Dissociative Aphonia Secondary to Nonorganic Vaginismus—A Case Report

Case Report

A 26-year-old married Hindu lady presented to the outpatient department of our hospital with a two-day history of inability to speak along with subsequent fearfulness and decreased sleep.

She was a homemaker who was educated up to high school. She had been married for six years in a third-degree consanguineous marriage and was residing in joint family that belonged to the lower socioeconomic strata in a rural locality in of Karnataka (India). Growing up, she reported that she was brought up in a restricted environment and had been married off at an early age despite wanting to study further. She expressed that most of her life decisions were made by her family, but she had always obliged as she did not want to go against them.

After her marriage, she reported that several interpersonal issues ensued with her husband that had begun a couple of months into the marriage due to her inability to engage in sexual intercourse. She reported that she was fearful of being penetrated and the pain that it would lead to. The couple had sought treatment for infertility from a local gynecologist, and then at our tertiary hospital where she was diagnosed with nonorganic vaginismus.

In the year preceding the admission, the interpersonal conflicts had aggravated as her family began getting involved and insisted that she should terminate the marriage as her husband was allegedly forcing her to engage in sexual activity. Further interviews with her parents revealed that they wanted her to terminate the marriage as they were also apprehensive about the family’s prestige being at stake due to her inability to consummate the marriage and procreate.

She reported continuing stressors but was maintaining well up until two days prior to the consultation where she presented with a history of abrupt onset of inability to speak following a fall which had led to fearfulness associated with palpitations and palmar sweating. The fall was reported to be accidental by the patient and the history surrounding the fall could not be corroborated with the partner or other relatives as they were not physically around to witness it at the time of the incident. The patient’s mother reported that during their last conversation, the patient expressed concern regarding the ongoing marital issues with her husband and that the “problems have come up to her neck.” The patient was largely unsure of why she had “lost her voice” but vaguely attributed it to a physical injury from the fall. A local physician who was consulted following the onset of the manifestations had reported that she could have been in “shock” possibly resulting in aphonia.

Her biological functions were normal. She reported irregular menstrual cycles occurring at a frequency of two to three months with the last menstrual period about three weeks prior to the consultation but no history suggestive of premenstrual dysphoric disorder. She had a known history of hypothyroidism for which she was on treatment. There was no history of giddiness prior to the fall or loss of consciousness following the fall. There were no reports of head injury, seizures, confusion, or amnesia associated with the event. No history suggestive of disordered mood, psychotic symptoms, or substance use was reported. She did not report any history suggestive of sexual abuse or previous sexual partners but also appeared to be guarded about the same. There was no family history of any psychiatric illnesses reported. Premorbidly, she had anxious and dependent traits.

The patient had been referred from the ENT department which had noted that the examination was essentially normal. Physical and systemic examination was also found to be normal albeit with a body mass index (BMI) of 18.13 kg/m ² putting her under the underweight category. On mental status examination at the time of admission, she was found to be conscious, co-operative, and well oriented to time, place, and person. She would communicate with gestures and in writing. Reading, writing, and comprehension were intact. Phonation on coughing was also present. Her mood and affect were noted to be anxious.

Given the above history and examination findings, a diagnosis of psychogenic aphonia and nonorganic vaginismus was made. Tablet lorazepam 3 mg in divided doses was started which was tapered off over three days. The patient was encouraged to speak beginning with monosyllabic and bisyllabic words. On day 2, she began whispering and eventually began enunciating complete words by day 3 of admission. Sex therapy was initiated with the couple in addition to family therapy involving the couple and the patient’s family. During the therapy sessions, the patient reported that she had been coaxed into marriage at an age when she wanted to study further to be able to pursue a career. Similarly, with the onset of the marital conflicts between the couple, the parents were insisting on terminating the marriage themselves without taking her opinion into consideration. This led to her feeling that she did not have “a voice of her own.”

On follow-up a month after discharge, the patient’s symptoms had resolved but the interpersonal conflicts persisted. The therapy session was continued at the follow-up wherein the interpersonal conflicts were further addressed and the patient’s family members were encouraged to allow the patient to regain autonomy over life. However, due to the coronavirus disease 2019 (COVID-19) pandemic and the consequent lockdown, the patient was lost to follow-up.

Discussion

Dissociative disorders have been known to be a means of alternate expressive as well a defense mechanism which in turn reflect as various primary and secondary gains. ⁵ In this patient, the expression that “her problems had come up to her neck” is a phrase that is colloquially used to denote an intolerable level of stress. This symbolically hinted at the need to address the significant underlying psychosocial conflicts that had led to the aphonia. More so, particularly noteworthy in this patient was the presence of vaginismus which had formed the ground for the current presentation. The probable etiology of the vaginismus, although difficult to isolate to medical pathology, could be attributed to the lack of sexual knowledge as well as the anxious disposition in the purview of her early childhood and adolescent life.

A review by Baker highlighting the predominant role of psychosocial factors in dissociative aphonia also described theoretical causal models behind the same. ⁶ As described by Baker, a model by Butcher proposed the stifling impact of social factors in androcentric environments on developmental personality traits, self-expression, and overall autonomy of women presenting with dissociative aphonia. ⁶ This model also illustrated the translation of internal conflicts of self-expression into a physical inability of voice production. ⁶ Due to which, more than the primary intervention given the diagnosis, secondary interventions regarding the interpersonal problems formed the primary focus. Further interviews led to an unveiling of other intricate interpersonal issues not only between the couple but also within the extended families particularly with respect to their over-involvement in the couple’s intimate life.

In conclusion, with cases of dissociative disorders, dissociative aphonia in this patient particularly, a multimodal management approach is required ranging from pharmacological to nonpharmacological with an added emphasis on the psychosocial aspects. Another subtle lacuna that needs to be taken into consideration in this patient with underlying nonorganic vaginismus, which was adding to the psychosocial conflicts, was the need for sex education among adolescents and adults of all genders. Sex education, specifically in our country, ironically being potentially the country with the largest population, is widely stigmatized or eluded. The need for the introduction of sex education in and outside of the academic curricula in the urban and rural settings needs to be looked into both as a mode of inculcating awareness and imparting knowledge.