Hypnosis as a Diagnostic Modality for Vocal Cord Dysfunction

CASE REPORT

An 11-year-old boy was admitted to the pediatric intensive care unit for elective fiber-optic laryngoscopy to confirm a diagnosis of VCD. The patient had a 4-year history of refractory asthma, gastroesophageal reflux disease (GERD), and suspected VCD.

The patient was diagnosed with asthma at 7 years of age, based on a history of cough and wheezing associated with recurrent upper respiratory tract infections that responded to therapy with inhaled bronchodilators. He also reported shortness of breath in association with physical exertion. On physical examination the patient demonstrated transient diffuse end-expiratory wheezing. Pulmonary function testing revealed a partially reversible moderate obstructive pattern.

At 9 years of age the patient began manifesting monthly respiratory distress episodes of a severe character different from those that had been attributed to his asthma. Typically, he awoke from sleep with shortness of breath and difficulty with inhalation. He described a “neck attack” during which he felt as if the walls of his throat were “beating together.” The patient was at times noted by his mother to exhibit a “suckling” behavior before onset of his respiratory distress episodes. On 4 occasions the patient became unconscious during an attack and then spontaneously regained consciousness after a few minutes. On these occasions, the severe difficulty with inhalation resolved within a few minutes on treatment in the hospital with oxygen and bronchodilators. Sometimes he was noted to manifest wheezing for several hours, which was responsive to bronchodilator therapy.

Despite therapy, including pulses of oral corticosteroids, long-term inhaled corticosteroids, long-acting bronchodilators, and leukotriene receptor antagonists, the severe episodes recurred. Allergy skin scratch tests revealed that the patient was sensitive to dust, dust mites, and mold. Environmental precautions were undertaken to minimize exposure to these allergens and the patient was started on a long-acting antihistamine with no clinical response. Chest radiographs, neck radiographs, and a barium swallow were all normal. Complement and C₁ esterase levels were normal. Cranial magnetic resonance imaging and an electroencephalogram were normal. A bronchoscopy revealed no structural abnormalities of the airway. Nasopharyngeal flexible laryngoscopy when the patient was asymptomatic revealed a minor nodularity of the right true vocal cord, which was not believed to be related to the episodes of respiratory distress.

A 72-hour pH probe study demonstrated severe gastroesophageal reflux. The patient was started on cisapride and omeprazole and subsequently experienced a decrease in the frequency of respiratory distress episodes. Nevertheless, the patient continued to experience episodes requiring hospitalization. After 18 months of medical antireflux therapy the patient underwent a Nissen fundoplication with the hopes that prevention of gastroesophageal reflux would result in an improvement of his respiratory symptoms. However, he was readmitted to the hospital 2 weeks after surgery in respiratory distress because of difficulty with inhalation.

A diagnosis of VCD was suspected at that time, but laryngoscopy could not be performed during severe episodes because of their brief nature. The patient was referred to a speech therapist. Although his episodes decreased in frequency after the initiation of speech therapy, the patient continued to experience severe episodes. The patient then was referred to a child psychiatrist, who met with the patient and his mother on one occasion. The psychiatrist believed that anxiety caused by the patient's relationship with his mother was probably a component of the patient's presentation. He assessed the patient's mother as overprotective, while the patient engaged in risk-taking behaviors, which apparently were designed to gain a sense of freedom from domination by the relationship with his mother. Likewise, the patient was overprotective of his mother, as he described behaviors she exhibited that were upsetting to him. For example, when his mother discussed her ambivalent relationship with her boyfriend, the patient interrupted and wanted to know when she would be done with the boyfriend. In treatment of the patient's anxiety, the psychiatrist recommended that the patient maintain his ongoing good relationship with his pulmonologist and that the patient be taught stress reduction techniques. The patient's mother found the interview with the psychiatrist helpful but chose not to make another appointment.

It was proposed to the patient that his respiratory symptoms might be related to anxiety, and, therefore, potentially controllable with stress reduction techniques. The patient agreed to undergo instruction in self-hypnosis for this purpose. He was found to be very open to hypnotic suggestion. For example, he reported that he could not separate his hands when he held them together and he imagined them to be strong magnets; his right arm levitated easily when he imagined helium balloons tied to his wrist; and he reported that he was unable to perceive the “outside world” when he imagined himself in a comfortable place. The patient practiced how he might terminate episodes of severe respiratory distress with self-hypnosis. He learned to induce warmth and relaxation of his neck when he touched it. He then imagined developing respiratory distress and eliminating it by touching his neck. The patient was advised to practice hypnosis on a regular basis and to apply it as needed for respiratory distress. During the subsequent 6 months, the patient reported that he was able to control some severe episodes with hypnosis but continued to have occasional nocturnal episodes, which he said he could not control because he was asleep when they started.

Given the severity of the patient's disease, it became imperative to determine whether VCD was the cause. It was proposed that an attempt be made to induce VCD by hypnotic suggestion, while the patient underwent a fiberscopic laryngoscopy to establish a definitive diagnosis. The patient and his mother gave written consent for this procedure. He was admitted for observation to the pediatric intensive care unit for the induction attempt. The patient requested that no local anesthesia be applied in his nose before passage of the laryngoscope because he wanted to eat right after the procedure. Therefore, the nasopharyngeal laryngoscope was inserted while he used self-hypnosis as the sole form of anesthesia. He demonstrated no discomfort during its passing. Once the vocal cords were visualized, the patient was instructed to develop an episode of respiratory distress while in a state of hypnosis by recalling a recent “neck attack.” His vocal cords then were observed to adduct anteriorly with each inspiration. The patient then was asked to touch his neck. When he did, the vocal cords immediately abducted with inspiration and he breathed easily. After removal of the laryngoscope, the patient alerted from hypnosis and said he felt well. He reported no recollection of the procedure, thus demonstrating spontaneous amnesia that sometimes is associated with hypnosis.

Because the diagnosis of VCD was confirmed, the patient was encouraged to continue use of self-hypnosis and speech therapy techniques to control his symptoms. He also was referred for counseling.