What is a Stuttering Disorder?
VCD, Vocal Cord Dysfunction, is the "short name" for a disorder originally termed "Paradoxical Vocal Fold Dysfunction Masquerading as Asthma" (PVFD.) The disorder was first identified and described in the Journal of the American Medical Association in 1983. A research team at the Jewish Respiratory Hospital (now the National Jewish Medical and Research Center) in Denver, Colorado reported that some patients who had been treated for many years as severe asthmatics were discovered not to have asthma-typical lung function at all. Rather, the obstruction of the airway in these patients occurred because of spasms of the vocal cords during inhalation. In clinical trials there, it was found that through breathing exercises, the symptoms of asthma, such as "attacks" featuring coughing, wheezing, and shortness of breath, could be eliminated and medications could be halted.

What happens in a VCD attack?

VCD is a behavioral disorder in which the vocal folds "mimic" the closure of the airway which is the symptom of asthma attacks. In asthma, the chambers in the lungs called the alveoli, located just past the bronchial tubes, become inflamed and fill with mucous. The patient struggles to breathe and often feels as if he is "drowning" or "strangling." The wheezing or rattle we hear in these attacks is the sound of air being pressed forcibly in or out of the lungs through these narrowed chambers.

When a VCD attack occurs, however, the alveoli are normal. Instead, it is the vocal cords that are causing the airway to be constricted. The vocal cords are two tiny muscles covered with folds of tissue (membrane) that are housed inside the larynx (commonly called the "voice box" or "Adam's apple.") Figure 1 shows a side view of the larynx in a cross section so you can see how the vocal cords are attached to the inside of the front of the larynx, which sits on top of the trachea (windpipe.) The other ends of the vocal cords attach to tiny cartilages, which act as "hinges" so the cords can open and close.

Figures 2 and 3 give you a view of the larynx looking down on it (as the doctor sees it when he uses a mirror or an endoscope.) In the first, the cords are wide open, as they are most of the time, to let air in and out of your lungs.

In the second, the cords are closed. Of course, the cords are actually covered with membranes, and surrounded by other muscles which operate the larynx. When you want to, you can close the folds tight so that you can "hold your breath" as you do when you dive beneath the water. The vocal folds prevent foreign bodies (like food fragments or fluid) from getting into your lungs. When your airway senses something that doesn't belong there, the vocal folds shut tight and are then blown open with a blast of air from the lungs that forces the foreign particle out. That's what is happening when you cough.

The only other time the vocal folds should close - gently, not tightly - is when you make a sound with your voice, as in when you are talking or singing. In that case, the vocal folds work like a valve, just like the one in your water faucet. When the vocal folds close as the air from the lungs is passing between them, air pressure builds up under the folds. The air trying to escape pushes against the folds and makes them vibrate. When they vibrate, they make a buzzing sound. The buzzing sound is your voice.

When you have a VCD attack, the folds are doing something they are never supposed to do. They are trying to close while you are trying to breathe in. In fact, these two tiny muscles are jerking closed in a spasm, thus closing off the airway and making it hard to breathe.

Sometimes the spasms result in coughing attacks, in other patients the folds close so tightly that the air has to be sucked in and wheezing occurs. Naturally, breathing becomes labored and the upper chest becomes tight and sometimes painful. Because the patient is not getting enough air, he can become lightheaded or dizzy, and headaches aren't uncommon following an attack. In a few patients, the attack can actually trigger fluid build up, so that "rattle" can be heard. Worst of all, in many patients the struggle to breathe triggers panic, which tends to escalate the attack.

Why do the vocal folds DO that?
Most frequently, the first attack is triggered by some severe acute allergic reaction. We have had patients report that on the day of their first attack they had been working or playing near some noxious substance, such as fresh hot asphalt, carpet glue, etc. Frequently they experienced coughing, sneezing, or eye burning and watering at the time, but the actual attack did not occur until hours later, sometimes in the night. Other patients report they experienced a very severe upper respiratory infection. The infection appeared to clear up, but the coughing spells continued. When a person is engaged in physical exercise, breathing rate increases and the airway becomes more vulnerable, so it is not a surprise that this may occur more frequently in those who already are diagnosed with mild exercise-induced asthma, and in people who suffer from post-nasal drip.

Some researchers speculate that the vocal folds begin to spasm spontaneously in an attempt to protect the airway from the same or a similar substance or respiratory event. This spasm activity seems to become a vicious circle, with the vocal folds responding to a wider and wider range of substances or events. So what started as a response to a noxious chemical can end up being triggered by a mild perfume or the smell of dried leaves or grass - or one's own breathing or snoring.

This sensitization can eventually force the patient to give up exercise, going in public places, or into the garden. Because the swallowing mechanism is so close to the airway, we also have reports that attacks can include gagging, or that attacks can be induced simply by eating or drinking. Some patients also have been diagnosed with GERD (gastroesophageal reflux disorder.)

How has VCD been treated?
Dr. Florence Blager, speech pathologist at the Denver clinic, developed the first protocol for treating VCD. The primary focus was "diaphragmatic breathing", in which the patient is taught to inhale deeply and slowly, using only the abdominal muscles rather than the muscles of the upper chest (thorax). An important principle is to make sure that the inspiration is quiet - that there is no audible inspiration (called stridor) which is similar to wheezing, and is the symptom which causes the VCD attacks to be taken as asthma attacks. An aid in slowing the breathing is "S-breathing" in which the patient releases the air while making an "s-s-s-s" through his teeth. This helps to slow the exhalation down, and opens the spaces above the vocal folds to widen the airway.

In the early years of treatment, it was often recommended that the patient also be treated with psychotherapy, since there was an assumption that the disorder was the result of some psychological trauma. There has in recent years been no research that supports that notion. That is not to say that psychotherapy is not appropriate for some VCD patients, particularly if they have suffered the effects of this disorder for some time. But there is no evidence that the disorder is the symptom of an underlying neurosis or the result of psychotrauma of any kind.

Could I have both asthma and VCD?
Yes. That's why your physician uses a variety of lung function tests like methylcholine challenge, bronchodilation, and views the motion of your vocal cords using a flexible scope. What starts as true allergies or asthma can become VCD. Patients learn to know what to look for, and can tell the difference when an attack starts. The VCD attacks will respond to the exercises, and eventually fade away. There is some evidence that true asthma attacks will respond positively to these exercises, but patients must work with their therapist and physician to develop a combined medical and behavioral model of treatment.

What treatment will be used in this clinic?
In therapy, we use a computer-aided biofeedback system which was developed in this clinic. The patient wears a respiratory sensor and microphone which enables him to "see" his own breathing and the effect of the movement of the vocal folds as a graph on the computer monitor. This makes learning the correct breathing and the other vocal exercises easier and faster for both children and adults.

In addition to diaphragmatic breathing, and s-breathing, we also teach another target. This is called inspiration phonation, which means that as you breathe in, you close your vocal folds gently and let them vibrate to make a vocal sound. This is a "paradoxical" motion, just as the spasms of PCD are paradoxical, but it is intentional, gentle, and controlled.

Typically, within four to six sessions, the patient has developed skill in the exercises and can successfully employ them at home in daily practice.

Once the patient is skilled in using the exercise, in consultation with the physician, medications (especially steroids) may be gradually reduced. It is very important that the patient develop confidence in his ability to use the exercises when he feels an attack coming on. It is equally important that medications never be dropped suddenly or without consulting the physician, since the sudden withdrawal could spark renewed spasm activity.

What is the rationale for this treatment?
Diaphragmatic breathing is important for two reasons. As you saw in figure 1, the diaphragm is a very large muscle, so you can develop very good control over it. In its relaxed position, it is dome-shaped and slightly lop-sided. When you contract this muscle, it flattens out and becomes quite thick. It pulls your lungs down, sucking the air in to fill them up. That's why your stomach pushes out as you breathe in. By redirecting the muscular activity in breathing away from the upper chest, tension in muscles of the neck and larynx, including the vocal folds, is reduced.

The second part of the exercises, Inspiration Phonation (IP) is a technique in which the sound is created with normal closure of the vocal folds, but the air pressure below the vocal cords drops. In IP, the ventricles, or pockets just above the vocal folds are widened. They fill with air, releasing pressure on the folds, and relaxing them. Therefore, IP permits the patient to deliberately control his vocal fold movement under conditions of muscle relaxation. This control helps reduce the panic when an attack begins, and calms the vocal musculature by preventing the spasms from occurring (in much the same way as holding the diaphragm tightly contracted helps stop the hiccups.)

How long must I continue the exercises?
A patient should continue the daily exercises until no attacks have been experienced for several months, then gradually reduce the frequency. When a patient is diagnosed with asthma as well, medical management must continue under the supervision of the physician.

References

Blood, Gordon W. (1995). A behavioral-cognitive therapy program for adults who stutter: Computers and counseling. Journal of Communication Disorders, 28, 165-180.

Goebel, M.D. (1990). Attitude change following behavioral treatment of stuttering. Poster session presented at the annual convention of the American Speech-Language-Hearing Association, Seattle.

Goebel, M.D. (1986) The use of a microcomputer in fluency therapy. American Speech and Hearing Foundation Conference Proceedings, Orlando, Florida.

Goebel, M., Hillis, J., and Meyer, R. (1985). The relationship between speech fluency and certain patterns of speech flow. Paper presented at Annual Convention of the American Speech-Language-Hearing Association, Washington.

Stillwell, C., Runyan, C.M. and Goebel, M.D. (1988) Speech Naturalness Rating of Stutterers Using the CAFET Program. Poster session presented at the annual convention of the American Speech-Language-Hearing Association, Boston.

Unpublished manuscripts available upon request.