Functional Aphonia in a 3.5-year-old Child

Introduction

Functional aphonia is a disease that occurs in 0.4% of the general population and affects mainly young women aged between 14 and 35 years.^[1] In the International Classification of Diseases and Related Health Problems, 10th Revision, functional aphonia is placed among the conversion disorders with motor symptoms or deficits (F44.4).^[2] In the Diagnostic and Statistical Manual of Mental Disorders-5 under “Somatic symptom and related disorders” as a “Conversion Disorder” (300.11).^[3]

Functional aphonia is also known as “psychogenic aphonia” or “hysterical aphonia” or “acute sudden voice loss” or “conversionaphonia.”^[4]

It was suggested that anxiety and elevated tension play a significant role in the pathomechanism of functional aphonia. As aphonic patients show poor stress-coping abilities (i.e., they tend to use escape strategies), the symptoms of the disease are thought to occur as a defense mechanism against anxiety.^[1]

Case Report

A 3.5-year-old child came with his father to the Psychiatry OPD of a Tertiary Care Hospital in Assam in the month of June 2019 with the chief complaint of not speaking for the last 15 days. The patient was referred to Psychiatry OPD from ENT OPD after a complete examination failed to find any physical abnormality. As per the history provided by the informants (parents), the child woke up screaming from sleep at around 12 midnight to 1 am 15 days ago. He was also sweating at that time. He told his father that he had seen a person with long hair in dream. Apart from this incident, no other precipitating factor was noted. Two days after this incident, his parents noticed that he had stopped speaking. He would not answer if he was asked something, nor would he ask anything of anyone. He started communicating with gestures when he was hungry or thirsty. He started showing a startled response to loud sounds like the barking of a dog, even while asleep. No other behavioral abnormality was present in him. He spent the day as before. He stopped going to school because of his illness. Around 7 days later, he was brought to the hospital but had to return without treatment as the OPD was closed that day. At around 8 pm that day, he suddenly started talking normally. He also recalled some events that occurred in the past 7 days. But the next evening, he again stopped talking.

There is no significant past history. There was no history of the patient having a similar illness in the family or neighborhood. Patient lives with his parents and elder sister who is 10 years older than him, and all of them pampered him a lot. He was delivered at home normally at term and cried immediately after birth. His birth weight was 3.6 kg. He has attained developmental milestones as per his age. Perinatal history was uneventful. The patient goes to a play school. Premorbidly, he enjoyed playing in groups, but he often demanded things like toys, chocolates and threw tantrums if his demands were not fulfilled. All the family members pampered him a lot, as he was considered a very precious male child who was born 10 years after the first girl child.

The patient was first taken to the ENT OPD and was referred to the Psychiatry OPD as after a detailed examination and investigation, no organicity could be detected.

His weight was 15 kg. No abnormality was detected on the general and physical examinations. The patient couldn’t sit still during the interview. He did not communicate but did cough normally after he was asked to do so 2–3 times. He was diagnosed as a case of functional aphonia as per International Classification of Diseases-10 where it is included in Dissociative motor disorders (F 44.4). He was discharged with a prescription for Tab Clobazam 5 mg (2.5 mg BD), Syp Multivitamin 5 ml twice daily after food. Non-pharmacological reassurance was given to the child, and a supportive approach was adopted. Parents of the child were counseled about the illness, and secondary gain was asked to be cut down. The child was called for a checkup after 2 weeks.

Discussion

Studies have found that cases of functional aphonia in individuals under the age of 15 are relatively rare and are reported to occur more often in women than in men.^[5,6] Yang et al. (2018) in a retrospective analysis of 595 cases of children from 3 to 18 years of age with dysphonia, found functional dysphonia in 42 patients, and among them, 25 patients had aphonia; however, none of the patients were among the 3–6-year group.^[5]

Hence, from all the data, it seems that this case is a rare case of conversion disorder, which can be of great value in future studies. Further, it also negates the psychoanalytic theory of Freud for dissociative disorders, where Freud postulated the origin of the problem to be the fixation at the phallic stage and described symptoms as compromise with the primary gain of conflict resolution through partial expression of the conflict without conscious awareness of its significance. All these are functions of the ego, which is not fully developed at the age of 3.5 years.^[7]