Vocal “vincibility” syndrome

Vocal “vincibility” syndrome is to believe mistakenly that one’s voice is inadequate to the demands of life. Typically, an individual with this syndrome becomes progressively averse to voice use. The term “vocal ‘vincibility’ syndrome” is not found in textbooks, but is coined here to describe this kind of self-sabotaging belief system.

A classic case of this disorder was a man who taught chemistry at the college level in the 1960s and felt vocally tired at the end of lectures. Though introverted and only moderately sociable by nature, and though lectures did not occupy more than two hours of any workday, he was advised to rest his voice. The problem only became worse, however, and he was advised to take even more stringent voice rest, despite the fact that this was not helping and that, from the start, the amount of voice use in a week for this man was quite modest. Eventually this man was forced by the stress he was experiencing and also by his progressive aversion to voice use to take a job as a research chemist, where the requirement to talk was minimal. When first evaluated at the age of about 65, this man had become semi-reclusive. His wife said that within 20 minutes of the start of any social gathering, he would find her in a mild panic and insist that they leave because his voice was failing him.

Treatment for this disorder is a “vocal boot camp” approach under the supervision of a voice-qualified speech pathologist. When the patient described above did his speech therapy sessions, the physician was also on hand, so as to allay the patient’s anxiety and to examine his larynx after each session. The patient’s belief system about his voice was reconfigured only as it was proven to him that, even after “marathon” sessions of strenuous voice use, his voice was not being harmed and his vocal cords remained unbruised and quite normal-looking. Once this patient’s “vocal vincibility” subsided, he experienced a remarkable “rebirth” as a person, without further social vocal limitations.

Vocal fry dysphonia

An abnormal production of voice during speaking, generating vocal fry (“pulse register”) phonation with only the true vocal cords. The voice quality from vocal fry phonation tends to be rough, very low-pitched, “gritty,” and monotonal. A typical pitch at which vocal fry occurs is around E2 (~82 Hz) or lower, and airflow required for vocal fry is minimal. An individual with vocal fry dysphonia cannot maintain vocal fry (that is, will move to more normal voice production) if asked to project the voice, or to raise pitch even a few semi-tones.

The only disorder occasionally confused with vocal fry dysphonia is false vocal cord phonation. Vocal fry dysphonia (when functional rather than the result of a disorder such as Parkinson’s disease) is most often seen in individuals from the “underdoer” end of the vocal “overdoer-underdoer” spectrum.

For those who desire treatment, speech/voice therapy is the course to take. The individual must first develop the ability to identify normal and abnormal pitch and quality, and then adopt a higher pitch and a bit more vocal vitality, with strategies such as imagining that they are “reading to children.”


Puberphonia is the inappropriate persistence of higher-pitched prepubertal voice long after puberty and normal voice change. Also called mutational falsetto. Such individuals maintain something like their high-pitched, childhood voice by speaking in falsetto register.

The cause of puberphonia is never known with precision. Some think the condition arises more often in men whose voices mutate to the normal and mature male quality suddenly and precipitously, dropping abruptly into the bass or bass-baritone range. It is as though the person isn’t given time to adapt to the new sound of the voice. Some individuals with puberphonia can produce normal voice on request, but consider it “ugly,” or even their “monster voice.” Others need considerable coaching to find the normal voice. Once convinced by voice experts that the “monster” voice actually sounds great and is the “normal” one, most individuals can adopt the new voice fairly rapidly. The process of normalization typically involves only two or three sessions of speech/voice therapy, provided the therapist is highly experienced and voice therapy-qualified.


Disorder of vocal loudness perception

A lack of awareness or perception of one’s personal vocal “volume level” to the point that it is creating difficulty in one’s life. If asked to place oneself on a personal loudness scale from 1 to 7, most individuals can do so with reasonable accurateness. Occasionally, however, an individual (with normal hearing ability) lacks this kind of self-insight, and such an individual could be said to have a disorder of vocal loudness perception.

At one end of this spectrum was a patient who was an operatic tenor. He had a powerful, almost head-rattling voice even in close quarters in a quiet room, and he was aware that others thought him loud, but he clearly could not “relate” to this. When coaxed and coached repeatedly to use a moderate voice to read a passage out loud, he quite sincerely (and loudly!) said, “Oh, I could never do that! That’s whispering!” At the other end of the spectrum, there was a 30-something woman with a voice one had to strain to hear. When she was coaxed and coached to read the same passage with a moderately loud voice, her utterly sincere but almost whispered reply? “Oh, I couldn’t talk like that. That’s yelling.”

Vocal loudness can vary between individuals considerably and still be accepted as “within normal limits.” Yet the two individuals described above were considered to have a disorder of vocal loudness perception because their inappropriate vocal loudness was exceptional enough to cause life difficulty. The man had considerable vocal cord injury, and the young woman was struggling at her job, with customers who were occasionally angry about the impossibility of hearing her. The approach was the same with both of these individuals: both were asked to retrain their “set point” for personal vocal loudness by recruiting other people (and their ears) to the re-training task.

Vocal underdoer syndrome

Vocal underdoer syndrome is a term coined by Dr. Anat Keidar and Dr. Robert Bastian to designate an individual whose amount and manner of voice use can be considered inadequate to keep the mechanism in good condition. Typically, the vocal underdoer syndrome comprises two parts: innate introversion/taciturnity and a life circumstance that permits, invites, or demands very little voice use.

Voice Building:

Voice Building (shorter version):

Vocal overdoer syndrome

Vocal overdoer syndrome is a term coined by Dr. Anat Keidar and Dr. Bastian1 to designate an individual whose amount and manner of voice use can be considered excessive and to thereby put the person at risk of mucosal injury. Typically, the vocal overdoer syndrome comprises two parts: 1) innate talkativeness; 2) a life circumstance (occupation, performance, family, hobby, social) that permits, invites, or demands much voice use.



Nodules and Other Vocal Cord Injuries: How They Occur and Can Be Treated
This video explains how nodules and other vocal cord injuries occur: by excessive vibration of the vocal cords, which happens with vocal overuse. Having laid that foundational understanding, the video goes on to explore the roles of treatment options like voice therapy and vocal cord microsurgery.

  1. Bastian RW. The vocal overdoer syndrome: a useful concept from the voice clinic. Journal of Singing. 2002; 58(5): 411-13. 

Nonorganic voice disorder

A persistent voice change found not to be infectious, irritative, neurogenic, or the result of drug side effect. Instead, this represents a behavioral disturbance that may be associated with secondary gain. Often the vocal phenomenology of a nonorganic voice disorder-induced voice change is stereotypical and predictable in its manifestations; it is most often seen in young women.



Nonorganic Voice Loss (or Functional Dysphonia)
In this video, you will see what the larynx looks like when a person with a nonorganic voice disorder makes voice, you will hear the clinician beginning to coax out the patient’s normal voice, and you will hear the patient learning to control this re-discovered normal voice.

Muscular Tension Dysphonia (MTD)

The term muscular tension dysphonia (MTD) was coined by Morrison and Rammage at the University of British Columbia. This is a syndrome consisting of some or all of the following:

1) Excess tension, sometimes to the point of discomfort/ pain in the paralaryngeal and suprahyoid muscles;

2) An open posterior glottic chink during phonation;

3) High larynx position in the neck;

4) Inappropriate contraction of pharyngeal constrictors with phonation;

5) Often but not always, vibratory mucosal injury.

The vocal cord mucosal changes associated with MTD are usually fleshy vocal nodules. This syndrome is seen most often in young women.

Photos of muscular tension dysphonia: