10.3 The dystonic syndromes

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Equally bizarre, but less malicious are compulsive movements of facial muscles and/or eyelids (known as tics and blepharospasm), of the neck (torticollis), and of the laryngeal closing mechanism during speech (spastic dysphonia or voice stuttering). Although considered as an organic affliction with unknown substrate by many neurologists and laryngologists, more and more reports appear of cures by reeducational training. Behaviour therapy and cognitive therapy, especially when applied in an early stage of development of the disorder, have resulted in a complete disappearance of the dysfunction.

Functional pathology is a promising approach for dystonic syndromes and probably explains a part of the dystonic syndromes. When driving a car, most of us have experienced a ticklish feeling on the scalp, the face or the neck, caused by a moment of stress, e.g. after a tense moment at a road crossing. This is what tic-patients have reported about how the symptom began: when they were tense or annoyed, a pricking sensation would be felt in the cheek or brow. A quick contraction of the muscles of that part of the face would make an end to it. The muscle twitch had soon become an automatism to chase the skin sensation. Later, the twitch had become a familiar part of themselves, an indispensable companion, a distraction during annoying moments. As happens more often in life, a companion may become obtrusive. Even with the help of a therapist one may not succeed to free oneself. This is true also of torticollis. When the behaviour has freshly shot up it can, like a green sprout, be easily redressed. When it has been allowed to become a fully grown automatism, hardened into wood, it is inaccessible for change. The art of healing therefore begins with detecting the very first signs that announce distress and dysfunction.

Early detection of spastic dysphonia is an art mastered by few. Dystonia of the vocal apparatus announces itself by minute symptoms. They come and go, much like the symptoms of multiple sclerosis, with which the disorder has been confused in the past. A slight tickle in the throat giving rise to a dry cough, an unexpected interruption of the voice in the middle of a word are alarming enough to consult a doctor. Since most doctors have heard of spastic dysphonia but have no profound understanding of it, they will do the inappropriate thing and refer the patient to a laryngologist or a voice clinic. Many voice specialists are fond of gadgets, and the odds are that our spastic dysphonia patient will be subjected to videolaryngosopy, voice recording, analysis of vocal acoustics, electromyography of the laryngeal muscles, tests of respiratory function, all of which tend to provoke more ticklish sensations in the throat and to increase the patient's worries. Inapt attempts at treatment follow, medication and respiratory and voice training. The voice becomes progressively worse: the interruptions last longer and end in explosive bellowing sounds, alternating with normally spoken phrases. The loss of control over one's voice upsets these patients to a degree that it worsens their condition. They are now in a stage that they cannot be treated by reeducation. The usual procedure is then to inject botulinum toxin in the vocal muscles to prevent them to contract during the speech effort. Since the artificial paralysis lasts only a limited time, the procedure is repeated every three months.

In an appropriate management of incipient spastic dysphonia the damaging diagnostic procedures just described are omitted. The seasoned doctor or voice clinician will recognise the minute symptoms as being caused by incipient spastic dysphonia. Moreover he/she will notice small signs of a mental depression, a subdued anger, a smouldering discontent. These are the important signs to follow through. Even if the clinician recognises this, it requires in addition a lot of sensitivity and tact not to sever the thin line of communication that will eventually guide the patient to the solution of his brewing dilemma. The somatic signs (voice interruptions, wavering voice, burning throat) point to inhibited expression of strong emotions. The voice interruptions are a bizarre defence against an uncontrolled outburst of feelings such as the patient would not allow himself. A good therapist will walk the thin tight rope to reach the pent up feelings and help the patient out of his quandary. During therapy the patient will be lifted to his feet from were he can look at the conflict that has caused the turmoil and can work out a solution.

The personality that is inclined to get tangled up in functional disorder has been described as rigid and, when deeply touched by conflict, lacking flexible defence and adaptation.

10.4 Stuttering.