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Dysarthria happens when the muscles used for speech are weak or are hard to control. Dysarthria often causes slurred or slow speech that can be difficult to understand.

Common causes of dysarthria include conditions that affect the nervous system or that cause facial paralysis. These conditions may cause tongue or throat muscle weakness. Certain medicines also can cause dysarthria.

Treating the underlying cause of dysarthria may improve your speech. You also may need speech therapy. For dysarthria caused by prescription medicines, changing or stopping the medicines may help.

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Symptoms of dysarthria depend on the underlying cause and the type of dysarthria.

Symptoms may include:

• Slurred speech.
• Slow speech.
• Not being able to speak louder than a whisper or speaking too loudly.
• Rapid speech that is difficult to understand.
• Nasal, raspy or strained voice.
• Uneven speech rhythm.
• Uneven speech volume.
• Monotone speech.
• Trouble moving your tongue or facial muscles.

When to see a doctor

Dysarthria can be a sign of a serious condition. See a healthcare professional right away if you have sudden or unexplained changes in your ability to speak.

Dysarthria can be caused by conditions that make it hard to move the muscles in the mouth, face or upper respiratory system. These muscles control speech.

Conditions that may lead to dysarthria include:

• Amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease.
• Brain injury.
• Brain tumor.
• Cerebral palsy.
• Guillain-Barre syndrome.
• Head injury.
• Huntington's disease.
• Lyme disease.
• Multiple sclerosis.
• Muscular dystrophy.
• Myasthenia gravis.
• Parkinson's disease.
• Wilson's disease.

Some medicines also can cause dysarthria. These may include certain sedatives and seizure medicines.

Risk factors

Dysarthria risk factors include having a neurological condition that affects the muscles that control speech.

Complications

Complications of dysarthria may come from having trouble with communication. Complications may include:

• Trouble socializing. Communication problems may affect your relationships with family and friends. These problems also may make social situations challenging.
• Depression. In some people, dysarthria may lead to social isolation and depression.
• Jankovic J, et al., eds. Dysarthria and apraxia of speech. In: Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed March 27, 2024.
• Dysarthria. American Speech-Language-Hearing Association. https://www.asha.org/public/speech/disorders/dysarthria/. Accessed April 6, 2020.
• Maitin IB, et al., eds. Current Diagnosis & Treatment: Physical Medicine & Rehabilitation. McGraw-Hill Education; 2020. https://accessmedicine.mhmedical.com. Accessed April 10, 2020.
• Dysarthria in adults. American Speech-Language-Hearing Association. https://www.asha.org/practice-portal/clinical-topics/dysarthria-in-adults/. Accessed March 27, 2024.
• Drugs possibly associated with dysarthria. IBM Micromedex. https://www.micromedexsolutions.com. Accessed April 4, 2024.
• Lirani-Silva C, et al. Dysarthria and quality of life in neurologically healthy elderly and patients with Parkinson's disease. CoDAS. 2015; doi:10.1590/2317-1782/20152014083.
• Signs and symptoms of untreated Lyme disease. Centers for Disease Control and Prevention. https://www.cdc.gov/lyme/signs_symptoms/index.html. Accessed March 27, 2024.
• Neurological diagnostic tests and procedures. National Institute of Neurological Disorders and Stroke. https://catalog.ninds.nih.gov/publications/neurological-diagnostic-tests-and-procedures. Accessed March 27, 2024.

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Difficulty Talking, Speaking, Moving Mouth and Tongue Anxiety Symptoms

Difficulty speaking and talking, or moving the mouth, tongue, or lips are common symptoms of anxiety disorder , including generalized anxiety disorder , social anxiety disorder , panic disorder , and others.

This article explains the relationship between anxiety and the difficulty talking symptom.

Difficulty speaking, talking, moving mouth, tongue, or lips anxiety symptoms descriptions:

• Having difficulty or unusual awkwardness speaking; pronouncing words, syllables, or vowels.
• Having difficulty moving your mouth, tongue, or lips.
• Suddenly become self-conscious of your problems talking, speaking, moving your mouth, tongue, or lips.
• Uncharacteristically slurring your speech.
• You are uncharacteristically speaking much slower or faster than normal.
• You are uncharacteristically jumbling up words or fumbling over your words when speaking.
• You find that your mouth, tongue, or lips aren’t moving the way they normally would.
• Your mouth, tongue, lips, or facial muscles aren’t responding the way they normally do.
• It can feel as if your face muscles are unusually stiff, which is making talking difficult and forced.
• It can feel as if your face has been anesthetized somewhat, making speaking or moving your mouth, tongue, or lips difficult.

This symptom is often described as “slurred speech.”

This symptom can persistently affect just the mouth, lips, or tongue only, can affect more than one at the same time, can shift from one to another, and can involve all of them over and over again.

Having difficulty speaking can come and go rarely, occur frequently, or persist indefinitely. For example, you might have difficulty speaking once in a while and not that often, have difficulty speaking or moving your mouth, tongue or lips off and on, or have difficulty all the time.

Difficulty speaking can precede, accompany, or follow an escalation of other anxiety sensations and symptoms, or occur by itself. It can also precede, accompany, or follow an episode of nervousness, anxiety, fear, and elevated stress, or occur “out of the blue” and for no apparent reason.

This symptom can range in intensity from slight, to moderate, to severe. It can also come in waves where these mouth and speaking symptoms are strong one moment and ease off the next.

This symptom can change from day to day and from moment to moment.

All of the above combinations and variations are common.

Difficulty speaking or moving your mouth, tongue, or lips can seem more troublesome when in social, professional, or public settings.

To see if anxiety might be playing a role in your anxiety symptoms, rate your level of anxiety using our free one-minute instant results Anxiety Test , Anxiety Disorder Test , or Hyperstimulation Test .

The higher the rating, the more likely it could be contributing to your anxiety symptoms, including having difficulty talking or moving your mouth, tongue, or lips.

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Why does anxiety cause difficulty speaking, talking, or moving your mouth, tongue, or lips?

Medical Advisory

When this symptom is caused by anxiety, there are many reasons why anxiety can cause this symptom. Here are two of the most common:

1. Stress response

Behaving anxiously activates the stress response , also known as the fight or flight response . The stress response causes body-wide changes that prepare the body for immediate emergency action.[ 1 ][ 2 ] Because of the many changes, stress responses stress the body.

A part of these changes include altering brain function so that our attention is primarily focused on danger detection and reaction, and stimulating the nervous system so that the body is energized and can react quickly.[ 2 ] These changes can affect muscle movements, including the muscles in the mouth, tongue, and lips.

Many people experience difficulty talking and moving their mouth, tongue, or lips when anxious and stressed.

2. Hyperstimulation

Hyperstimulation can keep the stress response changes active even though a stress response hasn’t been activated. Chronic difficulty speaking, talking, and co-ordination problems with the mouth, tongue, and lips are common symptoms of hyperstimulation.

There are many other reasons why anxiety can cause this symptom. We explain these additional reasons under the symptom “Difficulty Speaking” in the Symptoms section (chapter 9) in the Recovery Support area of our website. The Symptoms section lists and explains all of the symptoms associated with anxiety.

How to stop the difficulty talking and moving the mouth, tongue, or lips anxiety symptoms?

When this anxiety symptom is caused by apprehensive behavior and the accompanying stress response changes, calming yourself down will bring an end to the active stress response and its changes. As your body recovers from the active stress response, this anxiety symptom should subside. Keep in mind it can take up to 20 minutes or more for the body to recover from a major stress response. This is normal and shouldn’t be a cause for concern.

When difficulty speaking or moving your mouth, tongue, or lips is caused by chronic stress (hyperstimulation), such as from overly apprehensive behavior, it can take much longer for the body to calm down and recover, and to the point where this anxiety symptom subsides.

Nevertheless, since this symptom is a common symptom of anxiety and stress, it needn't be a cause for concern or worry. This symptom subsides when you’ve eliminated the active stress response or hyperstimulation.

As the body recovers, difficulty speaking and talking, or moving your mouth, tongue, and lips problems disappear and normal functioning returns.

Many of those who struggle with anxiety worry that MS, ALS, a brain tumor, or other neurological condition may be the cause of their symptoms. Checking on the Internet may cause more anxiety, since co-ordination problems are common symptoms of these medical conditions.

But again, these types of symptoms are common for anxiety and stress. Therefore, they needn’t be a cause for concern.

For a more detailed explanation about all anxiety symptoms, why symptoms can persist long after the stress response has ended, common barriers to recovery and symptom elimination, and more recovery strategies and tips, we have many chapters that address this information in the Recovery Support area of our website.

If you are having difficulty containing your worry, you might want to connect with one of our recommended anxiety disorder therapists to help you learn this important skill. Working with an experienced anxiety disorder therapist is the most effective way to overcome what seem like unmanageable worry and problems with anxiety.

Common Anxiety Symptoms

• Heart palpitations
• Dizziness, lightheadedness
• Muscle weakness
• Numbness, tingling
• Weakness, weak limbs
• Asthma and anxiety
• Shooting chest pains
• Trembling, shaking
• Depersonalization
• Chronic pain
• Chronic fatigue
• Muscle tension
• Lump in throat

Additional Resources

• For a comprehensive list of Anxiety Disorders Symptoms Signs, Types, Causes, Diagnosis, and Treatment.
• Anxiety and panic attacks symptoms  can be powerful experiences. Find out what they are and how to stop them.
• How to stop an anxiety attack and panic.
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• Anxiety 101 is a summarized description of anxiety, anxiety disorder, and how to overcome it.

Return to our anxiety disorders signs and symptoms page.

anxietycentre.com: Information, support, and therapy for anxiety disorder and its symptoms, including Difficulty Talking, Speaking, Moving The Mouth Anxiety Symptoms.

1. Selye, H. (1956). The stress of life. New York, NY, US: McGraw-Hill.

2. Folk, Jim and Folk, Marilyn. “ The Stress Response And Anxiety Symptoms. ” anxietycentre.com, August 2019.

3. Hannibal, Kara E., and Mark D. Bishop. “ Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. ” Advances in Pediatrics., U.S. National Library of Medicine, Dec. 2014.

4. Justice, Nicholas J., et al. “ Posttraumatic Stress Disorder-Like Induction Elevates β-Amyloid Levels, Which Directly Activates Corticotropin-Releasing Factor Neurons to Exacerbate Stress Responses. ” Journal of Neuroscience, Society for Neuroscience, 11 Feb. 2015.

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Conversion Disorder: Symptoms, Causes, Treatment

Akeem Marsh, MD, is a board-certified child, adolescent, and adult psychiatrist who has dedicated his career to working with medically underserved communities.

Markus Spiering / EyeEm / Getty Images

Causes and Risk Factors

Conversion disorder (also known as functional neurological symptom disorder) is a psychological condition that causes symptoms that appear to be neurological, such as paralysis, speech impairment, or tremors, but with no obvious or known organic causes. In the past, these events were often referred to as "hysterical blindness" or "hysterical paralysis."

Conversion disorder is a relatively rare mental illness, with 2 to 5 out of 100,000 people reporting symptoms per year.  It is categorized as a type of somatic symptom disorder, according to the  Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ),   the leading diagnostic guide for the mental health profession.

Understanding the medical definition of conversion disorder is the first step toward getting help for yourself or someone you love.

There's typically a sudden onset of symptoms that affect voluntary motor or sensory function—and these symptoms can disappear just as suddenly, without any physiological reason. 

The physical symptoms of conversion disorder are often described as your body's way of dealing with unresolved stress or unexpressed emotions that triggered the disorder. In other words, the physical symptoms distract the person from the emotional duress. Conversion disorder typically affects movement function as well as the senses.

Symptoms of conversion disorder can be about any neurological deficit imaginable, including:  

• Abnormal walking or tremors
• Blindness or double vision
• Deafness or problems hearing
• Disturbances in coordination
• Episode of unresponsiveness
• Loss of balance
• Loss of the sense of smell (anosmia)
• Loss of touch (anesthesia)
• Loss of voice (aphonia)
• Numbness or loss of the sensation of touch 
• Seizures or convulsions
• Slurred speech or inability to speak
• Temporary blindness or double vision
• Trouble swallowing or feelings of "a lump" in your throat
• Weakness or paralysis

The DSM-5 offers several specific criteria for diagnosing conversion disorder, including:   

• There must be at least one symptom of sensory or motor impairment.
• Symptoms are not caused by a neurological condition, physical disease, or substance use.
• Symptoms are associated with significant distress.
• Symptoms are not better explained by another physical or psychological condition.

Differential Diagnosis

Your healthcare provider will also need to rule out conditions that may cause similar symptoms, including:  

• Multiple sclerosis (blindness resulting from optic neuritis)
• Myasthenia gravis (muscle weakness disorder)
• Periodic paralysis (muscle weakness)
• Polymyositis (muscle weakness)
• Spinal cord injury

While exact causes are not well understood, research suggests that it could be caused by abnormal flow to certain areas of the brain.  

Conversion disorder may also be a psychological reaction to a highly stressful event or emotional trauma. For example, a soldier who subconsciously wishes to avoid firing a gun may develop paralysis in their hand. 

The disorder does not necessarily develop immediately following the trigger, so it's important to disclose recent and past stress when speaking to your therapist.

Other risk factors of conversion disorder include:  

• Being female (Women have a higher risk of developing the disorder.)
• Being highly conscientious, hard-working, compulsive and a perfectionist
• Having a family member with conversion disorder (People with a first-degree female relative—sister, mother, or daughter—with conversion disorder are more likely to develop symptoms than females in the general population.)
• Having a mental health condition, including mood or anxiety disorders , dissociative identity disorder (formerly known as multiple personality disorder) or other personality disorders
• Having maladaptive personality traits
• Having a neurological disease that causes similar symptoms (such as non-epileptic seizures in people that have epilepsy)
• History of physical or sexual abuse and neglect as a child

Research also suggests that people with conversion disorder also tend to have abnormal emotional regulation.  

Conversation disorder is not a lifelong disorder. If you or someone you love is experiencing severe or lingering symptoms of conversion disorder, treatment may be required and will depend on your individual symptoms.

However, symptoms may improve on their own with time even without treatment, and most people do get better with time and reassurance.  

Psychotherapy

Psychotherapy, including individual or group therapy, cognitive-behavioral therapy (CBT) , hypnosis, biofeedback , and relaxation therapy, have been found to help people with conversation disorder recognize triggers and symptoms and learn new ways to cope with them.  

Your healthcare provider may prescribe an anti-anxiety medication or antidepressant to treat the underlying stress or anxiety that is causing the symptoms of conversion disorder.

Physical Therapy

Physical therapy is often used for people with conversation disorders who have movement disturbances, including problems with coordination, balance, or walking or weak limbs. It's also important to prevent any secondary complications, including muscle weakness and stiffness, that result from inactivity.  

Non-Invasive Brain Stimulation (NIBS) Methods

Non-invasive brain stimulation (NIBS) methods, such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) , are possible alternative treatments to reduce conversion disorder symptoms, including limb weakness and paralysis.  

However, it is important to be aware that these treatments are considered experimental and there is a lack of rigorous randomized controlled trials. Because of this, these treatments should be viewed with caution.

In addition to treatment, adopting some healthy lifestyle changes can help ensure that you better manage any stress and anxiety causing your symptoms. This could include:

• Eating a balanced diet.
• Fostering positive relationships.
• Getting ample sleep .
• Practicing relaxation techniques like yoga, meditation, or progressive muscle relaxation .

Seeking Support

In addition to emotional support, online support communities and Facebook groups can help ensure that you're educated on the latest findings and approaches to managing conversion disorder. A few social networking websites to consider include:  

• Conversion Disorder (aka Functional Neurological Disorder) Facebook Group
• Conversion Disorder Awareness Facebook Group
• Conversion Disorder Support Group

If you or a loved one are struggling with conversion disorder, contact the  Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline  at 1-800-662-4357 for information on support and treatment facilities in your area.

For more mental health resources, see our  National Helpline Database .

National Center for Advancing Translational Sciences. Conversion disorder .

American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders.  5th ed. Washington D.C.: 2013. doi:10.1176/appi.books.9780890425596

Ali S, Jabeen S, Pate RJ, et al. Conversion disorder- mind versus body: A review . Innov Clin Neurosci . 2015;12(5-6):27-33.

National Center for Advancing Translational Sciences. Genetic and Rare Diseases Information Center. Conversion Disorder. 2017.

Aybek S, Nicholson TR, O'daly O, Zelaya F, Kanaan RA, David AS. Emotion-motion interactions in conversion disorder: an FMRI study . PLoS ONE . 2015;10(4):e0123273. doi:10.1371/journal.pone.0123273

 Kaur J, Garnawat D, Ghimiray D, et al. Conversion disorder and physical therapy .  Delhi Psychiatry J . 2012;15(2):394–397.

Schönfeldt-Lecuona C, Lefaucheur JP, Lepping P, et al. Non-invasive brain stimulation in conversion (functional) weakness and paralysis: A systematic review and guture perspectives . Front Neurosci . 2016;10:140. doi:10.3389/fnins.2016.00140

By Lisa Fritscher Lisa Fritscher is a freelance writer and editor with a deep interest in phobias and other mental health topics.

Anxiety Paralysis: How to Overcome the Overwhelming Stagnation

Feeling overwhelmed and stuck, unable to take any action? You may be experiencing what is commonly known as “anxiety paralysis.” This phenomenon refers to a state of immobilization caused by excessive worry, fear, or stress. It’s that feeling of being trapped in your own mind, unable to move forward or make decisions.

Anxiety paralysis can manifest in various ways. Some individuals may find themselves constantly overthinking every possible outcome, leading to indecisiveness and the inability to take even simple steps. Others may feel a physical heaviness or tightness in their chest, making it difficult to breathe and leaving them feeling incapacitated.

This condition can be debilitating and impact many aspects of life – from relationships and work performance to personal goals and overall well-being. Understanding the underlying causes of anxiety paralysis is crucial in finding effective strategies for managing it. In the following sections, we’ll explore some potential triggers and practical tips for breaking free from this cycle of stagnation.

Remember that anxiety paralysis is not uncommon, and you are not alone in experiencing it. By acknowledging its presence and seeking support when needed, you can gain control over your thoughts and emotions, enabling yourself to move forward with confidence. So let’s dive deeper into understanding anxiety paralysis and discover empowering ways to overcome it together. Understanding Anxiety Paralysis

Anxiety paralysis is a phenomenon that many people experience when faced with overwhelming levels of anxiety. It can manifest as a temporary inability to take action or make decisions due to the intense fear and worry associated with anxiety. This state of immobilization can be incredibly frustrating and debilitating for those who are affected by it.

One key aspect of understanding anxiety paralysis is recognizing that it is not a choice or a sign of laziness. It’s important to remember that anxiety disorders are legitimate mental health conditions that can have profound effects on an individual’s daily functioning. The brain’s response to perceived threats triggers a cascade of physiological and psychological reactions, which can result in the freezing up or avoidance behavior characteristic of anxiety paralysis.

To further comprehend this phenomenon, let’s delve into some common examples:

• Academic Anxiety: Imagine a student preparing for an important exam. As the pressure mounts, their mind becomes clouded with worries about failure and disappointing others. Despite having studied diligently, they may find themselves unable to proceed with answering the questions due to paralyzing fear.
• Social Anxiety: Social situations can be particularly challenging for individuals experiencing social anxiety disorder. Even simple tasks like making phone calls or attending social events can trigger overwhelming feelings of self-consciousness and fear of judgment, leading to avoidance behaviors and an inability to engage in social interactions.
• Decision-Making Paralysis: When confronted with numerous choices, individuals with anxiety may struggle immensely in making decisions. The fear of making the wrong choice and facing potential negative consequences becomes overpowering, causing them to feel stuck and unable to move forward.

It’s crucial not to dismiss or trivialize someone’s experience with anxiety paralysis but rather offer support and understanding during these difficult moments. By fostering empathy and providing resources such as therapy, relaxation techniques, or medication if necessary, we can help individuals overcome their anxiety paralysis and regain control over their lives.

Remember that each person’s journey with anxiety paralysis is unique, and it’s essential to approach the topic with sensitivity and respect. By shedding light on this phenomenon, we can foster a greater understanding of mental health challenges and work towards creating a more supportive and inclusive society.

Causes of Anxiety Paralysis

When it comes to understanding anxiety paralysis, it’s crucial to explore the underlying causes that contribute to this debilitating condition. While each individual may have unique triggers, there are several common factors that can lead to anxiety paralysis. Let’s delve into some of these causes:

• Traumatic experiences: Past traumatic events can have a significant impact on an individual’s mental well-being and trigger anxiety paralysis. Whether it’s a physical assault, natural disaster, or emotional abuse, such experiences can create a deep-rooted fear response in the brain, leading to immobilization during moments of heightened stress.
• Chronic stress: Prolonged exposure to high levels of stress can overwhelm the body and mind, resulting in anxiety paralysis. As daily pressures mount up and individuals find themselves constantly juggling responsibilities, their ability to cope diminishes, leaving them susceptible to experiencing paralyzing bouts of anxiety.
• Perfectionism and fear of failure: Striving for perfection and fearing failure can be exhausting and emotionally draining. The constant pressure individuals place on themselves to meet impossibly high standards can lead to overwhelming anxiety that manifests as paralysis when faced with challenging tasks or decisions.
• Negative thinking patterns: Negative self-talk and distorted thinking patterns play a significant role in fueling anxiety paralysis. When individuals consistently engage in catastrophic thinking or anticipate worst-case scenarios, they inadvertently reinforce their fears and increase the likelihood of becoming paralyzed by anxiety-inducing situations.
• Lack of coping mechanisms: Insufficient coping mechanisms or poor stress management skills can make it difficult for individuals to effectively navigate stressful situations without succumbing to anxiety paralysis. Without healthy strategies in place for managing stressors, individuals may feel overwhelmed and unable to take any action at all.

Understanding these underlying causes is instrumental in developing effective strategies for managing and overcoming anxiety paralysis. By addressing these root factors through therapy, support systems, self-care practices, and adopting healthier coping mechanisms, individuals can regain control over their lives and reduce the impact of anxiety paralysis. Remember, everyone’s journey is unique, so it’s important to approach treatment with patience and compassion.

Anxiety paralysis can manifest in various ways, affecting both the mind and body. Understanding the symptoms and effects of this condition is crucial for individuals experiencing it, as well as for those supporting them. Here are a few key aspects to consider:

Physical Symptoms

• Muscle tension: People with anxiety paralysis often experience muscle tightness or stiffness, particularly in the neck, shoulders, and back.
• Rapid heartbeat: Increased heart rate is a common physical symptom associated with anxiety. It can make individuals feel on edge or as if they are constantly on high alert.
• Shortness of breath: Feeling like you can’t catch your breath or experiencing shallow breathing is another manifestation of anxiety paralysis.
• Sweating and trembling: Excessive sweating and shaking are physiological responses that may accompany anxiety episodes.

Cognitive Symptoms

• Racing thoughts: An overwhelmed mind filled with racing thoughts is a hallmark symptom of anxiety paralysis. These thoughts may be negative or irrational, contributing to increased stress levels.
• Difficulty concentrating: Anxiety can make it challenging to focus on tasks at hand or stay engaged in conversations due to mental distractions.
• Irritability and restlessness: Individuals experiencing anxiety paralysis may find themselves easily agitated, restless, or feeling constantly on edge without any apparent reason.

Emotional Effects

• Fear and apprehension: Overwhelming fear about everyday situations or future events is a significant emotional effect of anxiety paralysis. This fear might lead to avoidance behavior in an attempt to prevent triggering situations.
• Feelings of helplessness: Anxiety paralysis can leave individuals feeling helpless as they struggle with their own emotions and inability to overcome their fears.
• Low self-esteem: The constant battle with anxious thoughts can take a toll on self-confidence, leading to feelings of inadequacy.

Impact on Daily Life

• Social isolation: Anxiety paralysis often leads people to withdraw from social activities due to fear of judgment or triggering their anxiety.
• Disrupted sleep patterns: Anxiety can interfere with getting quality sleep, leading to fatigue and decreased productivity during the day.
• Impaired decision-making: Overthinking and second-guessing oneself are common challenges for those experiencing anxiety paralysis, making it difficult to make decisions confidently.

It’s important to note that symptoms and effects of anxiety paralysis can vary from person to person. Seeking professional help from a therapist or psychologist is recommended for individuals who experience persistent symptoms that significantly impact their daily lives.

Coping Strategies for Anxiety Paralysis

When faced with anxiety paralysis, it can feel overwhelming and paralyzing. However, there are several coping strategies that can help you navigate through these challenging moments. Here are a few examples:

• Deep Breathing: Taking slow, deep breaths is a simple yet effective technique to calm your mind and body during an anxiety episode. Find a quiet space, close your eyes, and focus on your breath as you inhale deeply through your nose and exhale slowly through your mouth. Repeat this process for a few minutes until you start to feel more grounded.
• Grounding Techniques: Grounding techniques involve redirecting your attention to the present moment by engaging with your senses. One common grounding technique is the 5-4-3-2-1 method: identify five things you can see around you, four things you can touch, three things you can hear, two things you can smell, and one thing you can taste. This exercise helps bring your awareness back to the present and away from anxious thoughts.
• Progressive Muscle Relaxation: Progressive muscle relaxation involves tensing and then releasing each muscle group in your body to promote overall relaxation. Start by tensing the muscles in one area (e.g., clenching your fists) for a few seconds before releasing them completely while focusing on the sensation of relaxation spreading throughout that area. Move systematically from one muscle group to another until you’ve relaxed all parts of your body.
• Mindfulness Meditation: Practicing mindfulness meditation allows you to observe your thoughts and emotions without judgment or attachment. Find a quiet place where you won’t be disturbed, sit comfortably with good posture, and bring attention to your breathing or any other anchor point like bodily sensations or sounds. Whenever distracting thoughts arise (which they inevitably will), gently acknowledge them without getting caught up in them and refocus on the present moment.
• Seek Support: Don’t be afraid to reach out for support from trusted friends, family members, or mental health professionals. Talking about your anxiety and sharing your experiences can provide you with a fresh perspective, reassurance, and guidance on how to manage anxiety paralysis effectively.

Remember that coping strategies may vary in their effectiveness for different individuals. It’s important to experiment with different techniques and find the ones that work best for you. With time and practice, you can develop a toolkit of coping strategies that will help you navigate through anxiety paralysis and regain control over your life.

When to Seek Professional Help

Navigating the challenges of anxiety paralysis can be overwhelming. Sometimes, despite our best efforts, we find ourselves struggling to overcome this debilitating condition on our own. It’s crucial to recognize when seeking professional help is necessary. Here are a few indicators that it may be time to reach out to a mental health professional:

• Persistent and Intense Symptoms: If you experience persistent symptoms of anxiety paralysis that significantly impact your daily life and well-being, it could be a sign that professional intervention is needed. These symptoms may include constant feelings of dread or fear, difficulty concentrating or making decisions, uncontrollable worry, and avoidance behaviors.
• Interference with Everyday Functioning: Anxiety paralysis can interfere with various aspects of your life, including work performance, relationships, and personal goals. If you find yourself unable to fulfill responsibilities or engage in activities you once enjoyed due to overwhelming anxiety, it may be beneficial to seek professional guidance.
• Failed Self-Help Strategies: Despite trying various self-help techniques or coping mechanisms such as deep breathing exercises, mindfulness practices, or relaxation techniques without significant improvement in your condition, consulting with a mental health professional can provide additional tools and strategies tailored specifically for your needs.
• Impact on Physical Health: Anxiety can manifest not only in emotional distress but also physical symptoms such as headaches, digestive problems, muscle tension, insomnia, and fatigue. If these physical symptoms persist alongside anxiety paralysis and begin affecting your overall well-being, seeking professional help is advisable.
• Suicidal Thoughts or Self-Harm Urges: If you are experiencing thoughts of self-harm or suicide related to your anxiety paralysis or feeling like there’s no way out from the overwhelming emotions you’re facing; please don’t hesitate – reach out immediately for immediate assistance from a mental health professional or call emergency services right away.

Remember that seeking help is not a sign of weakness but rather an empowering step towards regaining control of your life. A mental health professional can provide support, guidance, and appropriate treatment options to help you manage anxiety paralysis more effectively.

If you or someone you know is struggling with anxiety paralysis, please don’t hesitate to seek the help you deserve.

Tips for Preventing Anxiety Paralysis

Feeling overwhelmed by anxiety can sometimes lead to a state of paralysis, where it becomes difficult to take action or make decisions. It’s important to remember that you have the power to break free from this cycle and regain control of your life. Here are some practical tips that can help prevent anxiety paralysis:

• Recognize and acknowledge your triggers: Take a moment to reflect on what situations or thoughts tend to trigger your anxiety. By identifying these triggers, you can start developing strategies to manage them more effectively. Whether it’s public speaking, social situations, or challenging tasks at work, understanding your triggers is the first step towards overcoming anxiety paralysis.
• Practice deep breathing and relaxation techniques: When anxiety strikes, our bodies often respond with shallow breathing and tense muscles. Learning deep breathing exercises and relaxation techniques like progressive muscle relaxation or guided imagery can help calm both the mind and body in moments of stress . Incorporate these practices into your daily routine as a proactive way to reduce overall anxiety levels.
• Break tasks into manageable steps: Anxiety paralysis often stems from feeling overwhelmed by the magnitude of a task or goal. To combat this, break down larger projects into smaller, more manageable steps. Focus on completing one step at a time rather than fixating on the entire picture all at once. Celebrate each small achievement along the way, as it will boost your confidence and motivation.
• Establish a self-care routine: Taking care of yourself is essential for managing anxiety effectively. Make sure you’re getting enough sleep, eating well-balanced meals, exercising regularly, and engaging in activities that bring you joy and relaxation. Prioritize self-care as an integral part of your daily routine – it will provide you with mental strength and resilience when facing stressful situations.
• 5.Seek support from loved ones or professionals: Don’t hesitate to reach out for support when needed – whether it’s talking things through with trusted friends or family members, seeking guidance from a therapist, or joining a support group. Sharing your thoughts and feelings with others who understand can provide valuable insights, encouragement, and reassurance.

Remember, preventing anxiety paralysis is an ongoing process that requires patience and self-compassion. Be kind to yourself as you navigate through challenging times, and know that with the right strategies in place, you can overcome anxiety and regain control of your life.

Supporting Loved Ones with Anxiety Paralysis

When a loved one is struggling with anxiety paralysis, it can be challenging to know how to provide the support they need. It’s important to approach this situation with empathy, understanding, and patience. Here are a few ways you can assist your loved one in navigating through their anxiety paralysis:

• Validate Their Feelings: One of the most crucial aspects of supporting someone with anxiety paralysis is acknowledging and validating their emotions. Let them know that their feelings are valid and that you understand their struggle. Avoid dismissing or downplaying their experience, as this can make them feel unheard or misunderstood.
• Be a Good Listener: Sometimes, all your loved one needs is a listening ear. Create a safe space for them to express themselves without judgment or interruption. Encourage them to share their thoughts and concerns openly and actively listen without offering unsolicited advice.
• Offer Encouragement: Anxiety paralysis can make even the simplest tasks seem daunting for individuals experiencing it. Offer words of encouragement to help motivate your loved one when they’re feeling overwhelmed or stuck. Remind them of their strengths and accomplishments, reinforcing their belief in themselves.
• Educate Yourself: Take the time to educate yourself about anxiety disorders and learn more about anxiety paralysis specifically. Understanding the condition better will enable you to have more informed conversations with your loved one, as well as equip you with strategies on how best to support them.
• Respect Boundaries: While it’s important to offer support, it’s equally essential to respect your loved one’s boundaries during times of anxiety paralysis. Everyone copes differently, so be mindful not to push too hard or try to force solutions upon them if they’re not ready for it yet.

By implementing these strategies in supporting your loved one with anxiety paralysis, you can create an environment that fosters trust, understanding, and growth together. Remember that each person’s journey is unique; be patient, compassionate, and consistent in your support. Conclusion

To wrap up our discussion on anxiety paralysis, it’s evident that this phenomenon can have a significant impact on individuals’ lives. Through exploring its causes, symptoms, and potential coping strategies, we’ve gained valuable insights into the nature of anxiety paralysis. Let’s summarize some key takeaways from our exploration:

• Anxiety paralysis is a state of intense fear or worry that can immobilize individuals, preventing them from taking action or making decisions.
• It often stems from underlying anxiety disorders such as generalized anxiety disorder (GAD), panic disorder, or social anxiety disorder.
• Common symptoms of anxiety paralysis include feeling overwhelmed, experiencing physical sensations like rapid heartbeat and shortness of breath, having racing thoughts, and feeling unable to move forward.
• Recognizing the signs of anxiety paralysis is crucial in order to address it effectively. Seeking professional help from therapists or psychologists who specialize in treating anxiety disorders can provide guidance and support.
• Various coping strategies can be employed to manage and overcome anxiety paralysis. These may include deep breathing exercises, mindfulness techniques, cognitive-behavioral therapy (CBT), medication under medical supervision if necessary, and building a strong support network.
• It’s important to remember that everyone’s experience with anxiety paralysis is unique; what works for one person may not work for another. It requires patience and self-compassion while finding individualized approaches that suit each person best.

In conclusion, understanding the complexities of anxiety paralysis allows us to approach it with empathy and support those experiencing its effects more effectively. By providing education about this condition and promoting open conversations around mental health challenges like anxiety paralysis, we contribute to reducing stigma and fostering a healthier society overall.

Remember: You are not alone in your struggle with anxiety paralysis – there is hope for healing and growth!

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Paralyzing Anxiety: What It Is, Symptoms, & How to Cope

Author: Lea Flego Secord, MA, LMFT

Lea Flego MA, LMFT

Lea specializes in psychotherapy for adults and youth with anxiety, depression, and trauma. She also offers couples and family therapy focused and integrates somatic therapy into her practice.

Heidi Moawad MD

Heidi Moawad, MD is a neurologist with 20+ years of experience focusing on mental health disorders, behavioral health issues, neurological disease, migraines, pain, stroke, cognitive impairment, multiple sclerosis, and more.

Paralyzing anxiety is a debilitating, but natural, response all bodies can experience under threat or significant stress. It is a full-body experience that creates a sensation of being frozen or stuck. Though it can be troubling to experience, especially without an understanding of what is happening, strategies exist that can manage the symptoms, and mental health professionals can help you cope.

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What Is Paralyzing Anxiety?

Anxiety is an automatic response that prepares the body to react to a threat. Paralyzing anxiety is a type of anxiety disorder and a severe form of the body’s automatic response, also known as the “freeze” aspect of the fight, flight, and freeze response . It is the equivalent of “playing dead” in the animal world and is adaptive in that becoming immobilized helps avoid detection from a predator, unlike the “flight” response, and can reduce strain on the body, unlike the “fight” response. 1

Paralyzing anxiety differs from everyday stress or nervousness in that it temporarily freezes the body in response to a detected threat rather than activating a “get up and go” response to help tackle a stressor daily life presents. It also differs in that it impairs functioning in one or more areas of life and is distinct from other anxiety disorders that have specific symptom criteria.

Physical Anxiety Paralysis

Some people can become physically paralyzed when experiencing this type of anxiety. This paralysis is temporary and affects a person’s ability to move, think, and speak. The physical effects of anxiety paralysis can include tingling and numbness in the limbs but differ from when a part of the body “falls asleep” in that paralyzing anxiety causes the whole body to become immobilized.

This happens because the amygdala, the part of the brain that constantly scans the environment, has detected a threat and initiated a process via the hypothalamus to ensure the best chance of survival. This process involves the release of stress hormones such as adrenaline and cortisol which prepare our body to fight, flight , or freeze. 1

Emotional Anxiety Paralysis

People can also feel emotionally paralyzed when experiencing this type of anxiety and might not experience the full effects of strong feelings of fear, panic, worry, or impending doom. This differs from less severe forms of anxiety in that these feelings are overwhelming. With low to moderate anxiety, the person can still function but with paralyzing anxiety, the person experiences a complete shutdown of their system.

Symptoms of Paralyzing Anxiety

Anxiety symptoms can vary depending on the individual, but the common denominator is that the symptoms completely overwhelm the person. Paralyzing anxiety symptoms are invasive and debilitating but temporary. Once the threat has passed, it takes between 20 and 60 minutes for the body to return to its normal state. 2

Symptoms of paralyzing anxiety may include:

• Feelings of fear, worry, panic, anxiety, or impending doom
• Difficulty moving parts of your body or complete immobilization
• Difficulty thinking, making decisions, and speaking
• Increased heart rate
• Shallow and rapid breath
• Persistent negative thoughts
• Face tingling
• Avoidance behaviors
• Shaking, tingling, or numbness in limbs
• Muscle tension 3

Paralyzing anxiety can cause dizziness or lightheadedness, which can make you feel unsteady and impact your daily functioning.

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What Causes Paralyzing Anxiety?

Paralyzing anxiety is caused by an interaction of biopsychosocial factors with the environment and the synchronous activation of the nervous system’s sympathetic (active) and parasympathetic (resting) parts in response to a real or perceived threat. Anxiety paralysis can be triggered by certain situations or stimuli, such as public speaking, seeing a spider, or leaving the house.

Factors that contribute to paralyzing anxiety include an overactive amygdala, a history of traumatic events, negative thinking patterns, a family history of anxiety disorders, and significant stressors. Genetics also play a role as anxiety disorders occur more frequently in females than males. 3 Those with a combination of these factors are more likely to struggle with anxiety and anxiety paralysis.

Possible causes of paralyzing anxiety include:

• History of traumatic events: trauma establishes an association between a stimulus that was present during the event and danger. When the person encounters that stimulus again, the body reacts as if it is unsafe as they were during the traumatic event even if at that moment they are not in danger.
• Overactive sympathetic nervous system: the sympathetic nervous system is what gets activated when the brain interprets a threat and the threshold of when this system gets activated varies from person to person. A lower threshold means reacting more quickly to danger than someone with a higher threshold thus someone can experience paralyzing anxiety in situations that others don’t.
• Social situations: public speaking, meeting someone new, or being in a crowded area can all trigger paralyzing anxiety.
• Phobias : paralyzing anxiety can occur when encountering the object or situation associated with the specific phobia such as blood, heights, or spiders.
• Taking an exam: it’s common and adaptive to experience a low to moderate level of anxiety in response to taking a test but for some, paralyzing anxiety can occur in response to test-taking.

Impacts of Paralyzing Anxiety

Paralyzing anxiety makes it difficult to navigate life. As paralyzing anxiety creates a “stuckness,” it can make it difficult to follow through on tasks and obligations. Additionally, as it is wired in us to avoid danger and paralyzing anxiety creates a sensation that danger is present, paralyzing anxiety is associated with avoidant behaviors.

Relationships

Paralyzing anxiety can impact relationships as it impairs a person’s ability to engage in healthy relationship behaviors like communicating effectively. The avoidance associated with paralyzing anxiety also can impair a person’s ability to regularly engage with their partner, resolve conflicts and repair relationship injuries. If these conflicts and injuries go unaddressed, it can lead to a breakdown in the relationship.

Work & Professional Settings

Paralyzing anxiety can negatively impact a person’s work. Work anxiety impacts the professional life as it can impair a person’s ability to attend job interviews, concentrate on the task at hand, complete projects by the deadline, work through problems in the workplace, and expand their career by taking on new and different responsibilities.

Personal Self-Care

Paralyzing anxiety affects a person’s ability to practice self-care because of the stuckness this kind of anxiety causes. Self-care can be hindered as it can be difficult for a person to leave the house, reach out for help, express feelings and needs, pursue personal goals, or even get out of bed to practice regular hygiene.

Mental Health

Paralyzing anxiety also impacts a person’s mental and emotional health because the frozen emotional state impairs a person’s ability to access, process, and regulate emotions. Paralyzing anxiety puts the body in survival mode, only focusing on what is essential. Processing emotions are essential for a person’s well-being but not for their immediate survival, and as a result, the processing of emotions gets inhibited.

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How to Cope With Paralyzing Anxiety

In the same way the human body is wired to respond to threats with the fight, flight, freeze response, it is also wired to return to a state of calm when not in danger, and there are strategies that can help. Practicing emotional self-care by attending to your emotions will help you apply coping strategies when needed to help you calm your body and mind.

Below are 10 tips for coping with paralyzing anxiety:

1. Practice Mindfulness

Mindfulness is a skill that helps a person be aware of what’s happening in the present moment so they can become a witness to their experience rather than become overwhelmed by it. Knowing you are experiencing anxiety can help you identify the need to utilize other coping skills.

2. Make Use of Helpful Mantras

A mantra is a short phrase a person can recite to help them focus and move into a calm emotional state. Developing a mantra such as “This is temporary” or “I am safe” can help center and ground during severe anxiety.

3. Identify Your Triggers

The experience of anxiety can worsen when we are caught off guard. Knowing your triggers helps to prepare you for when you know you are likely to experience paralyzing anxiety and allows time to create a plan for how to cope with it.

4. Breathwork

Developing a calming breathing practice and utilizing it when experiencing paralyzing anxiety helps regulate the nervous system and bring it from a frozen state to a calm state. Try using the 4-7-8 breathing method , breathing in through your nose for 4 counts and out through your mouth for 8 counts and repeat. 4

5. Move Your Body

Inviting even subtle movements into the body helps get it out of the paralyzed state, especially when you engage both the right and left sides of the body. This could look like a gentle sway from side to side, wiggling your fingers and toes, tossing a small object between your hands, or going on a walk. Exercise for anxiety helps keep your thinking brain online and manage emotional flooding. 5

6. Practice Yoga

Yoga, particularly styles that pair body movement with the breath, helps regulate anxiety and the nervous system, improves a person’s ability to feel calm, and strengthens their ability to tolerate uncomfortable sensations. Specific yoga poses can help manage feelings of anxiety and overwhelm, such as the crocodile pose and child’s pose. 6

7. Grounding techniques

These techniques help calm anxiety and racing thoughts by turning your attention to the sensations you are experiencing in the present moment. One popular practice is the 54321 technique: name 5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you can smell, and 1 thing you can taste. This is especially effective if what you focus on is associated with a sense of safety.

8. Eye Movement

Taking a moment to look in all directions helps regulate the nervous system as this serves the same function as scanning your environment for threats. When the eyes don’t see a real threat, the body knows it can return to a calm state.

9. Vocalizations

Using your voice by singing, humming, or chanting stimulates the vagus nerve which is crucial in regulating the nervous system. 7

10. Radical acceptance

Rather than judge yourself while experiencing paralyzing anxiety, practice accepting and allowing the emotions and sensations to be present. Judgment is interpreted as an additional threat and can maintain a state of anxiety. 8

Treatment for Paralyzing Anxiety

Paralyzing anxiety can be addressed with typical treatments, such as therapy for anxiety and medication. The treatment plan and course of therapy can vary from person to person, but you can expect to learn coping skills for managing anxiety and be in treatment for anxiety between 3-12 months. Natural remedies for anxiety include lavender, chamomile, valerian, passionflower, and kava. 9

Therapy is important for treating anxiety as it provides psychoeducation, offers effective coping strategies, and reduces feelings of isolation. There are various treatment options for anxiety therapy, including individual and group therapies and online or in-person sessions. You can begin the process of finding a therapist by asking for a referral from your primary care doctor or insurance company or by using one of the many online therapist directories .

Therapy options for paralyzing anxiety include:

• Cognitive behavioral therapy (CBT): An evidenced-based model, CBT for anxiety helps change thought and behavior patterns. This would benefit those struggling with persistent negative thoughts and avoidant behaviors.
• Exposure therapy: The exposure therapy model involves gradually exposing yourself to anxiety triggers until your distress tolerance increases. This can be of particular help to those experiencing paralyzing anxiety when encountering specific situations.
• Acceptance and commitment therapy (ACT) : ACT for anxiety combines strategies that address the cognitive, emotional, and behavioral aspects of paralyzing anxiety.
• Art therapy: Art therapy for anxiety uses creative expression through a wide variety of artistic modalities to relieve anxiety symptoms.
• Dialectical behavioral therapy (DBT) : Another popular evidence-based model, DBT for anxiety helps develop dialectical thinking, the ability to hold conflicting ideas simultaneously. Additionally, this model teaches coping skills such as distress tolerance and mindfulness to help regulate emotions.
• Eye movement desensitization and reprocessing (EMDR): The EMDR model helps a person process unresolved traumatic events that are contributing to paralyzing anxiety using bilateral stimulation of the brain. 10

Someone may consider taking medication to treat their paralyzing anxiety if their symptoms impair their ability to access therapy or if other treatment options have been insufficient in managing symptoms. Be sure to ask your doctor about the risks and benefits of taking the medication so that you are aware of potential side effects.

Antidepressants are often a first-line treatment for anxiety. This group of medications includes selective serotonin reuptake inhibitors ( SSRIs ), serotonin-norepinephrine reupdate inhibitors (SNRIs), and tricyclics. If meeting in person with your prescriber is not an option, online psychiatry options are available. 11

In My Experience

I regularly encounter people that struggle with paralyzing anxiety but also witness them finding relief from their symptoms and experiencing empowerment in their daily lives. If you have experienced paralyzing anxiety, I want you to know that you are not alone, nothing is wrong with you, and though we are wired to experience anxiety, there are strategies to help your body move into a state of calm and safety so you can enjoy life to the fullest.

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For Further Reading

• The Best Yoga Poses for Anxiety, Stress, and Panic Attacks – Yoga Journal
• Anxiety Treatment Without Medication: Non-Drug Options

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How Does ERP Help With Intrusive Thoughts?

Obsessive compulsive disorder (OCD) is a psychiatric condition marked by the presence of obsessive thoughts, images, doubts, or urges, followed by compulsive behaviors or acts aimed at easing the distress caused by the obsession. While the content of the obsessions can take many forms, they are always repetitive, persistent, involuntary, and intrusive, and they often result in a great deal of anxiety for the person experiencing them.

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Choosing Therapy strives to provide our readers with mental health content that is accurate and actionable. We have high standards for what can be cited within our articles. Acceptable sources include government agencies, universities and colleges, scholarly journals, industry and professional associations, and other high-integrity sources of mental health journalism. Learn more by reviewing our full editorial policy .

Livermore, J. J., Klaassen, F. H., Bramson, B., Hulsman, A. M., Meijer, S. W., Held, L., Klumpers, F., de Voogd, L. D., & Roelofs, K. (2021). Approach-avoidance decisions under threat: The role of autonomic psychophysiological states . Frontiers in Neuroscience, 15. https://doi.org/10.3389/fnins.2021.621517

Cherry, K. (2019). How the fight or flight response works. https://www.stress.org/how-the-fight-or-flight-response-works

Chand SP, Marwaha R. Anxiety. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470361/

Marksberry, K.M. (2012, August). Take a deep breath . American Institute of Stress. Retrieved from https://www.stress.org/take-a-deep-breath

Van Der Kolk, B. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma . Penguin Books.

National Center for Complementary and Integrative Health. (2020). Yoga for Health: What the Science Says. Retrieved from: https://www.nccih.nih.gov/health/providers/digest/yoga-for-health-science

Porges, S. W. (2022). Polyvagal Theory: A Science of Safety. Frontiers in Integrative Neuroscience , 16 . https://doi.org/10.3389/fnint.2022.871227

Brach, T. (2003). Radical acceptance: embracing your life with the heart of a Buddha. New York, Bantam Books.

Locke, A., Kirst, N., & Shultz, C. G. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. American Family Physician, 91 (9), 617–624. https://www.aafp.org/afp/2015/0501/p617.html

Anxiety and Depression Association of America. (n.d.) Therapy. Retrieved from https://adaa.org/finding-help/treatment/therapy .

Anxiety and Depression Association of America. (n.d.) Medication. Retrieved from https://adaa.org/finding-help/treatment/medication .

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A Systematic Review of Psychological Interventions for Adult and Pediatric Patients with Vocal Cord Dysfunction

Loveleen guglani.

1 Department of Communication Disorders, Wayne State University, Detroit, MI, USA

Sarah Atkinson

2 Wayne State University School of Medicine, Detroit, MI, USA

Avinash Hosanagar

3 Department of Psychiatry, Veterans Affairs Medical Center, University of Michigan Medical School, Ann Arbor, MI, USA

Lokesh Guglani

4 Division of Pulmonary Medicine, The Carman and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA

Background: Vocal cord dysfunction (VCD) or paradoxical vocal-fold motion (PVFM) is a functional disorder of the vocal cords that requires multidisciplinary treatment. Besides relaxation techniques, the use of psychological interventions can help treat the underlying psychological co-morbidities. There is currently no literature that examines the effectiveness of psychological interventions for VCD/PVFM.

Objectives: To review the evidence for psychological interventions used for the treatment of patients with VCD/PVFM.

Data sources: We searched electronic databases for English medical literature using Pubmed (Medline), PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Registry of Controlled Trials, and Clinicaltrials.gov. The date range for our search is from June 1964 to June 2014.

Study eligibility criteria, participants, and interventions: We included studies that reported the use of psychological interventions in both adults and children diagnosed with VCD/PVFM. We included randomized controlled trials, case-control studies, retrospective chart reviews, prospective case series, and individual case reports.

Results: Most reported studies are small case series or individual case reports that have described the use of interventions such as psychotherapy, behavioral therapy, use of anti-anxiety and anti-depressant medications, and hypnotherapy in conjunction with breathing exercises taught by speech therapists for symptomatic relief. Among the various psychological interventions that have been reported, there is no data regarding effectiveness and/or superiority of one approach over another in either adult or pediatric patients.

Conclusions: Psychological interventions have a role to play in the management of adult and pediatric patients with VCD/PVFM. Future prospective studies using uniform approaches for treatment of associated psychopathology may help address this question.

Vocal cord dysfunction (VCD) or paradoxical vocal-fold motion (PVFM) is a functional disorder of the vocal cords characterized by episodic adduction of vocal cords, leading to significant inspiratory airflow limitation ( 1 ). Patients experience intermittent symptoms that range from neck or throat tightness, inability to breathe in, persistent cough, or inspiratory stridor ( 2 ). Since symptoms can closely mimic that of an asthma attack, many patients are frequently misdiagnosed and inappropriately treated ( 3 , 4 ). The exact incidence or prevalence of this condition is not clearly known, as there are no large-scale studies for this disorder. Most case series have noted a greater prevalence in females ( 5 , 6 ) and 29% cases occurring in those <18 years of age ( 7 ), with an average age of 14.5 years in adolescents and 33 years in adults ( 2 ). Nevertheless, prompt recognition and treatment is crucial, as inappropriate treatment has been associated with significant costs and morbidity.

This abnormal adduction of vocal cords is believed to be primary (psychological) in 70% of cases, while in the remaining 30% it may be secondary to disorders causing laryngeal hypersensitivity or other neurologic disorders ( 8 ). It is also important to exclude any vocal cord pathologies such as paralysis (unilateral or bilateral), granulomas, or airway malacia, and can be done with the help of detailed clinical assessment, direct laryngoscopy, and pulmonary function testing in most patients ( 9 ). Since this disorder is episodic, vocal cord adduction may not be present at the time of laryngoscopy and several methods (exercise or use of chemical irritants) have been used to simulate symptoms and demonstrate the typical findings ( 10 ).

Treatment of patients with VCD involves a multidisciplinary approach that involves use of breathing techniques to help relax the vocal cords, reduce muscle tension through relaxation techniques, and psychological interventions to help deal with underlying stressors or triggers for symptoms ( 11 ). While breathing techniques provide symptomatic relief, psychological interventions can help treat underlying causes such as anxiety or conversion disorder. However, there is no uniform approach advocated for the management of these patients and treatment is individualized on a case-by-case basis. Treatment of co-morbid conditions such as asthma, gastroesophageal reflux, or neurologic disorders also requires the involvement of many different specialists ( 12 ). There are many centers (including ours 1 ) that have initiated a multidisciplinary approach toward the management of these patients ( 13 ). Most teams comprise pulmonologists, otorhinolaryngologists, speech and language pathologists, and psychologists or psychiatrists.

Although first described in 1974 by Patterson et al. who named it Munchausen’s stridor ( 14 ), there are few studies about treatment approaches for this condition. While there are more than 170 published case reports ( 15 ), there has been little focus on effectiveness of various interventions. In developing our institutional protocols 1 for the management of these patients, we decided to focus on interventions that have been proven to be effective for the management of VCD/PVFM. Psychological interventions for the management of these patients have been reported in multiple reviews, but there is no literature examining the effectiveness of psychological interventions for these patients. We decided to undertake a systematic review of the literature to review the evidence for psychological interventions that have been reported to be helpful in the treatment of patients with VCD/PVFM.

Description of the intervention

Psychological interventions that have been reported to be effective in patients with VCD/PVFM include biofeedback, hypnosis, and psychotherapy such as cognitive–behavioral therapy, personal construct therapy, and patient education. Rarely, psychoactive medications (anti-anxiety and anti-depressants) have been used, depending on the underlying psychiatric morbidity.

How the intervention might work

Interventions help to reduce anxiety and stress that are known to be triggers for episodes of VCD/PVFM in many cases. Biofeedback can help patients control their symptoms better by improving the patient’s understanding of their own breathing and their symptoms, and helping them understand what is happening to their vocal cords during acute episodes of VCD. In many adolescents and young adults, who develop VCD/PVFM symptoms in relation to sports or activity, learning relaxation techniques and anxiety coping skills has also been noted to be effective.

Why it is important to do this review

Until now, most centers have treated VCD/PVFM patients based on their own approach and availability of multidisciplinary resources. By clearly identifying the psychological interventions that are known to help patients with VCD/PVFM, this systematic review will better inform treating health care professionals. This review will help to identify gaps in the literature regarding the psychological interventions and help direct future research to address these gaps.

The objective of our review is to identify and assess the effectiveness of psychological interventions for the treatment of patients with VCD/PVFM.

Criteria for considering studies for review

All publications related to use of psychological interventions for treatment of patients with VCD were included for this review. An initial search pertaining to VCD/PVFM was done and articles related to psychological interventions/psychiatric assessment and treatments were included for this systematic review. Any cross-referenced studies from these papers were also reviewed and included if they met our criteria for inclusion. This systematic review was also registered in the International Prospective Register of Systematic Reviews called PROSPERO ( www.crd.york.ac.uk/NIHR_PROSPERO ) (registration # CRD42013004873).

Types of studies

We limited our search to studies published in the English language. We included all types of studies and reports that included randomized controlled trials, case-control studies, retrospective reviews, prospective case series, and case reports.

Types of participants

We included studies that reported the use of psychological interventions in both adults and children diagnosed with VCD/PVFM.

Types of outcome measures

The outcome measures were varied across different studies. Most studies reported symptomatic improvement in VCD symptoms as the main outcome measure. There was no standardized tool that was used to measure the response to the psychological interventions in these patients.

Primary outcomes

Primary outcome measure was improvement in symptoms related to VCD.

Secondary outcomes

Secondary outcomes that were assessed included effects on quality of life and improvement in the diagnosis and management of underlying psychiatric co-morbidities.

Search methods for identification of studies

We searched electronic databases for English medical literature using Pubmed (Medline), PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Registry of Controlled Trials, and Clinicaltrials.gov. The date range for our search was all publications from June 1964 to June 2014. We also scanned the bibliographies and references cited in the publications selected for this systematic review to look for any additional studies that may not have been covered in our initial search. We used search terms “vocal cord dysfunction,” “paradoxical vocal fold motion,” “vocal cord dysfunction and psychological,” “vocal cord dysfunction and psychological interventions,” “paradoxical vocal fold motion and psychological,” and “paradoxical vocal fold motion and psychological interventions”. These search terms were used for searches in all the databases listed above.

Data Collection and Analysis

Selection of studies.

The authors reviewed all the studies collected during the initial search. Only the ones pertaining specifically to psychological interventions or those that described psychological interventions as part of multidisciplinary management were considered for inclusion in the systematic review.

Data extraction and management

Data about the number of cases treated using psychological interventions, effectiveness of this treatment approach, and outcomes were assessed from each selected publication (see Table ​ Table1). 1 ). Risk of bias was assessed for each study that was included in the systematic review. Measures of treatment effect were not applicable in most of the publications as they were small case series or case reports, where the use of psychological intervention for each individual patient was briefly described. There was no uniform approach that was followed in the management of the reported cases and the response to psychological interventions was reported to a variable degree. The studies included in this review were heterogeneous in terms of the types of psychological interventions that were utilized.

List of studies that have reported the use of various psychological interventions for patients with VCD/PVFM .

Based on the search strategy described above, we screened all the papers identified and specifically looked for psychological interventions reported in these publications. Figure ​ Figure1 1 shows the flowchart of the studies that were screened and included in this review.

Description of study selection process for systematic review .

Results of the search

We initially found 2944 publications related to VCD. Majority of these publications were review articles, diagnostic studies, related to other vocal cord disorders, or case reports that did not describe any psychological assessment or interventions and hence were excluded. The remaining 30 manuscripts were carefully reviewed by the authors to assess the usefulness of psychological interventions that were reported. Among these 30 manuscripts, another 14 were excluded as they did not describe any specific psychological intervention (3), reported only psychological assessment (4), or included cases of spasmodic dysphonia (7). After this step, there were 16 manuscripts that described some form of psychological intervention and these were selected for inclusion in the systematic review (Table ​ (Table1 1 ).

Description of studies

Included studies.

Varney et al. ( 6 ) reported their experience with 62 adults with VCD who were treated with low-dose amitriptyline in conjunction with psychotherapy and behavioral therapies. The authors reported additional improvement in insomnia and anxiety symptoms in majority of the patients and the treatment was well tolerated, with only two patients reporting dry mouth as a side effect. There were some treatment failures (eight females and one male), where VCD symptoms continued despite treatment with amitriptyline. Since there were no controls in this study and a detailed psychiatric assessment was not done in these patients, the authors concluded that further studies are needed for this intervention.

Maturo et al. ( 16 ) described a cohort of 59 pediatric patients with VCD that were evaluated and treated at a multidisciplinary airway disorders clinic. Among them, 10% of the patients had a known psychiatric disorder at presentation, but after assessments 30% were noted to have psychiatric co-morbidity in their cohort. The authors reported the use of biofeedback and hypnosis and the use of reflux medications, either alone or in combination, and these were decided on the basis of individual patient characteristics. Overall, they reported a good success rate for psychiatric interventions in combination with speech therapy and/or medical therapy.

Richards-Mauzé et al. ( 17 ) recently reported the use of a four-session cognitive–behavioral therapy intervention in 36 children and adolescents with VCD. The authors have described a unique combination of cognitive–behavioral therapy in combination with diaphragmatic breathing and progressive muscle relaxation. During the first two sessions, the patients were asked to identify anxious or negative thoughts related to VCD episodes and positive coping strategies were discussed. The patients were also given an audio instruction tape for continuing progressive muscle relaxation at home on a regular basis in the first few weeks. For the third and fourth sessions, the patients jogged or ran on a treadmill while the psychologist recorded their ratings of their breathing every 2 min. The authors reported that by gradually exposing the patients to VCD symptoms and identifying and targeting the anxious thoughts related to VCD episodes, they were able to reframe these negative thoughts and teach the patients guided imagery and distraction techniques.

The authors reported significant improvement in symptom severity, perceived coping, control over breathing, and functional disability scores for all patients that underwent this intervention.

The seminal paper on VCD by Christopher et al. ( 5 ) first reported it as a functional disorder, also described the use of psychological evaluation in all the five patients that were described in that paper. All patients underwent “brief psychotherapy” and showed good response to therapy with a combination of use of breathing techniques and psychotherapy.

Freedman et al. ( 18 ) reported a small case series of three adults with VCD, who had history of childhood sexual abuse that was felt to be a significant stressor for these patients. One patient was treated with individual psychotherapy, and another was treated with anti-depressant medication but the third refused psychiatric treatment. No further details regarding the nature and outcomes of their psychiatric therapy are presented in this paper.

Anbar ( 19 ) described the outcomes for 22 patients who underwent hypnotherapy for persistent dyspnea that was refractory to medical therapy. Even though this cohort included only two patients with VCD, the paper reported good outcomes with use of hypnotherapy. Another report from the same author ( 26 ) described a single case of VCD where the diagnosis of VCD was confirmed with the help of hypnosis and the patient was subsequently treated with a combination of self-hypnotherapy and speech therapy. In a retrospective study from a single center ( 30 ), Anbar also reported a case series of patients who were treated with hypnotherapy between May 1998 and October 2000. Of the 303 patients who underwent hypnotherapy, 33 had VCD but only 29 accepted the treatment. Outcomes were reported for 22 patients, while 7 were lost to follow-up. Twenty of the 22 patients who underwent hypnotherapy reportedly had improvement in symptoms, with 11 showing complete resolution of symptoms after a single hypnotherapy session. Yet another retrospective case series of hypnotherapy reported by Anbar et al. ( 31 ) covered an 18-month period starting from January 1, 2000. A total of 133 patients were offered hypnotherapy for diagnoses ranging from anxiety, habit cough to VCD and 81 received the hypnotherapy intervention. According to the authors, 75% had a follow-up assessment and 95% of these patients reported improvement in symptoms. The authors did not provide how many VCD patients were treated with hypnotherapy and how the improvement in symptoms was assessed. Similarly, Smith ( 27 ) also reported the case of an adolescent who developed acute onset symptoms due to significant psychosocial stress and his symptoms were successfully relieved after he was taught self-hypnosis technique to relax his vocal cords during acute episodes. Caraon ( 28 ) also reported the case of an adolescent who had significant anxiety due to incessant bullying at school and developed VCD. After two sessions of hypnotherapy his symptoms improved dramatically.

Earles et al. ( 21 ) reported the use of biofeedback self-regulation in two military service members who had developed VCD symptoms during training. One case had received speech therapy intervention in addition to the authors’ use of Procomp+ system with Biograph software for biofeedback training sessions. Both cases showed resolution of VCD symptoms leading the authors to suggest the use of a multidisciplinary approach in the management of VCD patients. Another report ( 22 ) of VCD occurring in army personnel described two females who had significant VCD symptoms during times of war and detailed psychiatric assessment revealed post-traumatic stress disorder in the first patient and anxiety disorder with histrionic personality in the second case. While the first patient improved with psychotherapy, the second patient resisted therapy and continued to remain symptomatic.

Selner et al. ( 20 ) reported their experience with three cases, where significant psychological factors were operational in the form of primary and secondary gain related to somatoform disorder. Two of the three patients underwent intensive psychotherapy that was tailored to each case’s needs but the third patient refused treatment.

McQuaid et al. ( 32 ) reported a single case of VCD where the role of the pediatric psychologist in the integrated management was emphasized. This patient received behavioral therapy along with speech therapy during an inpatient stay and showed improvement after many days of initial therapy for asthma exacerbation. Similarly, Corren et al. ( 25 ) also reported the case of a 20-year old with VCD who responded to the combination of psychotherapy and speech therapy. Brown et al. ( 29 ) reported an adult with VCD along with depression and psychogenic amnesia that was treated with psychotherapy and oral desipramine therapy. Another adult with VCD reported by Thurston et al. ( 24 ) had been treated with a combination of psychotherapy and multiple medications, which included citalopram and venlafaxine and later a higher dose of venlafaxine with lithium augmentation.

Warnes et al. ( 23 ) used electromyography (EMG) related biofeedback therapy for a patient with VCD who was not responding to breathing exercises taught by a speech therapist. Similar to the description of use of biofeedback by Earles et al., this therapy required 10 weekly sessions where the patient was taught how to reduce muscle tension in laryngeal muscles using EMG signals to reinforce relaxation behaviors.

Excluded studies

Arick-Forest et al. ( 8 ) reported the results of a prospective study of 170 adults (>18 years of age) with VCD, which included the psychological analysis of a subset of 47 newly diagnosed patients. The authors used the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and life experiences survey (LES) to evaluate stress and found that a significant number of patients demonstrated a conversion disorder pattern ( p  < 0.01). When the authors compared subjects with known psychological disorders to those without a psychological history, there was a significantly higher score on the depression and anxiety scales. Overall, roughly a quarter of their cohort had normal psychological outcomes. However, no specific psychological interventions were performed as part of the treatment strategy for these patients. Husein et al. detailed the results of psychological testing in 45 patients from the same institution, describing the use of MMPI-2 and LES, but no interventions were reported in this report.

Dietrich et al. ( 33 ) reported a retrospective analysis of 160 patients who presented to their voice disorders clinic with various voice disorders (including VCD) and the authors analyzed the distribution and frequency of perceived stress, anxiety, and depression in these patients. They reported the highest prevalence of these in the VCD patients. Even though females outnumbered males in most voice disorder categories in their cohort by a factor 4 to 6:1, the authors found that males with VCD had a much higher prevalence perceived stress, anxiety, and depression. Again no psychological interventions were reported in this retrospective study.

Gavin et al. ( 34 ) described the psychological and familial characteristics of adolescents with VCD from a multidisciplinary clinic of a single institution. The authors used several tools such as Child and Adolescent Psychiatric Assessment (CAPA), Child Behavior Checklist, Teacher Report Form, Youth Self Report, and Family Assessment Device. Based on these assessments, the authors could compare VCD patients with matched controls and found a higher prevalence of anxiety symptoms in VCD patients. No additional psychological interventions were reported in this study.

Seifert et al. ( 35 ) reported the impact of self-perception and the ability to deal with aggressiveness in VCD patients using two scales but did not report any psychological interventions. Staudenmayer ( 36 ) reported the occurrence of mass psychogenic illness in the occupants of a single office building who presented with symptoms suggestive of possible VCD. The alleged source of symptoms was reported to solvents used in membrane roof repair work but extensive environmental testing revealed no significant exposures. The authors reported significant underlying psychopathology in the occupants, but no treatment interventions were outlined in this report.

Risk of bias in included studies

We also assessed the studies for possible bias that may affect the interpretation of the results of various psychological interventions that were used for patients with VCD. Because a majority of the reports included in the analysis were small case series or individual case reports, there is no reliable data on the effectiveness of any of the psychological interventions used. In some cases, treatments such as psychotherapy were still ongoing so there might be some attrition bias due to incomplete outcome data being available for the psychological intervention being utilized. There is also a risk of reporting bias for cases that were successfully treated that are more likely to be reported in the literature.

This systematic review focuses on the available literature regarding the use of various forms of psychological interventions for patients with VCD. Most studies have described use of individual psychotherapy, behavioral therapy, and biofeedback techniques as being effective in the treatment of associated psychological conditions in VCD patients. The duration of these interventions has also been variable and many of the cases had ongoing psychotherapy for prolonged periods of time (which was not clearly specified in most reports). The use of anti-depressant or anxiolytic medications is limited to a select few reports. While tricyclic anti-depressants such as amitriptyline were used most commonly; anti-depressants in general improved symptoms in conjunction with other behavioral/psychological interventions. None of the reported studies utilized medication treatment alone. Hypnotherapy has also been effective in many patients although its availability is limited due to the paucity of trained individuals who can successfully use this modality for VCD patients. While the use of breathing techniques (such as diaphragmatic breathing or relaxed throat breathing) has been universally applied for VCD patients with the help of a speech and language pathologist at most centers, the need for psychological evaluation and intervention has been determined on a case-by-case basis. In fact, many centers have an individualized approach for the management of each patient and most centers do not have a psychologist available to evaluate these patients in conjunction with the ENT or pulmonary physicians that usually treat these patients. The creation of specialized multidisciplinary teams or clinics for VCD as described by Maturo et al. ( 16 ) can be helpful in creating a standardized approach for the management of VCD patients. At these centers, the effectiveness of various approaches can then be evaluated in a prospective manner with the help of all the specialists involved in assessment and management of VCD patients.

The evidence regarding the use of psychological interventions in patients with VCD is limited to only small case series and case reports, and there are no prospective studies that have used a standard psychological intervention or tried to assess the effectiveness of one approach over another in these patients. The quality of the evidence available is also limited, as there are no large randomized controlled trials or multicenter studies. Most case series were single-center experiences that provide limited evidence regarding the effectiveness of these interventions. Another drawback is the limited evidence for usefulness of psychological interventions for pediatric cases of VCD as compared to that for adult patients. Most cases receive a combination of several interventions, as summarized in Table ​ Table2. 2 . This makes it more difficult to evaluate whether the improvement seen in patients’ symptoms can be attributed to any one particular intervention.

Use of different treatment modalities in patients with VCD undergoing psychological interventions .

*Not all patients in this study received this intervention .

There have been additional systematic reviews evaluating the usefulness of psychological interventions for adults ( 37 ) and children with asthma ( 38 ). Additional reviews of therapies available for dyspnea in patients with various other lung disorders have also included several pharmacological and non-pharmacological interventions ( 39 ). Psychological interventions like hypnosis, biofeedback, psychotherapy, and cognitive–behavioral therapy have been found to be very useful in symptom reduction and in improving the overall outcome in these pulmonary disorders with significant psychological contribution, as in VCD. Similar approaches as that used for VCD patients have also been utilized in the treatment of psychiatric disorders with somatic manifestations like conversion disorders ( 40 ) and somatoform disorders ( 41 ). Because the prevalence of psychological co-morbidity in patients with VCD has been reported to be as high as 75% ( 24 ), it is essential to carefully evaluate these interventions so that the most the effective approaches can be adopted for the management of patients with VCD.

Although the authors made every possible attempt to find all published studies pertaining to psychological interventions for VCD/PVFM, it is possible that some studies may have been missed. There have been no other systematic reviews on the role of psychological interventions for VCD patients to the best of our knowledge. Most reviews of VCD/PVFM that have discussed treatment approaches for this condition have recommended referral for psychological interventions in most patients.

Based on the limited data available from retrospective case series and case reports, we conclude that psychological interventions do have a role to play in the management of adult and pediatric patients with VCD. There is no uniform approach that can be applied for all patients and psychological assessment, and intervention is individualized based on each patient’s characteristics. Further studies for validating the use of standardized approaches for treatment of VCD-associated psychopathology are needed.

Author Contributions

Loveleen Guglani wrote the manuscript and performed the literature searches. Sarah Atkinson compiled the references for the systematic review and extracted the data from the individual studies. Avinash Hosanagar edited the manuscript. Lokesh Guglani initiated this systematic review, performed the literature review, and also helped to write and edit the manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors would like to acknowledge the help of the library staff at Shiffman Medical Library at Wayne State University in collecting all the studies that were included in this review.

1 Division of Pulmonary Medicine, The Carman and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA.

• Slurred Speech

6 Causes of Slurred Speech

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6 most common cause(s)

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What is slurred speech?

Slurred speech is when you have trouble speaking, your words are slow or garbled, or your words run together. When you talk, many components of your nervous system work together to form words. When these parts don’t work correctly, your speech can become distorted, or “slurred.” The medical term for slurred speech is dysarthria.

Slurred speech includes problems pronouncing words and regulating the speed or pace of your speech. It can range from a barely noticeable problem to one that’s so severe that others can’t understand what you’re saying.

People often describe slurred speech as feeling like you’re trying to talk with your mouth full of marbles.

Common causes of slurred or slow speech include drinking too much alcohol and not getting enough sleep. In these cases, the slurring will stop once you’re sober again and have gotten rest, respectively.

There are also other causes of slurred speech such as a stroke (a medical emergency), brain tumor, Bell’s palsy, or a serious migraine.

Does slurred speech always need to be treated?

"People often think slurred speech is a minor symptom that does not need a medical evaluation. As our speech and ability to speak is our main form of communication, it is important to look for correctable causes." — Dr. Karen Hoerst

Should I go to the ER for slurred speech?

You should call 911 if:

• Your slurred speech starts suddenly.
• You have other symptoms, such as a sudden or severe headache and weakness or numbness of one side of your body.
• Your tongue, face, or lips are swelling, which could mean you’re having an allergic reaction.

1. Stroke or TIA (transient ischemic attack)

• Slurred speech
• Drooping of one side of the face
• Weakness or trouble controlling one side of the body
• Numbness in the face , arm , or leg
• Difficulty walking
• Sudden loss of vision or double vision
• Sudden, severe headache

A stroke occurs in the brain because the blow flow in a blood vessel is blocked. It can also happen when a blood vessel ruptures or leaks. This affects the blood supply to parts of the brain, which leads long-term damage. If it affects the area of the brain responsible for speech, it can cause slurred speech.

A transient ischemic attack , or TIA, is sometimes called a "mini stroke." A TIA is a temporary interruption of blood flow that causes the same symptoms as a stroke, but improves without any permanent damage to the brain or symptoms.

For example, if you have slurred speech because of a TIA, once the blood flow is restored to that area of the brain, the slurred speech goes away. But people who have a TIA are at a high risk of having a stroke in the future, especially if their risk factors are not treated. Risk factors are the same for stroke and TIA and include smoking, obesity, and cardiovascular disease.

It’s extremely important to call 911 right away if you suddenly have slurred speech. Getting immediate treatment is critical to minimizing permanent damage. Paramedics can begin treating you in the ambulance on the way to the hospital, so it’s better to call 911 than go to the ER yourself.

Treatments for strokes and TIAs include medications to break up blood clots and surgery to remove blood clots from the vessels. If your stroke is from bleeding in the brain, you may need surgery to repair a blood vessel.

Following treatment, your doctor will recommend medications to prevent another TIA or stroke. These typically include drugs that prevent clots from forming in the blood (like aspirin or other blood thinners) and cholesterol medication to prevent plaque from building up on the walls of the blood vessels. You may also need to take medication to control your blood pressure.

Speech therapy is recommended to help treat problems with speech.

It may not be a stroke

"There are so many possible causes of slurred speech. Most of the time we need a detailed history and physical exam to guide the diagnosis and treatment." — Dr. Hoerst

2. Bell’s palsy

• Drooping of the face
• Drooping of the eye
• Changes in taste or hearing

Bell’s palsy is a relatively common condition that affects the facial nerve, which is responsible for movement of your face.

In Bell’s palsy, the nerve gets inflamed typically because of a recent viral infection. This inflammation can cause the facial nerve to not work as well, leading to drooping and slurred speech.

Bell’s palsy usually improves in a few months, but medications such as steroids and antiviral drugs are typically given to help speed the process. If nerve problems continue, physical therapy is recommended. In rare instances, surgery may be needed to help improve facial muscle function.

3. Brain tumor

• Slurred speech or speech difficulties
• New or changing headaches
• Weakness or coordination and balance problems
• Abnormal vision

A brain tumor is an abnormal growth of cells in the brain. A brain tumor may be cancerous (malignant) or noncancerous (benign). Both types can cause symptoms including slurred speech.

The diagnosis of a tumor in the brain or spinal cord is based on an exam and imaging of the brain, such as an MRI or CT scan. A biopsy (tissue sample) may be needed to determine what type of tumor it is.

Some tumors, such as a small noncancerous tumor, do not need treatment, though your doctor will recommend periodic MRI scans to make sure it hasn’t changed.

Most larger or cancerous tumors do require treatment, which may consist of chemotherapy, radiation, or surgery. If you develop physical or cognitive (mental) problems from the tumor, rehabilitation such as physical therapy, occupational therapy, or speech therapy may be needed.

4. Multiple sclerosis

• Blurred vision or decreased vision, typically in one eye
• Weakness or trouble walking
• Numbness or pins-and-needles sensation on your face, arm, or leg (typically on one side)
• A band-like squeezing sensation around the chest or abdomen
• Difficulty focusing

Multiple sclerosis, or MS, is a central-nervous system disease that affects the cells of the brain and spinal cord. In MS, a fatty tissue that surrounds nerve fibers (myelin) is attacked. Myelin helps to insulate the electrical signals sent through the nerves. When there is a problem with this fatty tissue, information sent to and from the brain can be disrupted.

MS is most common in young adults between the ages of 20 and 50, according to the National MS Society .

MS is not curable , but treatments have dramatically improved the ability to control MS, so people usually have fewer symptoms and less disability.

Treatment includes medications that may be taken orally or injected or infused through an IV line. Physical therapy and speech therapy are commonly used to help in physical recovery, and medications can be used to treat other symptoms, such as depression, pain, and fatigue.

5. Amyotrophic lateral sclerosis (ALS)

• Difficulty with speech, including slurred speech
• Progressive weakness and difficulty balancing
• Muscle cramps, twitching, and stiffness
• Difficulty swallowing

Amyotrophic lateral sclerosis (ALS) is also known as Lou Gehrig’s disease. It affects nerve cells called motor neurons that control your movement.

The disease primarily causes a loss of strength, impaired swallowing and speech, and in most cases, difficulty breathing because of impaired respiratory muscles. It is a progressive disease, meaning that symptoms are mild at first and worsen over time.

Previously, it was thought that ALS doesn’t affect a person’s mental ability. But it’s now known that people with ALS can get a specific type of dementia called frontotemporal dementia (FTD). That condition can affect behavior, mood, and speech.

Symptoms of ALS can develop in adults of any age, but it’s most commonly diagnosed in people who are between the ages of 40 and 70, according to the ALS Association .

While there are some medications that can be used to delay the progression of the disease, there is currently no cure for ALS. Treatment includes rehabilitation with physical therapy, occupational therapy, speech therapy, and respiratory therapy.

6. Migraine

• Sensitivity to light and sound
• Visual disturbances

A migraine causes a severe headache that is often accompanied by nausea and sensitivity to light or sound. But some migraines don’t cause head pain.

Other symptoms that involve the nervous system can occur. Some of these sensory symptoms are called “auras.” These distortions can cause visual changes , including flashing lights or distorted vision. People may feel tingling or numbness of their face, arm, or leg.

In some types of migraine, people may even develop slurred speech and weakness of the face, arm, or leg. These are also symptoms of a stroke, so it may be hard to figure out which condition you have. If you develop sudden slurred speech or weakness, go to the ER immediately.

In an acute migraine attack, medications can be used to stop a migraine that has already started, such as triptans or newer medications called CGRP inhibitors. These medications can be in pill form, inhaled form, or injectable medications.

Migraine prevention can include taking medications for blood pressure, anticonvulsants, or even antidepressants. In some instances, Botox treatments are used to prevent migraine.

Behavior and lifestyle changes such as exercise, improved sleep, and healthy diet or weight loss are also often recommended to help decrease the number of migraine headaches you experience.

Other possible causes

Slurred speech may occur from alcohol intoxication or tiredness. It can also be a side effect of medications like high dose pain medications, antipsychotic medications or even some allergy medications like antihistamines. Other causes include:

• Infections such as urinary tract infections or electrolyte imbalances (particularly in elderly people).
• Brain infections such as meningitis or encephalitis.
• Problems that affect your mouth or throat, such as poorly fitting dentures, dental infections, dental numbing medications, swelling in your throat, or muscle or nerve problems.
• An allergic reaction , especially if you notice slurred speech along with tongue swelling , lip swelling, or shortness of breath.

"Early speech therapy can not only help with early improvement but also with diagnosis. Speech-language pathologists have special training in detecting the various types of slurred speech, which helps to determine the possible causes."— Dr. Hoerst

Specialty treatment options

• Speech therapy is the most common treatment for slurred speech.
• Injected medications such as Botox are sometimes used, depending on the cause of slurred speech.
• Medications to improve nerve and muscle function.

While it's important to follow your healthcare provider's guidance, here are some over-the-counter (OTC) options that might provide extra support.

• Proper nutrition supports overall health, including nerve function. Supplements like B vitamins may support neurological health.
• Staying hydrated is key, especially if speech difficulties make it hard to drink. Consider a no-spill, easy-sip water bottle designed for easy grip.
• Engaging in exercises to improve speech clarity can be helpful. Explore speech therapy tools and resources that you can use at home.

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6 Causes of Slurred Speech: Why You May Have Difficulty …

Table of Contents

Neurological disorders and slurred speech.

Medications and Slurred Speech

Alcohol and Slurred Speech

Stroke and slurred speech.

Traumatic Brain Injury and Slurred Speech

Slurred speech refers to a condition where an individual’s speech becomes unclear, difficult to understand, or distorted. There are various causes that can contribute to slurred speech, ranging from temporary conditions to more serious underlying health issues. Understanding these causes is crucial in order to identify and address the underlying problem. In this article, we will explore six common causes of slurred speech, shedding light on why individuals may experience difficulty in their speech.

Slurred speech, also known as dysarthria, is a condition that affects the ability to articulate words clearly and smoothly. It can be caused by various factors, including neurological disorders. Understanding the causes of slurred speech is crucial in order to seek appropriate medical attention and treatment. In this article, we will explore six common causes of slurred speech related to neurological disorders.

One of the primary causes of slurred speech is a stroke. When a stroke occurs, blood flow to the brain is disrupted, leading to damage in certain areas responsible for speech production. This damage can result in slurred speech, as well as other communication difficulties. It is important to seek immediate medical attention if you experience sudden slurred speech, as a stroke requires urgent treatment.

Another neurological disorder that can cause slurred speech is multiple sclerosis (MS). MS is a chronic condition that affects the central nervous system, including the brain and spinal cord. As the protective covering of nerve fibers is damaged, communication between the brain and the rest of the body is disrupted. This can lead to slurred speech, among other symptoms such as fatigue and muscle weakness.

Parkinson’s disease is yet another neurological disorder associated with slurred speech. This progressive condition affects the nervous system, particularly the part responsible for controlling movement. As the disease progresses, muscles involved in speech production can become stiff and rigid, resulting in slurred speech. Other symptoms of Parkinson’s disease include tremors, balance problems, and muscle stiffness.

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a degenerative disorder that affects nerve cells in the brain and spinal cord. As the disease progresses, the muscles responsible for speech become weaker and less coordinated, leading to slurred speech. ALS is a progressive condition with no known cure, so treatment focuses on managing symptoms and improving quality of life.

Huntington’s disease is a genetic disorder that causes the progressive breakdown of nerve cells in the brain. This breakdown affects movement, cognition, and behavior. As the disease advances, individuals may experience slurred speech due to the deterioration of the muscles involved in speech production. Other symptoms of Huntington’s disease include involuntary movements, difficulty swallowing, and cognitive decline.

Lastly, a brain tumor can also cause slurred speech. Tumors in the brain can disrupt the normal functioning of brain cells, leading to various symptoms, including slurred speech. The specific location of the tumor determines which areas of the brain are affected and the resulting symptoms. Prompt medical evaluation is crucial if you experience persistent slurred speech, as brain tumors require specialized treatment.

In conclusion, slurred speech can be caused by various neurological disorders. Stroke, multiple sclerosis, Parkinson’s disease, ALS, Huntington’s disease, and brain tumors are all potential causes of slurred speech. If you or someone you know experiences persistent slurred speech, it is important to seek medical attention to determine the underlying cause and receive appropriate treatment. Early intervention can help manage symptoms and improve quality of life for individuals with slurred speech.

Slurred speech can be a distressing symptom that affects individuals of all ages. It can make communication difficult and lead to feelings of frustration and embarrassment. While there are various causes of slurred speech, one potential culprit is the use of certain medications. In this article, we will explore six common medications that may contribute to slurred speech.

1. Sedatives and tranquilizers: Sedatives and tranquilizers are commonly prescribed to treat anxiety, insomnia, and certain neurological conditions. These medications work by depressing the central nervous system, which can result in slowed speech and impaired coordination. Examples of sedatives and tranquilizers include benzodiazepines like diazepam and lorazepam.

2. Antipsychotics: Antipsychotic medications are often prescribed to manage conditions such as schizophrenia and bipolar disorder. While they can be highly effective in treating these conditions, they may also cause side effects such as slurred speech. This is because antipsychotics affect the dopamine receptors in the brain, which can impact speech production. Common antipsychotics include risperidone and olanzapine.

3. Muscle relaxants: Muscle relaxants are commonly prescribed to alleviate muscle spasms and stiffness associated with conditions like multiple sclerosis and fibromyalgia. These medications work by reducing muscle tone, but they can also affect the muscles responsible for speech production. As a result, slurred speech may occur as a side effect. Examples of muscle relaxants include baclofen and cyclobenzaprine.

4. Anticonvulsants: Anticonvulsant medications are primarily used to manage seizures in individuals with epilepsy. However, they may also be prescribed for other conditions such as neuropathic pain and mood disorders. While anticonvulsants are generally well-tolerated, they can cause side effects such as slurred speech. This is thought to be due to their impact on the central nervous system. Common anticonvulsants include carbamazepine and valproic acid.

5. Opioids: Opioids are powerful pain medications that are commonly prescribed for acute and chronic pain management. While they can provide much-needed relief, they also come with a range of side effects, including slurred speech. Opioids work by binding to opioid receptors in the brain, which can affect speech production and coordination. Examples of opioids include oxycodone and morphine.

6. Antihistamines: Antihistamines are commonly used to manage allergies and cold symptoms. While they are generally safe and well-tolerated, some antihistamines can cause drowsiness and sedation, which may result in slurred speech. This is particularly true for first-generation antihistamines such as diphenhydramine and chlorpheniramine.

It is important to note that not everyone who takes these medications will experience slurred speech. The occurrence and severity of this side effect can vary from person to person. If you are experiencing slurred speech while taking any of these medications, it is crucial to consult with your healthcare provider. They can evaluate your symptoms, review your medication regimen, and make any necessary adjustments to ensure your safety and well-being.

In conclusion, medications can sometimes be the cause of slurred speech. Sedatives, antipsychotics, muscle relaxants, anticonvulsants, opioids, and antihistamines are all examples of medications that may contribute to this symptom. If you are experiencing slurred speech while taking any of these medications, it is important to seek medical advice to determine the best course of action. Your healthcare provider can help identify the underlying cause and explore alternative treatment options if necessary.

Alcohol is a depressant that affects the central nervous system, including the brain. When consumed in excessive amounts, alcohol can impair the functioning of the brain, leading to slurred speech. This occurs because alcohol affects the muscles responsible for speech production, causing them to become weak and uncoordinated.

Another factor that contributes to slurred speech is the impact of alcohol on the brain’s communication pathways. Alcohol interferes with the transmission of signals between different parts of the brain, including those involved in speech production. As a result, the coordination required for clear and precise speech is compromised, leading to slurring of words.

Furthermore, alcohol can also affect the muscles of the tongue and lips, which are crucial for articulating sounds correctly. These muscles may become relaxed and less responsive under the influence of alcohol, making it difficult to form words accurately. This relaxation of the muscles can also lead to a slower rate of speech, further contributing to slurred speech.

In addition to the direct effects of alcohol on speech production, alcohol intoxication can also impair cognitive functions. Alcohol affects the brain’s ability to process information and make decisions, which can impact speech clarity. Individuals under the influence of alcohol may struggle to find the right words or maintain a coherent train of thought, resulting in slurred speech.

Moreover, alcohol can cause dehydration, which can further exacerbate slurred speech. Dehydration affects the vocal cords and the mucous membranes in the mouth and throat, making it harder to produce clear speech. Dryness in these areas can lead to a hoarse or raspy voice, adding to the slurring effect.

Lastly, alcohol can also affect an individual’s balance and coordination, which can indirectly contribute to slurred speech. When a person’s motor skills are impaired, they may have difficulty controlling the muscles required for speech production. This lack of coordination can result in slurred speech as the individual struggles to articulate words accurately.

In conclusion, alcohol consumption can lead to slurred speech due to its effects on the central nervous system, muscle coordination, cognitive functions, dehydration, and motor skills. It is important to note that slurred speech caused by alcohol is temporary and typically resolves once the effects of alcohol wear off. However, chronic alcohol abuse can lead to long-term damage to the brain and speech-related functions. If you or someone you know experiences persistent slurred speech, it is essential to seek medical attention to determine the underlying cause and receive appropriate treatment.

Slurred speech is a condition that affects the clarity and articulation of one’s speech. It can be a symptom of various underlying causes, ranging from temporary issues to more serious medical conditions. Understanding the potential causes of slurred speech is crucial in order to seek appropriate treatment and address any underlying health concerns.

One common cause of slurred speech is stroke. When a stroke occurs, blood flow to the brain is disrupted, leading to damage in certain areas responsible for speech production. This damage can result in slurred speech, as well as other symptoms such as weakness or numbness on one side of the body. If you experience sudden slurred speech along with these other symptoms, it is important to seek immediate medical attention, as stroke is a medical emergency.

Another potential cause of slurred speech is alcohol or drug intoxication. When under the influence of alcohol or certain drugs, the central nervous system is affected, leading to impaired coordination and muscle control, including the muscles involved in speech production. This can result in slurred speech, as well as other signs of intoxication such as unsteady gait or altered mental state. It is important to remember that driving or operating machinery while under the influence can have serious consequences, not only for yourself but also for others.

Certain medical conditions can also cause slurred speech. One such condition is multiple sclerosis (MS), a chronic autoimmune disease that affects the central nervous system. In MS, the protective covering of nerve fibers in the brain and spinal cord is damaged, leading to a wide range of symptoms, including slurred speech. Other neurological conditions, such as Parkinson’s disease or amyotrophic lateral sclerosis (ALS), can also cause slurred speech due to the progressive degeneration of nerve cells involved in speech production.

In some cases, slurred speech may be a side effect of medication. Certain medications, such as muscle relaxants or sedatives, can affect muscle control and coordination, leading to slurred speech. If you notice slurred speech after starting a new medication, it is important to consult with your healthcare provider to determine if the medication is the cause and discuss potential alternatives.

Additionally, slurred speech can be a symptom of a transient ischemic attack (TIA), also known as a mini-stroke. A TIA is a temporary disruption of blood flow to the brain, often caused by a blood clot. While the symptoms of a TIA are similar to those of a stroke, they typically resolve within a short period of time. However, a TIA should not be ignored, as it can be a warning sign of an impending stroke.

Lastly, slurred speech can be a result of a traumatic brain injury (TBI). When the brain experiences a sudden impact, such as in a car accident or a fall, it can lead to damage in the areas responsible for speech production. Depending on the severity of the injury, slurred speech may be temporary or long-lasting.

In conclusion, slurred speech can have various causes, ranging from temporary issues such as alcohol intoxication to more serious medical conditions like stroke or multiple sclerosis. Recognizing the potential causes of slurred speech is essential in order to seek appropriate medical attention and address any underlying health concerns. If you or someone you know experiences slurred speech, especially when accompanied by other concerning symptoms, it is important to consult with a healthcare professional for a proper evaluation and diagnosis.

Slurred speech can be a distressing symptom that affects individuals who have experienced a traumatic brain injury (TBI). This condition can significantly impact a person’s ability to communicate effectively, leading to frustration and difficulties in daily life. Understanding the causes of slurred speech in individuals with TBI is crucial for both patients and healthcare professionals. In this article, we will explore six common causes of slurred speech in individuals with traumatic brain injury.

1. Muscle Weakness and Paralysis

One of the primary causes of slurred speech in individuals with TBI is muscle weakness and paralysis. When the brain sustains an injury, it can affect the nerves that control the muscles responsible for speech production. As a result, the affected individual may experience difficulty in coordinating the movements required for clear speech, leading to slurring of words.

2. Damage to the Speech Centers in the Brain

Another cause of slurred speech in individuals with TBI is damage to the speech centers in the brain. These speech centers, located in the left hemisphere of the brain, are responsible for controlling the muscles involved in speech production. When these areas are damaged, it can result in slurred speech as the brain struggles to send the appropriate signals to the muscles.

3. Cognitive Impairments

Cognitive impairments, such as difficulties with attention, memory, and problem-solving, are common after a traumatic brain injury. These impairments can also contribute to slurred speech. Individuals with TBI may struggle to find the right words or organize their thoughts, leading to hesitations and slurring of speech as they try to express themselves.

4. Swelling and Inflammation

Following a traumatic brain injury, the brain often experiences swelling and inflammation as part of the body’s natural response to injury. This swelling can put pressure on the surrounding brain tissue, including the areas responsible for speech production. As a result, slurred speech may occur due to the physical compression of these vital speech centers.

5. Damage to the Cranial Nerves

The cranial nerves play a crucial role in controlling various functions, including speech. A traumatic brain injury can damage these nerves, leading to slurred speech. The cranial nerves involved in speech production include the facial nerve, which controls the muscles of the face and mouth, and the hypoglossal nerve, responsible for controlling the tongue’s movements. Damage to these nerves can result in difficulties with articulation and pronunciation, leading to slurred speech.

6. Medications and Treatments

Lastly, certain medications and treatments used to manage the symptoms of traumatic brain injury can also contribute to slurred speech. For example, muscle relaxants prescribed to reduce muscle spasms and stiffness can affect the coordination of speech muscles, resulting in slurring. Additionally, sedatives and pain medications may also have side effects that impact speech clarity.

In conclusion, slurred speech is a common symptom experienced by individuals with traumatic brain injury. Muscle weakness and paralysis, damage to the speech centers in the brain, cognitive impairments, swelling and inflammation, damage to the cranial nerves, and certain medications and treatments can all contribute to this speech difficulty. Understanding these causes is essential for healthcare professionals to develop appropriate treatment plans and for individuals with TBI to seek the necessary support and interventions to improve their speech and overall quality of life.

1. What are the common causes of slurred speech? The common causes of slurred speech include stroke, brain injury, neurological disorders, alcohol or drug intoxication, medication side effects, and certain medical conditions.

2. How does a stroke cause slurred speech? A stroke can cause slurred speech by affecting the brain’s ability to control the muscles involved in speech production.

3. What types of brain injuries can lead to slurred speech? Brain injuries such as traumatic brain injury (TBI) or brain tumors can disrupt the normal functioning of the brain, leading to slurred speech.

4. Which neurological disorders can cause slurred speech? Neurological disorders like multiple sclerosis, Parkinson’s disease, and amyotrophic lateral sclerosis (ALS) can result in slurred speech due to the damage they cause to the nerves and muscles involved in speech.

5. Can medication side effects cause slurred speech? Yes, certain medications, such as sedatives, muscle relaxants, and antipsychotics, can have side effects that include slurred speech.In conclusion, there are several potential causes of slurred speech, including neurological conditions, medication side effects, alcohol or drug use, stroke or brain injury, fatigue or exhaustion, and certain medical conditions. It is important to consult with a healthcare professional for a proper diagnosis and appropriate treatment if you are experiencing slurred speech.

Hi, I’m Pablo Garduno. I am a biohacking enthusiast, and Head Writer of SanDiegoHealth.org. I write the majority of the content on this site, and appreciate you taking the time to read my work.

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Voice Disorders

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The scope of this page focuses on voice disorders of organic, functional, and psychogenic origin(s).

See the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

For information on gender-affirming voice services, see ASHA’s Practice Portal page on Gender Affirming Voice and Communication .

A voice disorder occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual’s age, gender, cultural background, or geographic location (Aronson & Bless, 2009; Boone et al., 2010; Lee et al., 2004). A voice disorder is present when an individual expresses concern about having an abnormal voice that does not meet daily needs—even if others do not perceive it as different or deviant (American Speech-Language-Hearing Association [ASHA], 1993; Colton & Casper, 2011; Stemple et al., 2010; Verdolini & Ramig, 2001).

For the purposes of this document, voice disorders are categorized as follows:

• alterations in vocal fold tissues (e.g., edema or vocal nodules) and/or
• structural changes in the larynx due to aging.
• vocal tremor,
• spasmodic dysphonia, or
• vocal fold paralysis.
• vocal fatigue,
• muscle tension dysphonia or aphonia,
• diplophonia, or
• ventricular phonation.

Voice quality can also be affected when psychological stressors lead to habitual, maladaptive aphonia or dysphonia. The resulting voice disorders are referred to as psychogenic voice disorders or psychogenic conversion aphonia/dysphonia (Stemple et al., 2010). These voice disorders are rare. Speech-language pathologists (SLPs) may refer individuals suspected of having a psychogenic voice disorder to other appropriate professionals (e.g., psychologist and/or psychiatrist) for diagnosis and may collaborate in subsequent behavioral treatment.

The complementary relationships among these organic, functional, and psychogenic influences ensure that many voice disorders will have contributions from more than one etiologic factor (Stemple et al., 2014; Verdolini et al., 2006). For example, vocal fold nodules may result from behavioral voice misuse (functional etiology). However, the voice misuse results in repeated trauma to the vocal folds, which may then lead to structural (organic) changes to the vocal fold tissue.

SLPs may also be involved in the assessment and treatment of disorders that affect the laryngeal mechanism (i.e., the aerodigestive tract) and that are not classified as voice disorders, such as the following:

• Paradoxical vocal fold movement (PVFM)—a condition in which there is intermittent adduction of the vocal folds that interferes with breathing. When this is suspected, SLPs may be consulted to help identify abnormal laryngeal and respiratory function and to teach various techniques (e.g., vocal exercises, relaxation techniques, quick-release breathing techniques, and proper breath management) to improve laryngeal and respiratory control (Mathers-Schmidt, 2001; Patel et al., 2015; Traister et al., 2016).
• Exercise-induced laryngeal obstruction (EILO)—EILO is most often diagnosed in adolescence and is typically due to obstruction at the laryngeal level due to inappropriate glottic closure or adduction/collapse of supraglottic structures (Maat et al., 2011). EILO may go by other names such as supraglottic airway obstruction during exercise (Murry & Milstein, 2016).

For further information, see ASHA’s Practice Portal page on Aerodigestive Disorders .

Incidence and Prevalence

Incidence of voice disorders refers to the number of new cases identified in a specific time period.

Prevalence refers to the number of individuals who are living with voice disorders in a given time period.

Estimates of incidence and prevalence vary due to a number of factors, including etiology, age, gender, and occupation.

In the pediatric population, the reported prevalence of a voice disorder has ranged from 1.4% to 6.0% (Black et al., 2015; Carding et al., 2006). Longer stays in the neonatal intensive care unit and prolonged intubation (more than 28 days) were associated with more severe dysphonia in premature infants (Hseu et al., 2018). An estimated range of 41%–73% of children were identified with vocal nodules, indicating vocal nodules as a predominant cause of pediatric dysphonia (Martins et al., 2015); however, there can be a variety of causes other than vocal fold nodules that result in dysphonia in the pediatric population. Rates indicated no statistically significant differences across race in preschool-aged children (Duff et al., 2004).

Approximately one out of 13 adults in the United States will experience a voice problem annually, but only a relative minority seek treatment (10%; Bhattacharyya, 2014). The rate of young adults (aged 24–34 years) with voice disorders was estimated to be 6%, with no significant difference across age groups, race/ethnicity, or education levels (Bainbridge et al., 2017). Prevalence was reported to be higher in adults aged 60 years and older, with estimates ranging from 4.8% to 29.1% in population-based studies (de Araújo Pernambuco et al., 2014).

Among adults (between 19 and 60 years of age) with a voice disorder, the most frequent diagnoses included functional dysphonia (20.5%), acid laryngitis (12.5%), and vocal polyps (12%; Martins et al., 2015).

Of individuals over the age of 60 years who had been evaluated for vocal problems, voice disorders were most commonly associated with presbyphonia (changes associated with aging voice), reflux/inflammation, functional dysphonia, vocal fold paralysis/paresis, and Reinke’s edema (Martins et al., 2015). Laryngeal cancer diagnoses were reported to have peaked in adults between 75 and 79 years of age and decreased thereafter (Roy et al., 2016).

Studies reported results based on gender; however, there were no indications whether the data collected were based on sex assigned at birth and/or gender identity. Voice disorders were reported to be significantly more prevalent in male children than in female children (Carding et al., 2006; Martins et al., 2015). In adulthood, however, prevalence was higher in female adults than in male adults, with a reported ratio of 1.5:1.0 (Martins et al., 2015; Roy et al., 2005).

Although female adults more frequently received diagnoses of dysphonia with no specific cause noted, male adults were more frequently diagnosed with chronic laryngitis (Cohen et al., 2012). Also, after the age of 40 years, male adults had higher prevalence rates of laryngeal cancer than female adults (Cohen et al., 2012).

Teachers were estimated to be two to three times more likely than the general population to develop a voice disorder (Martins et al., 2014). Certain factors, such as number of classes per week, noise generated outside of the school setting, and volume of voice while lecturing, were indicated to increase the risk of teachers developing a voice disorder (Byeon, 2019).

The mean prevalence of voice disorders was estimated to be 46% among singers (Pestana et al., 2017). The most prevalent laryngeal pathologies and voice disorder symptoms reported in singers included, but were not limited to, Reinke’s edema, polyps, gastroesophageal reflux disease, laryngeal pain, and hoarseness; however, risk of developing laryngeal pathologies or vocal cord symptoms may vary based on differences in singing style and genre (Kwok & Eslick, 2019).

According to a claims-based study, almost 30% of dysphonia claims were individuals in the service industry. Those in the service industry were estimated to be 2.6 times more likely to develop benign laryngeal growth and individuals in the manufacturing industry were estimated to be 1.4 times more likely to develop malignant laryngeal growth compared to the general population (Benninger et al., 2017).

Signs and Symptoms

The term dysphonia encompasses the auditory-perceptual symptoms of voice disorders. Dysphonia is characterized by altered vocal quality, pitch, loudness, or vocal effort.

Perceptual signs and symptoms of dysphonia include

• rough vocal quality (raspy, audible aperiodicity in sound);
• breathy vocal quality (audible air escape in the sound signal or bursts of breathiness);
• strained vocal quality (increased effort; tense or harsh);
• strangled vocal quality (as if talking with breath held);
• abnormal pitch (too high, too low, pitch breaks, decreased pitch range);
• abnormal loudness/volume (too high, too low, decreased range, unsteady volume);
• abnormal resonance (hypernasal, hyponasal, cul-de-sac resonance);
• aphonia (loss of voice);
• phonation breaks;
• asthenia (weak voice);
• gurgly/wet-sounding voice;
• pulsed voice (fry register, audible creaks or pulses in sound);
• shrill voice (high, piercing sound, as if stifling a scream); and
• tremorous voice (shaky voice; rhythmic pitch and loudness undulations).

Other signs and symptoms include

• increased vocal effort associated with speaking,
• decreased vocal endurance or onset of fatigue with prolonged voice use,
• variable vocal quality throughout the day or during speaking,
• running out of breath quickly,
• frequent coughing or throat clearing (may worsen with increased voice use), and
• excessive throat or laryngeal tension/pain/tenderness.

Signs and symptoms can occur in isolation or in combination. As treatment progresses, some may dissipate, and others may emerge as compensatory strategies are eliminated.

Auditory-perceptual quality of voice in individuals with voice disorders can vary depending on the type and severity of the disorder, the size and site of the lesion (if present), and the individual’s compensatory responses. The severity of the voice disorder cannot always be determined by auditory-perceptual voice quality alone. Therefore, further instrumental assessment may be indicated to determine the severity and/or etiology of a voice disorder.

Normal voice production depends on power and airflow supplied by

• the respiratory system;
• laryngeal muscle activation;
• balance, coordination, and stamina of respiration, phonation, and resonation subsystems; and
• oral cavity, and
• nasal cavity.

A disturbance in one of these subsystems or in the physiological balance among the systems may lead to or contribute to a voice disorder. Disruptions can be due to organic, functional, and/or psychogenic causes.

Organic causes include the following:

• vocal nodules, cysts, or polyps
• glottal stenosis
• recurrent respiratory papilloma
• sarcopenia (muscle atrophy associated with aging)
• arthritis of the cricoarytenoid or cricothyroid,
• laryngitis, or
• laryngopharyngeal reflux
• intubation trauma
• chemical exposure
• external trauma
• recurrent laryngeal nerve paralysis
• adductor/abductor spasmodic dysphonia
• Parkinson’s disease
• multiple sclerosis
• pseudobulbar palsy

Functional causes include the following:

• phonotrauma such as
• excessive throat clearing/coughing
• speaking in too high or too low pitch
• muscle tension dysphonia
• ventricular phonation
• vocal fatigue due to

Psychogenic causes include the following:

• chronic stress disorders
• conversion reaction such as
• conversion aphonia
• conversion dysphonia

Making modifications to pitch without the guidance of a skilled service provider is not recommended and may result in vocal misuse. However, voice services may be provided to assist with appropriate pitch modifications.

Recognizing associations among these factors, along with patient history, may help in identifying the possible causes of the voice disorder. Even when an obvious cause is identified and treated, the voice problem may persist. For example, an upper respiratory infection could be the cause of the dysphonia, but poor or inefficient compensatory techniques may cause dysphonia to persist, even when the infection has been successfully treated.

Roles and Responsibilities

SLPs play a central role in the assessment, diagnosis, and treatment of voice disorders. The professional roles and activities in speech-language pathology include the following:

• prevention and advocacy
• administration

SLPs are trained to evaluate voice use and function to determine the cause of reported symptoms and select treatment methods for improving voice production.

Appropriate roles for SLPs include the following:

• Provide prevention information to individuals and groups known to be at risk for voice disorders, as well as to individuals working with those at risk.
• Conduct a comprehensive voice assessment, including clinical and instrumental evaluation.
• Identify normal and abnormal vocal function, describe perceptual qualities of voice, and assess vocal habits.
• Diagnose a voice disorder.
• Refer individuals to other professionals as needed to obtain a medical diagnosis (e.g., unilateral vocal fold immobility as the cause of dysphonia).
• Refer individuals to other health care professionals when medical/surgical or psychological evaluation and treatment are indicated and facilitate patient access to comprehensive services.
• Make decisions about management of voice disorders and develop culturally responsive treatment plans.
• Provide treatment, document progress, and determine appropriate dismissal criteria.
• Counsel patients and provide education aimed at preventing further complications from voice disorders.
• Serve as an integral member of a collaborative team (see ASHA’s resources on  collaboration and teaming  and  interprofessional education/interprofessional practice [IPE/IPP] ) that includes professionals such as
• otolaryngologists/laryngologists,
• pulmonologists,
• allergists,
• gastroenterologists,
• neurologists,
• endocrinologists,
• mental health professionals, and
• vocal coaches or voice teachers.
• Consult with other professionals, family members, and caregivers to facilitate program development and to provide
• supervision,
• evaluation, and/or
• expert testimony (as appropriate).
• Remain informed of research related to voice disorders and help advance the knowledge base related to the nature and treatment of voice disorders.
• Advocate for individuals with voice disorders at the local, state, and national levels.

As indicated in the ASHA  Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

See the Assessment section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Screening may be conducted if a voice disorder is suspected. It may be triggered by concerns from individuals, parents, teachers, or health care providers. When deviations from normal voice are detected during screening, further evaluation is warranted.

Screening includes evaluation of vocal characteristics related to

• respiration;
• resonance; and
• pitch range, and

Clinicians may use a formal screening tool (Lee et al., 2004) or obtain data using informal tasks. Standardized self-report questionnaires can be included for a more thorough screening (e.g., Deary et al., 2003; Hogikyan & Sethuraman, 1999; Jacobson et al., 1997).

Comprehensive Assessment

All patients/clients with voice disorders should be examined by a physician, preferably in a discipline appropriate to the presenting complaint. The physician’s examination may occur before or after the voice evaluation by the SLP. Consultation with an otolaryngologist can be important, particularly in the case that an SLP does not have access to instrumentation for evaluation. Assessment and treatment of voice disorders may require use of appropriate personal protective equipment .

A comprehensive assessment is conducted for individuals suspected of having a voice disorder, using both standardized and nonstandardized measures (see ASHA’s resource on assessment tools, techniques, and data sources ). For a review of clinical voice assessments, see Roy et al. (2013).

Diagnostic therapy may be performed as part of the comprehensive assessment to help in making a diagnosis and to determine if the individual is stimulable to voice therapy efforts.

Comprehensive assessment is conducted to identify and describe

• impairments in body structure and function , including underlying strengths and weaknesses in speech sound production and verbal/nonverbal communication;
• comorbid deficits such as other health conditions and medications that can affect voice;
• limitations in activity and participation , including functional status in communication and interpersonal interactions;
• contextual (environmental and personal) factors that affect communication and life participation; and
• quality of life related to communication impairment and functional limitations.

See ASHA’s resource titled person-centered focus on function: voice [PDF] for an example of assessment data.

Comprehensive Assessment for Voice Disorders: Typical Components

Case history.

• the individual’s description of the voice problem, including onset and variability of symptoms
• medical status and history, including surgeries, chronic disorders, and medications
• previous voice treatment
• daily habits related to vocal hygiene

Self-Assessment

• the individual’s self-perception of voice/vocal quality
• emotions and self-image and
• the ability to communicate effectively in everyday activities as well as in social and work settings (e.g., Hogikyan & Sethuraman, 1999; Jacobson et al., 1997; Ma & Yiu, 2001)

Oral-Peripheral Examination

• assessment of structural or motor-based deficits that may affect communication and voice, including oral musculature, strength, speed, and range of motion
• assessment (during rest and purposeful speech tasks) of symmetry and movement of structures of the face, oral cavity, head, neck, and respiratory system
• testing of mechano-sensation of face and oral cavity
• testing of chemo-sensation (i.e., taste and smell)
• assessment of laryngeal sensations (dryness, tickling, burning, pain, etc.) and palpation of extrinsic laryngeal musculature, as indicated

Assessment of Respiration

• respiratory pattern (abdominal, thoracic, clavicular)
• coordination of respiration with phonation (breath-holding patterns, habitual use of residual air, length of breath groups)
• maximum phonation time (Dejonckere, 2010; Speyer et al., 2010)
• s/z ratio to assess for glottal insufficiency, which may be indicative of laryngeal pathology (Eckel & Boone, 1981; Stemple et al., 2010)

Auditory-Perceptual Assessment

This subjective assessment is based on the clinical impressions of the SLP during production of sustained vowels, sentences, and running speech.

Voice Quality

• roughness —irregularity in voicing source
• breathiness —audible air escape in voice
• strain —perception of excessive vocal effort
• pitch —perceptual correlate of fundamental frequency
• loudness —perceptual correlate of sound intensity
• overall severity —global, integrated impression of voice deviance
• additional perceptual features
• diplophonia
• pitch instability
• wet/gurgly quality

The perceptual features above are defined in ASHA’s Consensus Auditory-Perceptual Evaluation of Voice ( CAPE-V ; ASHA, n.d., 2002; Kempster et al., 2009).

See ASHA’s Practice Portal page on Resonance Disorders .

• Assess resonance quality, such as
• hypernasal, or
• cul-de-sac.
• If abnormal, assess stimulability for normal resonance.
• If normal, evaluate the focus of resonance, such as
• pharyngeal/laryngeal, or
• voice onset/offset characteristics, such as
• delayed voice onset and
• quality of voice at onset
• ability to sustain voicing for appropriate phrasing during speech
• ability to demonstrate a strong and consistent rate of vocal fold valving during diadochokinesis

Rate of Speech

Rate of speech may be indirectly impacted by voice disorders. For instance, a patient with a voice disorder may deliberately slow rate of speech to compensate for a voice disorder and increase intelligibility. For reasons such as these, an SLP may consider assessment of rate of speech (e.g., via diadochokinetic rate assessment).

Instrumental Assessment

Physicians are the only professionals qualified and licensed to render medical diagnoses related to the identification of laryngeal pathology as it affects voice. Imaging should be viewed and interpreted by an otolaryngologist with training in this procedure when it is used for medical diagnostic purposes. 

Laryngeal Imaging

Measures of structure and gross function (using videoendoscopy) and measures of vocal fold vibration during phonation (using videostroboscopy). Please see ASHA’s resource on Vocal Tract Visualization and Imaging for more information.

Acoustic Assessment

Objective measures of vocal function related to vocal loudness, pitch, and quality (Patel et al., 2018).

• Vocal amplitude
• habitual sound pressure level (SPL) in decibels (dB)—typical sound level of voice during connected speech
• minimum and maximum vocal SPL (dB)—softest and loudest sustainable phonation
• Vocal frequency
• mean vocal F0 in hertz (Hz)—average of the estimates of the F0 for acoustic signal recorded during connected speech
• vocal F0 standard deviation (Hz)—standard deviation of the estimates of the F0 for acoustic signal recorded during connected speech
• minimum and maximum vocal F0 (Hz)— F0 values for the lowest and highest pitched sustainable phonations
• Vocal signal quality
• vocal cepstral peak prominence (dB)—relative amplitude of the peak in the cepstrum that represents the dominant harmonic of the vocal acoustic signal (sustained vowels and connected speech samples)

Aerodynamic Assessment

Measures (using noninvasive procedures) of glottal aerodynamic parameters required for phonation.

• Glottal airflow
• average glottal airflow rate (L/sec or mL/sec)—estimated from oral airflow rate during vowel production
• Subglottal air pressure
• average subglottal air pressure (centimeters of water [cmH 2 O] or kilopascals [kPa])—estimated for intraoral air pressure produced during repetition of stop consonants in syllable strings
• Mean vocal SPL and F0 —extracted from simultaneously recorded acoustic signal; facilitates interpretation of airflow and air pressure measurements

SLPs should be aware of potential sources of error or impediments to recording quality during aerodynamic assessment. Sources of error may contribute to inaccurate data. These error sources include

• a microphone,
• a preamplifier,
• analog-to-digital conversion (i.e., digital interface), and
• consistent distance of sound source (voice) to microphone;
• acoustic qualities of room; and
• ambient noise (Patel et al., 2018; Švec & Granqvist, 2018).

Pediatric Voice Assessment Considerations

Although many of the same voice disorders may exist among children and adults, the following conditions tend to be unique to the pediatric population (Sapienza & Ruddy, 2009):

• This is the most common cause of infant inspiratory stridor.
• inspiratory stridor,
• immature laryngeal cartilage,
• floppy epiglottis, and/or
• foreshortened aryepiglottic folds.
• This occurs more frequently in the pediatric population during the 4th to 10th week of gestation.
• This may cause airway blockage.
• This may be acquired due to laryngeal trauma.
• Dyspnea and inspiratory stridor are associated symptoms.
• Type I—Interarytenoid deficit above the true vocal folds.
• Type II—The cricoid lamina is involved; the cleft extends below the true vocal folds.
• Type III—A total cricoid cleft that extends through the cricoid cartilage and may extend into the cervical trachea.
• Type IV—A cleft that extends into the posterior thoracic trachea wall and may extend to the carina.
• Puberphonia —a functional voice disorder that may occur to male adolescents following a voice change during puberty that results in maintaining a high-pitched voice

Further information regarding laryngomalacia and laryngeal cleft may be found in ASHA’s Practice Portal page on Aerodigestive Disorders .

See the Treatment section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Intervention is conducted to achieve improved voice production and coordination of respiration and laryngeal valving. The ASHA Practice Portal page on Head and Neck Cancer addresses intervention aimed at acquisition of alaryngeal speech sufficient to allow for functional oral communication.

Intervention is designed to

• establish appropriate vocal hygiene routines/practices;
• capitalize on strengths and address weaknesses related to underlying structures and functions that affect voice production;
• improve self-awareness of voice quality and kinesthetic factors (e.g., tension);
• facilitate the individual’s activities and life participation by assisting the person in acquiring new communication skills and strategies;
• modify contextual factors to reduce barriers and enhance facilitators of successful communication and participation; and
• provide appropriate accommodations and other supports as well as training in how to use them.

Voice use within different settings should be considered when determining vocal needs and establishing goals. For example, vocal needs within the workplace may be different from those within the community (e.g., home and social settings).

Collaborating With Other Professionals

SLPs often team with otolaryngologists/laryngologists and other medical professionals (e.g., pulmonologists, gastroenterologists, neurologists, allergists, endocrinologists, and occupational medicine physicians) and, if appropriate, develop treatment plans to support the medical plan and to optimize outcomes. Collaboration with otolaryngologists/laryngologists is especially important to rule in or rule out underlying pathologies. SLPs can only diagnose functional abnormalities, and only otolaryngologists can diagnose organic pathologies (e.g., nodules, polyps, tumors).

Some individuals develop voice disorders in the absence of structural pathology (e.g., functional aphonia, muscle tension dysphonia, and mutational/functional falsetto) and may benefit from psychological counseling in addition to what can be provided by the SLP. Counseling, direct manipulation of the voice, and use of interview questions can be used to probe possible factors contributing to the voice problem. SLPs refer the individual to the appropriate health care professional(s) to address issues outside the SLP’s scope of practice (ASHA, 2016).

See ASHA’s resources on collaboration and teaming and interprofessional education/interprofessional practice (IPE/IPP) .

Treatment Approaches

Approaches can be direct or indirect, and SLPs often incorporate aspects of more than one therapeutic approach in developing a treatment plan.

Direct Approaches

Direct approaches focus on manipulating the voice-producing mechanisms (phonation, respiration, and musculoskeletal function) to modify vocal behaviors and establish healthy voice production (Colton & Casper, 2011; Stemple, 2000).

Indirect Approaches

Indirect approaches modify the cognitive, behavioral, psychological, and physical environments in which voicing occurs (Roy et al., 2001; Thomas & Stemple, 2007). Indirect approaches include the following two components:

• Patient education —discussing normal physiology of voice production and the impact of voice disorders on function; providing information about the impact of vocal misuse and strategies for maintaining vocal health (vocal hygiene).
• Counseling —identifying and implementing strategies such as stress management to modify psychosocial factors that negatively affect vocal health (Van Stan et al., 2015).

Therapeutic Plan

A therapeutic plan typically involves at least one direct approach and one or more indirect approaches based on the patient’s condition and goals. Some clinicians concentrate on directly modifying the specific symptoms of the inappropriate voice, whereas others take a more holistic approach, with the goal of balancing the physiologic subsystems of voice production—respiration, phonation, and resonance.

Clinicians may begin by

• identifying behaviors that are contributing to the voice problems, including unhealthy vocal hygiene practices such as
• talking loudly over noise,
• throat clearing, and
• poor hydration.
• implementing practices to reduce vocally traumatic behaviors (e.g., voice conservation) and healthy vocal hygiene practices such as
• drinking plenty of water and
• talking at a moderate volume.

Use of personal protective equipment (PPE) (i.e., face mask) can potentially cause increased strain on voice and perception of vocal effort (Ribeiro et al., 2020). Please see ASHA's Aerosol Generating Procedures and the Resources section below for further information.

Pediatric Voice Treatment Considerations

There may be differences between treating voice disorders in adults and pediatrics due to differences in anatomy, etiology, and developmental level. According to Braden (2018), anatomical differences between pediatric and adult voice include the following:

• laryngeal size
• size of the vocal tract
• Pediatric vocal folds are shorter than adult vocal folds.
• Pediatric vocal folds lack the five-layer structure until adolescence.
• Infant vocal folds are monolayer.
• Infant vocal folds have hyaluronic acid distributed evenly (concentrated in adults).
• Infant vocal folds have more fibroblasts than adults in the lamina propria.
• The newborn larynx is located at approximately C4.
• The adult larynx is located at approximately C6-C7.

As a child’s phonatory structures grow and develop, the respective speaking pitch decreases (decreased frequency of vocal tract formants and fundamental frequency). There is a rapid decrease in mean fundamental frequency in the first 3 years, with another significant change at puberty (McAllister & Sjölander, 2013). Abnormal voice changes may be monitored during adolescence as they may be indicative of a functional voice disorder such as puberphonia. Stridor should also be closely monitored in the pediatric population as it could potentially indicate a compromised airway (Theis, 2010).

Many treatment approaches used for adult populations may be considered for the pediatric population, although adaptations may be needed to meet each child’s developmental level (Braden, 2018). Comorbid developmental disorders such as expressive or receptive language deficits may further complicate treatment of voice in the pediatric population. Some children may not have an internal concept of normal versus abnormal voicing (Hooper, 2004) and, therefore, may have difficulty addressing dysfunction.

Another consideration is potential difficulties that may occur in obtaining treatment in the school-based setting. Challenges may include

• difficulty obtaining referrals to ENT/voice specialists,
• delays in scheduling pediatrician and/or ENT visits,
• difficulty accessing imaging and medical records,
• insurance coverage or payment for MD visits, and
• barriers in eligibility criteria and determining adverse effects on educational performance.

Please see Childes et al. (2017) for further consideration of barriers and challenges.

Treatment Options

The following subsections offer brief descriptions of general and specific treatments for individuals with voice disorders. They are organized under two categories: physiologic voice therapy (i.e., those treatments that directly modify the physiology of the vocal mechanism) and symptomatic voice therapy (i.e., those treatments aimed at modifying deviant vocal symptoms or perceptual voice components using a variety of facilitating techniques). The inclusion of any specific treatment approach does not imply endorsement by ASHA. For more information about treatment approaches and their use with various voice disorders, see Stemple et al. (2010).

Treatment selection depends on the type and severity of the disorder and the communication needs of the individual. Clinicians incorporate functional daily voice needs into goals that reflect inclusion and participation in home, work, and social communities. Linguistic features in some languages may influence the need for specific aspects of voice treatment, such as influences of tonal languages on resonance. In addition, consideration of individuals’ needs, such as gender and/or gender expression or use of regional accents, is an important aspect of goal development.

Physiologic Voice Therapy

Physiologic voice therapy programs strive to balance the three subsystems of voice production (respiration, phonation, and resonance) as opposed to working directly on isolated voice symptoms. Most physiologic approaches may be used with a variety of disorders that result in hyper- and hypofunctional vocal patterns. Below are some of the physiologic voice therapy programs, arranged in alphabetical order.

Accent Method

The accent method is designed to increase pulmonary output, improve glottic efficiency, reduce excessive muscular tension, and normalize the vibratory pattern during phonation. During therapy, the clinician may do one or more of the following tasks (Kotby et al., 1993; Malki et al., 2008):

• facilitate abdominal breathing by initially placing the patient in a recumbent position;
• use rhythmic vocal play with models of accented phonation patterns, which the patient then imitates; and/or
• transfer rhythms to articulated speech, initially being given a model and eventually progressing through reading, monologues, and conversational speech.

Conversation Training Therapy (CTT)

CTT focuses exclusively on voice awareness and production in patient-driven conversational narrative, without the use of a traditional therapeutic hierarchy. Grounded in the tenets of motor learning, CTT strives to guide patients in achieving balanced phonation through clinician reinforcement, imitation and modeling in conversational speech. CTT incorporates six interchangeable components (Gartner-Schmidt et al., 2016; Gillespie et al., 2019), as follows:

• clear speech
• auditory and kinesthetic awareness
• negative practice/labeling
• embedding basic training gestures into speech
• prosody, projection, and pauses
• rapport building

Expiratory Muscle Strength Training (EMST)

EMST improves respiratory strength during phonation. Increase in maximum expiratory pressure can be trained with specific calibrated exercises over time, thus improving the relationship between respiration, phonation, and resonance. EMST uses an external device to mechanically overload the expiratory muscles. The device has a one-way, spring-loaded valve that blocks the flow of air until the targeted expiratory pressure is produced. The device can be calibrated to increase or decrease physiologic load on the targeted muscles (Pitts et al., 2009).

Lee Silverman Voice Treatment (LSVT)

LSVT (Ramig et al., 1994) is an intensive treatment developed for patients with Parkinson’s disease. It is designed to maximize phonatory and respiratory function using a set of simple tasks. Individuals are instructed to produce a loud voice with maximum effort and to monitor the loudness of their voices while speaking. The effort that is involved generates improved respiratory support, laryngeal muscle activity, articulation, and even facial expression and animation. Using a sound-level meter, visual biofeedback may be provided to demonstrate the effort necessary to increase loudness. LSVT is provided by clinicians who are trained and certified in the administration of this technique.

Five basic principles are followed in LSVT, as follows:

• Individuals should “think loud.”
• Speech effort must be high.
• Treatment must be intensive.
• Patients must recalibrate their loudness level.
• Improvements are quantified over time.

Manual Circumlaryngeal Techniques

Manual circumlaryngeal techniques are intended to reduce musculoskeletal tension and hyperfunction by re-posturing the larynx during phonation. There are three main manual laryngeal re-posturing techniques, as follows:

• Push-back maneuver—place forefinger on the thyroid cartilage and push back to change the shape of the glottis.
• Pull-down maneuver—place thumb and forefinger in the thyrohyoid space and pull the larynx downward.
• Medial compression and downward traction—place thumb and forefinger in the thyrohyoid space and apply medial compression.

Applying these maneuvers during vocalization allows the individual to hear resulting changes in voice quality (Andrews, 2006; Roy et al., 1997). Care is taken when employing these techniques, as some patients report discomfort.

Phonation Resistance Training Exercises (PhoRTE)

PhoRTE (Ziegler & Hapner, 2013) was adapted from LSVT and consists of four exercises, as follows:

• producing /a/ with loud maximum sustained phonation
• producing /a/ with loud ascending and descending pitch glides over the entire pitch range
• producing functional phrases using a loud and high (pitched) voice
• producing the same functional phrases using a loud and low (pitched) voice

Individuals are reminded to maintain a “strong” voice throughout these treatment exercises. PhoRTE has a less intensive intervention schedule than LSVT. PhoRTE also differs in that it combines both loudness and pitch when producing phrases (i.e., loud and low pitch, loud and high pitch). Use of PhoRTE has been studied in adults with presbyphonia (aging voice) as a way to improve vocal outcomes (e.g., decrease phonatory effort) and increase voice-related quality of life (Ziegler et al., 2014).

Resonant Voice Therapy

Resonant voice therapy uses a continuum of oral sensations and easy phonation, building from basic speech gestures through conversational speech. Resonant voice is defined as voice production involving oral vibratory sensations, usually on the anterior alveolar ridge or lips or higher in the face in the context of easy phonation. The goal of resonant voice therapy is to achieve the strongest, “cleanest” possible voice with the least effort and impact between the vocal folds to minimize the likelihood of injury and maximize the likelihood of vocal health (Stemple et al., 2010). The program incorporates humming and both voiced and voiceless productions that are shaped into phrase and conversational productions (Verdolini, 1998, 2000).

Stretch and Flow Phonation

Stretch and flow phonation —also known as Casper-Stone Flow Phonation —is a physiological technique used to treat functional dysphonia or aphonia (Stone & Casteel, 1982). It focuses on airflow management and is used for individuals with breath-holding tendencies. Individuals are instructed to focus on a steady outflow of air during exhalation. Various biofeedback methods are used, including placing a piece of tissue in front of the mouth or holding one’s hand in front of the mouth to monitor airflow. Voicing is introduced once the individual masters continuous airflow during exhalation. As such, this technique produces a breathy voice quality and a slowed speaking rate. Eventually, this voice quality is carried into trials with spoken words and phrases, and the breathiness is gradually reduced.

Flow phonation (Gartner-Schmidt, 2008, 2010) is a hierarchical therapy program designed to facilitate increased airflow, ease of phonation, and forward oral resonance. It was modified from stretch and flow phonation by eliminating the “stretch” component, which reduced the rate of speech in the original therapy.

Vocal Function Exercises (VFEs)

VFEs are a series of systematic voice manipulations designed to facilitate return to healthy voice function. VFEs work to strengthen and coordinate laryngeal musculature and improve efficiency of the relationship among airflow, vocal fold vibration, and supraglottic treatment of phonation (Stemple, 1984). Sounds used in training are specific, and correct production is encouraged. VFEs consist of four exercises—warm-up, stretching, contracting, and power exercises. Exercises are completed twice a day (morning and evening) in sets of two. Maximum phonation time goals are set on the basis of individual lung capacity and an airflow rate of 80 mL/sec. Individuals are advised to use a soft, engaged tone and are trained to use a semi-occluded vocal tract (SOVT) without tension during voice productions.

Symptomatic Voice Therapy

Symptomatic voice therapy focuses on the modification of vocal symptoms or perceptual voice components. Symptomatic voice therapy assumes voice improvement through direct symptom modification using a variety of voice facilitating techniques (Boone et al., 2010) that are either direct or indirect. Symptoms to be addressed may include

• pitch that is too high or too low,
• voice that is too soft or too loud,
• breathy phonation,
• hard glottal attacks, or
• glottal fry.

Amplification

Amplification devices such as microphones can be used to increase voice loudness in any situation that requires increased volume (e.g., when speaking to large groups or during conversation when the individual’s voice is weak). As such, voice amplification can function as a supportive tool or as a means of augmentative communication. It can help prevent vocal hyperfunction that may be a result of talking at increased volume or for extended periods of time.

Auditory Masking

Auditory masking is used in cases of functional aphonia/dysphonia and often results in changed or normal phonation. Individuals are instructed to talk or read passages aloud while wearing headphones with masking noise input. Using a loud noise background, the individual often produces voice at increased volume (Lombard effect) that can be recorded and used later in treatment as a comparison (e.g., Adams & Lang, 1992; Brumm & Zollinger, 2011).

Biofeedback

Biofeedback is the concept that self-control of physiologic functions is possible given external monitoring of internal bodily state. Biofeedback may be kinesthetic, auditory, or visual and is intended to provide clear and reliable information in response to alterations in voice production. Thus, patients may make real-time adjustments regarding vocal pitch, loudness, quality, and effort. Ideally, biofeedback helps increase awareness of physical sensations with respect to respiration, body position, and vibratory sensation. This awareness may help individuals understand physiological processes when generating voice.

Chant Speech

Chant speech uses a rhythmic, prosodic pattern as a template for spoken utterances. It is used in therapy to help reduce phonatory effort that results in vocal fatigue and decreased phonatory capabilities. Chant speech requires pitch fluctuations and coordination of respiratory, phonatory, and resonance subsystems. Speakers habituate to these more efficient vocal patterns. The increased lung pressure required for these tasks may also decrease reliance on laryngeal resistance and reduce fatigue (e.g., McCabe & Titze, 2002).

Confidential Voice

Confidential voice is designed to reduce laryngeal tension/hyperfunction and increase airflow (Casper, 2000). The individual begins with an easy and breathy vocal quality and builds to normal voicing without decreasing airflow. This technique is intended to address excessive vocal tension and to facilitate relaxation in the muscles of the larynx.

Inhalation Phonation

Inhalation phonation is used to facilitate true vocal vibration in the presence of habitual ventricular fold phonation, functional aphonia, and/or muscle tension dysphonia. Individuals produce a high-pitched voice on inhalation. Upon inhalation voicing, the true vocal folds are in a stretched position, suddenly adducted, and in vibration. Upon exhalation, patients try to achieve a nearly matched voice. This approach eases the way to gaining true vocal fold vibration.

The patient is instructed in the technique of sitting with upright posture and with the shoulders in a low, relaxed position to facilitate voice production with less effort. Collaboration with a physical therapist or an occupational therapist may be necessary with some patients.

In cases of vocal hyperfunction, a variety of relaxation techniques may be useful as a tool to reduce both whole-body and laryngeal area tension. The goal of these techniques is to reduce effortful phonation. Frequently used techniques include progressive muscle relaxation (slowly tensing and then relaxing successive muscle groups), visualization (forming mental images of a peaceful, calming place or situation), and deep breathing exercises.

Semi-Occluded Vocal Tract (SOVT) Exercises

SOVT exercises involve narrowing at any supraglottic point along the vocal tract in order to maximize interaction between vocal fold vibration (sound production) and the vocal tract (the sound filter) and to produce resonant voice.

Cup bubble , also known as Lax Vox , is an aerodynamic building task aimed at improving the ability to sustain phonation while speaking. It is done by having a patient blow air initially into a cup of water without voice. Voicing can be added for subsequent trials, and in time, pitch can be altered across and within trials. Eventually, the cup is removed during voicing, and the phonation continues. These exercises are thought to widen the vocal tract during phonation and reduce tension in the vocal folds. Biofeedback increases the individual’s awareness of their healthy voice production (e.g., Denizoglu & Sihvo, 2010; Simberg & Laine, 2007).

Straw phonation is one of the most frequently used methods to create semi-occlusion in the vocal tract (Titze, 2006). Narrowing the vocal tract increases air pressure above the vocal folds, keeping them slightly separated during phonation and reducing the impact collision force. To accomplish this, the individual semi-occludes the vocal tract by phonating through a straw or tube. Resistance can be manipulated by varying the length and diameter of the straw or immersing the opposite end of the straw in water. Individuals practice sustaining vowels, performing pitch glides, humming songs, and transitioning to the intonation and stress patterns of speech. Eventually, use of the straw is reduced and eliminated.

Lip trills can be used to create semi-occlusion at the level of the lips. This technique involves a smooth movement of air through the oral cavity and over the lips, causing a vibration (lip buzz), similar to blowing bubbles underwater. Often, the trills are paired with phonation and pitch changes. The focus is to improve breath support and produce voicing without tension.

Twang Therapy

Twang therapy is used for individuals with hypophonic voice. It involves the narrowing of the aryepiglottic sphincter using a “twang” voice to create a high-intensity voice quality while maintaining low vocal effort (Lombard & Steinhauer, 2007). The desired outcome is decreasing phonatory effort and increasing vocal efficiency.

This facilitating technique uses the natural functions of yawning and sighing to overcome symptoms of vocal hyperfunction (e.g., elevated larynx and vocal constriction). The technique is intended to lower the position of the larynx and subsequently widen the supraglottal space in order to produce a more relaxed voice and encourage a more natural pitch.

Treatment Considerations: Telepractice and Telecommuting

SLPs should take appropriate measures whether services are being delivered in-person or through telepractice. Teletherapy may not provide as reliable sound quality as in-person. Therefore, additional equipment (e.g., microphones) can enhance vocal quality while reducing vocal strain. Additionally, SLPs should take into consideration whether or not the patient is telecommuting for their profession, as there is some emerging research regarding effects of telecommunications on voice (Tracy et al., 2020).

Please see ASHA’s Practice Portal page on Telepractice and ASHA’s Telepractice Evidence Map .

Treatment Considerations: Rehabilitation of Professional Voice

Additional training/education may be necessary to provide professional voice rehabilitation. Clients who use their voice professionally (e.g., singers, voice actors) may have different needs than the usual client with a voice disorder and may seek services from multiple disciplines, including:

• an otolaryngologist
• a singing teacher
• a voice and speech trainer

Service Delivery

Refer to the Service Delivery section of the Voice Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the type of speech and language treatment that is optimal for individuals with voice disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may affect treatment outcomes.

• Format —the structure of the treatment session (e.g., group vs. individual; direct and/or consultative).
• Provider —the person offering the treatment (e.g., SLP, trained volunteer, caregiver).
• Dosage —the frequency, intensity, and duration of service. Clinicians consider the unique needs of each patient and the nature of the voice disorder in determining appropriate dosage for therapy. Some voice therapy programs will have specific dosage parameters. See De Bodt et al. (2015) for a summary of international practices regarding temporal variables (dosage and frequency) in voice therapy.
• Timing —when intervention is conducted relative to the diagnosis.
• Setting —location of treatment (e.g., home, community-based, work).

ASHA Resources

• Aerosol Generating Procedures
• ASHA CAPE-V Form
• ASHA Code of Ethics
• ASHA Scope of Practice in Speech-Language Pathology
• Consumer Resource Related to Voice Disorders
• Cultural Responsiveness
• Definitions of Communication Disorders and Variations
• Gender Affirming Voice and Communication
• Graduate Curriculum on Voice and Voice Disorders [PDF] (Developed by ASHA Special Interest Group 3: Voice and Voice Disorders)
• Multicultural Issues in the Treatment of Voice Disorders
• Preferred Practice Patterns for the Profession of Speech-Language Pathology
• States with Specific Instrumental Assessment Requirements
• Using Masks for In-Person Service Delivery During COVID-19 Pandemic: What to Consider
• Vocal Tract Visualization and Imaging 

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Academy of Otolaryngology–Head and Neck Surgery: Clinical Practice Guidelines
• The National Center for Voice and Speech
• National Institute on Deafness and Other Communication Disorders
• National Spasmodic Dysphonia Association
• RCSLT: New Long COVID Guidance and Patient Handbook
• Speech-Language & Audiology Canada: Covid-19 changes the way many people use their voices
• The Voice Foundation
• World Voice Day

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About This Content

Acknowledgements.

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Voice Disorders page:

• Julie M. Barkmeier-Kraemer, PhD, CCC-SLP
• Jennifer N. Craig, MS, CCC-SLP
• Archie B. Harmon, PhD, CCC-SLP
• Robert E. Hillman, PhD, CCC-SLP
• Barbara Jacobson, PhD, CCC-SLP
• Rita R. Patel, PhD, CCC-SLP
• Bari Hoffman Ruddy, PhD, CCC-SLP
• Joseph C. Stemple, PhD, CCC-SLP
• Yumi A. Sumida, MS, MFA, CCC-SLP
• Kristine Tanner, PhD, CCC-SLP
• Shannon M. Theis, PhD, CCC-SLP
• Miriam R. van Mersbergen, PhD, CCC-SLP
• Laura Purcell Verdun, MA, CCC-SLP

In addition, ASHA thanks the members of the ASHA-Special Interest Division 3: Working Group on Voice and Voice Disorders, whose work was foundational to the development of this content. Members of the working group were Julie Barkmeier (Chair), Glenn W. Bunting, Douglas M. Hicks, Michael P. Karnell, Stephen C. McFarlane, Robert E. Stone, Shelley Von Berg, and Thomas L. Watterson. Alex F. Johnson served as monitoring vice president. Amy Knapp and Diane R. Paul served as ex officio members.

ASHA also thanks the American Academy of Otolaryngology-HNS Speech, Voice and Swallowing Committee members and ASHA Special Interest Division 3, Voice and Voice Disorders Steering Committee members whose work was foundational to the development of this content.

The members of the AAO-HNS Speech, Voice and Swallowing Committee included Robert Sataloff, Jonathan Aviv, Mary Beaver, Alison Behrman (ASHA representative), Mark Courey, Glendon Gardner, Norman Hogikyan, Christy Ludlow (ASHA representative), Roger Nuss, Clark Rosen, Mark Shikowitz, Robert Stachler, Lee Akst, and Susan Sedory Holzer (staff liaison).

The members of the ASHA Special Interest Division 3, Voice and Voice Disorders Steering Committee included Leslie Glaze (coordinator), Bernice Klaben, Lori Lombard, Mary Sandage (associate coordinator), Susan Thibeault, and Michelle Ferketic (ex officio). Celia Hooper, vice president for professional practices (2003–2005), served as monitoring vice president for ASHA.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Voice Disorders. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Voice-Disorders/ .

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Dysphonia & Vocal Cord Paralysis

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Diagnosing & treating dysphonia.

Diagnosis starts with a comprehensive physical exam by our neuro-laryngology experts. We will review your medical history and symptoms. Symptoms might include: 

• Breathy vocal quality 
• Frequent coughing or choking when swallowing 
• Frequent throat clearing 
• Hoarseness 
• Loss of the gag reflex 
• Loss of pitch 
• Low or quiet voice 
• Noisy breathing 
• Shortness of breath when speaking 

Next, we will perform a speech evaluation to assess your baseline breathing, swallowing and speech. Depending on your symptoms, you may be diagnosed with one of the two main types of dysphonia: 

• Vocal cord paralysis – Nerve impulses to your larynx (voice box) are interrupted by a neurological condition or damage to the nerves from trauma, tumor or infection. One or both vocal cords can be affected.   
• Spasmodic (laryngeal) dysphonia – The vocal cords have sudden involuntary spasms that interfere with the ability to produce controlled sound for speech. Most cases of spasmodic dysphonia are caused by neurological disorders of the brain and/or peripheral nerves.

Houston Methodist offers advanced testing and technologies to determine the cause of your condition. Tests will vary depending on your history and symptoms and may include: 

• Speech evaluation by a speech-language pathologist  
• Evaluation for any neurological or movement disorders that may affect your speech, such as dystonia or Parkinson’s disease  
• Blood tests 
• Examination of your vocal cords using an endoscopeor a mirror to decide the position and movement of your vocal cords 
• Imaging scans, such as CT or MRI 
• Laryngeal electromyogram, in which electrodes placed into the vocal cord muscles measure the electrical currents of those muscles (rarely needed)

Though some cases are temporary, dysphonia can be a life-long, chronic condition. It can be caused by: 

• Overuse of your voice (screaming) 
• Excessive throat clearing 
• Substance use (smoking or alcohol) 
• Physical abnormality (nodules, polyps or inflammation) 
• Trauma or injury 
• Stroke  
• Tumor  
• Infection 
• Neurological disorders, such as Parkinson’s disease or dystonia 

It takes an experienced team to effectively treat or manage dysphonia. Houston Methodist offers leading-edge treatment options, backed by research and the combined expertise of our specialized team. We will work together to design a personalized care plan to fit your needs.  

While there is no cure for dysphonia yet, specialized care can significantly reduce symptoms. Treatment options depend upon the cause, severity and duration of symptoms. Recommended treatments may include:  

• Speech therapy 
• Medication 
• Injections of botulinum toxin (Botox®) into the affected muscles 
• Collagen or filler injections to bulk up the cord 
• Surgery, such as structural implants, nerve repair or vocal cord repositioning 

In severe cases, patients find that a mechanical speech device can help improve communication and quality of life. 

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Chapter 3: Managing Speech Anxiety

This chapter, except where otherwise noted, is adapted from Stand up, Speak out: The Practice and Ethics of Public Speaking ,  CC BY-NC-SA 4.0 .

How do I manage my speech anxiety?

Now that you have an understanding of how important it is for you to use ethical principles in creating an effective speech, let’s move to the topic you have all been either dreading or can’t wait to learn about: how to manage speech anxiety.

Take a look at this scene from the Albert Meets Hitch video and see if you can relate to how nervous these people are.

Hitch: Albert meets Hitch HD CLIP , by Binge Society – The Greatest Movie Scenes , Standard YouTube License. https://www.youtube.com/watch?v=MIBzVc3kJAM

You can imagine how much better this interaction would have gone had the participants not been so anxious. The question is, is it possible to manage your speech anxiety during a conversation, a job interview, or a speech?

Speech Anxiety/Communication Apprehension

Many different social situations can make us feel uncomfortable if we anticipate that we will be evaluated and judged by others. The process of revealing ourselves and knowing that others are evaluating us can be threatening whether we are meeting new acquaintances, participating in group discussions, or speaking in front of an audience.

Definition of Communication Apprehension

According to James McCroskey, communication apprehension is the broad term that refers to an individual’s “fear or anxiety associated with either real or anticipated communication with another person or persons” (McCroskey, 2001). At its heart, communication apprehension is a psychological response to evaluation. This psychological response, however, quickly becomes physical as our body responds to the threat the mind perceives. Our bodies cannot distinguish between psychological and physical threats, so we react as though we are facing a Mack truck barreling in our direction. The body’s circulatory and adrenal systems shift into overdrive, preparing us to function at maximum physical efficiency, kicking in the “flight or fight” response (Sapolsky, 2004). Yet instead of running away or fighting, all we need to do is stand and talk.

The excess energy our body creates can make it harder for us to be effective public speakers. But because communication apprehension is rooted in our minds, if we understand more about the body’s responses to stress, we can better develop mechanisms for managing the body’s misguided attempts to help us cope with social judgment fears.

Physiological Symptoms of Communication Apprehension

There are various physical sensations associated with communication apprehension. We might notice our heart pounding or our hands feeling clammy. We may break out in a sweat, have stomach butterflies, or even feel nauseated. Our hands and legs might start to shake, or we may begin to pace nervously. Our voices may quiver, and we may have a dry-mouth sensation that makes it difficult to articulate even simple words. Breathing becomes more rapid, and, in extreme cases, we might feel dizzy or light-headed. Communication anxiety is profoundly disconcerting because we feel powerless to control our bodies. We may become so anxious that we fear we will forget our name, much less remember the main points of the speech we are about to deliver.

The physiological changes our bodies produce at critical moments are designed to contribute to ensure our muscles work efficiently and expand available energy. Circulation and breathing become more rapid so that additional oxygen can reach the muscles. Increased circulation causes us to sweat. Adrenaline rushes through our body, instructing the body to speed up its movements. If we stay immobile behind a lectern, this hormonal urge to speed up may produce shaking and trembling. Additionally, digestive processes are inhibited so we will not lapse into the relaxed, sleepy state that is typical after eating. Instead of feeling sleepy, we feel butterflies in the pit of our stomach. By understanding what is happening to our bodies in response to public speaking stress, we can better cope with these reactions and channel them in constructive directions.

Watch this Ted Ed video, The Science of Stage Fright by Mikael Cho. In it, Cho shares what physically happens when we become anxious. It is now called the “fight, flight, or freeze” response because sometimes we hold very still when frightened.

The video can make you feel scared just watching it, but try and notice that there is an actual science to stage fright or speech anxiety, and you are not alone in feeling nervous or scared.

Pay particular attention near the end when Cho gives you one option to help manage your anxiety.

The science of stage fright (and how to overcome it) – Mikael Cho , by TED-Ed , Standard YouTube License. https://www.youtube.com/watch?v=K93fMnFKwfI

After watching the video, did you realize that anxiety is a normal human reaction? We can help reduce the anxiety, but not totally eliminate it. As you continue with this module you will learn strategies to reduce anxiety.

• Any conscious emotional state, such as anxiety or excitement consists of two components:
• A primary reaction of the central nervous system.
• An intellectual interpretation of these physiological responses.

The physiological state we label as communication anxiety does not differ from those that we label rage or excitement. Even seasoned effective speakers and performers experience some communication apprehension. What differs is the mental label that we put on the experience. Effective speakers have learned to channel their body’s reactions, using the energy released by these physiological reactions to create animation and stage presence.

It has been documented that famous speakers throughout history such as Cicero, Daniel Webster, Abraham Lincoln, Eleanor Roosevelt, Winston Churchill, and Gloria Steinem conquered significant public speaking fears. Celebrities who experience performance anxiety include actor Harrison Ford, Beyonce, Lady Gaga, Katy Perry, Rihanna, Matt Damon, and George Clooney (Hickson, 2016).

Myths about Communication Apprehension

Before we look at how to manage our speech anxiety, let’s dispel some myths.

• People who suffer from speaking anxiety are neurotic. As we have explained, speaking anxiety is a normal reaction. Good speakers can get nervous, too, just as poor speakers do.
• Telling a joke or two is always a good way to begin a speech. Humor is some of the toughest material to deliver effectively because it requires an exquisite sense of timing. Nothing is worse than waiting for a laugh that does not come. Moreover, one person’s joke is another person’s slander. It is extremely easy to offend when using humor. The same material can play very differently with different audiences. For these reasons, it is not a good idea to start with a joke, particularly if it is not well related to your topic. Humor is just too unpredictable and difficult for many novice speakers. If you insist on using humor, make sure the joke is on you, not on someone else. Another tip is never to pause and wait for a laugh that may not come. If the audience catches the joke, fine. If not, you’re not left standing in awkward silence waiting for a reaction.
• Imagine the audience is naked. This tip just plain doesn’t work because imagining the audience naked will do nothing to calm your nerves. The audience is not some abstract image in your mind. It consists of real individuals who you can connect with through your material.
• Any mistake means that you have “blown it.” We all make mistakes. What matters is how well we recover, not whether we make a mistake. A speech does not have to be perfect. You just have to make an effort to relate to the audience naturally and be willing to accept your mistakes.
• Audiences are out to get you. An audience’s natural state is empathy, not antipathy. Most face-to-face audiences are interested in your material, not in your image. Watching someone who is anxious tends to make audience members anxious themselves. Particularly in public speaking classes, audiences want to see you succeed. They know that they will soon be in your shoes, and they identify with you, most likely hoping you’ll succeed and give them ideas for how to make their own speeches better. If you establish direct eye contact with real individuals in your audience, you will see them respond to what you are saying, and this response lets you know that you are succeeding.
• You will look as nervous as you feel. Empirical research has shown that audiences do not perceive the level of nervousness that speakers report feeling (Clevenger, 1959). Most listeners judge speakers as less anxious than the speakers rate themselves. In other words, the audience is not likely to perceive accurately your anxiety level. Some of the most effective speakers will return to their seats after their speech and exclaim they were so nervous. Listeners will respond, “You didn’t look nervous.” Audiences do not necessarily perceive our fears. Consequently, don’t apologize for your nerves. There is a good chance the audience will not notice that you’re nervous if you do not point it out to them.
• TRUE. A little nervousness helps you give a better speech. This myth is true! Professional speakers, actors, and other performers consistently rely on their nervous heightened arousal to channel extra energy into their performance. People would much rather listen to a speaker who is alert and enthusiastic than one who is relaxed to the point of boredom. Many professional speakers say that the day they stop feeling nervous is the day they should stop public speaking. The goal is to control those nerves and channel them into your presentation.

Common yet unexpected difficulties can increase speech anxiety: how do we cope?

The following sections are adapted from Stand up, Speak out: The Practice and Ethics of Public Speaking ,  CC BY-NC-SA 4.0 .

Speech Content Issues

Nearly every experienced speaker has gotten to the middle of a presentation and realized that a key notecard is missing or that he or she skipped important information from the speech’s beginning. When encountering these difficulties, a good strategy is to pause for a moment to think through what you want to do next. Is it important to include the missing information, or can it be omitted without hurting the audience’s ability to understand the rest of your speech? If it needs to be included, do you want to add the information now, or will it fit better later in the speech? It is often difficult to remain silent when you encounter this situation, but pausing for a few seconds will help you to figure out what to do and may be less distracting to the audience than sputtering through a few “ums” and “uhs.”

Technical Difficulties

Technology has become a very useful public speaking aid, allowing us to use audio or video clips, presentation software, or direct links to websites. However, one of the best-known truisms about technology is that it can and does break down. Web servers go offline, files will not download in a timely manner, and media are incompatible with the presentation room’s computer. It is important to always have a backup plan, developed in advance, in case of technical difficulties. As you develop your speech, visual aids, and other presentation materials, think through what you will do if you cannot show a particular graph or if your presentation slides are hopelessly garbled. Although your beautifully prepared chart may be superior to the oral description you can provide, your ability to provide a succinct oral description when technology fails can give your audience the information they need.

External Distractions

Although many public speaking instructors directly address audience etiquette, you’re still likely to experience an audience member walking in late, a cell phone ringing, or even a car alarm blaring outside your room. If you are distracted by external events like these, it is often useful, and sometimes necessary—as in the case of the loud car alarm—to pause and wait so that you can regain the audience’s attention and be heard.

Whatever the unexpected event, as the speaker, your most important job is to maintain your composure. It is important not to get upset or angry because of these glitches—and, once again, the key is to be fully prepared. If you keep your cool and quickly implement a plan B for moving forward with your speech, your audience is likely to be impressed and may listen even more attentively to the rest of your presentation.

Anticipate Your Body’s Reactions

There are various steps you can take to counteract stress’ negative physiological effects on the body. You can place words and symbols in your notes that remind you to pause and breathe during points in your speech, such as “slow down” or ☺.

It is also a good idea before you get started to pause a moment to set an appropriate pace from the onset. Look at your audience and smile. It is a reflex for some of your audience members to smile back. Those smiles will reassure you that your audience members are friendly.

Physical movement helps to channel some of the excess anxiety-induced energy that your body produces. If at all possible, move around the front of the room rather than remaining imprisoned behind the lectern or gripping it for dear life; however, avoid pacing nervously from side to side. Move closer to the audience and then stop for a moment. If you are afraid that moving away from the lectern will reveal your shaking hands, use note cards rather than a sheet of paper for your outline. Note cards do not quiver like paper, and they provide you with something to do with your hands.

Vocal warm-ups are also important to do before speaking. Just as athletes warm up before practice or competition and musicians warm up before playing, speakers need to get their voices ready to speak. Talking with others before your speech or quietly humming to yourself can get your voice ready for your presentation. You can even sing or practice a bit of your speech out loud while you’re in the shower, where the warm, moist air is beneficial for your vocal mechanism. Gently yawning a few times is also an excellent way to stretch the key muscle groups involved in speaking.

Immediately before you speak, you can relax your neck and shoulder muscles by gently rolling your head from side to side.

Focus on the Audience, Not on Yourself

During your speech, make a point of establishing direct eye contact with your audience members. By looking at individuals, you establish a series of one-to-one contacts similar to interpersonal communication.

The Magic of Science

Now for some scientific managing-speech-anxiety magic. You are welcome to use what you hear in your own plan if you choose. Take a listen to Harvard Professor Amy Cuddy and a surprising two-minute strategy that many students find very effective. It is worth watching the full twenty-minute video, Your Body Language May Shape Who You Are.

Amy Cuddy: Your Body Language May Shape Who You Are , by TEDGlobal 2012, CC BY-NC-ND 4.0

Yes, two minutes, two minutes, two minutes. Remember the audience is more interested in learning about what you have to say than in judging you. So, forget yourself and be there for the audience.

Note: Are you a good people watcher? I hope you are because it will aid your progress as a speaker. You will be viewing video clips of speakers throughout the course. Pay attention to what went well in a speech and what you would recommend a speaker change to make their speech better.

For example, In Amy Cuddy’s speech, her data visual aids helped in better understanding the speech. Did you notice where her hair was? Would you recommend she do something different with it? Notice, notice, notice. It will help you know what you want to do and not do in your own speeches.

Ackrill, C. (2012, October 5). 6 thought patterns of the stressed: No. 3 – catastrophizing. American Institute of Stress. Retrieved from http://www.cynthiaackrill.com/6-thought-patterns-of-the-stressed-no-3-catastrophizing-lions-and-tigers-and-bears-oh-my/

Allen, M., Hunder, J.E., & Donohue, W.A. (2009). Meta-analysis of self-report data on the effectiveness of public speaking anxiety treatment techniques. Communication Education , 38, 54–76.

Ayres, J. (2005). Performance visualization and behavioral disruption: A clarification. Communication Reports , 18 55–63.

Ayres, J., & Hopf, T. (1995). Coping with speech anxiety . Norwood, NJ: Ablex

Bodie, G.D. (2010). A racing heart, rattling knees, and ruminative thoughts: Defining, explaining, and treating public speaking anxiety. Communication Education , 59, 70–105.

Boyes, A. (2013a, March 13). 6 tips for overcoming anxiety-related procrastination. Psychology Today . Retrieved from https://www.psychologytoday.com/blog/in-practice/201303/6-tips-overcoming anxiety-related-procrastination

Boyes, A. (2013b, January 10). What is catastrophizing? Cognitive distortions. Psychology Today . Retrieved from https://www.psychologytoday.com/blog/in-practice/201301/what-is-catastrophizing-cognitive-distortions

Cunningham, V., Lefkoe, M., & sechrest, L. (2006). Eliminating fears: An intervention that permanently eliminates the fear of public speaking. Clinical Psychology and Psychotherapy , 13, 183–193

Dean, J. (2012, October 10). The illusion of transparency. PsyBlog . Retrieved from http://www.spring.org.uk/2012/10/the-illusion-of-transparency.php

Ellis, A. (1995). Thinking processes involved in irrational beliefs and their disturbed consequences. Journal of Cognitive Psychotherapy , 9, 105 –116.

Ellis, A. (1996). How I learned to help clients feel better and get better. Psychotherapy , 33, 149–151.

Finn, A.N., Sawyer, C.R, & Schrodt, P. (2009). Examining the effect of exposure therapy on public speaking state anxiety. Communication Education , 58, 92–109.

Grohol, J.M. (2013). What is catastrophizing? Psych Central . Retrieved from http://psychcentral.com/lib/what-is-catastrophizing/1276/

Holmes, E.A., & Mathews, A. (2005). Mental imagery and emotion: A special relationship? Emotion , 5, 489–497.

Horowitz, B. (2002). Communication apprehension: Origins and management . Albany, NY: Singular.

Jones, C.R., Fazio, R.H., & Vasey, M.W. (2012). Attention control buffers the effect of public-speaking anxiety on performance. Social Psychology & Personality Science , 3, 556–561.

Lucas, S. E. (2012). The art of public speaking . (11th ed.). McGrawHill.

MacInnis, C.C., MacKinnon, S.P., & MacIntyre, P.D. (2010). The illusion of transparency and normative beliefs about anxiety during public speaking. Current Research in Social Psychology , 15(4). Retrieved from http://www.uiowa.edu/~grpproc/crisp/crisp15_4.pdf

Motley, M.T. (1995). Overcoming your fear of public speaking: A proven method . New York, NY: McGraw-Hill

Motley, M.T. (1997). COM Therapy. In J.A. Daly, J.C. McCroskey, J.Ayres, T. Hopf, & D.M. Ayres (Eds.) Avoiding communication . Creskill, NJ: Hampton Press.

Motley, M.T. (2011, January 18). Reducing public speaking anxiety: The communication orientation. YouTube. Retrieved from http://www.youtube.com/watch?v=GYfHQvi2NAg

Noonan, P. (1998). Simply speaking: How to communicate your ideas with style, substance, and clarity . New York, NY: Harper Collins.

O’Donohue, W.T., & Fisher, J.E. (2008). Cognitive behavior therapy: Applying empirically supported techniques in your practice . Hoboken, NJ: John Wiley.

Pertaub, D., Slater, M., & Barker, C. (2002). An experiment on public speaking anxiety in response to three different types of virtual audiences. Presence: Teleoperators and Virtual Environments , 11, 670–678.

Peterson, C. (2000). The future of optimism. American Psychologist , 55, 44–55.

Prochow, H.V. (1944). Great stories from great lives . New York, NY: Harper & Brothers.

Roby, D.E. (2009). Teacher leadership skills: An analysis of communication apprehension. Education , 129, 608–614. Retrieved from http://eric.ed.gov/?id=EJ871611

Sandburg, C. (2002). Abraham Lincoln: The prairie years and the war years . New York, NY: Houghton Mifflin Harcourt.

Savitsky, K., & Gilovich, T. (2003). The illusion of transparency and the alleviation of speech anxiety. Journal of Experimental Social Psychology , 39, 618–625.

Seim, R.W., Waller, S.A., & Spates, R.C. (2010). A preliminary investigation of continuous and intermittent exposures in the treatment of public speaking anxiety. International Journal of Behavioral Consultation and Therapy , 6, 84–94.

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Media References

(no date). man, portrait, grown up, people, smiling, facial hair, one person, beard, looking at camera, emotion [Image]. pxfuel. https://www.pxfuel.com/en/free-photo-ehnup

Binge Society – The Greatest Movie Scenes. (2020, November 6). Hitch: Albert meets Hitch HD CLIP [Video]. YouTube. https://www.youtube.com/watch?v=MIBzVc3kJAM

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TED-Ed. (2013, October 8). The science of stage fright (and how to overcome it) – Mikael Cho [Video]. YouTube. https://www.youtube.com/watch?v=K93fMnFKwfI

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Public Speaking Copyright © 2022 by Sarah Billington and Shirene McKay is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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• Voice problems

Vocal cord paralysis

How we can help people with vocal cord paralysis.

Vocal cord paralysis happens when there is damage to the nerves that are attached to the voice box. Damage to these nerves may mean that the vocal cords do not open and close in the correct way.

What is vocal cord paralysis?

Vocal cord paralysis is when there is no movement of the vocal cords due to damage to the nerves. A person can be affected at any age and for a number of reasons. When the vocal cords are in the closed position, air is able to pass through creating the vibration needed for speech. If the vocal folds are damaged, or paralysed, then this function will not happen in the correct way, leading to a person’s speech being affected. The severity of the effect on a person’s speech will depend how badly the nerves are damaged. People, who suffer from this condition, may find that swallowing and coughing is hard. This is because the folds are not able to close properly and so this leaves the windpipe open to particles of food and saliva being inhaled into lungs and trachea (aspiration).

What causes vocal cord paralysis?

Paralysis of the vocal cords is caused by nerve damage. They can be damaged in a number of different ways. Some of which are listed below:

• Traumatic brain injury
• Lung or thyroid cancer.
• Tumour which presses on the nerve.
• Viral infection.
• Parkinson’s disease

Some nerve damage will resolve itself over time, in these cases it is not recommended to operate on as it may be too dangerous and resolve itself anyway. The exact cause in most cases is not known and varies from person to person.

What problems caused by vocal cord paralysis can SLT UK help with?

SLT UK can help with a number of associated problems which result from vocal cord paralysis. Vocal cord paralysis may cause voice problems, speech sound problems, swallowing difficulties and communication problems.

Speech and language therapy will help in these areas and enable a patient to overcome or manage their paralysis and therefore improve their own communication. Some paralysis may return back to normal whilst others may not. Speech and language therapy will help a patient to adjust to these changes either way.

How does speech and language therapy help vocal cord paralysis?

Speech and language therapy can be done before or after surgery or it can be the individual method of treatment. The extent of damage will depend upon what type of input is needed for each individual case. Speech and language therapy will enable an individual to cope with the effects of paralysis; this may involve working on different methods of communication.

Speech and language therapy can help improve any aspect of an individual's communication dependent on their needs. It can also help increase confidence and self-esteem whilst reducing anxiety when communicating with others.

What would speech and language therapy treatment for vocal cord paralysis involve?

Speech and language therapy treatment may involve assessments, reports, reviews, therapy programmes, support groups, training, advice and education.

An initial assessment will be carried out by one of our speech and language therapists. This will highlight any worries and difficulties concerning communication, speech and swallowing. It will also provide a chance for you to share any concerns you may have, and allow you to discuss what you would like to work on and improve.

Vocal cord paralysis can occur at any age or stage in life and can differ in severity depending upon the extent of damage to the nerves. Some paralysis may resolve itself, whilst others may be permanent. Speech and language therapy will help this condition as it will enable a patient to try different ways of communicating if needed, and also give some guidance on how to incorporate the paralysis into everyday life.

If you feel you may benefit from speech and language therapy or would like any more information on our services please email [email protected] or call 0330 088 5643.

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• Anxiety Guide
• Help & Advice

Related Medical Issues

Anxiety and paralysis.

• Anxiety can cause emotional paralysis
• Anxiety can also cause paralysis-like physical symptoms, though should not cause actual paralysis
• Severe anxiety, such as with a strong phobia, can lead to someone feeling stuck in place and possibly even fainting, which may feel like being paralyzed
• By definition, this type of symptom is difficult to treat as an independent entity
• Controlling anxiety can assist in reducing feelings of paralysis in all forms

Fact Checked

Micah Abraham, BSc

Last updated February 12, 2021

Anxiety can be paralyzing, both figuratively and literally. Often, living with anxiety feels like you’re being deprived of the ability to live a normal life. Emotionally, you may constantly feel like a deer in the headlights, unable to move or get out of the way of the threat.

Anxiety can also be paralyzing physically. At least, there are symptoms that can make you feel like your body is literally paralyzed. In this article, we'll explore the physical and emotional paralysis that can happen in people who have anxiety.

Emotional Paralysis

Let's start with the idea of emotional paralysis, because this is something that many people with anxiety deals with from time to time. 

Anxiety is caused by your body reacting to fear, even though a literal, dangerous threat isn't necessarily present. There may be something worth fearing, but the level of anxiety you experience may be disproportionate to the fear you should experience in that situation. For example, having to give a speech at your friend’s wedding is not a life-threatening situation, even though it may feel that way. 

Having said that, you may also experience anxiety in the absence of any easily noticeable fearful thoughts.. Anxiety itself is the activation of the fight or flight response - a reflex that your body uses to react to danger - and there are many people that experience these symptoms all the time, despite no rational fears serving as triggers for the anxiety. 

The fight or flight response can lead to a sense of emotional paralysis. This is because all of your mind’s energy is centered on one specific task: surviving danger. This not only stresses you out, but leaves you without enough emotional or cognitive resources to think calmly and rationally about what you need to do to tackle your anxiety. 

Many people experience anxiety as emotionally paralyzing because no matter how hard they try, they don't feel they can do anything about their symptoms. This is not true, however: there are things that you can do! Anxiety treatment programs are often highly effective, even though these are commitments that require you to dedicate time and energy in order for them to be effective. 

Physical Paralysis-Like Symptoms

Apart from the way that anxiety can affect our emotions, this disorder can also cause physical symptoms that resemble paralysis. You may experience a sense - in your face, arms, legs or torso - that you’re simply unable to move your body. 

There are two reasons that this occurs. The first is hyperventilation. Hyperventilation is the act of breathing out too much carbon dioxide, so that your body responds by slowing down blood flow to certain areas of your body. This is what causes it to feel as though certain body parts can't move. They may start to tingle or feel numb, causing you to feel as though your muscles aren't working. Hyperventilation is triggered by anxiety; and it may maintain or worsen your anxiety as well. 

The second issue is a bit more complex. Our bodies perform many movements automatically. These include, for example, blinking, swallowing, smiling or moving out of the way of an approaching vehicle. Your mind sends signals down your nerves for how to move, and you move them. When you walk, even if you are thinking about walking, you generally don't focus on literally each muscle movement one at a time. Walking - like all movements - are unconscious and controlled by your mind.

When someone suffers from anxiety, they often focus deeply on the way their body feels, becoming highly attuned and conscious of movements which would otherwise be performed spontaneously and automatically. The process of actively contemplating the series of movements that you’re performing may interfere with the automatic process whereby those actions would normally be carried out. This may make automatic movements harder to perform, creating a sense of immobilization. 

These issues are never permanent and not something you need to concern yourself with too much, but they do make it feel as though something is wrong with your muscles or body, and that can increase your anxiety in the future.

Fight - Flight - and Freeze

We often talk about the fight or flight response, because anxiety is directly linked to that response. But for some people, it is not as simple as “fight or flight.” For some people, they experience a drive to fight, flight, or even freeze. 

The analogy is of the “deer in the headlights.” When a deer is about to be hit by a car, it doesn’t run or otherwise fight in any way: rather, it freezes. That freezing - while not the best course of action when a car is coming your way - is an evolutionary adaptation because in nature, sometimes remaining perfectly still minimizes your chances of being spotted by a predator. 

That response is not limited to deer. Lots of animals have it, and so do humans. So, if you’re faced with extreme fear or panic and you feel like you can’t move at all, you may be experiencing the “Freeze” response. 

Control Anxiety to Stop This Type of Paralysis

Remember, anxiety really is something you can beat. But you need to make sure you're committed to your treatment plan and willing to do what it takes to combat your anxiety once and for all. Whether it’s therapy/counseling, medications (speak to your doctor or psychiatrist first), self-help, or some other method, anxiety is a manageable condition that responds well to treatment. You just need to make the first step.

SUMMARY: You can be emotionally and physically paralyzed by fear in some ways. Anxiety acts differently in each individual, including issues that relate to hyperawareness. Only reducing anxiety has the ability to stop this type of symptom. 

Questions? Comments?

Do you have a specific question that this article didn’t answered? Send us a message and we’ll answer it for you!

Where can I go to learn more about Jacobson’s relaxation technique and other similar methods? – Anonymous patient

You can ask your doctor for a referral to a psychologist or other mental health professional who uses relaxation techniques to help patients. Not all psychologists or other mental health professionals are knowledgeable about these techniques, though. Therapists often add their own “twist” to the technqiues. Training varies by the type of technique that they use. Some people also buy CDs and DVDs on progressive muscle relaxation and allow the audio to guide them through the process. – Timothy J. Legg, PhD, CRNP

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Democrats Begin Their Shift From Anxiety to Action

Amid deep concern about Biden’s capacity to continue as the nominee, party leaders are confronting the options and obstacles.

Listen to this article

Produced by ElevenLabs and News Over Audio (NOA) using AI narration.

T he ground may be starting to shift under President Joe Biden after his scattered and sometimes disoriented debate performance last week.

Across the party, widespread agreement is emerging that Biden’s chances of beating Donald Trump have dramatically diminished. “No one I have talked to believes Biden is going to win this race anymore: nobody,” said one longtime Democratic pollster working in a key battleground state who, like almost all of the party insiders I interviewed for this article, asked for anonymity to discuss the situation candidly.

That reticence about going public was symptomatic. A general reluctance to publicly express those concerns, or to urge Biden to step aside, has been obvious—particularly because the White House has pushed back fiercely against critics, and many senior Democrats have issued supportive, if not ironclad, statements. And even some of those Democrats who considered Biden’s performance calamitous continue to believe that replacing him with Vice President Kamala Harris or another candidate would endanger the party’s chances more than staying the course.

“Universally we’re in this state of suspended animation,” the leader of a prominent Democratic advocacy group told me.

Read: Biden’s delegates are flirting with a breakup

But the first signs that this paralysis may be lifting are appearing. Representative Mike Quigley of Illinois suggested yesterday that Biden may need to consider leaving the race; Representative Lloyd Doggett of Texas also called on him to do so yesterday, as did former Representative Tim Ryan , the party’s 2022 Senate candidate in Ohio, and Julián Castro, a rival for the 2020 Democratic presidential nomination. A senior House Democrat told me that many colleagues who are running in competitive districts express similar views and concerns in private. “The frontliners are melting down,” this high-ranking representative told me.

Notably, former Speaker Nancy Pelosi defended Biden on MSNBC yesterday, but acknowledged that after the debate, “It’s a legitimate question to say: Is this an episode or is this a condition?” (She said that question should apply to both candidates.) Democratic Senator Sheldon Whitehouse of Rhode Island likewise said that Biden must provide reassurance about his cognitive and physical abilities.

Despite these first few individuals going public with their doubts, no organized effort has yet coalesced in the party to encourage or pressure Biden to leave the race. Most Democrats feel helpless to affect Biden’s decision, even as they grow more concerned that his vulnerabilities may be paving the way to a Trump victory that would create an existential threat not only to the party’s policy priorities but to American democracy itself.

That’s the overwhelming conclusion from my conversations over the past few days with a broad cross section of Democratic leaders, including members of Congress, the directors of several major advocacy and constituency groups, large donors, and longtime pollsters and strategists.

“I think it’s a collective-action problem, where no one wants to go first, but as soon as someone does, it is going to feed on itself,” one prominent Democratic fundraiser told me.

P ublicly , the furthest that almost all Democrats have been willing to push Biden has been to call on him to schedule a flurry of voter town halls and media interviews through which he could try to offset the flailing and vacant impression that his debate performance left. “He needs to relentlessly speak to the American public in unscripted events over the next week,” Jim Kessler, the executive vice president for policy at Third Way, a centrist Democratic group that has led this push, told me. “The only way to replace a bad impression is with a good one. Success with unscripted events like town halls and press conferences can show that the debate was an anomaly.”

Biden’s campaign has scheduled an interview with George Stephanopoulos on ABC and a campaign appearance in Wisconsin, both on Friday, but it hasn’t announced anything like the volume of appearances that Third Way and others have urged; overall, the president’s schedule this week is light on public events. On Monday night, Biden gave very brief remarks responding to the decision handed down by the Supreme Court’s Republican majority that provides presidents with broad immunity for their actions in office.

The fact that Biden has not already announced such high-profile unscripted interactions is being interpreted by those worried about Biden’s prospects as confirmation of their fears. “You would have thought they would have quickly put together a roundtable with steelworkers, which is relatively safe, or have Shawn Fain pull together something with autoworkers,” the director of the advocacy group told me, referring to the United Auto Workers president. “Anything where he can be seen in conversation with people ... and people will see he can function without a script. They haven’t done it, because clearly, he can’t.” This official also noted how little Biden has interacted with the media in office and said the White House has virtually shut off small meetings between the president and key groups in the Democratic coalition.

One leader of a major liberal advocacy group told me that the organization viewed a gantlet of public events for Biden as a win-win proposition for the party. Either he performs well and eases concerns about his capacity, this official said, or he performs badly and explodes the idea that his debate performance was the result of a bad night—an idea that no one I spoke with, in fact, accepts.

This official at the liberal advocacy group told me that many in the party were focusing on the way Representative Jim Clyburn of South Carolina, one of Biden’s staunchest congressional allies, has phrased his support for the president since the debate. Clyburn has analogized Biden’s poor showing to a single strike during an at-bat, saying , “If this were a ball game, he’s got two more swings.”

The official said that some Democrats are taking that to mean Clyburn could urge Biden to step aside if the president continues to struggle in public settings. The high-ranking House Democrat I spoke with said that nervous members in competitive districts similarly view Clyburn—whose endorsement at a crucial moment in the primary was vital to Biden’s 2020 nomination—as the congressional leader with the greatest capacity to influence the president’s decision. Clyburn, this Democrat told me, has been telling those members to wait and see how Biden performs in the coming days. But, the Democrat added, Clyburn has also frustrated vulnerable members by so emphatically defending Biden in public, which they feel has limited their room to take a more critical stance.

Clyburn’s office did not respond to a request for comment on whether Democratic allies are correctly interpreting his three-strikes comments as a signal that he may be willing to break with Biden, if more episodes suggesting incapacity occur.

The president of another Democratic constituency group told me that multiple factors are discouraging activists from airing concerns about Biden, despite private anxieties that have exploded since the debate. “I don’t see anyone, whether it’s an elected official or nongovernmental organization, getting out there publicly saying he needs to go,” this official told me. “A: It’s not going to matter if we say it; and B: If he does win, we’re totally cut off from any conversation. So what’s the point?”

The group president continued: “I can say privately, and I have said it—I think it would be better if he was replaced. It’s a risky move but we are in a dark place, and I think it would be better if it’s someone else. It almost doesn’t matter who it would be. But none of us are going to say that publicly.”

This constituency-group leader and several others told me that a big part of the challenge in coalescing any organized pressure on Biden is that though virtually everyone agrees the debate weakened the president’s chances of beating Trump, no one can say that Biden has no chance of winning—or that a replacement candidate would surely run better. In addition, Biden is benefiting from the same dynamic that allowed Trump to once confidently claim that he could shoot someone on Fifth Avenue without losing any support: Most of the electorate is so dug in at this point that almost nothing could move them toward supporting the other party.

G enerally , public and private polling so far has not shown a collapse for Biden in the horse-race numbers against Trump. A national USA Today /Suffolk University survey released yesterday showed Trump slightly widening his lead to three percentage points; a CNN survey conducted by SRSS , also released yesterday, showed Trump holding a daunting six-point advantage, but that survey has typically been the worst major poll for Biden, and Trump’s lead was no larger than in the survey’s previous result, in April. A national CBS/YouGovAmerica poll released today put Trump’s lead at two percentage points, a statistically insignificant one-point decline from its previous survey.

Biden’s team has put forward its own campaign pollsters, Geoff Garin and Molly Murphy, to argue that the debate did not materially change the race. Garin and Murphy are widely respected in the party, but the Democratic strategists worried about Biden’s chances say that this optimism ignores two key messages from even a best-case reading of the polling.

One is that even a status-quo polling result after the debate leaves Biden on track to a probable defeat. Democrats almost universally agree that Biden’s campaign sought this early debate because it understood that he was losing and needed to change the dynamics of the race. Party strategists believe he has fallen almost out of range in his southeastern target states of Georgia and North Carolina, and faces a substantial, if less insurmountable, deficit in his southwestern targets of Arizona and Nevada.

Even before the debate, Biden’s most plausible path to 270 Electoral College votes was to sweep the three former “blue wall” states of Michigan, Pennsylvania, and Wisconsin. But before last week, most Democrats viewed his odds as no better than 50–50 in any of them—and the odds of winning all three below that (the chance of three successive coin flips falling on the same side is only one in eight).

The Democratic pollster working in one of these blue-wall states told me that his initial post-debate polling shows Trump slightly widening a lead he had taken in the weeks before the encounter. The question after the debate, this pollster said, was not whether Biden could stay within range of Trump (as the White House argues he can), but whether the president now could ever find the last few thousand votes he would need to overcome his Republican opponent.

“I don’t know where he gets the votes—his favorable ratings are so bad,” the pollster told me. “I think his odds in this state, which were probably getting close to 50–50 at best, are now at least two to one against.” (Another set of post-debate poll results from a different pollster circulating among liberal groups that was shared with me last night also found Biden’s deficit widening to an ominous level in these key states.)

The pollster’s comments point to the second polling problem facing Biden: The top-line number in polls, which generally show Trump ahead, is typically the best result for Biden. His standing in all the subsidiary polling metrics is almost without exception weaker. In yesterday’s CNN survey, for instance, Biden’s job-approval rating fell to 36 percent, the lowest level that poll has recorded for him. More than seven in 10 voters in the survey said that Biden’s physical and mental ability was a reason to vote against him.

The longtime Democratic pollster Stanley Greenberg, the senior campaign pollster in Bill Clinton’s 1992 victory, over the weekend released so-called dial groups tracking moment-by-moment voter reactions to the debate from Democratic-leaning groups that are not fully committed to Biden, including younger, Hispanic, and Black voters, as well as those considering support for a third-party candidate.

These respondents went into the debate supporting Biden by two to one, Greenberg reported, and Trump did nothing in the debate to improve their preponderantly negative perceptions of him. Those watching gave Biden credit on some fronts, such as standing up for the middle class, but “when asked the overall impression, the first was on his cognitive and physical fitness, expressing concern about his age, mental acuity, saying words, ‘confused,’ and ‘frail,’” Greenberg wrote. “Then, they commented on difficulty articulating his thoughts and his train of thought.” By his account, almost two-thirds of these Democratic-leaning voters concluded that he was too old to be president, with most of them “strongly” agreeing with that proposition.

“Those doubts make it pretty certain that he is going to … be behind in almost all the Electoral College states,” Greenberg told me. “You are going to go into the convention with that backdrop. In a very difficult year, it has become dramatically more difficult.”

A final line of defense for Biden is that even many Democrats who accept that he has been badly hurt remain uncertain that removing him would improve the party’s chances against Trump. The pollster working in one of the blue-wall states told me that although House and Senate candidates are alarmed about Biden’s position, “I think they are scared to death about Kamala. And they are scared to death about the fight. There isn’t a grand plan.”

The high-ranking House Democratic member told me that the party leadership in the chamber has given no indication that it would push for Biden to step aside—but it has signaled that if he does, the leadership will seek to quickly unify behind Harris as the alternative. (Likewise, Clyburn declared yesterday that he’d urge the party to consolidate behind Harris if Biden withdraws.) Other Democrats have noted that under campaign-finance rules, only Harris could utilize the $240 million in cash that the Biden ticket has stockpiled (although some believe that another candidate could find a way to access that money).

Adam Serwer: Biden must resign

The prospect of Harris replacing Biden, as I’ve previously written , deeply divides Democrats. One reason Biden didn’t face much pressure to drop out earlier is the double fear many of his critics have that she can’t win either, yet that denying the nomination to the first woman of color would tear the party apart.

Still, based on my conversations, even some of those skeptical of Harris are moving toward the belief that she presents a better bet than continuing with a diminished Biden. “People have seen something they can’t unsee about this guy. And his performance will not get better; it won’t,” the official at the liberal advocacy group told me. “Harris is better. She has the ability to rally the troops and create some energy with turnout in these places in a way that Joe Biden can’t.” The former Senate candidate Ryan, a centrist popular in Democratic circles usually skeptical of Harris, made similar points in his social-media posts yesterday. “ @VP has significantly grown into her job, she will destroy Trump in debate, highlight choice issue, energize our base, bring back young voters and give us generational change,” he wrote .

If Biden steps aside, plenty of influential Democrats would prefer the party to pass over Harris as well, for other alternatives such as Governor Gretchen Whitmer of Michigan or Governor Gavin Newsom of California. “I don’t think everybody is going to step aside,” James Carville, the longtime party strategist, said when I appeared on his podcast yesterday. With the Sun Belt swing states already moving out of reach, many Democratic strategists fear that Harris could not win nearly enough of the working-class white voters essential to success in the Rust Belt.

Other Democrats, though, are dubious that any major party figure would enlist in a contest with Harris for the nomination, a confrontation that would inevitably be racially fraught, especially given the uncertain prospect that anyone who succeeds Biden could beat Trump. With that in mind, the finding in yesterday’s CNN survey that Harris, though still trailing, was polling better against Trump than Biden definitely raised eyebrows among Democrats. If Biden’s skeptics scale the mountain of removing him from the ticket, they may conclude that accepting Harris, with all her own limitations, is a more plausible option than climbing the second mountain of dislodging her too.