Dr Judith Guedalia

The Case of the Soldier Who Couldn't Whisper
They were afraid, afraid for him and afraid for themselves.  He, let's call him Lochesh (the Hebrew word for whisper) could not whisper.  When they are out on dangerous missions, their faces painted in camouflage colors, their uniforms and helmets "adorned" with branches, their life is dependent on counting on each other. Having among them a soldier-in-arms who couldn't whisper was life threatening. 
The soldiers, with whom he was posted, went to their senior officer, who in turn went to the medic who went to his supervisor.  Eventually, Lochesh was referred to me by the doctor of the army unit in which he was serving after he had been checked by ENT (Ear, Nose, and Throat) and neurologists for muscle disorders such as Dystonia that can affect the vocal cords.  All of these more medical tests came back WNL, which is medicaleze for Within-Normal-Limits.
            The army doctor referred him for a Neuropsychological Assessment, to see if we could find the source of his problem in the intersect of neurology and psychology, or as neuropsychology is better understood, the brain-behavior relationship.
After speaking with the referring physician I thought of different types of language or neuropsychology disorders that might cause this "not being to whisper" problem.  Our method of problem solving is known as the hypothesis-testing-branching-approach.  We begin with a tree trunk of basic tests and we use the resulting data to branch upward and out-ward as we hypothesize what the problem might be, at each branch we go further out (using specialized tests and subtests) to refine our thinking, onto the twigs.  The goal, to paraphrase an early mentor of mine, is that the data has to make (neuropsychological) sense.
There are many aspects of spoken language:  Phonetics - the study of the sounds of human speech, is concerned with the physical properties of speech sounds (phones), and their physiological production, auditory perception and neurophysiologic status; Prosody - the systematic use of sound to encode meaning; Morphology - the identification, analysis and description of the structure of words; Syntax - the study of the principles and rules for constructing sentences in natural languages.
Neuropsychologists are familiar with people who after a brain injury (or children with specific developmental disorders) cannot modulate their tone of voice or have difficulties with prosody.  Psychiatry journals report cases of hysterical inability to speak (aphonia).  After researching I could not find another case of an inability to whisper. 
Anticipating his visit, I had prepared the literature and the test protocol based on projected hypothesis.  I must admit I was both curious and excited.
He walked in and sat down.  Observing him I must say that outwardly he looked just like most of the 20ish young soldiers that inhabit our world here and fill us with pride, anxiety and hope.  
During the hour and a half intake he told me about the different sorts of doctors he had seen, how many days of service he missed and what he does for enjoyment - he loved solitary hiking and sharp shooting.   I had a queasy feeling in the pit of my stomach. 

There is no objective test that I have studied or bought that produces this specific gut result, however years of experience and the differential diagnosis that usually explains this specific type of queasiness is scientific data to me.  I guess that this gut form of diagnostics is part of the reason I became a neuropsychologist.   


            I asked him: What do you hear when someone says whisper?
            He replied: "I hear the voices louder and if I'll whisper I won't be able to drown them out!!"
What do "they" [the voices] say?
"Kill yourself!"

            "I am very grateful that you shared this with me.  Now I'm going to tell you something that is just between us: If you listen to those voices you'll ruin my good record.  No one kills themselves when they are my patients!"  


Boy was that a conversation stopper!  He looked at me and just stared!
"You're a nice guy," I continued, "and I'm really serious about this, I promise I will get you help, the voices will stop and you will be okay again.  But no guns, no tiyulim on dangerous terrain, and no walks by yourself.  I'll speak to your folks and we'll work together to get you help, even by tonight.
"But promise me, and I trust you to keep your promise, nothing dangerous and especially NO whispering.  You must speak loudly and clearly, no listening to those awful voices in your head, and NO killing yourself!  Do we have a deal?  Let's shake on it."

We did.


Psychosis is a condition in which a person isn't in contact with reality. Psychosis can take many forms, including:

·         Sensing things that aren't really there (called hallucinations)

·         Having beliefs that aren't based on reality (called delusions)

·         Problems in thinking clearly (e.g. thought insertion, withdrawal, block, broadcasting)

·         Not realizing that there is anything wrong with themselves (called lack of insight)


In Psychiatry there are a number of disorders that come under the general title of the psychoses. They all differ in symptoms, but all are joined in that the person is in some way not experiencing reality like most people.


What Causes Psychosis? No one really knows, however, some popular theories include:

·         Genetics

·         A wiring problem in the brain

·         A chemical imbalance in the brain/body

·         Too much anxiety to stress 

·         It's a psychological defense mechanism

·         Any combination of the above


Sometimes psychosis can be brought onby:

·         Using Illegal Drugs (e.g. cannabis, LSD)

·         Infections (e.g. Meningitis)

·         Brain Tumors (Cancer)

·         Epilepsy

·         Head Injuries


It is imperative to ask about hallucinations and the risk of self-harm and of harm to others; these may be closely related when command hallucinations instruct the person to commit self harm or harm others.   Suicide is the chief cause of premature death among people with schizophrenia, with 4-13% of such people committing suicide and 25-50% making a suicide attempt.

            Do People Recover? Some people who experience a psychosis may only experience it once throughout their whole life (this is called a single episode), other people may have problems with it for the rest of their lives.


            In Lochesh's presence, I called his parents and asked them to come to the office immediately.  I called to find out which of the psychiatrists I knew would be available to see a new patient that very evening.  I called and postponed my other appointments.
I kept my end of the deal and he kept his.
He recovered from this Single Episode psychotic break.

I whisper thanks to Hashem that I have not heard anything new.


·          Fractured Minds: A Case-study Approach to Clinical Neuropsychology - Google Books Result

Jenni A. Ogden - 2005 - Medical - 397 pages

·          Neuropsychology Verbal Learning Test (Delis, Kramer, Kaplan, ... Tests of prosody Emotional tone in speech (prosody) is thought to be a right ...


·          Perception of Emotional Prosody: Moving Toward a Model That ...Cerebral mechanisms underlying facial, prosodic, and lexical emotional expression: A review of neuropsychological studies and methodological issues... bcn.sagepub.com/cgi/content/refs/5/2/92 -


·          Department of Neurology, Division of Neuropsychology, North Shore ....


·          Black, L.M. and van Santen, J.P. "Expressive and Receptive Prosody in Autism. ... www.cslu.ogi.edu/people/black/  


·          Hysterical Aphonia (inability to speak) in Soldiers Arthur F. Hursta1 and A. Wilson Gill The Journal of Laryngology, Rhinology, and Otology (1919), 34:189-200 Cambridge University Press


·          http://easyweb.easynet.co.uk/simplepsych/psychosis.html

Tags: Aphoniay | Dystonia | Jewish Press | Lochesh | Neuropsycholog | Psychosis | Whisper | Within-Normal-Limits | WNL