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His voice came out "strangled." "I can barely talk," Bill says of his voice. "It began right after I yelled at a baseball game. I was hoarse and I noticed my voice just wasn't coming out right anymore. I had to push and force my voice out in order to talk. Then it got harder and harder to get the sound out and I pushed more until I was out of sound. My face and my neck tightened up and my body was very tense. Still the voice wasn't coming out right. It sounded like I was strangling myself when I talked."

Years ago, in 1871, a German scholar, L. Traube, described the "strangled voice" and in 1875 Viennese laryngologist J. Schnitzler, M.D., named the condition Spastic Dysphonia. Spastic dysphonia describes a voice that has abrupt, uncontrolled changes in pitch, skips and breaks in the voice, temporary loss of voice during speech, and tone change from a clear sound to a choked, hoarse, and croaked sound.

The individual with this type of voice feels as though he is being strangled, and his voice sounds as though someone is choking him as he speaks. It is like a car in the wrong gear; the voice is bumpy, erratic, and jerky. This voice has a "vocal cramp" or a cramp of the voice muscles, which are all of the muscles used in projecting vocal sounds from the mid-section (or stomach) to the throat. In this type of disorder, one minute the voice is there and the next minute it isn't. As Bill says, "It drives me crazy I never know if my voice is going to come out. I never know if I can talk or not."

What causes this type of voice? Over the years, some doctors have written that emotional and psychological conditions or trauma have created spastic dysphonia. Still others believe that a problem or disorder in the nervous system is a contributing factor of the condition.

Our clinical experience with individuals who have spastic dysphonia has shown that their problem may start in one of three ways. The first is one that develops slowly, and gradually due to years of misusing the speaking voice. (This is an early or beginning form of spastic dysphonia.) The second way is similar to the first in that it involves misuse of the speaking voice-or "beginning spastic dysphonia" -which becomes established spastic dysphonia as a result of psychological or physical trauma, such as an illness, a death in the family a hormone problem, or a cold or upper respiratory infection. The third way is either beginning spastic dysphonia or established spastic dysphonia brought on suddenly by a traumatic incident, such as an accident, a death, a divorce, severe illness, or even an abrupt voice break.

What is misuse and abuse of the speaking voice which can lead to spastic dysphonia? The pitch that is used may be either too high or too low, which places a strain on the voice. The tone focus or sound of the voice is in the lower throat, thus squeezing and tightening the muscles of the neck, which in turn places severe tension on the voice.

Breathing for speech is from the upper chest, which again places tension on the lower neck. Incorrect breathing patterns may be used, such as: (1) reversed breathing in which the stomach goes in (instead of out) when the individual breathes in; (2) releasing the breath before speaking and attempting to speak with insufficient air in the lungs; or (3) taking in too much air which bloats and tenses the body. Individuals may abuse the voice continually talking in noisy situations, such as around machinery, in buses or cars, at parties, at sports events, over the sound of television, record players, or radios. This vocal abuse is intensified when the voice is misused in pitch, tone focus, or breath support.

Other factors that can cause vocal misuse and abuse and contribute to spastic dysphonia are an inappropriate vocal image and a wrong vocal identity. A vocal image is the sound or type of voice which appeals to you and which you try to use, as well as a sound of voice which you do not like and try to avoid using. The vocal image creates the vocal identity or the way you want to sound.

For example, if Philip, who has a natural tenor voice, thinks that a bass voice sounds more authoritarian and masculine, he tries to project a wrong vocal image. If he uses the phony bass voice, he is misusing his natural voice, thereby establishing a wrong vocal identity. Sue's natural voice would sound something like her mother's voice, which she does not like. Instead of using her normally clear, resonant voice, Sue elects to talk with a throaty, sultry tone and a low pitch.

These voices are not right for either Philip nor Sue. In fact, both tell their friends and associates about the trouble they are having with their voices. Philip often has bouts of laryngitis and is frequently hoarse. (Hoarseness may be a sign of a serious medical problem and should be checked by a physician.) Sue has difficulty being heard and feels extremely tired after talking for a while.

Many people misuse their voices but do not experience the strangled voice. For one reason or another, they stop short of this condition. They may get growths on their vocal folds, such as polyps, nodules, or contact ulcers, which is a warning that they are misusing the speaking voice. Some individuals may have growths on the vocal folds first, and then develop the strangled voice or spastic dysphonia.

Most people who develop spastic dysphonia have misused their voices for years. Vocal misuse, together with a lingering severe cold or some emotional problem, may be the causal factors that lead to the strangled voice. With Philip, the misuse and a lingering cold resulted in a forced, guttural voice which eventuated into spastic dysphonia. In Sue's case, a sudden divorce after years of what she thought was a happy marriage catapulted the vocal misuse into spastic dysphonia. Sue became depressed, which caused her to use a lower pitch of voice with a muffled throaty tone. To be heard, Sue forced the voice from the lower throat, squeezing the neck muscles, creating tension and ultimately spastic dysphonia.

What are the effects of spastic dysphonia on the speaker and on the listener? Listeners become embarrassed and self-conscious as well as irritated and tense from trying to listen to and understand the strangled voice. People who have the strangled voice are terribly self-conscious about the lack of carrying power, the lack of ease, flexibility, and clarity in their voices, and the noticeable negative effect the voice is having on the listeners. Speaking is such a strain and an effort, the speaker with spastic dysphonia quickly becomes fatigued mentally and physically. People with this problem may well undergo a personality change, becoming withdrawn and quiet, tending to avoid situations where they have to communicate. They may also become depressed.

Since speech is 80 percent of communication, it is not difficult to understand the social and financial impact on the person suffering from the strangled voice. Many individuals with spastic dysphonia have indicated that they are no longer the easy, outgoing, sociable, and assured people they once were.

What do you do if you have spastic dysphonia? Up to about 10 years ago, there was basically no effective treatment. Now, depending upon the severity of the condition, there is a good -to-excellent chance of recovery by means of direct vocal rehabilitation, surgery along or surgery followed by direct vocal rehabilitation. (In my opinion, surgery should be used only as a last resort, and should usually be followed by vocal rehabilitation.)

What is direct vocal rehabilitation? This is the technique which I have developed over the past 20 years in working with about 4,000 patients having various types of voice disorders. Direct vocal rehabilitation is the training of an individual's voice in the areas of pitch, tone focus, quality breath support, volume, and Tate to eliminate vocal misuse and abuse. It also involves establishing a new vocal, image and a new vocal identity through vocal psychotherapy. Techniques used in this program indude biofeedback as well as holistic and manipulative body techniques. Although vocal rehabilitation has proven successful in many cases of spastic dysphonia, unfortunately vocal rehabilitation is unknown as an essential approach in effecting recovery from the strangled voice. Another unfortunate aspect is that the condition of spastic dysphonia often goes uncorrected. Because of the lack of an accurate diagnosis or because of a misdiagnosis, treament ranges from irrelevant, to pointless; some treatment, in retrospect, is humorous, but sad.

Let's discuss some actual cases of patients who have had spastic dysphonia and who have recovered through direct vocal rehabilitation. (The names have been changed, but the people are real.)

Fred, a 40-year-old executive, was developing spastic dysphonia but was treated for sinusitis by his ear-nose-throat doctor. Fred was given strong medication to contain the sinusitis condition. Over the period of one year, Fred's voice went from beginning spastic dysphonia to established spastic dysphonia. Finally, a voice patient of mine who encountered Fred, suggested he come in for a voice evaluation. Fred said that he had pleaded with his ear-nose-throat doctor for help on his speaking voice, but the physician declined to refer him to anyone since he didn't believe in vocal rehabilitation. Because of his difficulty in talking, Fred was having problems with his job and at home. Today, through vocal rehabilitation, Fred can talk again.

Going from a troubled voice to a strangled voice occurred in Andrew's situation. A well-known lecturer in political science, Andrew (age- 36) developed a lingering cold that soon made his voice hoarse. He tried to speak through the hoarseness, making the voice responsive only to more volume and forceful voice production. Andrew was given a number of different medications by his physician. The cold disappeared, but the voice problem remained. The voice was strangled, and Andrew's efforts to speak resulted in extreme tension and pressure in his face and body He tried many approaches to help restore his voice. Tongue exercises improved his tongue flexibility and mobility, but "They didn't do anything for my voice," he said. He went from one doctor to another. "Chew a golf ball," wrote one physician. Andrew did. He broke a tooth doing it. A knowledgeable and eminent ear-nose-throat doctoz referred Andrew for vocal rehabilitation. Within one year, Andrew's voice was restored, and he returned to his job with a normal voice. A follow-up of Andrew's recovery was made some four years later, and Andrew remained, in his words, "fully recovered."

Jennifer, a 30-year-old school teacher, developed the strangled voice about five years ago from straining her voice in the classroom and from emotional problems. She could not control her voice and was terrified by the abrupt changes in pitch and tone. Within six months of therapy, she overcame her condition and remains recovered today.

Joe, a sports promotor, age 35, underwent a surgery for the removal of nodules from the vocal cords and developed the strangled voice after he tried to speak with the voice he had after surgery. A year later, Joe had a normal voice again, the strangled voice having yielded to direct vocal rehabilitation.

Ed, a 32-year-old inspector in a noisy factory, found that his voice was "strangled." He underwent a program of voice therapy for approximately one year, and today he speaks clearly and well.

James, a 28-year-old, was working as a meat packer in an extremely cold refrigerated meat room much of the time. James noticed that his speaking voice was hoarse and that he was having difficulty talking, but his physician could not diagnose the problem. James heard me describing vocal rehabilitation on a national television talk show and came in for a voice evaluation. Within six months, we had the strangled voice under control and an efficient and clear voice returned.

Another patient, a nationally known television personality, developed spastic dysphonia following a surgical procedure. He regained an efficient voice within one year of therapy.

For the first time ever, in 1973, I presented actual patients who had had spastic dysphonia and who had or who were presently undergoing vocal rehabilitation, to a state meeting of the California Speech and Hearing Association. In 1974 I presented tape recordings of recovered spastic dysphonia patients before and after therapy at the national meeting of the American Speech and Hearing Association. Information and education about the "strangled" voice or spastic dysphonia is essential in order to take the mystery out of it, to make people aware of this problem, and to indicate that there is recovery for it through direct vocal rehabilitation.

In summary spastic dysphonia or strangled voice is a condition that can be treated successfully by direct vocal rehabilitation in a relatively short period of time, usually six months to one year. The only difficulty is in the accurate recognition of this condition; it often goes unrecognized and therefore goes untreated or is treated improperly. Follow-up studies of individuals who have completed vocal rehabilitation indicate the success of this type of treatment.