If you have experienced a voice disorder, you will know how it can greatly impact upon your work and social life, causing both worry and frustration. Symptoms range from whispering to normal-sounding voices with pain and fatigue. An ENT Surgeon might diagnose a disease or abnormality on the vocal folds to explain the symptoms, but often no physical damage is found, and minor changes in voice production don’t account for severe voice loss.

It is astonishing to find out that there are no physical issues when symptoms are so acute. It can be a challenge to rationalise that the issue could in fact be stress related. 

What Is Stress?

When we refer to stress, we tend to think of major life events like serious illness, family issues, divorce or even death. Even positive events such as moving house, having a baby or getting married are also stressful. However, few of us would see daily routines as problematic. However, if we cast our minds back to the past few years there may have been times when life has gotten the best of us which can leave us feeling downtrodden. During these periods, unrecognised stress can impact our health and can lead to physical symptoms, including voice disorders,  

Stress triggers both physical and emotional reactions, such as  irritability, anxiety, depression, muscle tension, headaches, sleep difficulties, and digestive problems. At times, these symptoms are disregarded until they become severe or persistent.

What is the impact of stress on the voice?

The vocal tract, which includes the larynx and pharynx, features a complex nerve supply from both the Central Nervous System (CNS) and the Autonomic Nervous System (ANS). 

The ANS controls our internal organs and is organised into the parasympathetic, sympathetic and enteric system.  The parasympathetic system is our ‘rest and digest’ system which slows our heart rate, reduces blood pressure and increases digestion when relaxed. 

The sympathetic system prepares our body for action, it increases our heart rate, blood pressures and reduces digestion and the production of saliva and mucus. 

The enteric system is a network of nerves that serve the intestines, pancreas and gallbladder. 

The ANS’s connection with the brain’s emotional centre explains why we can recognise emotional states through slight changes in facial expression, voice and body posture. 

Emotions and their effects

Emotions are experienced both mentally and physically. If we take the example of excitement and fear, these emotions can cause muscular tension, tremors and palpitations, yet they are interpreted differently. Positive emotions are motivating and energising forces, whilst negative emotions impede our performance and make us feel distressed. Stress can be set off by extrinsic forces such as events or intrinsic forces such as inner thoughts and behaviours.  

Physical Signs of Distress

Stress can present physically as:

• Gut issues (acid reflux, IBS)
• Skin problems (eczema, psoriasis)
• Muscle pain (including laryngeal pain)
• Breathing difficulties
• Hoarseness or complete voice loss

Voice loss caused by emotional distress is referred to as a ‘psychogenic’ voice disorder. Sudden voice loss without any obvious reason, lingering hoarseness, or  excessive laryngeal pain are signs of psychogenic dysphonia.

Diagnosis

Psychogenic dysphonia voice disorders can affect adults and children alike. If you or your child experiences hoarseness or voice loss, the important thing to do is to exclude physical causes. It is important to see your GP, who may refer you to an ENT surgeon or a voice clinic where you would be assessed by a specialised Speech and Language Therapist (SLT) 

What are the treatment options?

• Speech and Language Therapy (SLT): SLTs use various vocal techniques and exercises to help to recover the voice and tackle any latent emotional causes. Many SLTs are also trained in counselling.
• Counselling/Psychotherapy: Professional help may assist in addressing emotional aspects that are causing the symptoms.  Research has shown that Cognitive Behavioral Therapy (CBT) has been successful for voice disorders.
• Manual Therapy/Laryngeal Massage: This type of treatment aids in the reduction of muscle tension in and around the larynx. This can be performed by trained SLTs, physiotherapists, or osteopaths.
• Medication: In circumstances where depression or other psychological disorders are present and do not respond to therapy, medication may be an option. 

If you’re experiencing a voice disorder that is stress related, there is no reason to be embarrassed. Voice disorders, even when triggered by stress, are normal and treatable. Think of it as your body’s way of signalling to you that there is a problem that needs to be addressed.  It is important to know that help is available to you and it is beneficial for you to seek help if you develop a voice related disorder. Psychogenic voice disorders often resolve quickly and completely with appropriate treatment.