The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 11

to worsen. ENT evaluation ruled out local causes
of obstruction, and speech pathology diagnosed
him with VCD. It appears that GERD perhaps acted
as a trigger for paradoxical VCD in this case,
but it did not explain the worsening choking
spells. Eventually, the psychiatry team assessed
him and started him on hydroxyzine. Patient was
also provided psychoeducation about the disease
and the possible relationship with anxiety
and sleep problem by psychiatry. In general, the
management of VCD requires a multidisciplinary
approach, which helps to provide appropriate diagnosis
and treatment of the disease. Treatment
team usually consists of an allergist, gastroenterologist,
otorhinolaryngologist, a pulmonologist, a
speech language pathologist, and a psychologist
and/or psychiatrist. It is important to evaluate
for and treat co-morbid conditions like GERD
or asthma. Once organic/anatomical factors are
ruled out, the patient should be evaluated for psychiatric
conditions.
On review of literature, it was found that the prevalence
of psychological/psychiatric comorbidity
in patients with VCD has been reported to be as
high as 75%. 6 Some of the psychiatric conditions
associated with VCD are depression 7 , anxiety 8 ,
post-traumatic stress disorder, conversion disorder,
and primary and secondary gain related to
somatoform disorders 8 . In a retrospective study
involving 160 patients, Dietrich et al. 9 analyzed the
distribution and frequency of perceived stress,
anxiety, and depression in patients who presented
to their voice disorders clinic with various voice
disorders (including VCD). The authors reported
that VCD patients had the highest prevalence of
stress, anxiety, and depression. Most voice disorders
were more common in females as compared
to males, but males with VCD had a much
higher rate of comorbid anxiety and depression.
Many studies have supported the use of various
types of psychological interventions/ psychotherapies
like cognitive-behavioral interventions,
hypnotherapy, biofeedback, speech therapy, and
psychotherapy 2,4,5,6 . Psychotropic medications
have been used but sparingly, mostly for the management
of underlying psychiatric comorbidity.
Benzodiazepines has proven successful in some
patients with VCD who have underlined anxiety
problem 3 . In treating 62 patients with VCD, Varney
et al. 5 reported generally positive experience
with low-dose amitriptyline, required mean dose
was 20 mg, in conjunction with psychotherapy
and behavioral therapies. Brown et al. 7 reported
an adult with VCD along with depression and
psychogenic amnesia who was treated with psychotherapy
and oral desipramine. One case report
by Thurston et al. 6 reported that one patient was
successfully treated by a single psychiatrist using
a combination of psychotherapy and high dose of
venlafaxine with lithium augmentation.
Our patient reported some anxiety symptoms
during the interview. Patient also complained
of anticipatory anxiety related to difficulty swallowing
food and multiple episodes of breathing
difficulty at night. The frequent ED visits were
an indicator of severe impairment. Patient had
significant sleep initiation problem. Hence, after
reviewing the overall condition, it was decided to
initiate hydroxyzine to help with sleep and anxiety.
Hydroxyzine is a first-generation antihistamine
that has anticholinergic antihistaminic, antiemetic,
antispasmodic, and anxiolytic properties. 10
Its selective anti-histamine profile leads to the
sleep-promoting benefits of H1-receptor blockade
with minimal anticholinergic side effects. 10
Although the exact mechanism of action is unknown,
hydroxyzine also plays a role in the management
of anxiety. Our case report show that
hydroxyzine can be a safe anxiolytic option. The
adverse reactions profile of the hydroxyzine, well
described in the literature, is limited, with dizziness,
drowsiness, blurred vision, dry mouth,
stomach upset, and headache. The most prominent
side effect is sedation. 10
Conclusion
Paradoxical VCD is a functional disorder whose
management requires a multidisciplinary approach.
Evidence on the use of psychological interventions
exists, but there is paucity of literature
on the use of psychotropic medications. At this
time, there are no established guidelines to treat
patients with VCD. Our case report indicated that
hydroxyzine could be a good treatment option for
VSD and can be used with minimal side effects.
More research is needed to explore the use of
psychotropic medications in VCD.
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