This vocal impairment results from vocal technique issues that start for a variety of reasons. I call this category nonorganic and place it in the behavioral hoarseness category because the mucosa is normal, the muscles are normal, all the structures are normal. The pattern of use of the vocal cords is the problem. This is the category where terms are most variable in my profession.
I find two subdivisions helpful. The first type of nonorganic patient is typically a singer, usually young, who complains they cannot sing as well as they used to. They may feel a lot of tension or discomfort. The second type of patient is one where there is some secondary gain perpetuating a voice problem that otherwise would resolve.
◆ Muscle Tension Dysphonia: Technique
Maria Cantata’s voice starts cutting out as she ascends the scale — not from nodes, but from her own PCA muscle pulling the cords apart at the very moment her LCA brings them together. A study in competing muscles and learned tension.
◆ Nonorganic Dysphonia: Secondary Gain
Andrew Smith lost his voice three years ago and has been on steroids, antibiotics, and anti-reflux drugs ever since. His vocal cords are structurally normal. The driving force is secondary gain — subtle, inadvertent, and recoverable.
◆ Nonorganic Dyspnea
Julie Soprano arrives in the waiting room breathing so loudly you want to call an ambulance. She has been in the ICU for two weeks for “asthma.” But she coughs just fine — and that single inconsistency changes everything.
◆ Malingering
When the patient has been shown their own normal voice on video, the inconsistencies have been pointed out, and the problem still persists — the secondary gain has become obvious. Escalating treatment for a nonorganic condition can produce real organic harm.
◆ Caution
Before the 1980s, patients with spasmodic dysphonia were sent to psychiatrists and uniformly failed to improve. A diagnosis of nonorganicity is a diagnosis of careful inclusion — not a label for patients who are puzzling or difficult.