional β-blocker users in the ICSOM survey,³⁷ 96% reported some success in reducing performance anxiety. Interestingly, among those who reported stage fright as a severe problem, success was about half as common (46%) for those who used medications without a prescription as for those who used a prescribed medication (92%). Sixty percent of those performers who sought psychological counseling for severe stage fright found it effective. Several other interventions were reported, notably including aerobic exercise, which was felt to be effective in 70% of cases of severe stage fright. In another study, full-time professionals were more likely to use β-blockers (67%), than part-time professionals (37%), students (13%), and serious amateurs (13%).⁴²

It is important to recognize that many performers obtain beta-blockers without a prescription from colleagues. Therefore, it is important to ask patients specifically whether they are taking medication without prescription. If used at all, β-blockers should be used only under the supervision of a physician who is able to rule out other causes of anxiety and monitor the dosage and side effects of these medications. Side effects may include bradycardia, hypotension, fatigue, and bronchospasm, particularly in those with asthma.⁷⁷

In carefully selected patients, β-blockers may be extremely helpful. However, further exploration of the underlying etiology of performance anxiety is critical, as medications do not address any underlying psychologic conflict.

For singers and other performers, such as dancers, who require “athletic stamina” for their performance, β-blockers should be used with great care or avoided.^57,72 Singing is an endeavor requiring physical effort leading to a kind of exercise-induced tachycardia, which may be inappropriately suppressed by these medications.

Nonrecommended Medications

Benzodiazepines, such as alprazolam, lorazepam, clonazepam, diazepam, and others, are commonly prescribed anxiolytics. However, these medications are generally not indicated for performance anxiety. First, they may cause side effects, such as sedation, dizziness, and weakness, possibly impairing performance parameters, such as intonation and rhythmic control.⁷⁸ Second, benzodiazepines often lead to tolerance and physiological addiction. Third, they may in fact impede the learning that takes place over repeated performances that could otherwise lead to extinction of performance anxiety over time.⁷⁹ The sensitive clinician must carefully distinguish performance anxiety from panic disorder (discussed below). Benzodiazepines, a common treatment for panic disorder, may be inappropriately used for situational performance anxiety that is mistaken for panic.

Antidepressants (discussed earlier) are often useful for patients who suffer from other anxiety disorders, such as generalized anxiety disorder, panic disorder, or posttraumatic stress disorder. There is also agreement that these medications are useful for those who clearly meet criteria for a diagnosis of social phobia.⁸⁰ However, there is no specific research on antidepressants for music performance anxiety.

Antidepressants also are discussed later in this chapter. Clark and Agras⁴² found that 41% of musicians attempted to treat their performance anxiety with alcohol and 20% had tried benzodiazepines. However, in a study of mostly students, an encouraging 98.7% “never” or “infrequently” used drugs or alcohol for performance anxiety, and only 6.5% believed that drugs or alcohol were “justified” for that symptom.⁴⁰ Steptoe and Fidler⁵² found that professional musicians with high performance anxiety were more likely to take sedatives (17%) than those with medium (4%) or low (0%) anxiety.

Future Research

To help inform better treatment decisions in the future, more research on psychotherapeutic and psychopharmacologic treatment approaches is clearly needed. Notably, there is no study combining β-blockers with any psychological treatment.⁴⁹ As Kenny⁵¹ noted, the current state of the literature on treatments for performance anxiety is “fragmented, inconsistent, and methodologically weak.” But simply more research is not necessarily better. First steps include more sound research designs, larger sample sizes, more careful selection of sample populations (both in terms of level of anxiety and other factors, such as students vs professionals), and better agreement on a definition of performance anxiety.

Ideally, future studies will continue to look at mediating factors and predictors of response to particular treatments. This information will one day allow the clinician to select an individualized treatment that best addresses a particular patient’s manifestation of performance anxiety. For example, one might select a behavioral approach for a patient who tends to catastrophize,⁴⁹ a pharmacological approach for a patient with prominent physiological symptoms and a psychodynamic approach for a patient whose unconscious conflicts seem to play a prominent role.

Clearly, some arousal or anxiety is necessary to a vital performance, just as some of Mahler’s genius flowed from his unresolved conflicts. To move forward, we must acknowledge the utility of adaptive anxiety, come to a consensus about how to identify the maladaptive variety, and set to work on rigorous and coordinated studies in an evidence-based manner, never forgetting to treat each patient as an individual meriting an individualized approach.⁸¹

Schizophrenia

Although psychotic behavior may be observed with major affective disorders, organic CNS disease, or drug toxicity, schizophrenia occurs in only 1% to 2% of the general population.⁸² Its onset is most prominent in mid- to late adolescence through the late 20s. Its incidence is approximately equal for males and females, and schizophrenia has been described in all cultures and socioeconomic classes. This is a group of mental disorders in which massive disruptions in cognition or perception, such as delusions, hallucinations, or thought disorders, are present. The fundamental causes are not fully known, but the disease involves excessive amounts of neurotransmitters, chiefly dopamine. There is evidence of genetic predisposition.

The typical signs and symptoms include clear indications of deterioration in social or occupational function, changes in personal hygiene, changes in behavior and movement, an altered sense of self, and the presence of blunted or inappropriate affect. Somatic delusions may present as voice complaints. However, flattening or inappropriateness of affect, a diagnostic characteristic of schizophrenia, will produce voice changes similar to those described for depression and mania. When the hallucinatory material creates fear, characteristics of anxiety and agitation will be audible. Perseveration, repetition, and neologisms may be present.^52,82

The disease is chronic and control requires consistent use of antipsychotic medications for symptom management. Social support and regulating activities of daily living are crucial in maintaining emotional control.

Psychoactive Medications

There are a wide variety of medications in the psychiatric pharmacopeia that can effectively be used to treat various psychiatric symptoms. All members of the voice care team should become familiar with all types of medications that their patients with psychiatric diagnoses are taking. Treatment may be improved through frequent, open collaboration between the psychiatrist and other members of the voice care team. It is important, with the patient’s consent, that the psychotherapist collaborate with the prescribing physician to help select the medications least likely to produce adverse effects on the voice while adequately controlling the psychiatric illness.⁸³

All psychoactive agents have effects that can interfere with vocal tract physiology, some more severely than others. Patients must be informed of the likelihood of experiencing known side effects, and the patient and physicians need to weigh carefully the benefits and side effects of available medications. This is especially critical to the professional voice user who may be keenly aware of physical side effects of medications, especially those that affect vocal production.

Antidepressants

Antidepressant medications include compounds from several different classes. The selective serotonin reuptake inhibitors (SSRIs), a group of antidepressant drugs that selectively inhibit the reuptake of neurotransmitter serotonin, include fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram, and vilazodone. The SSRIs are effective in the treatment of major depressive disorder, especially in the moderate to severe range, and for many anxiety disorders.^83,84

SSRIs have become popular first-line therapy for unipolar depression (nonbipolar) because of their relatively mild side effect profile compared with older antidepressant agents (described below). Patients often develop a small number of side effects, usually mild, which may abate over several weeks of continued therapy. The side effects will differ among patients. Those who do not respond to one agent or who experience intolerable side effects may try another agent with better results. It is important to remember that it may take 4 to 8 weeks to achieve the full benefit of an antidepressant medication when beginning therapy.

The most common initial side effects with SSRIs are restlessness, headache, gastrointestinal symptoms, and insomnia, but these symptoms generally subside in days. With all antidepressants, dry mouth may be a particularly bothersome symptom for voice professionals, and patients should be warned of this possibility. In the longer term, there exists the possibility of sexual dysfunction, which may be addressed by trying an alternate medication or by adding a medication to counteract the effect.

In 2004, a black box warning was added to antidepressants cautioning of the risk for increased suicidal thinking or behavior soon after initiating treatment in those younger than 24 years. While it is a rare occurrence, close and careful monitoring of younger patients starting these medications is critical.

Some controversy remains surrounding the risk of “switching” to mania if a patient with bipolar disorder is treated with a classic antidepressant, such as an SSRI.⁸⁵ These patients, especially at younger ages or with a history at all suggestive of bipolar disorder, should be monitored closely during the early weeks of treatment with an eye to this possibility.

Newer antidepressant medications include those with effects on multiple neurotransmitter systems: venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq) on both the serotonin and noradrenergic systems, and bupropion (Wellbutrin) on the dopaminergic and noradrenergic systems. Venlafaxine carries a risk of increased blood pressure. Bupropion, which decreases the seizure threshold, should be used only with extreme caution in those with an increased baseline risk of seizures and is contraindicated in patients with bulimia. Mirtazapine (Remeron) is an antidepressant that has significant side effects of weight gain and sedation and therefore may be beneficial in patients whose depressive symptoms include poor appetite or insomnia.

Older antidepressant medications, such as the tricyclic antidepressants (TCAs; eg, amitriptyline [Elavil]) and monoamine oxidase inhibitors (MAOIs; eg, phenelzine [Nardil]), are as effective as the newer medications but are now typically reserved for treatment-refractory cases due to their less favorable side effect profile and potential drug-drug or drug-food interactions. Side effects of the TCA may include the following:

• Anticholinergic: dry mouth and nasal mucosa, constipation, urinary hesitancy, gastroesophageal reflux

• Autonomic: orthostatic hypotension, palpitations, increased cardiac conduction intervals, diaphoresis (sweating), hypertension, tremor

• Other: stimulation, sedation, nausea, weight gain, sexual side effects

The side effects of MAOIs also may be serious. In addition to the effects described above for other antidepressants, MAOIs interact with a long list of foods that have high levels of tyramine, such as certain cheeses and meats (among others); these foods must be carefully avoided while taking these medications to prevent dangerous hypertensive crises. Dangerous interactions can occur when MAOIs are taken with certain drugs, such as meperidine, over-the-counter cold preparations, SSRIs, and others.⁸³

Many antidepressant medications produce bothersome and occasionally serious discontinuation effects if they are stopped suddenly. Medications should be discontinued only after a thorough discussion with the physician.

For severe depression that has not responded to multiple trials of psychotherapy and medication, as well as for other forms of severe, treatment-non-responsive psychiatric illness, electroconvulsive therapy (ECT) is a remarkably effective treatment, keeping in mind the risks of general anesthesia and the possibility of some cognitive side effects.⁸⁶

Mood-Stabilizing Drugs

The mood-stabilizing drugs are used to alleviate manic and hypomanic episodes and to prevent manic and depressive recurrences in patients with bipolar disorder. These medications include lithium salt formulations, various anticonvulsants, and antipsychotic medications.

Lithium, the classic mood stabilizer, is the only psychotropic medication that has been shown to decrease the risk of suicide.⁷⁸ Lithium has multiple side effects and a narrow therapeutic window, meaning that only a small range of blood levels is therapeutic, with higher levels placing the patient at risk for serious and potentially lethal toxicity. For these reasons, close clinical monitoring and routine blood level testing are important.

Side effects of lithium manifest in diverse organ systems. A common side effect is fine tremor, especially noticeable in the fingers. Some patients describe slowed thinking and memory deficit. Other patients gain weight progressively and may demonstrate increased thirst or appetite. Chronic nausea and diarrhea are usually related to gastrointestinal tract mucosal irritation but may be signs of toxicity. With toxic lithium levels, gross tremulousness, ataxia, dysarthria, and confusion or delirium may develop.

Lithium also may affect thyroid and renal function.⁸³ Polyuria and secondary polydipsia are complications and may progress to diabetes insipidus. In most cases, discontinuing the medication reverses the renal effects. There are important drug-drug interactions, including with certain diuretics, and lithium, like several other psychotropic medications, has clear teratogenic effects, should it be taken by pregnant women.

Anticonvulsant medications, such as valproic acid (Depakote), lamotrigine (Lamictal), and carbamazepine (Tegretol), among others, also may be used to treat bipolar disorder. Valproic acid, like lithium, requires regular blood level monitoring and may have effects on liver function and white blood cell counts. Sedation is common, and tremor, ataxia, weight gain, alopecia, and teratogenic fetal neural tube defects are all side effects that physicians and patients must discuss.

Lamotrigine, particularly useful for bipolar depression, carries a small but potentially lethal risk of severe rash. Carbamazepine carries a risk of agranulocytosis, and aplastic anemia and is monitored by complete blood counts.

Second-generation antipsychotics (see below) are now increasingly prescribed for their mood-stabilizing properties.

Anxiolytics

Benzodiazepines, such as alprazolam, lorazepam, clonazepam, diazepam, and others, are commonly prescribed anxiolytics. These medications produce effective relief of acute anxiety but have a high addictive potential and can lead to physical symptoms of withdrawal and possibly seizures if stopped abruptly. These medications are unfortunately often available on the streets and from colleagues. The most common benzodiazepine side effects are dose-related sedation, followed by dizziness, weakness, ataxia, decreased motor performance, and mild hypotension.

Benzodiazepines generally are not indicated for the treatment of performance anxiety. In addition to the above side effects and risk for tolerance and dependence, they may impair performance parameters such as intonation and rhythmic control.⁷⁹ They also may impede the learning that takes place over repeated performances that could otherwise lead to extinction of anxiety over time.⁸⁰ The sensitive clinician must carefully distinguish performance anxiety from panic disorder (see below). Benzodiazepines, a common treatment for panic disorder, may be used inappropriately for situational performance anxiety that is mistaken for panic.

Antidepressants, such as SSRIs and others (see above), are often first-line choices for patients who have anxiety disorders, such as generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and social phobia. However, there is no little research on antidepressants used in the treatment of performance anxiety other than the studies reviewed above (see section on Performance Anxiety).

Clomipramine, a tricyclic antidepressant, was formerly a first-line choice for treating obsessive-compulsive disorder, although SSRIs have become more common, given the side effects of TCAs, described above.

Hydroxyzine, an antihistamine, is occasionally prescribed for mild anxiety. It does not produce physical dependence but does potentiate the effects of CNS sedatives.⁸⁴

Buspirone is not sedating at its usual dosage levels and has little addictive potential. Its appears to be more useful for patients with generalized anxiety disorder who have not been on a benzodiazepine in the past.^83,81

Beta-blockers are often used to treat physiologic symptoms of sympathetic arousal in performance anxiety. This may help alleviate the bothersome symptoms of upper respiratory tract dryness experienced by voice professionals with debilitating performance anxiety, along with somatic symptoms of anxiety that may impair optimal performance. However, they may also cause serious side effects and can impair performance. Moreover, requiring a drug to perform daily activities of one’s chosen profession is problematic, and the underlying cause of anxiety should be identified. This important topic is reviewed in detail above in the section on performance anxiety.

Antipsychotics

Antipsychotic drugs (also termed neuroleptics) are used in the treatment of schizophrenia and various forms of mania and bipolar disorders, as well as other disorders. Antipsychotic medications include the first-generation medications haloperidol, fluphenazine, perphenazine, and chlorpromazine, among others. To address some of the side effects of these drugs, over the past two decades, newer so-called second-generation or “atypical” antipsychotics have emerged. These include risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, iloperidone, asenapine, and lurasidone. The anti-psychotic clozapine constitutes somewhat of a class of its own.

Antipsychotics are thought to act principally by blocking dopamine receptors in a particular part of the brain, but their action on dopamine receptors in others areas produces some of their most bothersome side effects. Also called extrapyramidal side effects (EPSs), these side effects include short-term effects, such as acute dystonia (involuntary and potentially dangerous muscle contractions), akathisia (a form a motor restlessness), and parkinsonian symptoms (which mimic those of Parkinson disease), and the long-term effect of tardive dyskinesia, an irreversible and potentially severe movement disorder. Important for vocal professionals, tardive dyskinesia and other EPSs often may involve the tongue, perioral, and even laryngeal musculature.

Second-generation antipsychotics appear to be as effective as their predecessors but were touted as having a lower risk of EPS. However, they come with a price of their own, including weight gain, hypercholesterolemia, and the potential of developing diabetes. Large studies in the past decade have questioned some of the assumptions made about the superiority of the second-generation antipsychotic.^87,88 Nevertheless, they often remain first-line treatment in clinical practice because of their presumed milder extrapyramidal side effect profile.

Clozapine (Clozaril) is the only medication that is consistently shown to be superior in efficacy to all other antipsychotics. It also has low likelihood of EPS. However, clozapine is generally reserved for refractory cases due to its low but significant 1% risk of agranulocytosis, a potentially fatal drop in white blood cells. Patients on clozapine need frequent monitoring of their blood counts for this complication.

Because antipsychotics are often effective adjunctive treatments for other psychiatric disorders (eg, obsessive-compulsive disorders, depression with psychotic features, bipolar disorders), it may be useful to discuss other side effects that would affect a voice professional using these medications. The pharmacology of antipsychotic medications is complex and unique to each medication and cannot fully be reviewed here. Suffice it to say that, in addition to blocking dopamine receptors, which can lead to EPS, each drug may cause side effects owing to actions on various other neurotransmitter systems:

• Hypotension from effects on the α-adrenergic system

• Weight gain and sedation due to effects on the histaminergic system

• Anticholinergic side effects such as dry mouth, blurred vision, and constipation

• A minor risk of cardiac arrhythmias, presumably mediated through effects on calcium channels in nerve and heart muscle cells

• Metabolic consequences, such as increased cholesterol or diabetes risk

All antipsychotics carry a small risk of the potentially lethal neuroleptic malignant syndrome, which presents with confusion, muscle rigidity, fever, and autonomic instability. Clozapine carries its particular risk for agranulocytosis and also may cause a troublesome increase in salivation.

Ongoing psychiatric treatment of patients with voice disorders mandates a careful evaluation of current and prior psychoactive drug therapy. In addition, numerous psychoactive substances are used in the medical management of such neurologic conditions as Tourette syndrome (antipsychotics), chronic pain syndromes (carbamazepine), and vertigo (diazepam, clonazepam). The vocal team thus must identify and avoid drug interactions. It is appropriate (with the patient’s consent) to consult with the prescribing physician directly to advocate the use of the psychoactive drug least likely to produce adverse effects on the voice while adequately controlling the psychiatric illness.⁸³

Additional Psychologic Etiologies and Treatments

Rapport with voice team members may allow patients to reveal other psychiatric disorders. Among the most common in arts medicine are eating disorders and substance abuse. Comprehensive discussion of these subjects is beyond the scope of this chapter, but it is important for the health professional to recognize such conditions, not only because of their effects on the voice but also because of their potentially serious general medical and psychiatric implications.

Eating Disorders

Bulimia nervosa and anorexia nervosa both involve disordered eating. Anorexia is a mental disorder that involves aversion to food and great fear of becoming obese, associated with disturbed body image. It afflicts young women most commonly and can be life threatening.⁸⁹ Bulimia involves episodes of rapid consumption of large quantities of food in short periods of time (binge eating) followed by purging using laxatives, diuretics, or self-induced vomiting. It also may be accompanied by vigorous exercise and fasting. Associated feelings of guilt are common, as is depression. It may occur sporadically or be a chronic problem.

Bulimia and binge eating may be more prevalent than is commonly realized. It is estimated to occur in as many as 1.5% to 3.5% of females, particularly adolescents and young adults (including female dancers). Males are also affected, although at lesser rates (0.5%–2%).⁹⁰ Bulimia also may be associated with anorexia nervosa.

Vomiting in bulimia produces signs and symptoms similar to severe chronic reflux as well as thinning of tooth enamel. In addition to posterior laryngitis and pharyngitis, laryngeal findings associated with bulimia include subepithelial vocal fold hemorrhages, superficial telangiectasia of the vocal fold mucosa, and vocal fold scarring. Clinicians must be attentive to the potential for anorexia or bulimia in the maintenance of a desirable body appearance in performers.

There is enormous popular interest in the use of appetite suppressants in weight management. Many myths persist about proper weight management approaches in singers and the value and/or risk of weight loss.

The availability and popularity of appetite suppressant drugs, and mass marketing approaches that made them available in franchised weight loss centers, led many Americans to explore the use of Fen-Phen (phentermine and fenfluramine) and dexfenfluramine HCI in the 1990s. These medications had limited efficacy in changing metabolism and craving, and many patients took these drugs in combinations that were never approved for concomitant use. These drugs were voluntarily withdrawn from the market by their manufacturers in 1997 due to a significant risk of cardiac valve damage and pulmonary hypertension.

Health professionals caring for singers and other performers should be certain to investigate the potential use of these medications, as well as other appetite suppressant or weight control drugs.

Substance Abuse

Alcohol, benzodiazepines, stimulants, cocaine, narcotics, and other drugs are notoriously readily available in the performing arts community and on the streets.^91,92 In patients who demonstrate signs and symptoms of substance abuse, or who admit that these areas of their lives are out of control, these problems should be acknowledged while efficiently arranging treatment for them. The window of opportunity is often remarkably narrow. The physician should establish close ties to excellent treatment facilities, where specialized clinicians can offer confidential outpatient management, with inpatient care available when required for safety.³⁷

Neurogenic Dysphonia

Patients with neurologic disease are likely to experience psychiatric symptoms, especially depression and anxiety. These disorders cause physiologic changes that may exacerbate or mask the underlying neurologic presentation. Metcalfe and colleagues⁹³ cited the incidence of severe depression and/or anxiety in neurologic patients at one-third.

The site of neurologic lesion affects the incidence of depression and anxiety, with lesions of the left cerebral hemisphere, basal ganglia, limbic system, thalamus, and anterior frontal lobe more likely to produce these effects.⁹⁴ The same structures are important in voice, speech, and language production, and so depression and anxiety logically coexist with voice and language disorders resulting from CNS pathology.^94,95

Dystonias and stuttering also are associated with both neurologic and psychogenic etiologies and must be carefully distinguished by the laryngologist before instituting interdisciplinary treatment.⁹⁶

Stress Management

Psychologic stress pervades virtually all professions in today’s fast-moving society. A singer preparing for a series of concerts, a teacher preparing for presentation of lectures, a lawyer anticipating a major trail, a businessperson negotiating an important contract, or a member of any other goal-oriented profession, each must deal with myriad of demands on his or her time and talents. Stress is recognized as a factor in many types of illness and disease. It is estimated that 50% to 70% of all physician visits involve complaints of stress-related illness.⁹⁷

Stress is a psychologic experience that has physiologic consequences. Stress-related problems are important and common among professional voice users. The stress may be physical or psychologic, and it often involves a combination of both. Either may interfere with performance. Stress represents a special problem for singers, because its physiologic manifestations may interfere with the delicate mechanisms of voice production.³⁷

A brief review of some terminology may be useful:

• The term stress is used broadly. Our working definition is emotional, cognitive, and physiologic reactions to psychologic demands and challenges.

• Stress level reflects the degree of stress experienced. Stress is not an all-or-none phenomenon. The psychologic effects of stress range from mild to severely incapacitating.

• Stress response refers to the physiologic reaction of an organism to stress.

• A stressor is an external stimulus or internal thought, perception, image, or emotion that creates stress.⁹⁸

Two other concepts are important in a contemporary discussion of stress: coping and adaptation. Lazarus and Folkman⁹⁹ have defined coping as “the process of managing demands (external or internal) that are appraised as taxing or exceeding the resources of the person.” In the early 1930s, Hans Selye, an endocrinologist, discovered a generalized response to stressors in research animals. He described their responses using the term general adaptation syndrome. Selye (cited in Green and Snellenberger⁹⁸) postulated that the physiology of the test animals was trying to adapt to the challenges of noxious stimuli. The process of adaptation to chronic and severe stressors was harmful over time. There were 3 phases to the observed response: alarm, adaptation, and exhaustion. These phases were named for physiologic responses during a sequence of events. The alarm phase is the characteristic fight-or-flight response. If the stressor continued, the animal appeared to adapt, where the physiologic responses were less extreme, but the animal eventually became more exhausted. In the exhaustion phase, the animal’s adaptation energy was spent, physical symptoms occurred, and some animals died.⁵⁵

Physical Effects of Stress

Stress responses occur in part through the autonomic nervous system.⁹⁸ A stressor triggers particular brain centers, which in turn affect target organs through nerve connections. The brain has 2 primary pathways for the stress response, neuronal and hormonal, and these pathways overlap. The body initiates a stress response through 1 of 3 pathways:

• Sympathetic nervous system efferents that terminate on target organs such as the heart and blood vessels

• Release of epinephrine and norepinephrine from the adrenal medulla

• Release of various other catecholamines⁹⁸

A full description of the various processes involved is beyond the scope of this chapter. However, stress has numerous physical consequences. Through the autonomic nervous system, it may alter oral and vocal fold secretions, heart rate, and gastric acid production. Under acute, anxiety-producing circumstances, such changes are to be expected. When frightened, a normal person’s palms become cold and sweaty, the mouth becomes dry, heart rate increases, his or her pupils change size, and stomach acid secretions may increase. These phenomena are objective signs that may be observed by a physician, and their symptoms may be recognized by the performer as dry mouth and voice fatigue, heart palpitations, and heartburn.

More severe, prolonged stress is also commonly associated with increased muscle tension throughout the body (but particularly in the head and neck), headaches, decreased ability to concentrate, and insomnia. Chronic fatigue is also a common symptom. These physiologic alterations may lead not only to altered vocal quality but also to physical pathology. Increased gastric acid secretion is associated with ulcers, as well as reflux laryngitis and arytenoid irritation. Other gastrointestinal manifestations, such as colitis, irritable bowel syndrome, and dysphagia, are also described.

Chronic stress and tension may cause numerous pain syndromes, although headaches, particularly migraines in vulnerable individuals, are most common. Stress is also associated with more serious physical problems such as myocardial infarction, asthma, and depression of the immune system.^66,98,100

Thus, the constant pressure under which many performers live may be more than an inconvenience. Stress factors should be recognized, and appropriate modifications should be made to ameliorate them.

Stressors in Vocalists

Stressors may be physical or psychologic and often involve a combination of both. Either may interfere with performance.

There are several situations in which physical stress is common and important. Generalized fatigue is seen frequently in hard-working singers, especially in the frantic few weeks preceding major performances. To maintain normal mucosal secretions, a strong immune system to fight infection, and the ability of muscles to recover from heavy use, rest, proper nutrition, and hydration are required. When the body is stressed through deprivation of these essentials, illness (such as upper respiratory infection), voice fatigue, hoarseness, and other vocal dysfunctions may supervene.

Lack of physical conditioning undermines the power source of the voice. A person who becomes short of breath while climbing a flight of stairs hardly has the abdominal and respiratory endurance needed to sustain him or her optimally through the rigors of performance. The stress of attempting to perform under such circumstances often results in voice dysfunction.

Oversinging is another common physical stress. As with running, swimming, or any other athletic activity that depends on sustained, coordinated muscle activity, singing requires conditioning to build up strength and endurance. Rest periods are also essential for muscle recovery. Singers who are accustomed to singing for 1 or 2 hours a day stress their physical voice-producing mechanism severely when they suddenly begin rehearsing for 14 hours daily immediately prior to performance.

Treatment Approaches for Stress

Medical treatment of stress depends on the specific circumstances. When the diagnosis is appropriate but poorly controlled anxiety rather than a physical problem, the physician’s evaluation itself may reassure the patient. Under ordinary circumstances, once the singer’s mind is put to rest regarding the questions of nodules, vocal fold injury, or other serious problems, his or her training usually allows compensation for vocal manifestations of anxiety, especially when the vocal complaint is minor.

Slight alterations in quality or increased vocal fatigue are seen most frequently. These are often associated with lack of sleep, oversinging, and dehydration associated with the stress-producing commitment. The singer or actor should be advised to modify these and to consult his or her voice teacher. The voice teacher should ensure that good vocal technique is being used under performance and rehearsal circumstances.

Frequently, young singers are not trained sufficiently in how and when to “mark.” For example, many singers whistle to rest their voices, not realizing that active vocalization and potentially fatiguing vocal fold contact occur when whistling. Technical proficiency and a plan for voice conservation during rehearsal and performances are essential under these circumstances. A manageable stressful situation may become unmanageable if real physical vocal problems develop.

Several additional modalities may be helpful in selected circumstances. Relative voice rest (using the voice only when necessary) may be important not only to voice conservation but also to psychologic relaxation. Under stressful circumstances, a singer needs as much peace and quiet as possible, not hectic socializing, parties with heavy voice use in noisy environments, and press appearances. The importance of adequate sleep and fluid intake cannot be overemphasized. Local therapy, such as steam inhalation and neck muscle massage, may be helpful in some people and certainly does no harm.

The doctor may be very helpful in alleviating the singer’s exogenous stress by conveying “doctor’s orders” directly to theater management. This will save the singer the discomfort of having to personally confront an authority and violate his or her “show must go on” ethic. A short phone call by the physician can be highly therapeutic.

Management of Chronic Stress

When stress is chronic and incapacitating, more comprehensive measures are required. If psychologic stress manifestations become so severe that they impair performance or necessitate the use of drugs to allow performance, psychotherapy is indicated. The goal of psychotherapeutic approaches to stress management includes changing external and internal stressors, affective and cognitive reactions to stressors, physiologic reactions to stress, and stress behaviors.

A psychoeducational model is customarily used. Initially, the psychotherapist will assist the patient in identifying and evaluating stressor characteristics. A variety of assessment tools are available for this purpose. Interventions designed to increase a sense of efficacy and personal control are designed. Perceived control over the stressor directly affects stress level, and it changes one’s experience of the stressor. Laboratory and human research has determined that a sense of control is one of the most potent elements in the modulation of stress responses.^101–103 Concrete exercises that impose time management are taught and practiced. Patients are urged to identify and expand their network of support as well.

Psychologic intervention requires evaluation of the patient’s cognitive model. Cognitive restructuring exercises are used, as well as classical conditioning tools that patients easily learn and utilize effectively with practice. Cognitive skills include the use of monitored perception, thought, and internal dialogue to regulate emotional and physiologic responses.

A variety of relaxation techniques are available and are ordinarily taught in the course of stress-management treatment. These include progressive relaxation, hypnosis, autogenic training and imagery, and biofeedback training. Underlying all of these approaches is the premise that making conscious normally unconscious processes leads to control and self-efficacy.³⁷

As with all medical conditions, the best treatment for stress in singers is prevention. Awareness of the conditions that lead to stress and its potential adverse effect on voice production often allows the singer to anticipate and avoid these problems. Stress is inevitable in performance and in life. Performers must learn to recognize it, compensate for it when necessary, and incorporate it into their singing as emotion and excitement. Stress should be controlled, not pharmacologically eliminated. Used well, stress should be just one more tool of the singer’s trade.

Reactive Responses

Reaction to illness is the major source of psychiatric disturbance in patients with significant voice dysfunction. Loss of communicative function is an experience of alienation that threatens human self-definition and independence. Catastrophic fears of loss of productivity, economic and social status, and, in professional voice users, creative artistry contribute to rising anxiety. Anxiety is known to worsen existing communication disorders, and the disturbances in memory, concentration, and synaptic transmission secondary to depression may intensify other voice symptoms and interfere with rehabilitation.

The self-concept is an essential construct of Carl Rodger’s theories of counseling.⁴⁵ Rodgers described self-concept as composed of perceptions of the characteristics of the self and the relationships of the self to various aspects of life, as well as the values attached to the perceptions. Rodgers suggested that equilibrium requires that patients’ self-concepts be congruent with their life experiences. It follows, then, that it is not the disability per se that psychologically influences the person but rather the subjective meaning and feelings attached to the disability.

According to Rodgers, the 2 major psychologic defenses that operate to maintain consistent self-concept are denial and distortion.⁴⁵ Families of patients are affected as well. They are often confused about the diagnosis and poorly prepared to support the patient’s coping responses. The resulting stress may negatively influence family dynamics and intensify the patient’s depressive illness.¹⁰⁴

As the voice-injured patient experiences the process of grieving, the psychologist may assume a more prominent role in his or her care. Essentially, the voice-injured patient goes through a grieving process similar to patients who mourn other losses, such as the death of a loved one. In some cases, especially among voice professionals, the patients actually mourn the loss of their self as they perceive it. The psychologist is responsible for facilitating the tasks of mourning and monitoring the individual’s formal mental status for clinically significant changes.^37,44,105

There are a number of models for tracking this process. The most easily understood is that of Worden,¹⁰⁶ as adapted by the author (DCR):

• Initially, the task is to accept the reality of the loss. The need for and distress of this is vestigial during the phase of diagnosis, is held consciously in abeyance during the acute and rehabilitative phases of treatment, but is reinforced with accumulating data measuring vocal function. As the reality becomes undeniable, the mourner must be helped to express the full range of the grieving effect. The rate of accomplishing this is variable and individual. Generally, it will occur in the style with which the person usually copes with crisis and may be florid or tightly constricted. All responses must be invited and normalized. The psychologist facilitates the process and stays particularly attuned to unacceptable, split-off responses or the failure to move through any particular response.

• As attempts to deny the loss take place and fail, the mourner gradually encounters the next task: beginning to live and cope in a world in which the lost object is absent. This is the psychoanalytic process of decathexis, which requires the withdrawal of life energies from the other and the reinvesting of them in the self. For some professional voice users, this may be a temporary state as they make adjustments required by their rehabilitation demands. In other cases, the need for change will be lasting: change in fach (voice classification), change in repertoire, need for amplification, altered performance schedule, or, occasionally, change in career.^37,44,105

• As the patient so injured seeks to heal his or her life, another task looms. Known as recathexis, it involves reinvesting life energies in other relationships, interests, talents, and life goals. The individual is assisted in redefining and revaluing the self as apart from the voice. The voice is then seen as the product of the self, rather than an equivalent to the self. For many performers, this is painfully difficult.^{37,44,105,106}

Rosen and Sataloff⁹ have described in detail research applying the various theoretical models of grief resolution to the perception of vocal injury in professional voice users.

Psychologic Responses to Surgery

When vocal fold surgery is indicated, many individuals will demonstrate hospital-related phobias or self-destructive responses to pain. Adamson et al¹⁰⁷ describe the importance of understanding how the patient’s occupational identity will be affected by surgical intervention. Vocal fold surgery affects the major mode of communication that all human beings utilize, and the impact is extraordinarily anxiety producing in professional voice users. Even temporary periods of absolute voice restriction may induce feelings of insecurity, helplessness, and dissociation from the verbal world. Carpenter¹⁰⁸ details the value of an early therapy session to focus on the fears, fantasies, misconceptions, and regression that frequently accompany a decision to undergo surgery.

A proper surgical discussion highlights vocal fold surgery as elective. The patient chooses surgery as the only remaining means to regaining the previously normal voice or to attain a different but desirable voice. Responsible care includes a thorough preoperative and written discussion of the limits and complications of surgery, with recognition by the surgeon that anxiety affects both understanding and retention of information about undesirable outcomes. Personality psychopathology or unrealistic expectations of the impact of surgery on their lives are elements for which surgical candidates can be screened.^48,109,110 Recognizing such problems preoperatively allows preoperative counseling and obviates many postoperative difficulties.

Although a thorough discussion is outside the scope of this chapter, surgically treated voice patients include those undergoing laryngectomy, with or without a voice prosthesis. The laryngectomized individual must make major psychologic and social adjustments. These include not only those adjustments related to a diagnosis of cancer but also to those of a sudden disability: loss of voice.

With the improvement in prognosis, research has begun to focus on the individual’s quality of life after the laryngectomy. There is wide variability in the quality of preoperative and postoperative psychologic support reported by patients during each phase of care. Special psychologic issues in professional voice users diagnosed with laryngeal cancer are discussed in detail in other works.³⁷ Providing this support is a crucial role for the voice team’s psychologist.^111–113

Voice Team’s Roles in Treating Psychogenic Problems

The Psychologic Professional

Both psychology and psychiatry specialize in attending to emotional needs and problems. Psychiatrists, as physicians, focus on the neurological and biological causes and treatment of psychopathology. Psychiatrists also may be trained to provide psychotherapy. Psychologists have advanced graduate training in psychologic function and therapy. They both concern themselves with cognitive processes, such as thinking, behavior, and memory; the experiencing and expression of emotions; significant inner conflict; characteristic modes of defense in coping with stress; and personality style and perception of self and others, including their expression in interpersonal behavior.

Other mental health professionals, such as social workers, also provide psychotherapy to performers. In the authors’ practice, clinical psychologists serve as members of the voice team. They work directly with some patients and offer consultation to the physician and other professionals.³⁷

In our center, patient assessment is done throughout the physician’s history taking and physical examinations, as well as in a formal psychiatric interview when appropriate. Personality assessment, screening for or evaluating known psychopathology, and assessment of potential surgical candidates are performed. Occasionally, psychometric instruments are added to the diagnostic interview. Confidentiality of content is extended to the treatment team to maximize interdisciplinary care. Because of their special interest in voicing parameters, the voice team psychologists are especially attuned to the therapeutic use of their own voices for intensifying rapport and pacing/leading the patient’s emotional state during interventions.^114–118

Psychotherapeutic treatment is offered on a short-term, diagnosis-related basis. Treatment is designed to identify and alleviate emotional distress and to increase the individual’s resources for adaptive functioning. Individual psychotherapeutic approaches include brief insight-oriented therapies, cognitive-behavioral techniques, Gestalt interventions, stress-management skill building, and clinical hypnosis.

After any indicated acute intervention is provided, and in patients whose coping repertoire is clearly adequate to the stressors, a psychoeducational model is used. The therapy session focuses on a prospective discussion of personal, inherent life stressors and predictable illnesses. Stress management skills are taught, and audiotapes are provided that offer portable skill building. Supplemental sessions may be scheduled by mutual decision during appointments at the center for medical examinations and speech or singing voice therapy.

A group therapy model, facilitated by the psychologist, has also been used to provide a forum for discussion of patient responses during the various phases of treatment. Participants benefit from the perspective and progress of other patients, the opportunity to decrease their experience of isolation, and the sharing of resources.

Long-term psychodynamic psychotherapy, chronic psychiatric care, and psychopharmacologic management are provided through referral to consultant mental health professionals with special interest and insight in voice-related psychologic problems. The voice team’s psychologists also serve in a liaison role when patients already in treatment come to our center for voice care.

The Speech-Language Pathologist

Speech-language pathology has its roots in psychology, as the original members of the field came primarily from psychology backgrounds. Early interest in the psychologic aspects of voicing are evidenced in texts such as The Voice of Neurosis.¹¹⁹ Luchsinger and Arnold¹²⁰ present an excellent review of the early literature in their text, Voice, Speech, Language.

At the present time, speech-language pathologists (SLPs) need to be familiar with models of treatment from the psychologic tradition, the medical tradition, and the educational tradition. In defining the SLP’s role in managing functional voice problems, it must be made clear that the SLP does not work in isolation but as a part of a team, which includes at a minimum a laryngologist and the SLP. Singing or acting instructors, stress specialists, psychologists, neurologists, and psychiatrists must be readily available and cognizant of the special needs to voice patients.

The SLP’s role in treating voice-disordered patients is to normalize the patient’s speaking and communication behavior. In this sense, many of the activities of SLPs with voice-disordered patients are “psychologic.” This section does not intend to present a full description of the SLP’s total function but instead focuses on areas in which the SLP must deal with issues not directly related to the physical vocal mechanism. Activities engaged in by the SLP with the patient can help to set the groundwork for discussion of psychologic issues. A more detailed description has been published elsewhere.¹²¹

Preparation for Treatment

The SLP must be aware of, and be able to interpret, the findings of the laryngologist, including strobovideolaryngoscopy. Particular attention should be paid to findings demonstrating muscle tension or lack of glottic closure not associated with organic or physical changes. The perceptions of the laryngologist regarding organic and functional aspects of the patient need to be known.

A case history is taken, reviewing and amplifying the case history reported by the laryngologist (Table 7–3). Subjective and objective measures of the patient’s vocal mechanism and communication skills need to be obtained, as outlined in Table 7–4. From these, the SLP should be able to develop a plan of behavioral changes.

During the patient interview, taking the case history provides the SLP with an ample sample of the patient’s voice use, including his or her communication style and verbosity. It is important to note how the patient’s voice changes when talking about certain topics and to note evidence of improvement or fatigue as the interview proceeds. It provides data on what speaking activities are most important to the patient and which may need to be addressed initially in therapy. It provides information on the patient’s willingness to talk about stressful issues or needs beyond direct focus on voicing and speech skills, which may be important regarding referral to other specialists for stress and emotional or physical health.

The physical assessment (see Table 7–4) provides the SLP with objective support for what the clinician has heard and information about how the patient is producing the voice. Because any behavioral change instituted during therapy is based on eradicating symptoms of maladaptive voice or communication, the SLP should list and evaluate confirmed symptoms at this stage in order to develop an overall therapeutic plan. The focus should be on identifying the underlying behavior or behaviors responsible for maintaining the current voice in order to address these underlying behaviors first, which reduces the length of therapy and should predict improvement of voicing.

Therapeutic Stage

Information giving is essential at the beginning of therapy and throughout the course of therapy. Patients need to know the reason for the activities in which they are engaging and why these activities are important in changing their current voice problem. Without a thorough understanding of the reasons for changing behavior, the probabilities of behavioral change are poor. The patient needs to know that a voice disorder is usually multifactorial and is maintained by a combination of physical changes (if present), communication demands on the voice, the patient’s skills in producing speech, and the patient’s attempts to compensate for vocal changes.

Initially, the goal in therapy is to manage communicative demands and improve the patient’s ability to produce more normal voice. Reassessment of the need for medical and/or surgical interventions for physical changes is planned with the patient. The patient is reassured that the goal of therapy is not to change personality or limit communication opportunities but to return him or her at least to the level of communication enjoyed prior to the onset of the voice problem.

Breathing Patterns

Information should be conveyed regarding the patient’s current breathing pattern. It may be insufficient for the demands placed on the patient’s voice or contribute to increased tension in the vocal mechanism.

Abdominal breathing is the natural and preferred method of breathing by the body. People are engaged in abdominal breathing when they are relaxed and when they are sleeping. Patients can be asked to observe or recall the breathing patterns of their pets, of babies engaging in comfort sounds vs painful or paroxysmal crying, or of significant others in repose. Their observations can be discussed and used as confirmation of the primacy of abdominal breathing. Predominantly clavicular or thoracic breathing is usually the product of stress, societal preference toward tight clothing, and/or demands by parents, teachers, and society in maintaining a tight tucked-in stomach. All of these factors lead to a reduction of abdominal release during inhalation that leads to restriction in diaphragmatic downward motion and maximal inflation of the lungs.

Stay updated, free articles. Join our Telegram channel

Join