This is a 16-year-old female with two siblings. She was referred by the Department of Otolaryngology after being diagnosed with paradoxical vocal fold disorder. Her parents are divorced, and her mother was soon to be remarried. She was a good student and actively involved in competitive track and orchestra. Her problems began while working out, when she experienced a feeling of tightness and difficulty breathing. The problem eased somewhat when she discontinued exercise; however, she noted that the episodes of breathing difficulty tended to come and go quickly and occurred almost every time she worked out. She was seen by a number of physicians and was initially treated for exercise-induced asthma, with no response to treatment. She indicated that she sometimes worried about breathing when she became stressed, and stress was more likely to influence her breathing difficulty. She reported being very sensitive emotionally and tended to have some emotional low times several days before menstruation. Both the patient and her mother described her as a worrier. She was also described as an excellent student who wanted to excel and do well and was held in high regard by both teachers and friends. She denied smoking, drinking, or drug use and stated that she didn't want these things in her life. She had some difficulty with one member of her track team, and her breathing difficulty was more apparent when she was practicing with that individual. She also noted that her breathing difficulty was much more pronounced during competition. The results of the MMPI-A indicated that all clinical scales were within the normal range, and the validity scale indicated a tendency to underestimate problems to present a more positive image. On the MMPI-A, Scales 1 and 3 were elevated more than Scale 2; however, all were within the normal range. This person did not complete the follow-up at one year.

This is a white male who was referred by his otolaryngologist at age 16 after being diagnosed with paradoxical vocal fold disorder. He was actively involved in competitive sports. About a year prior to being seen by the otolaryngologist, while swimming, he experienced chest pain and difficulty breathing, which was treated initially as exercise-induced asthma. He was tried on numerous inhalers, and obtained some relief; however, overall improvement was minimal. His performance in competitive athletics deteriorated. He was described as a healthy child who participated in track as well as swimming. He was described as a good student; however, his parents were eager to see him excel, especially academically. He was competitive in sports, and the breathing problems decreased his speed a great deal. He reported that he didn't suffer from significant problems unless he was training competitively or involved in active competition. His mother described him as tough on himself and demanding, and he agreed that he was very competitive. When I spoke with him privately, he indicated that competition would frequently magnify his breathing difficulties. He also indicated that his parents did not allow him as much freedom as his friends were allowed. On the MMPI-A, results indicated a valid profile with the possibility of a tendency to present himself in a favorable manner and to underestimate problems. There were no significant elevations on clinical scales; however, Scales 1 and 3 were elevated over Scale 2 in a manner consistent with Conversion V. On one-year follow-up, SS indicated that when he was first diagnosed, the vocal dysfunction episodes interfered with his lifestyle a great deal. At the time of follow-up, he felt that the vocal cord dysfunction affected his ability to participate in sports “a great deal” but affected his school and social activities only “moderately.” He felt it did not influence family relationships or work at all. He indicated that he had experienced about ten episodes per month over the previous six months, and he reported that he did not worry at all about having an episode. The episodes would generally last several minutes. He admitted that he sometimes avoided activities in order to prevent an episode. The activities he avoided were normally sporting activities. At the time of follow-up he was no longer seeing his physician for this condition. He denied having used alcohol or drugs in the previous six months, and he reported spending his free time with friends playing sports, going to movies, and swimming. In general, he felt his health was good, and compared to the previous year, he felt his health was very good.

This is a white female who was referred by her otolaryngologist at age 17 after being diagnosed with paradoxical vocal fold dysfunction. She has one sibling. According to her mother, she was born of a normal pregnancy and reached developmental milestones in a timely manner. She was described as a healthy child. She swam a great deal when she was young but stopped at about age 12 due to some problems with bronchitis. She played sports and a wind instrument in the band. She also sang in the choir. She had served as class president and maintained a near-4.0 grade point average with only one B. She began to experience some episodes of anxiety at the end of her grade school years. She had many friends but no one particular close girlfriend. She kept a very busy schedule with extracurricular activities and had a relative in her school with whom she had a competitive relationship. Her breathing difficulties began in middle school, when she began to participate in competitive sports. They worsened by high school while she was playing basketball. Her symptoms were much worse when she was in a competitive situation, and she began to have difficulty singing in the choir and playing the flute. Her breathing attacks were initially thought to be asthma. She was given inhalers, to which she did not respond. She cut back on her sporting activities but continued to experience some difficulty in competitive sports. She also had difficulties in performing a solo, either in band or in choir. She reported being fearful of pain and did not sleep well. She reported some irritability, which was worse around the time of her menstrual period. Finances were somewhat difficult within her family at that time, and she was experiencing some significant body image concerns. She also had a difficult relationship with the family member who attends her school, with whom she was competitive. The MMPI-A results indicated a tendency to underestimate symptoms and difficulties, and there were elevations on Scales 1 and 3 over Scale 2, which is indicative of the Conversion V pattern; however, none of the scales were elevated into the clinical range. At one-year follow-up, she reported that her vocal cord dysfunction episodes had influenced her lifestyle “moderately.” At the time of follow-up, her family relationships, social relationships, and work were “not at all affected.” She reported that her schoolwork activities were “moderately” affected and sporting activities were affected “a great deal.” When asked if she was currently experiencing difficulties with the vocal cord dysfunction, she said no. When asked how her life had changed, she said she could engage in more activities than previously, and she had learned strategies for dealing with the episodes. She experienced infrequent episodes, indicating she had fewer than one per month. She also indicated that she did not worry at all about having another episode. When she did experience the breathing episodes, they normally lasted about ten minutes. She said she no longer avoided activities in order to prevent an episode, and she did not see her otolaryngologist any longer. When asked how she spent her free time, she said she spent it watching TV, going to movies, and bowling, and she mainly spent her free time with friends and family.

This was a 16-year-old white female with three siblings. She maintained a B to B+ average and participated in track, basketball, and numerous extracurricular activities. She disliked many of her high school classes and felt unmotivated in them; however, she enjoyed her sports activities and felt successful in those areas. She also enjoyed social activities with friends. Her difficulties began in about the 8th grade. Symptoms included sweating, occasionally falling down, but not fainting. She reported a sensation of tension in her chest prior to attacks. When they first started, she could rest for about ten minutes and then continue her activities; however, at the time she was seen they had become severe enough that she had to stop her activities altogether. She noted that the attacks were unpredictable. They happened in competition, but they also happened during practice. She used inhalers during sports activities but said that they didn't work. History of smoking or using drugs was negative. She had some family stress due to her parents' frequent fighting. Her vocal cord dysfunction kept her from competing. Her parents reported that she was always an easy child to raise. She was never sick, and though she was shy as a young child, she seemed to have overcome that and had become outgoing. The MMPI-A was administered, and there was a tendency to under-report difficulties. None of the clinical scales were elevated. When asked if the difficulties interfered with her sports or other activities at the time of follow-up, she said yes, and the areas most affected were social relationships, sports, and work, with sports being the most affected. She indicated she continued to have these episodes, and over the previous six months she had experienced about three a week. She reported worrying a great deal about having another episode. Most of the episodes lasted about 15 minutes, and she sometimes avoided activities in order to prevent an episode. She continued to see her otolaryngologist. When asked how she generally spent her time, she said with friends and participating in sports. When asked if she had experienced any other health problems in the previous six months, she said she had developed a tendency to overeat.

Figure 2

Table 2: Questionnaire Responses One Year Following Discharge

The authors would like to express their gratitude to Beth Kaczmarek, Editorial Consultant for the Department of Plastic Surgery, Medical College of Wisconsin, for her assistance in the preparation and revision of this manuscript.