Positive/ Negative practice

This behavioral treatment is prescribed primarily for patients with nonorganic voice disorders. A patient with a nonorganic voice disorder has been diagnosed with aberrant voice production due to the abnormal use of a normal mechanism, often due to stress or some sort of secondary gain. She or he may have been ‘stuck’ with the abnormal voice for months to years, or may lurch between normal and abnormal voice production on an apparently involuntary basis. To help patients first “find” their normal voices, the clinician guides the patient through a variety of vocal elicitations such as: a yell, glissando, siren, or vocal fry. All of this may be with or without clinician digital manipulation of the laryngeal framework. After preliminarily ‘settling in’ the patient’s reestablished normal voice, the clinician quickly asks the patient to alternate between the re-established normal voice and the old abnormal voice. First, the patient alternates upon clinician cue, again optionally with or without digital manipulation, and then the patient demonstrates the ability to switch between the two kinds of voice production at the sentence level, and then every few words, and then word-by-word. The positive and negative practice demonstrates mastery / control over the abnormal/ nonorganic voice production. If possible, this process should occur with patient, clinician, and family/ friends in attendance. Other doctors, speech pathologists, pulmonologists, and allergists who may have previously attempted to help the patient using medical rather than behavioral treatments should also be made aware of the nature of the patient’s diagnosis, the purely behavioral approach to it, and the idea that behavioral intervention to resolve this problem completely should not normally exceed three visits to a speech pathologist, to avoid his or her becoming a co-dependent or source of secondary gain.

Listen to a few demonstrations below:

Mucosal chatter

The term ‘vocal cord chatter’ describes the audible phenomenon one hears when the voice starts and stops in rapid alternation because the mucosa is at the edge of its ability to vibrate at a given pitch, loudness, and subglottal air pressure. So, it “catches” the airstream and vibrates for a fraction of a second, then stops, then restarts, then stops, etc. The best understanding is gained through audio and video examples.

Patient examples:

Segmental vibration


Vocal instability

This characteristic might manifest most clearly during sustained phonation as a glitch, catch, wavering, tremor, in-and-out vocal fry, or other such finding. In each case, the patient would be unable, partially able, or only intermittently able to produce a steady and predictable voice.

Dystonic tremor of the voice or larynx

A tremor that sometimes accompanies laryngeal dystonia and its effects on voice function (spasmodic dysphonia), breathing function (respiratory dystonia), or both. This dystonic tremor is heard as a “wavering” in the voice (if the person has spasmodic dysphonia) or in the sound of inhaled or exhaled air (if the person has respiratory dystonia), or it can be detected in both the voice and the sound of inhaled or exhaled air (if the person has both spasmodic dysphonia and respiratory dystonia). A patient who exhibits this kind of tremor in tandem with spasmodic dysphonia, for example, may be described by the examining clinician as having “spasmodic dysphonia with a small/moderate/large/overwhelming tremor component.” Dystonic tremor can also appear in other parts of the body (e.g., as head or limb movements) when a person’s dystonia affects those parts, but our focus here is on dystonia of the larynx.

Voice-affecting dystonic tremor might sometimes be mistaken for the tremor induced by a different neurological disorder, essential voice tremor. If one knows what to listen for, however, it is usually possible to distinguish dystonic tremor from the tremor induced by essential voice tremor. Most obviously, dystonic tremor is almost always accompanied by other manifestations of dystonia, such as phonatory arrests, dropouts to a whisper, or squeezedowns. Dystonic tremor may worsen under specific circumstances—with stress, fatigue, or during telephone use, for example. Dystonic tremor is often (though not always) more pronounced in the patient’s chest register voice than falsetto register voice—sometimes dramatically so—and this difference might be heard when the patient is asked to sustain a single sung note as steadily as possible. Finally, dystonic tremor’s amplitude can vary from cycle to cycle; to use singers’ parlance, it is as though a couple of cycles of “wild” vibrato are followed by a few cycles of merely wide vibrato, followed by a second or two of much more stable voice. In the occasional case, however, a patient’s tremor is so overwhelming and these distinctive qualities of dystonic tremor so subtle that the clinician proceeds initially with a working, rather than settled, diagnosis.

Vocal tremor

Vocal tremor: A regular, wavering quality of voice, analogous to a singer’s vibrato but occurring, to an individual’s distress, during speaking, not just during singing. May occur as a sole abnormality in essential voice tremor, or in combination with spasmodic dysphonia.

Teaching demonstration (mimicked):

Patient example dystonic tremor: Note accompanying squeezedowns and difference in two registers

Vocal fry

The name given to a quality of sound produced at low pitch (generally below 90 Hz, or around E2 or F2 in musical notation). Vocal fry is produced in what some call pulse register, as compared with chest and falsetto registers. Once defined with the help of audible examples, most individuals can readily identify this quality of voice. It may be heard in poorly produced voices; in other cases, it is used intentionally as a training technique, particularly for air-wasting dysphonia that has a functional cause.