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97 Cards in this Set

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Describe in detail 5 charactersitics of physchogenic disorders?
1. voice disorders attributed to psychological state are said to be psychogenic in orign.
2. "conversion disorder" a psychiatric condtion in which emotional distress or unconscious conflict are expressed throufh physical symptoms
3. conversion disorders are stigmatized- healthcare providers or loved ones may have told loved ones "its all in your head" research on connection between mind and body should reduce stigma because the symptoms are real and cause distress.
4. symptom onset is usually acute and associated with a stressful experience
5. symptom characteristics include loss of function can unconsciously symbolize or relate to underlying conflict about a single or ongoing stressful experience.
Define 5 characteristics of Somatoform disorders
1. presence of physical symptoms not fully explained by a general medical condition, by the direct effects of a substance or by another mental disorder. (it would not be explained by panic disorder, anxiety disorder, psychosis, or neurologic disease that produces cog. affect).
2. Symptoms cause clinically sgnificant distress or impairment in social, occupationl, or other areas of functioning such as communication.
3. physcial symptoms are not intentional or under voluntary control- therefore do NOT represent facituous disorders and malingering
4. male:female ration ranges from 1:2 to 1:10
5. commonly occurs in the 2-5th decades of life though it can occur in childhood or senescence.
define somatization disorder
poly-symptomatic and begins before age 30, extending over a period of years, characterized by combination of pain, gastrointesttinal, sexual and psudo-neurological symptoms. If symptoms last at least 6 months but are below the threshold for somatrization disorder diagnosis, the term undifferentiated somatoform disorder may be applied
what four disorders do somatization disorders include
1. conversion disorder
2. pain disorder
3. hypochondrias
4. body dismorphic disoder
define conversion disorder
unexaplained symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition. Phychological factors are judged to be associated with the symptoms or deficit.
define pain disorder
characterized by pain as the predominant symptom
define hypochondriasis
fear of having a serious disease and may be based on the person's misinterpretation of bodily symptoms or functions
define body dismorhic disorder
preoccupation with an imagined or exaggerateds defect in physical appearace
describe the primary gain of a conversion disorder
keeps an internal conflict or need out of awareness. preserves a temproal relationaship between a conflict and the initiation or exacerbation of the symptom. symtom then remits sometime after the stimulus is no longer present (nurse who looses voice on days when assigned to triage emergency patients)
describe the secondary gain of a conversion disorder
relieves the patient from a particular activity that is noxious to the patient and gains support from the environment that otherwise may not be available (nurse is subsequently relieved from duty due to inability to communicate)
Name 5 characteristics of patients themselves with conversion disorders
1.socially-appropriate behavior,
2.lack signs of psychopathology
3. unaware of their role in symtoms or the cause
4. deny serious psychological problems but rather expect symptoms to relate to an organic disease or environmental cause
5. in some cases there is a lack of concern that would ordinarily accompany the severity of the symptoms known as "la belle indifference"(not always the case)
name some examples of neurologic-like conversion symptoms
paralysis, seizure, abnormal gait, diskinesia, discoordination, imbalance, deafness, blindness, amnesia, unconsciousness
name some examples of specific speech/airway-related conversion symptoms
hyper or hypofunctional voice, progrossive loss of voice, hoarseness, aphonia or breathlessness, excessive high pitc, vocal discomfort,mutism, etc.
4 steps to identify conversion disorders
1- medical evaluation
2-examine history
3-intensive symptomatic therapy probes as part of the speech eval
4- extended interview re psychogenic causes
3 criterion for indentification of conversion speech disorders
1- symptom incongruity (symptoms are internally inconsistent and or are incongruent with the localiztion, lateralization, course characteristics, or severity of an exisiting or suspected disease

2. symptom reversibility- symptoms can be immediately and substantially improved by therapy probe and/or the symptoms havea history of sudden (acute) onset, dissapearance and recurrence (excerbation-remission) without concurrent changes in the patient's medical status
3- psychological issues- symptoms are related or time-locked to specific conflicts, life stresses or primary or secondary gains and other findings such as abnormal findings on personality scales, depression, anxiety, la blle indifference may help confirm conversion disorder
T/F:
Psychogenic voice disorders may co-occur in patients with real disease, disorder, and anatomical difference.
True
T/F:
Psychogenic voice disorders are indicative of personality disorders and psychosis.
False. Psychogenic voice disorders may be associated with personality disorders and psychosis but are not indicative of them.
Because of the potential for confusion between a conversion disorder and a nerologic disorder, who should make the diagnosis?
A diverse medical team
What is the purpose of the medical evaluation in identifying a conversion disorder, and who provides it?
a medical evaluation provided by the primary physician as well as a neurological evaluation excludes other etiologies. A conversion diaorder is largely a diagnosis of exclusion.
what should you examine in patient history when diagnosing a conversion diaorder?
medical and psychiatric history, present and past symptoms, affect and mood, and how these are logically related to the patient's speech deficits
What is the purpose of the intensive symptomatic therapy probes as part of speech eval?
the intent is to demonstrate symptom reversability or incongruity. Patient must be symptomatic at thetime of the visit to do so. The eval may take several hours and may extend over more than 1 clinic visit.
what is the interview regarding psychogenic causes directed towards?
learning about when and how symptoms occur, and what the patient perceives will make the symptoms better or worse. One first asks open ended questions about the timing and circumstances of the symptoms. The query about how patients perceives the disability or fears the diability in certain circumstances. One does not suggest to the patient that the voice disorder is sychologically-based. However, it is appropriate during the interview to ask the patient directly whether they may have experienced any unusual stress or emotionally upsetting events at the time of symptoms onset. Emotionally-loading inormation may not be shared during the first visit.
give an example of internal inconsistency in symptoms?
patient with hypofunctional aphonia and weak cough may be present during oral motor, but full adduction of vocal folds and voicing are elicited during gag on endoscopy. Or poor adduction with weak cough internally inconsistent with strong adduction on hiccup.
give an example of incongruity in symptoms?
persistent ventricular phonation would be inconsistent with spastic dysarthria or spasmodic dysphonia, orwith the presence of full vocal fold mobility (as would rule out paralysis to explain compesatory ventricular phonation)
Would acute onset (within minutes) or subacute onset (within days) of vocal tremor and soft monotone voice be consistent with thhat expected for parkinson's disease?
no parkinson's disease has chronic onset (within months) and is progressive.
True or False
Where it would not be possible to eliminate vocal tremor in a patient with Parkinson's Disease or Spasmodic Dysphonia through the use of facilitating technique, vocal instanbility might be substantially improved y facilitating techniques in a patient with conversion disorder.
True
Are conversion disorders a functional disorder?
yes- given the asense of an anatomical difference, disease, or pathology to explain the cause
are all functional disorders conversion disorders? What are functional disorders
no- most functional disorders do not meet the criteria historically used for identification of conversion disorders (primary and secondary gain) functional disorders are thought to be learned, habituated behaviors. In some cases they have persisted as maladaptive compensations following illness, sudden periods of growth/laryngeal development, or extreme voice demand although these conditions are no longer present.
don't all voice disorders have a psychological component?
yes, patients with voice disorders have substantial disability, social isolation and understandably may experience associated depression or anxiety. It is also true that increases in sympathetic tone can exacerbate voice symptoms (dryness, tremor, muscle tension) However, most voice disoders are not caused by pre-existing psychological illness.
how would one treat psychogenic voice disorders?
through both behavioral therapy and psychotherapy and or stress management counseling.

ehavioral therapy is recommended to maintain the integrity of function until the conflict is brought to conscious attention and can be resolved. Learned vocal behaviors do not automatically dissapear with conscious awareness of the problem and an important goal of voice therapy is for the patient to demonstrate the ability to reverse the appearance of symptoms and to produce functional voice even in conditions that would otherwise evoke symptoms.
What are some differences between early objectives and later objectives in behavioral voice therapy for conversion/psychogenic disorders
early objectives are to establish functional voicing through the use of facilitiating techniques which will be utilized based on whether the symptoms are hypo or hyperfunctional in nature. Also early on, you will aimfor the client to identify those times and descrive the contexts in which voice symptoms exacerbate and remit - typically this is accomplished through the use of a structured voice diary or voice log.

Later objectives are attacked once voice is established, and the goal here is consistent and independent production of voice for communication-reduced dependence of clinician cues and overt use of facilitating techniques.
what is the difference betweenfunctional and organic disords
functional disorder is present despite the absense of a disease, pathology, anatomical difference. Organic disorders are caused by a disease, pathology, or anatomical difference.
three etiology categories that taxonomies are based on
environmental, systematic, traumatic conditions
taxonomies based on physical presentation of a difference or change specific to a phsyiologic subsystem
congential/structural disorders, disorders related to tissue change, disorders relatedto neurologic change or change in msucle function/use
What is voice classification based on?
Voice classification is based on the primary factors that relate to anatomical size and on secondary factors.
What are the scondary factors that affect voice classification?
1. muscle strength
2. muscianship
3. role models and culture
4. occupation and marketablity
What are the three primary factors that affect voice classification?
1. effective vocal fold length
2. vocal tract length determines vocal qualities that distinguish voice classification
3. combination of effective vocal fold length and tract length
3.
What is the difference in effective vocal fold length in males and females?
effective vocal fold length (referring to the membranous portion that vibates during normal voicing) is 60% longer in males than that of a female, which explains the primary gender difference. Longer= lower pitch
how does the vocal tract length determine vocal qualities that distinguish voice classifications?
dark voices are classified differently from bright voices even when FO ranges overlap. The long-term average of spectral speaks has been a useful correlate of voice classification because it is sensitive to the length of the vocal tract. Bright voices tend to have shorter vocal tracts and higher formant frequencies.
Explain the combination of effect vocal fold length and tract length
well, for example, those with long necks and short vocal folds may have high pitch but dark vocal quality This may contribute to subclassfications as in opera (heldon tenor)
how could msucle strength affect vocal classification?
tessitura may require sustrained high pitch range or occassional dramatic high notes. ENdurance for sustained or burts of muscle contraction may be neccessary. Prolonged use of one tessitura may cause difficulty with another. Sometimes good hogh voices during singing are noticeably poorer in quality during speaking. achieving relaxed conditions in the larynx may not be based on the same principles as achieving optimal tension.
define tessitura
an average pitch level of a song or piece of a song
define the obvious role of musicianship in voice classification
ability of a vocalist to execute musically challenging literature or on the basis of musical literacy and ability to sing harmony or countermelodies well.
discuss role models and culture in voice classification
in western cultures, vocal self-image may lead individuals to lower or raise vocal FO, with lower FO associated with authority and higher FO associated with kindness or submission. Breathy low pitch female voice is associated with female sensuality, while low pitched dark and smooth male voice may be associated with male sensuality.
True or False: occupation may cause people to sustain a disordered voice for purpose of marketability.
True! Tom Petty and vocal nodules to maintain raspy tom petty voice;

obviously not all professionals maintain maladaptive voice on purpose. consider voice classification as related to jobs (belt, blues, croone, twang, basso profundo....)
what is fach
job specificity
name some voice classifications related to fach in opera
1.basso cantante
2.buffo
3.coloratura
4.contra
5.counter
6.dramatic
7.flageolet
8.helden
9.lyric
10.profundo
11.robusto
12.Soubrette
13.Spinto
what is basso cantante
a lighter bass voice with extended range and ability to sing with coloratura (agile voice suited for many runs, trills, and extremely high notes)
what is buffo
a comical voice
what is the voice classification for primary soprano
coluratura
what is the voice classifican for alto
contra- exceptionally low voice that sings against te higher alto voices
what is the voice classification for tenor
counter- high male voice with strong falsetto-like production usually baritone speakers who have strong chest-falsetto register dichotomy
explain this voice classification:dramatic
powerful opera voice suited for dramatic interpretations
what is the voice classification for soprano
flageolet- high thin voice
wht is profundo?
basso, exceptionally low bass voice
what is robusto
robust voice
what is soubrette (soprano)
light voice
what is spinto (soprano and tenor)
slightly pushed, driven out, urged on
name the 8 non-opera voice classifications related to fach
1. belt- bright, high energy voice used in musical theatre
2. blues- sad, lamenting voice used in jazz
3. croon- soft, soothing voice used for lullabies, but more generally for sentimental songs
4. grunge- effortful, gravelly voice used in rock music
5. mope-low, muffled voice to express gloomy, dejected moods used in rock
6. pop- a unique sound; emphasizing a new style or personality
7. twang- bright, nasal voice used for country-western singing
. yodel-highly registered voice (flipping between chest and falsetto register) used primarily in alpine folk singing
discuss the change in length in vocal folds from childhood to adulthood?
the growth rate is 0.4 mm per year for females and 0.7 mm per year for males; leads to a maximum adult length of 16 mm for males and 10 mm for females. At infancy the membraneous length is about 2 mm.
discuss fundamental frequency in children versus adults?
It drops significantly from about 500 Hz to 100 Hz from ages 1-20 in males and from 500 Hz to 200 Hz from ages 1-20 in females. For some reason it drops the least between ages 3-10, although length is increasing significantly during this time.
When does development of the vocal ligament and the thyroarytnoid muscle begin?
age 3-4 -- this could stiffen vocal fold explaining the counteraction to the drop in FO
Why are children able to produce sounds as loud as adults with much smaller vocal folds and lungs?
1 answer) higher FO gaurentees a higher intensity all else beingequal. Vocal intensity increases about 8-9 dB per octave increase in FO. 2- It is important, however, to note that children's vocalizations are not just scaled down versions of adult vocalizations. A case to point out is the aerodynamic (pressure-low) relation to the glottis. Lung pressure or amplitude is significantly greater in children-- basically children attempt to match the vocal loudness of adults by working harder. They compromise the length of their vocal utterances to achieve this equality in loudness. It is well known that children take more frequent breaths during speech.
What is the mot obvious vocal change in adolescence?
occuring during puberty and especially in males. Male hormone testosteroneis responsible for the disporportionate growth of the larynx primarily in the membranous vocal fold lengthresulting in protruding adam's apple. A significant downcurve in FO occurs in males between 10 and 18. given an indiviual its more abrupt (within 1-2 years). Aside from the increase in vocal fold length, there is also an increase in the bulk of the thyroarytnoid muscle and the vocal fold thickens. HOwever, this thickening does not affect FO.
If added mass doesn't affect FO in pubescent males, what is the accoustic consequence of the enlarged thyroaryntoid muscle?
It produces a register change- change in vocal quality. More of the entire body of the vocal fold is set into virbatory action with greater overall amplitude, resulting in a richer tibre or chest/modal voice.
Why do boys find it difficult to control their register during the growth spurt?
as the folds become thicker and more rectangular, differentmuscle patterns need to be developed to control the modes of vibration. It is basically a trial and error process.
Why is it not wise to talk about specific voice classifications in adolescence?
development could be changing past growth spurt up until age 20.
under normal health conditions, how long is the human voice stable
4 decades (20-60)it has been repeatedly shown that normal ranges of intensity and FO can be maintained into the 7th decade, as well as basic voice quality
what is the distinction between chronological age and physiologic age?
c=physiologic age is determine by general measures of health- blood pressure, heart rate, vital capacity, etc. This truer age has a larger impact on how well the larynx functions in phonation. It has been shown that perceived age of a speaker is more associated with physiologic age.
There is a broad span of normal perceptual and accoustic characteristics with physiologic age. True or False
True- very broad- vocal performance often peaks in 30s or even 40s.
What explains better support for the tension of the vocal folds in middle-age life as opposed to younger life?
ossification of the larungeal cartilagesfolds- bone tends to deform less than cartilage under the same stress
When would ossification of the laryngeal cartilages work against productive voice?
eventually, the framework becomes too rigid, movement becomes impeded, arthritis may set in cricoartyntoid joint and lose arytnoid movement; limit adduction, abduction, and pitch range
What is the gender difference between female and male FO in adult through senscent life?
females FO tends to change more unidirectionally, gradually dropping whereas male fo tends to rise during old age approaching the female fo. diminishing estrogen levels in female FO may contribute to lowering and diminishing testosterone in make male may contribute to rising.
name 3 age related changes in senescence that affect the soft tissues specifically?
1. atrophy (a wasting away of cells)
2. dystrophy (a dysfunctioning of cells)
3. edema (excessive accumulation of fluids in the tissue)
how does atrophy in senescence cause vocal fold bowing?
atrophy of the thyroarytnoid muscle fibers tends to pull the medial surfaces of the vocal fold laterally creating a bowed fold.
what kind of sound does edema produce?
crackly, hoarse sound due to abnormal patterns of vibration. The cover is too loosely coupled to the body of the vocal folds- rough voice quality
If agility is lost because of slower muscle response or restricted movement of cartilages, coluratura is the ideal fach. true or false.
FALSE
dystrophy in the muscle fibers or in nerve cells makes voice sound how?
weak, fluttery, wobbly
pitch difference between male and female voice is?
a little over half an octave-- 8 semitones; (with a scale factor of 1.6 VF length)
% difference in vocal tract length (primary determinate in uniform scaling of formant frequencies) between males and females
(10-20%)
name four sources of maturational change in voice
1. neural
2. csrtilagenous
3. vascular
4. mucousal
other pitch differences not considered disorders?
behavioral voice and speech-language therapy typically are integrated with medical and behavioral approaches to transsexualism.
what is the difference between direct and indirect therapy?
direct therapy you are actually changing the voice, whereas indirect therapy you are changing maladaptive behavior in hopes it will benefit the voice
Is Bottom-up, speaker oreiented therapy direct or indirect?
direct (why??)
is top-down, communication-oriented therapy direct or indirect?
indirect
explain symptomatic voice therapy
use of facilitating techniques to improve pitch, loudness, quality, or effort assoiciated with voicing. involves DIRECT voice work, wthe voice therapist probes for "best voice" reinforces and stabalizes this "best voice" symptimatic therapy assumes that reduction in voice symptoms through direct modification results in healthier voice use
Discuss the anatomy of a voice session that uses facilitation techniques
1) patient reports on voice state since last visit
2) education relevant to goals, activities, questions, home program
3) baseline measures
4) establish a suitable working state of voice using facilitating techniques
5) rapidly extend and shape voice for use in structured activities (vocal warm-ups)
6) motor practice at an appropriate target working level
7) feedback from patient to clinician and vice verse on success level, activities,
8) successful demonstration of related home-program
9) voice cool down or rest period
Discuss when to use biofeedback as a facilitating approach
used only when the desired target cannot be achieved by the patient without this additional support. Biofeedback is typically used early in therapy sessions.
Types of niofeedback
1) visual or tactile regarding movement (endoscopy, electroglottogrpahy, egg-white masks, mirror)

2) visual feedback about pressure or flow (tissue, candle, pneumotachography,see-scape, mirror

3) audio perservation, enhancement or modification: audio playback, pitch or amplitude-modulated feedback, auditory masking, delayed auditory feedback.

4) visual or tactile feedback about acoustic parameters of voice: spectral feedback, intensity or freqeuncy plots, sound level indicatios, vibrotactile transduction
discuss psychogenic voice therapy approach
focuses on identification oandmodification of emptional and psychosocial triggers associated with related voice symptoms. Includes counselling, interview, referral for psychological services, group interation and support services, integrates use offacilitating techniques to restore voice, negative practice, desensitixation activities, voice session are typpically intensive in duration
Explain etiologic voice programs
thought to address the cause of the disorder with relatively minimal direct voice manipulation or extensive vocal motor learning (confidential voice therapy, vocal hygiene program
physiologic voice therapy
focus is on voal motor learning. Programs involve extensive direct voice manipulations (vocal exercise program (Stemple, Accent Method, Lee Silvermann Voice Treatment Approach)
What to keep in mind when building a treatment hierarchy:
-be prepared in advance with multiple levels of your objectives and actities; work progresses toward a functional goal within each therapy session, never plan to work on any activity that has no immediate goal, begin at highest level critical to your goal that patient can have successful practice never less than 75% correct level so you dont confuse or fatigue, choose to work on functional speech wherever possible, progress to elimination of cues, work begins at lingustically simple targets and moves to linguistically complex, work begins with less cognitive and phsychosocial load but progresses to more
explain confidential voice therapy
use soft breathy voice to reduce vocal process adduction as well as subglottic pressure, thereby also reducing vocal fold collision and shear stresses; usually used early rather than later in therapy, seldom the sole therapy type, need to explain it to get compliance
explain vocal hygiene program
called vocal dfiet, change in behaviors to affect reflux, abuse, allow rest, healthy voice schedule, never be a lit of dos and donts because knowledge does not equal behavior-- not devoid of direct voice work becasue you are also educating and changing maladaptive voice as part of the plan
explain voice exercise program-
exercise in striated muscle reults in greater strength, tone, and muscle flexiblity- improve either the range, endurance, or comfort of phonation. Goals may be directed toward any of the vocal pitch, loudness, or quality. All vocal activities begin with daily warm up, dailing isometric and isotonic exercises with phonation, stretching upward glides and contracting downwoard glides without pitch break, adductory power exercises during singing. exercises are performed twice in a row 2 times per day; frontal focus and easy onset enforced; Tx is weeks but exercises continued long-term because reversal is expected and earliest effects are only metabolic
accent method purpose
increase respiratory support- increase glottal efficienncy, reduce laryngeal tension, and normalize vibratory pattern.