Chronic Dissociation Presenting as Dysphonia Plica Ventricularis: An Atypical Presentation.

Dr Pragya Semwal* , Dr Shobit Garg

 

Department Of Psychiatry, Shri Guru Ram Rai Institute Of Medical & Health Sciences, and Associated Shri Mahant Indiresh Hospital.

 

 ABSTRACT:-

Dissociation is a psychobiological process, possibly related    to  the  mammalian   freezing   response   to   overwhelming threat where flight or fight is impossible. Dysphonia Plica Ventricularis (DPV) is a condition in which phonation is done by using false  vocal  cord  vibration    rather than true vocal cord. The etiology of DPV is diverse but psychological and psychiatric causes are some of the common etiological contributors for development of DPV. One of the rarest presentations of dissociation is psychogenic dysphonia. The term “psychogenic” indicates clearly that the primary etiology is of a psychological nature, but it does not rule out that muscle tension may play a part in the presentation of the dysphonia.  We here present a case of 48 yr old housewife having Chronic Dissociation Presenting as Dysphonia Plica Ventricularis.                       

Keywords: Dysphonia Plica Ventricularis, Chronic Dissociation, Dissociative Motor Disorder. 

 

INTRODCUTION:-

Dissociation is a psychobiological process, possibly related to the mammalian freezing response to overwhelming threat where flight or fight is impossible [1]. World Health Organization defines dissociation disorders as partial or complete loss of integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements [2]. One of the rarest presentations of dissociation is psychogenic dysphonia. The term “psychogenic” indicates clearly that the primary etiology is of a psychological nature, but it does not rule out that muscle tension may play a part in the presentation of the dysphonia.  Extrinsic and intrinsic laryngeal muscles are exquisitely sensitive to emotional stress [3]. Ventricular dysphonia is characterized by a typical rough, low-pitched voice quality resulting from false vocal fold vibration [4]. Despite of high prevalence of dissociation; 18.3 % in the community   it is diagnosed in chronic states because of dilemma in diagnosis of patients presenting with rare phenotypes.  

CASE REPORT:-

A 48-year-old housewife with a BMI of   25.6 living in an extended family with nil contributory family, past history was not responding to empirical treatment of oral antibiotics, analgesics, voice therapy for “Dysphonia Plica Ventricularis” diagnosed on endoscopy after undergoing thorough Blood Investigation and Neuroimaging.Her endoscopy reports showed B/L edematous arytenoids. Bilateral congestion in ventricular bands with cyst in left aryepiglottic fold. On phonation adduction of ventricular bands were present. (Fig 1). 

 

 Figure 1: Congestion and Hypertrophied Aryepiglottic folds. Note Bilateral congestion in ventricular bands with cyst in left aryepiglottic fold.

Patient family first sought Psychiatry consultation at SMIH after multidisciplinary voice clinic’s for complaints of Change in her voice for 6 weeks and Difficult to arouse her from sleep. Patient history of complaints were insidious in onset, continuous and deteriorating precipitated with verbal arguments with her Son. On general examination patient had mild pallor. On mental status examination patient had poor hygiene, her speech was low in intensity with hoarseness in quality. Patient affect was depressed and her thought content was suggestive of her preoccupation with symptoms and worry about her son’s careless attitude. Patient had an impaired personal judgment with grade 3 Insight. Following the provisional diagnosis of Dissociate Disorder; Dissociative Motor Disorder; Psychogenic Dysphonia; presenting as Dysphonia Plica Ventricularis patient was given multiple psychotherapy session of Cognitive Behavioral and Supportive Therapies. Her presumptive stressful life event questionnaire predicted her recent conflict with family member. Pharmacological interventions were daily steam inhalation along with benzodiazepines. Patient showed improvement in her complaints with first intermittent recover in her dysphonia and later complete recovery in follow ups.

DISCUSSION:

Human Voice production involves the synchronization of optimal glottis positioning with the control of the airflow from lungs to the oropharynx. Factors influencing aerodynamic configuration or vibratory property of glottis result in dysphonia [5]. In the absence of anatomic and neurologic factors a functional voice disorder should be suspected. Altered laryngeal muscle tension is believed to result in altered laryngeal performance despite of normal anatomy [3]. In psychodynamic terms, dissociation is a defense to sequester memories of overwhelming experiences and their attendant intolerable affects, cognition, and object relational schemas [1]. The onset and termination of dissociative states are often reported as being sudden but chronic states, particularly paralysis and anesthesia develop gradually [2]. Chronic Dissociation though a well-known entity with such high prevalence could present with diagnostic dilemma due to its atypical presentation as in our case.

In our case even though the patient underwent multiple investigation’s and treatment for 6 weeks did not respond.  Her delay in the presentation to the OPD with ongoing stressor not properly addressed led to chronic nature of her Dissociation. This case is interesting because of its atypical phenotype presentation of Dysphonia Plica Ventricularis in a patient suffering from Chronic Dissociation and thereafter fast resolution of symptoms with psychotherapy with earlier non response to pharmacotherapy. 

 

 

 REFERENCES:

1. Loewenstein  .R, Frewen P.       et al.  Dissociative    Disorder. In Sadock  BJ,      Sadock  VA, Ruiz  P,   editors.   Comprehensive   Textbook         of        Psychiatry.9th  ed.Philadelphia:Wolters Kluwer Health/Lippincott Williams & Wilkins,2009.p1866- 1952.

2.  World Health Organization. International statistical classification of mental and behavioral disorder: Diagnostic Criteria for research. (10th revision).       Geneva . World health Organisation;1992.

3.  Andersson K, et. al. Etiology and treatment of psychogenic voice disorders: results of a follow-up study of thirty patients. J Voice 1998; 12: 96-106.

4.  Chevlaier J. Dysphonia Plicae Ventricularis. Arch Otolaryngol.2017; 21(2): 157-167.

5.   Garg k.(4) In B. D Chaurasia’s Human Anatomy.4 TH edition. New Delhi.CBS Publisher ;2004.p 250-1.

 

Cite This Article : Dr Pragya Semwal, Dr Shobit Garg Chronic Dissociation Presenting as Dysphonia Plica Ventricularis: An Atypical Presentation. Int. j. med. case reports Vol 6 Issue 3 Jul-Sep 2020  1-3. 

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