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Diagnosis and Treatment of Hysterical Aphonia and the Diagnosis of Malingering in These Cases
Medical Clinics of North America July, 1937. Philadelphia Number
CLINIC OF DR. N. W. WINKELMAN GRADUATE SCHOOL OF MEDICINE, UNIVERSITY OF PENNSYLVANIA DIAGNOSIS AND TREATMENT OF HYSTERICAL APHONIA AND THE DIAGNOSIS OF MALINGERING IN THESE CASES HYSTERICAL aphonia is one of the most common forms of psychogenic paralysis. In order to understand the term it is first necessary to define these words. By hysteria is meant a condition characterized by changes in mood or affect, with alterations in character or personality and with physical or somatic manifestations. Every case of hysteria usually has all of the above characteristics, although one of them predominates and gives the characteristic coloring to the clinical picture. In aphonia of hysterical nature, it is the difficulty in talking which overshadows the clinical picture, although the other manifestations are also present to a lesser degree. The term "aphonia" signifies an "absence of voice." This term is not entirely correct in the designation used because, as a matter of fact, there is usually a hoarseness or whispering type of speech rather than a complete absence of all vocal manifestations. When even the whispered voice is absent the term "absitheria," which has been coined by Dr. Chevalier Jackson, is applied. To understand the mechanism of the problem we must. give a brief resume of the present-day conception of hysteria. Hysteria is regarded as a "flight into disease." It is usually an ineffectual but a determined effort on the part of the patient to escape from reality. It represents the best solution for adjustment that he can make. Usually the effort is poorly carried out and the plan is frequently infantile, and is often an impossible one, but it is a purposive effort notwithstanding. 12II
1212
N. W. WINKELMAN
The physical manifestations are the result of repression in the unconscious of unpleasant experiences which are prevented from reaching consciousness because of their painful associations. Every hysterical symptom has a definite meaning and no therapy can be successful without recognizing this basic fact. It is true that the symptoms may defy direct interpretation but usually the significance and the psychogenic origin can be detected by "probing" beneath the surface. It may require hours of work with the patient before the interpretation of the condition is correctly made. If the above tenets are correct, then an aphonia of hysterical origin must have as its basis an unconscious or uncontrollable desire on the part of the patient to prevent audible speech. The reason for this is not identical in every case, as will be illustrated. REPORT OF CASES
Case I.-An insight into the mechanism of hysterical aphonia is afforded by a woman 'of forty-five, who was studied many years ago at one of the local hospitals. Her chief complaint was an inability to speak above a whisper. She was a clinic patient and was emaciated and showed the terrific strain of life. On account of her ignorance it was impossible to analyze her by the usual methods and no cause for the loss of voice could be uncovered. Various methods of treatment then in vogue were tried but without success. It was finally determined to try the effect of light etherization. It was argued that possibly during the excited stage of anesthesia the patient would cry out and if the crying could be continued until consciousness returned the speech mechanism might be restored to normal. The patient was willing to cooperate and light anesthesia was induced. As predicted the patient began to mumble during the excitement stage and finally cried out . rather suddenly in an extremely loud tone, "God damn you, John, I won't call you." The anesthesia was immediately stopped. The patient was crying and talking at the time that she regained consciousness and her speech was restored to normal. With the patient's statement as a clue and with the patient's.. cooperation, it was rather easy to reconstruct her story. Her husban~, was a drunkard and many times came home late
HYSTERICAL APHONIA
121 3
and intoxicated. In the morning it was necessary to call him many times before he was able to arouse himself sufficiently to go to his work. It was her practice to have the entire breakfast prepared prior to calling him. It was not unusual for the husband to quarrel with his wife and occasionally strike her for no apparent reason. She suffered many body and facial bruises as the result of his temper in the morning. She told. us that on one occasion her nose was broken. She eventually became extremely fearful about awakening him because it would mean verbal abuse at least and sometimes physical violence. In view of the fact that her children came down to breakfast at the same time it was impossible for her to run to the second floor to call him but it was necessary to yell to him on several occasions before he would be awakened. With the onset of the aphonia, of course, she was unable to call her husband. She noted that since her loss of voice her husband had been more solicitous. In an analysis of a case of this sort the underlying mechanism is very clearly brought out. The patient's hatred toward her husband as the result of his abuse can be very easily suspected from even a superficial study. Her desire not to awaken him in the morning was a very natural one. She, therefore, assumed the only defensive mechanism that she could to prevent arousing him in the morning. This served a double purpose. It incited a little sympathy in him and was a defense against calling him in the morning. It was, however, not a rational procedure because their livelihood was endangered. A case of this sort is frequently easily cured of the presenting symptom of aphonia but the underlying family situation is not relieved thereby.
Case II.-A priest, aged fifty-five, was referred by Dr. Chevalier Jackson. His chief complaint was inability to speak above a whisper. He had been in charge of a large church in an adjacent city for many years. His work had been interesting and he had developed an implicit faith in his religion and his parish. He acted as counselor and as a friend to his people. He would help. them with their business ventures and he had always found them honest. Just before the financial
1214
N. W. WINKELMAN
depression he was asked to sign notes for two members of his congregation. He had done this on so many previous occasions that he did not hesitate. The depression came and both of the men for whom he had signed the notes lost heavily in their business ventures. Both disappeared from the city within a period of two weeks without leaving their forwarding addresses. It was, therefore, necessary for the priest to make good on both notes. When he came to see us he was paying small amounts to the bank every month for these notes. As the result of these dealings with people who had professed faith in religion, he had lost his belief in human beings and in religion in general. He, therefore, found his enthusiasm gradually waning and became more and more discouraged in his dealings with human beings. Suddenly an aphonia developed which was a means of escape from duties that were gradually becoming odious to him. His aphonia was easily relieved by strong suggestion, reenforced by faradic stimulation, but his faith in religion was still shattered. It has been several years since he has fully recovered his speech, but he tells me that he is unable to put into his work the enthusiasm that he did prior to the development of the aphonia.
Case III.-A school teacher of thirty was referred by Dr. Chevalier Jackson because of difficulty in speaking. In a detailed survey of her life these factors stood out. She lived in a small town; and her parents were at odds with each other. She did not live at home because of the family difficulties. Her family insisted on her telephoning them- every day. She was ashamed of what was going on because of the scandal that was caused by her parents' marital difficulties. She also felt that it was spoiling her matrimonial chances. She was also a Sunday school teacher -and she felt somewhat abashed to talk on religion and conduct to her Sunday school class in view of everyone's knowledge of her own family difficulties. She was ashamed to go out into public places. The conditions preyed on her mind to such an extent that she became seclusive. With the onset of the aphonia, however, her on.e problem was solved, although her other problem of earning a liv~lihood was jeopardized.
HYSTERICAL APHONIA
121 5
Assured by Dr. Jackson and his staff that there was no organic difficulty associated with her loss of voice, it was very easy to effect an almost immediate relief of the aphonia by strong suggestion. Frank discussion of her problem had the effect of giving her a different outlook on the entire situation. She left Philadelphia completely relieved of the hysterical symptom and with an indifference to her family problems because of her realization that she herself was not to blame for the dissensions between her parents.
Case IV.-Mr. W. was referred by Dr. Chevalier Jackson, because of aphonia. The patient was a minister. He also did a great deal of singing and talking. He had been engaged in this type of work for about twenty-three years and had had no difficulty until approximately two years before we saw him. He noted gradually that it required more and more effort for him to speak. He was compelled to give up his work in February of 1935 because he found that he was unable to speak above a whisper. He consulted many throat specialists and was told by some that he had laryngitis. No improvement resulted from a great deal of treatment, including local applications, and osteopathic and chiropractic adjustments. He found that when he was singing as a guest in another city his speech was improved but in his own church his difficulties became markedly intensified. With this clue the family situation was gone into very carefully. He confessed that there was considerable difficulty with his wife. She was sexually frigid. About ten years before the onset of his difficulty, his wife engaged a boy of sixteen to help with the housework. He was not suspicious of the boy until a few years later when he came upon him and his wife suddenly and found them embracing and kissing. His wife's excuse was that her feeling for the boy was that of a mother. It was only after considerable wrangling that his wife permitted the boy to be discharged. She kept in communication with him for a period of about three years. The patient's mother-in-law, who was living with them, had frf:lquently warned him about her daugh~ ter's infidelity. After the boy left the house he proceeded to discard the entire matter from his mind, but later his suspicions became directed against a man who was having dif-
12I6
N. W. WINKELMAN
ficulties with his own wife. On several occasions the patient found his wife in rather compromising situations with this man, for whom she admitted a great deal of sympathy in view of his marital difficulties. She planned and made trips to New York with him and many gifts came to the house from this man. There was no doubt in his mind that his wife was maintaining a clandestine affair. During the time while he was away from his home his mother-in-law would occasionally write him letters airing her suspicions to him about her daughter. This would have the effect of disturbing him to such a point that it interfered with his work. Gradually his speech difficulty became so great that he was unable to carry on his work and remained at home doing odd jobs not connected with church affairs. It was not difficult to relieve this patient of the presenting symptom of aphonia, but it was extremely difficult to acclimate him to what was going on at home. There was financial difficulty because of his inability to work and, in addition, his children were suffering because of the tense family situation. The patient has since left Philadelphia and has gone to a distant city to do another type of work not associated with the church, which does not demand vocal exertion. His wife is not with him. A differentiation from malingering or feigning is necessary in every case of hysterical aphonia. To state glibly that hysterical aphonia is the result of an unconscious repression and malingering a conscious one does not help in their clinical differentiation. It is true that most persons tend to exaggerate their complaints and particularly so when the question of compensation comes into play. This, however, is not malingering in the psychiatric sense. The true malingerer consciously tries to simulate signs and symptoms for the purpose of monetary 'gain or to evade responsibility. The fundamental psychologic distinction is that the malingerer consciously attempts to deceive while in the hysteric the manifestations are unconsciously determined and beyond his control. Mutism is a much more common form of malingering than is aphonia. A careful survey of the entire clinical picture will usually suffice to make a distinction, although at times even the most expert maybe baffled.
HYSTERICAL APHONIA
12 17
As a general rule the malingerer is not anxious for medical examination because he fears detection. The hysteric, on the contrary, usually welcomes medical study. Frequently the malingerer can be caught off guard when he believes he is not being watched. It is not infrequent for the person to talk when he is not aware that he is being observed medically. A hysteric cannot be caught "off guard" in this way. A great many psychologic "tricks" have been devised to "catch" the malingerer. During the World War it was not uncommon to find malingering in the drafted men. Psychologic tricks were devised to confuse the person during the test such as dropping a coin in back of the person who claimed deafness; two-colored glasses when blindness in one eye was claimed, and so on. A thorough knowledge of the neurologic and psychiatric manifestations and thorough study of the patient will serve as the best differentiating medium between hysteria and malingering. In the treatment of hysterical aphonia a sharp distinction must be made between the treatment of the presenting symp~ tom, the aphonia, and the treatment of the underlying condition, the hysterical personality. In the treatment of the aphonia the therapist must have a combination of tact, art, self-assurance and, last and least, knowledge. Yet with all of this the inaccessibility of the patient himself may prevent a good result. There is no doubt that the personality of the therapist plays a tremendous role in the treatment. That actual knowledge is not a requisite can be judged from the excellent results obtained by quacks in the treatment of conditions of this type. The tact of the therapist is shown by his handling of the patient. The patient will resent any suggestion by doctor or relative that his condition is "imaginary." It often provokes greater resentment and renders the problem much more difficult, if not impossible. A complete study. of the patient must be made in order to convince him that his problem has been taken seriously. This will include a detailed history, consisting of a social and psychiatric study and a very careful physical examination. It must be explained to the patient that the fact that nothing of an organic nature is found to account for the VOL. 21-77
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N. W. WINKELMAN
symptoms does not mean that he is not ill. It must also be careflllly explained to the patient that a nervous disease is like any other illness and it requires treatment for its relief. It is wise, at times, when the patient is intelligent, to give him an insight into the mechanism of hysteria and explain the role played by the various emotional factors. This will dispel for the patient the fear that his condition is entirely the result of his imagination. An error is often made to concentrate the patient's attention on somatic conditions. To claim that an aphonia is the result of "laryngitis" is to give the patient a self-satisfying explanation for his complaints. No local instrumentation or operation should be suggested because they only tend to perpetuate symptoms which should be easily removed by psychotherapeutic measures. The method and means of therapy will vary with the individual therapist. Any therapeutic measure which promises relief is indicated and justified. There is no objection to the use of medicaments, electricity or hypodermic injections, provided the physician realizes that he is using these as suggestive measures to influence the patient psychically. No two patients can be treated alike. The therapist must realize, however, that he cannot expect the medication or other suggestive measure to clear up a severe mental conflict or to adjust some family situation. Suggestion plays the major role in the treatment, but the susceptibility of these patients to suggestion has been overemphasized. It is true that a symptomatic cure of hysterical aphonia can easily be accomplished with suggestion alone, but we should go beyond this. For immediate relief of the presenting symptom, strong suggestion or even hypnosis may be employed, but the goal is to find the forces which have caused the repression. One should not be satisfied with the clearing up of the hysterical manifestation but should probe into the mechanism of the condition, without subjecting the patient to a prolonged psychoanalytic procedure. It is necessary in most cases to complete the study and give the patient an insight into the mechanism of the problem as quickly as possible. The personality defect must also be subjected to minute investigation and must be corrected if at all possible. It is to be" stressed that most of the patients can be treated in one's
HYSTERICAL APHONIA
121 9
office without interruption of their routine of work. This is also a very important point because not only must the patients' time be occupied, but also they are earning enough to take care of their obligations. They also have impressed on them the fact that they are not sick enough to stop their work. It must be recognized that the patient had made a "flight into disease" as a means of solving what to him had become an intolerable situation. All the facts of his difficulties must be obtained so that the therapist will know the conditions from which the patient is making an escape. A frank discussion of his problem is essential. It must be realized that the therapist is unable to adjust family difficulties or financial reverses, but he can re educate the patient to re40nsider his problems and to readjust himself to conditions. It is manifestly impossible for the therapist to correct an erring wife, as in Case IV, or to cure the alcoholic cravings of the husband of our first patient. Sufficient time should be taken with the patient to go over the entire situation, to make the patient more satisfied with his lot, to try to get him to seek other outlets for his energies, and to take an interest in outside affairs. A good many of our patients have been school teachers who have reached the age where marriage is a forlorn hope. To hold out hope to patients of this sort for matrimony is wrong, but to educate them to be satisfied with their lots is essential. As a rule a prolonged psychoanalysis is not indicated in these cases. While intensive analysis revealing the basic psychogenic factors may be desirable in certain cases of hysteria, it is unnecessary and frequently undesirable in the great majority of these hysterical individuals who show but one symptom of that disease. At no time should the patient be accused of not desiring to get well because it indicates a poor understanding on the part of the doctor. Even when this is suspected it should be made part of the psychotherapeutic procedure and not the topic for argument or accusation. As the patient's entire life is reviewed before us, we can frequently give the patient a little insight into his own problem by appropriate hints during the recital. This is frequently part of the therapeutic procedure and is of value in helping the patient to solve his problem.
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N. W. WINKELMAN
My own procedure in a case of hysterical aphonia is to obtain a detailed history from the patient at the first consultation. A great many significant facts can be uncovered in the first interview, but at times repeated interviews are necessary before the complete story can be obtained. The entire sequence of events leading to the los~ of voice can frequently be disclosed in the course of five or six interviews. During this time treatment for the somatic symptom is undertaken after a thorough physical study. As a rule these cases have been referred by laryngologists who have completely ruled out any organic involvement. Strong suggestion is given and augmented when necessary by faradic stimulation of the muscles of the throM. As a rule complete relief of the aphonia has been obtained in the course of two or three treatments. Our most difficult cases have been those who have had a peculiar grunting type of speech rather than a true aphonia. This condition might more appropriately be called "hysterical dysphonia." This has usually become so deeply ingrained that an actual habit has been established of talking in this. peculiar way. In the meantime, the rest of the interview is taken up with delving into the history to determine the psychogenic factors responsible for the condition. In our experience sex has not played the dominant role. A very frank discussion with the patient is often conducive to a marked change in the patient's attitude toward his own problems. I try to get the patient to view his own condition from an impartial angle and will frequently ask him to give advice to someone else under the same conditions. It has usually not been necessary to resort to intensive psychoanalytic measures because the aphonia has most often followed close upon the precipitating situations. As a rule our results in the treatment of hysterical aphonia have been excellent. In 1 or 2 cases seen within the last two or three years where relief of the symptoms has not occurred promptly, prolonged psychoanalytic treatment in other hands has also been unsuccessful. Best results are obtained in cases where the aphonia has been present but a short time. As already stated, those cases with the grunting or "bearingdown" type of speech are the most resistant, and particularly so if the condition has been present for months or years prior to ,therapy.
CLINIC OF DR. N. W. WINKELMAN GRADUATE SCHOOL OF MEDICINE, UNIVERSITY OF PENNSYLVANIA DIAGNOSIS AND TREATMENT OF HYSTERICAL APHONIA AND THE DIAGNOSIS OF MALINGERING IN THESE CASES HYSTERICAL aphonia is one of the most common forms of psychogenic paralysis. In order to understand the term it is first necessary to define these words. By hysteria is meant a condition characterized by changes in mood or affect, with alterations in character or personality and with physical or somatic manifestations. Every case of hysteria usually has all of the above characteristics, although one of them predominates and gives the characteristic coloring to the clinical picture. In aphonia of hysterical nature, it is the difficulty in talking which overshadows the clinical picture, although the other manifestations are also present to a lesser degree. The term "aphonia" signifies an "absence of voice." This term is not entirely correct in the designation used because, as a matter of fact, there is usually a hoarseness or whispering type of speech rather than a complete absence of all vocal manifestations. When even the whispered voice is absent the term "absitheria," which has been coined by Dr. Chevalier Jackson, is applied. To understand the mechanism of the problem we must. give a brief resume of the present-day conception of hysteria. Hysteria is regarded as a "flight into disease." It is usually an ineffectual but a determined effort on the part of the patient to escape from reality. It represents the best solution for adjustment that he can make. Usually the effort is poorly carried out and the plan is frequently infantile, and is often an impossible one, but it is a purposive effort notwithstanding. 12II
1212
N. W. WINKELMAN
The physical manifestations are the result of repression in the unconscious of unpleasant experiences which are prevented from reaching consciousness because of their painful associations. Every hysterical symptom has a definite meaning and no therapy can be successful without recognizing this basic fact. It is true that the symptoms may defy direct interpretation but usually the significance and the psychogenic origin can be detected by "probing" beneath the surface. It may require hours of work with the patient before the interpretation of the condition is correctly made. If the above tenets are correct, then an aphonia of hysterical origin must have as its basis an unconscious or uncontrollable desire on the part of the patient to prevent audible speech. The reason for this is not identical in every case, as will be illustrated. REPORT OF CASES
Case I.-An insight into the mechanism of hysterical aphonia is afforded by a woman 'of forty-five, who was studied many years ago at one of the local hospitals. Her chief complaint was an inability to speak above a whisper. She was a clinic patient and was emaciated and showed the terrific strain of life. On account of her ignorance it was impossible to analyze her by the usual methods and no cause for the loss of voice could be uncovered. Various methods of treatment then in vogue were tried but without success. It was finally determined to try the effect of light etherization. It was argued that possibly during the excited stage of anesthesia the patient would cry out and if the crying could be continued until consciousness returned the speech mechanism might be restored to normal. The patient was willing to cooperate and light anesthesia was induced. As predicted the patient began to mumble during the excitement stage and finally cried out . rather suddenly in an extremely loud tone, "God damn you, John, I won't call you." The anesthesia was immediately stopped. The patient was crying and talking at the time that she regained consciousness and her speech was restored to normal. With the patient's statement as a clue and with the patient's.. cooperation, it was rather easy to reconstruct her story. Her husban~, was a drunkard and many times came home late
HYSTERICAL APHONIA
121 3
and intoxicated. In the morning it was necessary to call him many times before he was able to arouse himself sufficiently to go to his work. It was her practice to have the entire breakfast prepared prior to calling him. It was not unusual for the husband to quarrel with his wife and occasionally strike her for no apparent reason. She suffered many body and facial bruises as the result of his temper in the morning. She told. us that on one occasion her nose was broken. She eventually became extremely fearful about awakening him because it would mean verbal abuse at least and sometimes physical violence. In view of the fact that her children came down to breakfast at the same time it was impossible for her to run to the second floor to call him but it was necessary to yell to him on several occasions before he would be awakened. With the onset of the aphonia, of course, she was unable to call her husband. She noted that since her loss of voice her husband had been more solicitous. In an analysis of a case of this sort the underlying mechanism is very clearly brought out. The patient's hatred toward her husband as the result of his abuse can be very easily suspected from even a superficial study. Her desire not to awaken him in the morning was a very natural one. She, therefore, assumed the only defensive mechanism that she could to prevent arousing him in the morning. This served a double purpose. It incited a little sympathy in him and was a defense against calling him in the morning. It was, however, not a rational procedure because their livelihood was endangered. A case of this sort is frequently easily cured of the presenting symptom of aphonia but the underlying family situation is not relieved thereby.
Case II.-A priest, aged fifty-five, was referred by Dr. Chevalier Jackson. His chief complaint was inability to speak above a whisper. He had been in charge of a large church in an adjacent city for many years. His work had been interesting and he had developed an implicit faith in his religion and his parish. He acted as counselor and as a friend to his people. He would help. them with their business ventures and he had always found them honest. Just before the financial
1214
N. W. WINKELMAN
depression he was asked to sign notes for two members of his congregation. He had done this on so many previous occasions that he did not hesitate. The depression came and both of the men for whom he had signed the notes lost heavily in their business ventures. Both disappeared from the city within a period of two weeks without leaving their forwarding addresses. It was, therefore, necessary for the priest to make good on both notes. When he came to see us he was paying small amounts to the bank every month for these notes. As the result of these dealings with people who had professed faith in religion, he had lost his belief in human beings and in religion in general. He, therefore, found his enthusiasm gradually waning and became more and more discouraged in his dealings with human beings. Suddenly an aphonia developed which was a means of escape from duties that were gradually becoming odious to him. His aphonia was easily relieved by strong suggestion, reenforced by faradic stimulation, but his faith in religion was still shattered. It has been several years since he has fully recovered his speech, but he tells me that he is unable to put into his work the enthusiasm that he did prior to the development of the aphonia.
Case III.-A school teacher of thirty was referred by Dr. Chevalier Jackson because of difficulty in speaking. In a detailed survey of her life these factors stood out. She lived in a small town; and her parents were at odds with each other. She did not live at home because of the family difficulties. Her family insisted on her telephoning them- every day. She was ashamed of what was going on because of the scandal that was caused by her parents' marital difficulties. She also felt that it was spoiling her matrimonial chances. She was also a Sunday school teacher -and she felt somewhat abashed to talk on religion and conduct to her Sunday school class in view of everyone's knowledge of her own family difficulties. She was ashamed to go out into public places. The conditions preyed on her mind to such an extent that she became seclusive. With the onset of the aphonia, however, her on.e problem was solved, although her other problem of earning a liv~lihood was jeopardized.
HYSTERICAL APHONIA
121 5
Assured by Dr. Jackson and his staff that there was no organic difficulty associated with her loss of voice, it was very easy to effect an almost immediate relief of the aphonia by strong suggestion. Frank discussion of her problem had the effect of giving her a different outlook on the entire situation. She left Philadelphia completely relieved of the hysterical symptom and with an indifference to her family problems because of her realization that she herself was not to blame for the dissensions between her parents.
Case IV.-Mr. W. was referred by Dr. Chevalier Jackson, because of aphonia. The patient was a minister. He also did a great deal of singing and talking. He had been engaged in this type of work for about twenty-three years and had had no difficulty until approximately two years before we saw him. He noted gradually that it required more and more effort for him to speak. He was compelled to give up his work in February of 1935 because he found that he was unable to speak above a whisper. He consulted many throat specialists and was told by some that he had laryngitis. No improvement resulted from a great deal of treatment, including local applications, and osteopathic and chiropractic adjustments. He found that when he was singing as a guest in another city his speech was improved but in his own church his difficulties became markedly intensified. With this clue the family situation was gone into very carefully. He confessed that there was considerable difficulty with his wife. She was sexually frigid. About ten years before the onset of his difficulty, his wife engaged a boy of sixteen to help with the housework. He was not suspicious of the boy until a few years later when he came upon him and his wife suddenly and found them embracing and kissing. His wife's excuse was that her feeling for the boy was that of a mother. It was only after considerable wrangling that his wife permitted the boy to be discharged. She kept in communication with him for a period of about three years. The patient's mother-in-law, who was living with them, had frf:lquently warned him about her daugh~ ter's infidelity. After the boy left the house he proceeded to discard the entire matter from his mind, but later his suspicions became directed against a man who was having dif-
12I6
N. W. WINKELMAN
ficulties with his own wife. On several occasions the patient found his wife in rather compromising situations with this man, for whom she admitted a great deal of sympathy in view of his marital difficulties. She planned and made trips to New York with him and many gifts came to the house from this man. There was no doubt in his mind that his wife was maintaining a clandestine affair. During the time while he was away from his home his mother-in-law would occasionally write him letters airing her suspicions to him about her daughter. This would have the effect of disturbing him to such a point that it interfered with his work. Gradually his speech difficulty became so great that he was unable to carry on his work and remained at home doing odd jobs not connected with church affairs. It was not difficult to relieve this patient of the presenting symptom of aphonia, but it was extremely difficult to acclimate him to what was going on at home. There was financial difficulty because of his inability to work and, in addition, his children were suffering because of the tense family situation. The patient has since left Philadelphia and has gone to a distant city to do another type of work not associated with the church, which does not demand vocal exertion. His wife is not with him. A differentiation from malingering or feigning is necessary in every case of hysterical aphonia. To state glibly that hysterical aphonia is the result of an unconscious repression and malingering a conscious one does not help in their clinical differentiation. It is true that most persons tend to exaggerate their complaints and particularly so when the question of compensation comes into play. This, however, is not malingering in the psychiatric sense. The true malingerer consciously tries to simulate signs and symptoms for the purpose of monetary 'gain or to evade responsibility. The fundamental psychologic distinction is that the malingerer consciously attempts to deceive while in the hysteric the manifestations are unconsciously determined and beyond his control. Mutism is a much more common form of malingering than is aphonia. A careful survey of the entire clinical picture will usually suffice to make a distinction, although at times even the most expert maybe baffled.
HYSTERICAL APHONIA
12 17
As a general rule the malingerer is not anxious for medical examination because he fears detection. The hysteric, on the contrary, usually welcomes medical study. Frequently the malingerer can be caught off guard when he believes he is not being watched. It is not infrequent for the person to talk when he is not aware that he is being observed medically. A hysteric cannot be caught "off guard" in this way. A great many psychologic "tricks" have been devised to "catch" the malingerer. During the World War it was not uncommon to find malingering in the drafted men. Psychologic tricks were devised to confuse the person during the test such as dropping a coin in back of the person who claimed deafness; two-colored glasses when blindness in one eye was claimed, and so on. A thorough knowledge of the neurologic and psychiatric manifestations and thorough study of the patient will serve as the best differentiating medium between hysteria and malingering. In the treatment of hysterical aphonia a sharp distinction must be made between the treatment of the presenting symp~ tom, the aphonia, and the treatment of the underlying condition, the hysterical personality. In the treatment of the aphonia the therapist must have a combination of tact, art, self-assurance and, last and least, knowledge. Yet with all of this the inaccessibility of the patient himself may prevent a good result. There is no doubt that the personality of the therapist plays a tremendous role in the treatment. That actual knowledge is not a requisite can be judged from the excellent results obtained by quacks in the treatment of conditions of this type. The tact of the therapist is shown by his handling of the patient. The patient will resent any suggestion by doctor or relative that his condition is "imaginary." It often provokes greater resentment and renders the problem much more difficult, if not impossible. A complete study. of the patient must be made in order to convince him that his problem has been taken seriously. This will include a detailed history, consisting of a social and psychiatric study and a very careful physical examination. It must be explained to the patient that the fact that nothing of an organic nature is found to account for the VOL. 21-77
I218
N. W. WINKELMAN
symptoms does not mean that he is not ill. It must also be careflllly explained to the patient that a nervous disease is like any other illness and it requires treatment for its relief. It is wise, at times, when the patient is intelligent, to give him an insight into the mechanism of hysteria and explain the role played by the various emotional factors. This will dispel for the patient the fear that his condition is entirely the result of his imagination. An error is often made to concentrate the patient's attention on somatic conditions. To claim that an aphonia is the result of "laryngitis" is to give the patient a self-satisfying explanation for his complaints. No local instrumentation or operation should be suggested because they only tend to perpetuate symptoms which should be easily removed by psychotherapeutic measures. The method and means of therapy will vary with the individual therapist. Any therapeutic measure which promises relief is indicated and justified. There is no objection to the use of medicaments, electricity or hypodermic injections, provided the physician realizes that he is using these as suggestive measures to influence the patient psychically. No two patients can be treated alike. The therapist must realize, however, that he cannot expect the medication or other suggestive measure to clear up a severe mental conflict or to adjust some family situation. Suggestion plays the major role in the treatment, but the susceptibility of these patients to suggestion has been overemphasized. It is true that a symptomatic cure of hysterical aphonia can easily be accomplished with suggestion alone, but we should go beyond this. For immediate relief of the presenting symptom, strong suggestion or even hypnosis may be employed, but the goal is to find the forces which have caused the repression. One should not be satisfied with the clearing up of the hysterical manifestation but should probe into the mechanism of the condition, without subjecting the patient to a prolonged psychoanalytic procedure. It is necessary in most cases to complete the study and give the patient an insight into the mechanism of the problem as quickly as possible. The personality defect must also be subjected to minute investigation and must be corrected if at all possible. It is to be" stressed that most of the patients can be treated in one's
HYSTERICAL APHONIA
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office without interruption of their routine of work. This is also a very important point because not only must the patients' time be occupied, but also they are earning enough to take care of their obligations. They also have impressed on them the fact that they are not sick enough to stop their work. It must be recognized that the patient had made a "flight into disease" as a means of solving what to him had become an intolerable situation. All the facts of his difficulties must be obtained so that the therapist will know the conditions from which the patient is making an escape. A frank discussion of his problem is essential. It must be realized that the therapist is unable to adjust family difficulties or financial reverses, but he can re educate the patient to re40nsider his problems and to readjust himself to conditions. It is manifestly impossible for the therapist to correct an erring wife, as in Case IV, or to cure the alcoholic cravings of the husband of our first patient. Sufficient time should be taken with the patient to go over the entire situation, to make the patient more satisfied with his lot, to try to get him to seek other outlets for his energies, and to take an interest in outside affairs. A good many of our patients have been school teachers who have reached the age where marriage is a forlorn hope. To hold out hope to patients of this sort for matrimony is wrong, but to educate them to be satisfied with their lots is essential. As a rule a prolonged psychoanalysis is not indicated in these cases. While intensive analysis revealing the basic psychogenic factors may be desirable in certain cases of hysteria, it is unnecessary and frequently undesirable in the great majority of these hysterical individuals who show but one symptom of that disease. At no time should the patient be accused of not desiring to get well because it indicates a poor understanding on the part of the doctor. Even when this is suspected it should be made part of the psychotherapeutic procedure and not the topic for argument or accusation. As the patient's entire life is reviewed before us, we can frequently give the patient a little insight into his own problem by appropriate hints during the recital. This is frequently part of the therapeutic procedure and is of value in helping the patient to solve his problem.
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N. W. WINKELMAN
My own procedure in a case of hysterical aphonia is to obtain a detailed history from the patient at the first consultation. A great many significant facts can be uncovered in the first interview, but at times repeated interviews are necessary before the complete story can be obtained. The entire sequence of events leading to the los~ of voice can frequently be disclosed in the course of five or six interviews. During this time treatment for the somatic symptom is undertaken after a thorough physical study. As a rule these cases have been referred by laryngologists who have completely ruled out any organic involvement. Strong suggestion is given and augmented when necessary by faradic stimulation of the muscles of the throM. As a rule complete relief of the aphonia has been obtained in the course of two or three treatments. Our most difficult cases have been those who have had a peculiar grunting type of speech rather than a true aphonia. This condition might more appropriately be called "hysterical dysphonia." This has usually become so deeply ingrained that an actual habit has been established of talking in this. peculiar way. In the meantime, the rest of the interview is taken up with delving into the history to determine the psychogenic factors responsible for the condition. In our experience sex has not played the dominant role. A very frank discussion with the patient is often conducive to a marked change in the patient's attitude toward his own problems. I try to get the patient to view his own condition from an impartial angle and will frequently ask him to give advice to someone else under the same conditions. It has usually not been necessary to resort to intensive psychoanalytic measures because the aphonia has most often followed close upon the precipitating situations. As a rule our results in the treatment of hysterical aphonia have been excellent. In 1 or 2 cases seen within the last two or three years where relief of the symptoms has not occurred promptly, prolonged psychoanalytic treatment in other hands has also been unsuccessful. Best results are obtained in cases where the aphonia has been present but a short time. As already stated, those cases with the grunting or "bearingdown" type of speech are the most resistant, and particularly so if the condition has been present for months or years prior to ,therapy.