Paradoxical Vocal Cord Motion and Vocal Cord Dysfunction: Should These Terms Be Retired?

Abstract

The terms Paradoxical Vocal Cord Motion (PVCM) and Vocal Cord Dysfunction (VCD) have long been used to describe episodic difficulty breathing. Yet both terms, though entrenched among laryngologists and speech pathologists, may obscure more than they clarify, suggesting that they be retired.

Drawing on extensive clinical experience, the author proposes that the phenomenon labeled PVCM/VCD is, in many cases, better understood as a nonorganic, behavioral disorder of laryngeal use—whether conscious or subconscious. Other breathing disturbances rooted in structural abnormality or neurological dysfunction carry their own specific diagnoses—for example, bilateral vocal cord paralysis, subglottic stenosis, laryngeal dystonia, or laryngospasm.

When those diagnoses are ruled out and nonorganic phenomenology is unmistakable, the author believes that the term “nonorganic” can and should be used directly with patients.

The terms PVCM and VCD (along with the descriptor “functional”) are unnecessary and, in fact, work against the patient’s deeper insight. 

A clear nonorganic diagnosis, paired with a respectful explanation, using the word, sets the stage for disciplined behavioral treatment while protecting the patient from both medicalization and psychologization.

A well-circumscribed therapeutic approach for nonorganic breathing disorders is described here.

Introduction

Paradoxical Vocal Cord Motion (PVCM) and Vocal Cord Dysfunction (VCD) appear to be terms used essentially interchangeably. A formal definition abstracted from the literature might be:

Paradoxical vocal cord motion (vocal cord dysfunction) is the unwanted, episodic adduction of the vocal cords during inspiration (and sometimes expiration), producing airflow limitation and airway noises that can mimic asthma or upper-airway obstruction.

A search of the literature^1-6 seems to this author to leave this disorder conceptually defocused. He has even seen “VCD” applied to patients with laryngospasm, a voice disorder, or sensory neuropathic cough. There are comments about misdiagnosis as asthma and that is a good insight. There is mention of the preponderance of young female patients. One review suggested that PVCM and VCD are triggered by postnasal drip, reflux, irritants, or psychological factors.

In response, I think: Since postnasal drip, reflux, and irritants are suffered by millions, PVCM/VCD in this group would need to have an additional explanation that does not seem to be clearly specified in the literature.

Another article suggests this is a “complex disorder,” that workup needs to be detailed, and that speech therapy is a crucial avenue of management. But what exactly is the workup proving or disproving? And what exactly is speech therapy addressing? Another article suggests that this disorder can be exercise induced, but not how and why, since the world is full of exercisers who do not have PVCM/VCD.

The General Picture

Over the course of 40 years, the author has evaluated and treated diverse upper airway disorders: laryngeal, subglottic, or tracheal stenosis from breathing tube injuries or autoimmunity, tumors, classic laryngospasm, and laryngeal dystonia affecting respiration. An estimated 200+ patients of this much larger caseload did not have any of the above diagnoses and came to him in unresolved distress that had been treated elsewhere as asthma, or via psychotherapy for “stress” or “anxiety.” And they all had intermittent symptoms despite many – in some cases, dozens – of speech therapy sessions.

Here’s a “severe” case example, to provide the picture:

A young woman had experienced intermittent, dramatic respiratory distress for nearly a year. She had been seen emergently and admitted to the ICU approximately five times. During each admission, she received high-dose systemic steroids, racemic epinephrine, bronchodilators, and serial respiratory-therapy treatments. Peculiarly, her symptoms tended to diminish only after two or three days of hospitalization rather than within the first several hours, and throughout each admission her oxygen saturation remained normal.

By this point, the medical team had begun to consider what was noted in the chart as a functional etiology, given the combination of dramatic inspiratory and expiratory noises, agitation, partial distractibility, and quiet, normal breathing during sleep. (The word “nonorganic” had not been used.) An ENT physician had diagnosed VCD and referred her for speech-pathology work, focused on “breathing exercises and relaxation techniques,” and a psychotherapist had been engaged, but without benefit. The family and referring clinicians felt stuck, unsure how to proceed.

She was transferred directly from the outside hospital to the author’s hospital-attached office. During evaluation, she appeared highly agitated, producing a varied repertoire of gasping and mostly inspiratory noises, along with a continuous, seemingly panicked insistence that she “could not breathe.” The presentation resembled a severe panic attack, yet carried an unconvincing quality—notably, intermittent distractibility and frequent visual checking of her parents’ reactions, suggesting a significant relational component.

Auscultation of lungfields revealed no wheezes. ENT examination demonstrated that the respiratory noises were entirely laryngeal in origin. Brief moments of full vocal-cord abduction were captured, but most of the time the folds were held in near-approximation, generating inspiratory and occasional expiratory sounds such as gasping, grunting, and coughing. She even produced tears, particularly as the therapeutic approach described below was initiated. The diagnosis: a nonorganic, laryngeal-based breathing disorder rather than asthma or lower-airway pathology. This diagnosis was “unpacked” in a respectful and face-saving but directive fashion for both patient and parents. The terms “PVCM and VCD” were not used.

Based upon deep experience with diverse airway disorders, the author proposes that when no organic explanation is found, the terms PVCM and VCD be retired. That is because when there are no forthright organic (e.g., neurological, inflammatory, neoplastic, etc.) findings, only two plausible explanations remain for the abrupt, episodic vocal cord adduction that produces such dramatic symptoms: either a “mysterious” neurological disorder or a behavioral (nonorganic) one. Either of these diagnoses is more precise—and far more therapeutically directive—than the broad, ambiguous labels PVCM or VCD.

If Neurological…

One possibility might be dystonia. But laryngeal dystonia causing respiratory symptoms is a rare but straightforward diagnosis, recognizable through characteristic history, elicited phenomenology, and examination findings—all of which differ markedly from those seen in so-called PVCM or VCD. For example, the associated airway noises in RD are usually less dramatic, more momentary than continuous, tend to occur throughout the day rather than in discrete and often dramatic episodes, and disappear during sleep. Furthermore, there is often—though not invariably—an accompanying voice disorder: spasmodic dysphonia.

Another possibility might be paresis or paralysis? All of the variants of paresis (single and combination of muscles) were described years ago by the author and are found on Laryngopedia.com. These are clearly diagnosable with that information. Furthermore, the author has never observed paresis or paralysis occurring episodically, as though controlled by an “on/off” switch.

Another neurological breathing disorder is laryngospasm, an abnormally sensitive laryngeal closure reflex. This is also a straightforward diagnosis. Episodes are abrupt but brief, typically lasting about one minute (range 10 to 90 seconds), though occasionally occurring in series spanning several minutes. That is, as one is resolving, another can be triggered. Treatment is inspiratory straw breathing or in the rare case where the patient is experiencing several per week, a neuromodulator such as amitriptyline or gabapentin. Laryngospasm, once correctly identified and explained, mutes the patient’s fear and abolishes the healthcare system’s burden.

If Behavioral / Nonorganic…

First, a preliminary attempt to explain why nonorganic disorders often bog down our medical system… Many clinicians are exquisitely trained to detect organic disease yet may be less equipped with the “radar” and diagnostic tools needed to first sense, then behaviorally and via elicitation validate, and finally, formulate and oversee treatment of nonorganic or relationally sustained disorders. “Radar” for this nonorganic disorder seems to be comprised of the clinician’s general discernment, rapport with his or her own breathing and voice including basic ability to mimic, empathy, and a personality-based willingness to be direct and to take the time required to work effectively with the patient and family or significant other. Therefore, not every clinician will be equally capable of, or interested in, focusing on this caseload.

Does the condition historically labeled PVCM or VCD bear the hallmarks of a nonorganic disorder? In the author’s large patient population, yes, based on the following recurring characteristics.

1. Abrupt onset and sometimes, offset

   Episodes typically begin suddenly, sometimes instantaneously—and often at moments of heightened stress or public visibility, such as while approaching the finish line of a track event. Except for laryngospasm (again, a readily distinguished alternate diagnosis), such abrupt onset is a strong hallmark of nonorganic disorders, including those that affect not only breathing but also voice.

2. Often dramatic manifestations

   Although patient distress varies within and across individuals—from mild to profound—the observable (visual and auditory) display in those reaching tertiary care can often be strikingly intense, elaborate, and at times almost theatrical. The patient’s gasping, posturing, and breathing noises may appear grave—even life-threatening—to the lay observer, family, or to an inexperienced clinician. With familiarity, however, the examiner perceives the incongruity: normal skin color, stable oxygen saturation, possibly a peculiarly produced yet functional voice, and overall physiological stability all stand in contrast to the apparent extremity of distress, rendering even the most severe episode appear—respectfully but unmistakably—unconvincing.

3. Triggers and associations

   Episodes are often reported as exercise-induced, particularly during athletic competitions such as track, soccer, or swimming—most often in high-performing student athletes. Patients may also attribute attacks to irritant exposures such as smoke, perfume, or cold air. (This could happen of course with the easily diagnosed laryngospasm). Typical remarks include, “My boss has banned my coworkers from wearing perfume.” Such trigger narratives, while sincerely offered, often reflect the patient’s tendency to specify an external cause for what is a behavioral (nonorganic) disorder.

4. Extensive but fruitless medical evaluation elsewhere

   These patients have often undergone extraordinary levels of medical attention—multiple visits, tests, and specialist consultations—yet without resolution. This pattern of disproportionate medical effort yielding minimal clarity can itself be a hallmark of many nonorganic conditions. And even when the disorder has been confidently—though incorrectly—diagnosed as asthma, the clinician will want to ask him- or herself: “Why are the standard treatments such as bronchodilators, systemic steroids, etc. not working as expected?”

   Speech therapy directed at PVCM/VCD may devolve into a “whack-a-mole” process, yielding temporary improvement without generalization or lasting cure. In such circumstances, both patient and speech pathologist can inadvertently drift into an enabling alliance, becoming (along with others) “co-satellites” to the problem.

   At the extreme of “medicalization,” the author has seen patients intubated and one who even received a tracheotomy for this nonorganic disorder.

   The inconsistency or absence of therapeutic benefit further distinguishes these episodes from true organic airway disease. All too often, repeated medicalization and/or psychologization lead to a downward spiral of medication side effects, loss of employment, relational strain and, in some cases, estrangement or divorce.

5. Apparent secondary gain

   The clinician attuned to nonorganic phenomena may wonder if the episode affords an advantage—a reprieve from the sting of failure or humiliation, a surge of attention and sympathy. Or the disorder may be the focus and support for a lawsuit or disability claim. In yet other cases, the episodes may appear to provide escape from an unwanted obligation: an examination, a performance, or some dreaded challenge. Whether triggered consciously or unconsciously, illness behavior can afford the patient powerful “rewards.” It is beyond the scope of this article to dissect out all the subtypes of secondary gain is, but just to suggest that detectable secondary gain may validate the diagnosis of non-organicity.

6. Relational gain as a major subset of secondary gain

   Expanding on #5 above: Nonorganic disorders often extend to the relationships that surround patients who have them. The symptom may appear to secure connection, empathy, or control. The sufferer’s distress keeps others close: the parent, spouse, or partner who is deeply empathic and unsuspecting becomes the vigilant caregiver. Over time, this pattern may crystallize into codependency or enabling, in which illness becomes relational glue. It is possible that both parties are sincere—the sufferers in their distress, and the caregivers “satellites of compassion”—yet the dynamic leads away from relational health. Recognizing this requires the ability to perceive both the biology and the psychodynamics of the disorder, and to stand apart and keep some objectivity rather than being drawn in, inappropriately. As the author has often said, “Leading with empathy—and nothing but empathy—can go to bad places.”

A Suggested Diagnostic Process and Treatment Protocol

The author’s long-held aphorism—perhaps borrowed—is that “precise treatment depends upon precise diagnosis.” That is why use of the term “nonorganic” is necessary to support the treatment process described here.

In presenting the approach that follows, some readers may regard it as too complicated or time-consuming. Yet, as with learning to drive, what begins as deliberate and effortful soon becomes nearly automatic—and so it is with the management of nonorganic breathing disorders.

Others may find the approach overly direct, “frontal,” and even harsh. To this, the author would reply that many patients and those in relationship with them are being governed by the disorder. In fact, it can reach the point of being in bondage to it. Just as surgeons sometimes wound to heal, so the clinician may, in certain cases, be justified in “going for broke” to liberate spouse, children, and colleagues—from being consumed by this disorder.

A comment about the directness and commitment to efficiency of the approach below. Years ago, I presented (with my team) a course on nonorganic voice disorders. It was a similarly directive approach. Afterwards, a speech pathologist approached me at the front of the room and said, “Thank you so much for this course. Every year I come to a course on this subject, and it’s just about empathy, empathy, empathy. The approach you taught today is so refreshing!”

Proposed Approach for Diagnosis and Treatment

The author recognizes again that the following may seem complicated and time-consuming. For clarity, it is necessary to explain it in a way that seems so. But with modest experience, this process becomes second nature, and efficient.

Cultivate Nonorganic “Antennae” or Identify Someone Who Has Them

Many clinicians can develop “nonorganic radar” as described above. At the same time, they can develop a commitment to resist medicalization or psychologization. To repeat: A clinician’s personal rapport with his or her own breathing and voice, and an ability to mimic what patients demonstrate are invaluable assets.

Of course, some clinicians may prefer to defer to colleagues with greater experience and insight into nonorganic or behavioral disorders.

Confirm the Diagnosis Using a Diagnostic Model

1. Take the trouble to mine the history.

   The clinician begins by gathering clues that suggest a nonorganic origin. Helpful indicators summarized detectable may include abrupt onset (“like flipping a switch”); recognizable relational or situational triggers interwoven with what appears to be secondary gain; a review of prior tests and treatments whose findings are typically non-validating of organic disease; and a gradual escalation in frequency or severity of episodes over months or years. Such a history helps distinguish organic from nonorganic disease.

2. Use elicitation and mimicry—gently and above all, respectfully

   A skilled clinician can often reproduce the patient’s characteristic breathing or voice sounds—sometimes prompting astonished recognition from family members as their insight begins to dawn. The examiner may also use a volley of breathing and phonatory elicitations, requesting that the patient respond rapidly to each. Rapid “panting,” forced expiration or inspiration, throat clearing, straw breathing, coughing, sirens, and much more. This typically demonstrates that the patient’s responses are inconsistent, paradoxical, idiosyncratic, or mixed with protestations (“I can’t do that.”) Or that there are long latencies between the elicitation and the patient’s response. The peculiar phenomenology of patient responses can engender stirrings of insight in the patient and in all but the most co-opted, highly empathic observers.

3. Examine to rule out, or recognize as red herrings, any organic findings

   In most cases, the physical examination will be normal. Most valuable are examinations during an attack, showing inappropriate adduction of the vocal folds during inspiration; yet even at the height of an episode, one can often see brief flickers of full abduction after a cough or during distracting vocal tasks. If the examination is occurring between episodes when breathing is normal, vocal fold motion is entirely normal. In this instance, the patient will be told that if possible, we will make ourselves available during any future attack. Recognizing this pattern—paradoxical adduction during attacks with preserved baseline mobility—is key to confirming the diagnosis.

Place the Diagnosis on the Table

Once the diagnosis is clear, the clinician should name it directly and respectfully. It is best to do so forthrightly in a positive, face-saving way. As illustrated in the sample script below, the clinician should (1) name the problem, (2) place the patient in good company so they do not feel exposed or singled out, and (3) gently transfer responsibility for recovery, with guidance and support, to the patient and family.

Warn Against Medicalization or “Psychologization.”

It is important to emphasize to patient and family/friends that there is no solution through medicine, surgery, or psychotherapy. As we often tell patients, “The solution is teaching and behavioral training, not medicine or surgery.” Otherwise, the patient may unconsciously offload responsibility for recovery onto others, viewing the problem as something that happens to them rather than something they can learn to control. In the author’s experience, psychologists and psychiatrists have an important role in society, but have not in any patients he has seen succeeded in bringing about remission of this disorder. The focus must remain behavioral, not medical or psychological. That said, once the disorder resolves, psychological insight often follows. The downward spiral stories as described next include further warnings against medicalization.

Consider Telling Stories of the “Downward Spiral” (Medical, Relational, or Social)

Selectively, depending on individual circumstances, it can be useful to tell real clinical anecdotes—especially when a patient already seems deeply committed to medicalization or if they seem particularly attached to the secondary gain engendered by their problem. Examples:

• A woman in her forties who, after months of high-dose steroid therapy developed aseptic necrosis of both hips, requiring bilateral hip replacement.
• Another who was admitted to the intensive care unit multiple times for what was later recognized as a nonorganic breathing disorder.
• And one who underwent tracheotomy for the same functional condition.
• Divorce by a spouse to emancipate himself from an all-consuming issue.
• Loss of job and friends.

Such stories are not shared to shame, but to protect and motivate by awakening the patient’s understanding that continued pursuit of a medical solution can have grave and unnecessary consequences. When offered with empathy and credibility, these narratives can motivate willingness to try a behavioral path to recovery.

Communicate with the Patient’s Other Physicians.

The treating clinician should send letters to the primary physician and to all other specialists who have evaluated the patient. The goal is to align understanding across disciplines—to ensure that everyone is on the same page and to halt the cycle of testing and medicalization.

Occasionally, a patient may shift hospital systems in an effort—conscious or unconscious—to escape this coordinated approach. Even then, communication among clinicians remains vital; it may be the only means of interrupting the pattern of repeated investigation and medicalization.

Be prepared for objections and even hostility. Most diagnostic encounters proceed smoothly. The clinician conveys respect for the patient and for accompanying family members or partners, and the discussion ends constructively and with a clear plan. Yet, on some occasions, the interaction may take a sudden turn toward hostility.

In the author’s experience, this reaction does not stem from disrespect or mishandling by the clinician, but rather from the perceived threat to secondary gain. Two representative responses illustrate the point:

• From a patient suddenly turned hostile: “You know I’m on disability for this—are you saying I have to go back to work?” (In fact, no mention of employment had been made.)
• From an angry spouse, sharing in the secondary gain: “You know, Doctor, we have a two-million-dollar lawsuit resting on this.” (This, in reference to a transient and fully resolved work injury.)

Such reactions, while uncommon, underscore the psychological and relational entanglements that can accompany nonorganic disorders. Recognizing them calmly—and without counter-reaction—allows clinicians to non-defensively “stand their ground” and maintain both therapeutic poise and diagnostic clarity.

Initial Script After Evaluation and Making the Diagnosis

I’m so pleased to share with you a diagnosis that we can identify clearly—one with which we have enormous experience and great success in treatment.

As background, in this room—the voice lab—we see all kinds of problems: tumors, injuries, neurological disorders, inflammatory conditions, and many others. All of those are disorders of the mechanism; they require medicine or surgery. I’m glad to tell you that your disorder is nothing like those.

This is a diagnosis we love to make, because it can be fixed with teaching and training, rather than medicine or surgery—and often quite rapidly, even when it has been present for ______ months, as in your case. It’s a disorder we know well; in fact, we’ve helped I’m sure more than 200 others with the same problem.

Your diagnosis is what we call nonorganic. That means the problem is not in the mechanism—such as a tumor or nerve injury—but in the use of the mechanism. It’s like the difference between poor posture and a bent, arthritic spine: one can be retrained, the other cannot. Just as we can teach and train posture, we can teach and train your breathing. And again, we love it that the fix is usually quick and decisive.

<I want to work with you briefly to see if we can fix the problem right now.> Or, we’re going to have you see a speech pathologist who is very experienced with this disorder. You’ll probably need only two sessions at most. The final step of your work with her involves what we call positive and negative practice. What does that mean? When you practice making hoops basketball, you try to make every shot. But in this case, we’ll practice both—sinking the basket and missing intentionally—so that you gain full control. For you, that means alternating rapidly between normal and abnormal breathing.

<Here, the clinician demonstrates—alternating between normal breathing and as-close-as-possible mimicry of the patient’s breathing noises. This mimicry often defines the disorder more powerfully than words.>

You’ll then practice this positive and negative exercise so that you have complete mastery of your breathing and the problem will no longer return. And if you’re unable to perform positive and negative practice (alternating between normal and abnormal breathing) or if the problem isn’t resolved within two sessions, I will need to see you again promptly.

The Elements Contained Within This Script

1. A Gentle Claim to Expertise

   Why? The patient may have seen multiple clinicians, received conflicting explanations, and grown either confused or attached to the role of being “unsolved.” This script establishes confident diagnostic clarity—essentially conveying: “This is the diagnosis that supersedes all others.”

2. Reassurance Through Inclusion and Face-Saving

   By stating that “we have seen hundreds of others with your problem,” the clinician places the patient in good company, normalizing the experience and preventing defensive barriers. Respect for the individual is maintained, while offering a graceful exit for those ready to relinquish the problem but uncertain how.

3. A Subtle Line in the Sand

   The assertion “we have helped at least 200 others” quietly sets an expectation of success. It functions as a therapeutic boundary disguised as optimism—the implicit message being, “You will improve too.”

4. A Face-Saving Analogy

   Comparing the disorder to poor posture rather than illness or deception preserves dignity. The analogy reframes the condition as a problem of skill and habit, inviting cooperation rather than defensiveness.

5. Expectation of Rapid Resolution

   A defined time frame—typically two sessions, occasionally three—prevents drift into open-ended, potentially codependent therapy. The underlying message is empowering: “You are capable of mastering this quickly.”

6. Diagnostic Mimicry

   The clinician’s demonstration—alternating between normal and abnormal breathing—silently confirms the diagnosis and models control. The patient hears and sees, in the clinician’s own body, both the cause and the cure.

7. Alignment of the Treatment Team

   The chosen speech pathologist must share the same diagnostic clarity and therapeutic stance: respectful directness, high expectation for rapid resolution, and confidence in the patient’s capacity for recovery. Consistency among clinicians reinforces credibility and accelerates success.

What If the Patient Fails to “Cure”?

First, one must expect occasional failure—most often in patients highly motivated to protect secondary gain. In the author’s experience, initial resolution occurs in roughly 90% of cases. Many patients are then lost to follow-up after early success, making long-term durability difficult to verify. A smaller number never proceed to speech-pathology intervention—either because the problem resolves spontaneously after the consultation (especially in younger patients) or because secondary gain is so much more “valuable” (consciously or unconsciously) than “primary loss.”

Some patients do return unresolved. When that happens, the clinician must remain objective and outside the disorder, avoiding any gravitational pull to become a participant. The task is to reaffirm the diagnosis and reaffirm treatment, not to re-enter the cycle of reassurance, testing, or speculation.

Discussion should center on the patient’s experience with the speech pathologist and how both patient and significant others have processed the first visit and subsequent therapy. At times it is helpful to revisit the original video and re-define “nonorganic” in direct terms.

At this point, a more direct and reality-based conversation may be warranted. This can feel “frontal,” even “harsh,” but this again must be understood in context: these patients are often caught in a deep downward spiral. They have re-entered the medical system repeatedly—at great cost of time, relational strain, physical risk, and financial burden, sometimes reaching tens of thousands of dollars through emergency and ICU care. Families are in bondage; the patient is in bondage. The stakes are high.

Follow Up Script for Failure to Resolve

When we diagnose a disorder such as yours, but the problem is not resolved even after expert treatment, one might wonder whether the diagnosis is wrong.

I want you to know that I am a physician who is very comfortable saying, ‘I don’t know,’ or ‘I’m not sure.’ But this is a case where I am sure. So, why has the problem not resolved?

What we have learned from our dozens of other patients is that, for a few people, the secondary gain has become too much to relinquish. Do you understand that concept?

<If not, I explain primary loss—such as the ability to breathe normally, lost school days, or workdays lost by a spouse. Then I explain that secondary gain is what comes as a result of that loss. For example—and I always clarify, ‘not necessarily you, but in others I have seen’—attention, disability payments, or legal advantage.> In some cases, for reasons I may not fully understand in your situation, secondary gain can make primary loss worth it.

To review our treatment plan: the idea is not that we fix this for you, but that we act as expert coaches—helping you rediscover normal breathing and take command of it. If you remember the old Star Trek series, we try to do a ‘Spockian mind meld’ to help you find your way back to normal function.

So, when recovery does not occur, it is not that the diagnosis is wrong, nor that we don’t know how to help, since we have done so successfully with so many others as a regional center known for this problem. It means that, for some reason, we have not yet formed a complete team between you and the speech pathologist.

For now, I propose that we take a pause. Let’s simply leave things as they are. Know that we would absolutely love to help you move past this, and that we are ready whenever you are to work on this again.

This is a disorder we take very seriously because of the downward spiral it can cause. <At this point, I often share or repeat a few brief stories—patients who required unnecessary tracheotomy, repeated ICU admissions, or whose families suffered major relational and financial loss.>

When you feel ready to try again, simply make another appointment with the speech pathologist or me. We’ll be here.”

This second script may again feel uncomfortable to highly empathic clinicians. If so, it is helpful to keep an eye on the stakes: too often, nonorganic breathing disorders have already been, and continue to be, managed with a level of complexity disproportionate to their behavioral nature. The entire scenario becomes ponderous for the patient, exhausting to the family, and frustrating to the medical system in which the patient finds themselves. What is needed instead is more clarity and less complexification—less a therapeutic symphony and more a small, disciplined chamber ensemble of direct behavioral correction.

Conclusion

The approach described here is intentionally direct, efficient and yet humane. Empathy—for the patient, but also family and even medical system, are needed along with unwavering respect for all parties.

The clinician must be unwilling to lead with empathy alone, focusing more immediately on precise diagnosis using the term “nonorganic,” and proceeding with both expectation and tools for resolution. The story above of the speech pathologist who described the usual and ineffective (in her experience) use of “empathy, empathy, empathy” captured the essence of what this work tries to avoid.

Too much empathy can unwittingly sustain and prolong the multidirectional bondage of this disorder. The clinician must never embarrass or dismiss the patient, but rather lead all involved towards emancipation from having to center their lives around this disturbance and its potential medicalization and psychologization. The result of the consultation must include “permission” and even a kind of gentle instruction to family, friends, other healthcare workers to gently pull away not from the patient, but from becoming satellites to the patient’s disorder.

Given the nature of this disorder, we cannot expect perfect results every time. Still, most often the result is not merely symptom relief but the restoration of agency and differentiation of patient from “behavior” and liberation of those who may have been enmeshed in this scenario.

Is follow-up needed after the abnormal breathing behavior is abolished? Surprisingly infrequently, especially when the person involved is a teenager. In older patients for whom this nonorganic disorder has become more entrenched as a dysfunctional means of managing their lives, the behavior may recur and a patient will return for a second, straightforward visit.

What about psychotherapy?

There will be those who think so, wondering about “a cry for help” or “hidden abuse.” We prefer to think of all that has gone on above as a kind of “cognitive-behavioral” approach that suffices. That said, some patients—and certainly their families—may find counseling to be useful, not to treat the breathing disorder itself; not to develop a life of its own as a focus around which patient and family begin to revolve as another kind of bondage; but to “put a ribbon” on understanding of nonorganic behavior. And perhaps to briefly explore relational patterns or deficits.

In the end, it seems that focusing on insight (giving the disorder a precise name) and abolishing dysfunctional behavior restores family life and releases all involved from the bondage imposed by the disorder.