This paper is published in the Journal of Voice
https://doi.org/10.1016/j.jvoice.2025.11.021
Stephen R King and Jenevora Williams
Laryngeal guarding is a term used informally by clinicians and teachers which has yet to be clearly defined until now. This paper examines its potential role as an unconscious block within the body, hindering progress in voice rehabilitation and limiting the development of efficient singing and speaking behaviours. Through a narrative review, it traces a continuum of guarding from reflexive responses to learned behaviours, drawing on findings from pain science, fear-avoidance processes, dispositional and psychoanalytic formulations, and research on functional voice disorders and secondary gain.
The review reframes persistent functional dysphonia as potentially underpinned by unconscious protective strategies, showing how anticipatory anxiety, trauma, and hypervigilance may contribute to maladaptive laryngeal co-contraction. In cases of hyperfunctional patterns or “guarding,” the alteration is not only a loss of parasympathetic modulation but, in some instances, a reversal of its expected function. The paper proposes a theoretical account of why the system may shift from a restorative, protective parasympathetic state toward a heightened sympathetic or anticipatory mode. In this up-regulated state, the larynx adopts a physiologic posture of defence rather than rest: an adaptive contraction that becomes maladaptive when sustained over time.
This paper also offers practical insights into how therapists and pedagogues can identify the role of laryngeal guarding in voice disorders and support clients and students to move beyond this limitation. It outlines key features clinicians and teachers might observe in order to recognise and conceptualise laryngeal guarding within clinical or studio practice.
Key words: Guarding, voice therapy, muscle tension dysphonia, voice rehabilitation, psychogenic voice, biopsychosocial.
Stephen R King and Jenevora Williams
In the context of this enquiry, guarding is the body's involuntary or voluntary tensing of muscles around an injured area or a site of potential pain, as a protective mechanism. This bracing or stiffness aims to limit movement and prevent further injury or pain. Muscle guarding is a common protective response to pain, where muscles around the affected area spasm to restrict movement. It is also a response to anticipated pain or injury, and hence has a relationship with anxiety and fear. Guarding has been well documented in areas of study such as chronic lower back pain (1), abdominal pain (2), and shoulder injuries (3). While patterns of muscle tension in the intrinsic and extrinsic laryngeal muscles are often observed and experienced during vocal and laryngeal activity, the term 'laryngeal guarding' has not yet been officially used. This paper aims to investigate whether certain known features in voice use associated with anticipatory anxiety, pain experiences, or vocal overload, may trigger guarding reflexes and behaviours that we may refer to as laryngeal guarding.
This literature review was constructed to explore the currently undocumented phenomenon of “The Guarded Larynx,” by synthesising theoretical and empirical literature from pain science, psychology, psychosomatic, and psychoanalytic traditions. Given the absence of direct literature linking the concept of muscular or physiological guarding to the laryngeal complex, a scoping approach was taken to map relevant conceptual and clinical domains that would support the theoretical construction of this phenomenon.
A narrative literature review methodology was employed due to the interdisciplinary and theoretical nature of the research question. Unlike a systematic review that requires predefined clinical questions and outcomes, a narrative approach was more suited to inductively mapping the conceptual terrain across multiple fields (4). This method enabled theoretical saturation and cross-disciplinary synthesis, a crucial component given that “The Guarded Larynx” is not yet a formal term in the clinical or academic literature.
Databases including PubMed, PsycINFO, Scopus, and Google Scholar were searched using combinations of the following keywords: “muscle guarding, guarding reflex, psychological guarding, signal anxiety, fear-avoidance, functional voice disorder, psychosomatic voice, biopsychosocial pain, larynx and anxiety, Reich and body armour, anticipatory anxiety and voice, psychogenic voice, functional neurological disorder.”
The inclusion criteria focused on what became the development of four prominent themes:
1. Empirical or theoretical papers that discussed the psychophysiological mechanisms of guarding,
2. Literature on chronic pain and muscle tension involving fear-based or protective responses,
3. Psychoanalytic and phenomenological theory describing embodied anxiety or signal-based anticipatory processes,
4. Voice-specific literature where psychological processes may affect phonation.
Papers were excluded if they focused solely on mechanical injury without reference to psychological or behavioural dimensions. Due to the conceptual scope of this study, documents from as early as Descartes’ Treatise of Man to contemporary neuroscience and psychotherapy literature were included to help map the historical and epistemological arc of the term “guarding” and its relevance to the voice.
The selected literature was organised thematically using a process of abductive reasoning, working from observed clinical phenomena in voice therapy (e.g. chronic muscle tension or inconsistent voice quality in the absence of organic pathology) towards theoretical constructs that might explain them. Four themes were drawn inductively across the domains of:
This was further triangulated through literature on more current phenomenological concepts such as sensorimotor priors (16), and stress in performers (17), to contextualise the hypothesis that the larynx may hold a defensive, anticipatory, or compensatory posturing that echoes the function of guarding elsewhere in the body.
It wasn’t that long ago that Wilhelm Reich was writing about ‘muscular armour’ as he split away from the Freudian ideas of psychology. According to Reich, muscular armour is part of the body's psychological defence mechanism that seeks to keep us safe (11). This safety mechanism is like other bodily blueprints encoded in our nervous system through events, occurrences, trauma, or even our personality structure. In current literature, this phenomenon of muscular armour is now termed “guarding”. Reich’s original concept has taken on new life and is now represented as less of a purely psychological concept. Thus, guarding is an unconscious (or semi-conscious) protective behaviour designed to minimise real or anticipated pain or emotional vulnerability. It may involve bracing, limiting movement, or altering posture (5). The specific phrase “guarding reflex” was first used in a urological context by R. C. Garry in 1959. He described it concerning the external urethral sphincter, noting how it reflexively contracts to prevent involuntary bladder emptying during filling (6). From organisations like the American Psychological Association to various papers and accounts, guarding, as a protecting and holding mechanism, is an important component of human physiology.
René Descartes introduced foundational ideas about reflexes in his posthumously published work, Treatise of Manwritten in 1664 (7). In this influential treatise, Descartes described human and animal bodies mechanistically, comparing bodily processes to machines. Reflex actions, according to Descartes, were involuntary and automatic responses, triggered only by external stimuli. He conceptualised these reflexes through mechanical analogies, likening nerves to hydraulic tubes filled with "animal spirits" (a fine fluid), which transmit sensations and initiate muscle movements (18). Our understanding of human physiology has moved on a great deal since Descartes and allows us to examine these ideas in a more distant manner; however, the sentiment that sensations and noxious stimuli can activate involuntary muscle movement is a widely agreed-upon consensus.
In contemporary pain science, the biopsychosocial (BPS) model stands as the prevailing paradigm for understanding the multifaceted nature of chronic pain and other complex human experiences in health. This epistemological stance was first proposed by George Engel in 1977 through a keynote address (19). In this keynote, he called out to the psychiatrists in the crowd for change from the rigid biomedical, dualistic paradigm that was well-viewed and respected at the time. This model represented a significant departure from the biomedical reductionism that had dominated much of 20th-century medicine, along with Descartes’ ideas of dualism. Engel argued that human illness, like chronic pain, could not be adequately explained through biological mechanisms alone, but rather required an integrated framework that recognised the dynamic interplay of biological, psychological, and social domains (19).
Holding, tightening or stiffening is a very natural reaction in the body in relation to pain or discomfort (20). This can be an immediate response to acute, sudden or unexpected pain. It can also be a longer-term holding habit for the person with chronic pain (21). It is important to note that guarding is triggered by a completely subconscious response that is essential for human survival. It only becomes problematic or limiting if these patterns remain once the pain or threat has gone, or if they become linked with other feelings or responses which may cumulatively exaggerate their impact on the person’s health and wellbeing (22).
Applied to chronic pain, the biopsychosocial model helps explain why individuals with similar injuries or diagnoses can experience vastly different levels of pain, disability, and distress. Biological contributions may include peripheral or central sensitisation, inflammation, or altered motor patterns. Yet these do not act in isolation. Cognitive-emotional factors such as catastrophic thinking, hypervigilance to bodily sensations, depression, and anxiety are well-documented in modulating pain perception (23, 24). In parallel, social influences such as familial responses, workplace expectations, economic pressures, and culturally shaped beliefs about illness and the body, can either exacerbate or buffer pain-related distress (25). We have a theoretical ‘cycle’ that is well documented in pain science called the ‘Fear Avoidance Model” that begins to explain this in practice (8), it is detailed below.
Figure 1: Fear Avoidance Model from Bunzli et al (9).
Imagine a patient experiencing acute back pain as a result of lifting a heavy box. In many individuals, this pain might resolve over a short period of time through graded exposure and ultimately a resumption of normal activity. But in others, especially those who are predisposed to catastrophise, perhaps because of prior trauma, health anxiety, or certain personality traits, then that initial pain is interpreted catastrophically by the body: “This is serious,” “I might have done real damage,” or “If I move again, I’ll make it worse.” What happens next after the initial catastrophe is a sum of avoidance behaviours. The patient stops bending over or walking long distances, and over time they may even withdraw socially and psychologically. This is where pain becomes chronic and not necessarily because the tissue damage persists, but because the fear of pain drives an avoidance reaction, and that avoidance erodes physical capacity and resilience (8). This is not merely hypothetical, as a substantial body of empirical work supports this model. Crombez and colleagues (10) reinforced the point that fear-related avoidance is a more potent predictor of long-term disability than pain intensity itself.
Essentially, it’s not how much it hurts, but how afraid of the hurt you are, and then what you do about that fear, that predicts whether someone returns to function or descends into a spiral of chronicity. But what sets someone up to go to fear or avoidance rather than tackling a problem head-on and subsequently living a fulfilled life? According to Olugbade’s team, the way we feel about how we move is far more important than any physiological mechanism when addressing pain-related fear avoidance (5). Hence, the importance of a holistic, biopsychosocial lens for understanding, interpreting and treating these behaviours.
Translating these insights to rehabilitation technology, Aung et al developed a Random-Forest model that detects guarding (defined as stiff, interrupted or slowed movement) in chronic low-back-pain patients using motion-capture kinematics and lumbar EMG (20). Hip–knee angles, joint “energy” and paraspinal EMG were the strongest features, yielding F-scores ≥ 0.8 for sit-to-stand recognition. Such automated feedback could prompt relaxation cues or graded-exposure tasks the instant guarding emerges, tackling the fear-avoidance loop in real time (20).
Main and Watson (26) propose that "guarded movements", defined as protective, fear-driven motor patterns, contribute to chronic pain by reinforcing muscle overactivity and dysfunctional movement. These behaviours are linked more to anxiety and low self-efficacy than to pain itself, highlighting the need for psychologically informed rehabilitation with evidence that a significant proportion of chronic incapacity is preventable. Using a rat incision model, Xu and Brennan demonstrated that incising skin plus deep fascia and muscle, but not skin alone, induces days of guarding behaviour and a six-fold rise in spontaneous nociceptor firing. Deep-tissue injury, therefore, drives guarding via ongoing afferent input, whereas cutaneous injury mainly evokes brief mechanical and heat hyperalgesia. This research work positions guarding as a biologically purposeful defence of our more vulnerable deep structures. However, there is a paradoxical nature to this guarding as it ends up maintaining pain through continuous peripheral bombardment of the spinal cord (27).
When it comes to the anticipation of pain, guarding can be conceptualised as the expression of sensorimotor priors that have been shaped by previous noxious or affective experiences and stored in autobiographical memory. Bayesian and active-inference models of pain propose that, after an injurious or threatening incident, the brain updates its generative model so that defensive muscle co-contraction is predicted and pre-activated whenever similar contextual cues recur (28). These models suggest that pain isn't just a direct response to stimuli, but rather an interpretation based on predictions and expectations.
Empirical support for this mechanism comes from experimental work showing that long-term pain memories will lower pressure-pain thresholds in otherwise pain-free individuals with a prior injury history, indicating a durable anticipatory priming of protective responses (29). Computational perspectives further demonstrate that the perception–action loop in pain is continuously driven by predictions about bodily threat; and when those predictions remain uncorrected, motor output defaults to rigid, and energetically costly, physical bracing (30).
The anticipation of potentially damaging stimuli that may be strong enough to potentially cause tissue damage or pain will activate nociceptors: specialised sensory receptors that transmit information about potentially harmful stimuli to the nervous system. The input from these receptors can lead to various responses, including pain perception and protective reflexes. McParlin’s active-inference account of therapeutic touch suggests that social–affective contact can revise these maladaptive responses or priors: affiliative touch provides exteroceptive and interoceptive evidence that down-weights these stimuli, thereby recalibrating the set-point of protective reflexes in anterior insular and cingulate circuits (16).
A study on “frozen shoulder” found that under anaesthesia (removing voluntary guarding), passive range of motion improved dramatically. This is indicative that active muscular guarding, not necessarily joint pathology, was the major restriction in movement (3). A 2024 ultrasound study showed that greater pain-related anxiety predicts thicker abdominal muscle layers in standing tasks (3), reinforcing the link between threat appraisal and abdominal co-contraction. Abdominophrenic dyssynergia is now recognised as a learned viscerosomatic reflex in functional bloating and distension. During a colonic‐gas load, patients showed paradoxical diaphragmatic contraction coupled with relaxation of the internal oblique muscles, an abnormal strategy to “shield” visceral motion (32).
Hypermobility Spectrum Disorders (HSDs) were introduced in 2017 to replace the older “joint hypermobility syndrome” terminology and to clarify the boundary with hypermobile Ehlers–Danlos Syndrome (hEDS). Electromyographic and kinetic studies show that hypermobile individuals often increase antagonist co-contraction to stiffen lax joints (32). This protective “muscle guarding” augments joint compression and reduces shear, but chronically elevated tone produces fatigue, a subjective sense of stiffness, and secondary myofascial pain. Estimates of the prevalence of HSDs approach 26.2 % overall (females 36.7 %, males 13.7 %) (33). Cited elsewhere, the prevalence is said to be between 4 and 20% of the general adult population, yet there is an under-recognition that persists because of variable presentation and limited clinician familiarity (34). It is worth noting here that hypermobility among dancers can be as high as 44% of the population (35).
These phenomena have been observed in the performing arts and in the field of sports psychology, this anticipatory anxiety is also observable and seen to be pathological for athletes. Sport participants who experience recent stressors and who do not have the strategies and skills to cope with the stress seem most at risk for injury (36). In a prospective cohort study by Prkachin et al, workers were observed after an acute low-back injury, objectively coded pain behaviours showed that only one category, guarding (rigid posturing, breath-holding, bracing), consistently predicted every downstream disability outcome: days lost, treatment costs and delayed return to work. Guarding acted as a behavioural amplifier of threat, independent of initial pain intensity, implying that early interventions must target the cognitive-affective triggers of bracing to prevent chronicity (37).
Working with women who lived with long-term, medically unexplained musculoskeletal pain, Hamberg et al. found that many who had endured partner abuse described being “always on guard.” That hyper-vigilant state made the body tense reflexively, producing chronic low-grade muscle activation that both protected against further harm and perpetuated pain. Shame and fear kept this guarding implicit; patients hinted at it before disclosing abuse, encouraging the need for sensitive inquiry into psychosocial drivers of muscular bracing (38). Surface-EMG during treadmill walking revealed that people with chronic low-back pain keep their erector-spinae muscles switched on throughout the gait cycle, failing to relax even during swing. This tonic co-contraction supports the “guarding hypothesis”: movement is stabilised by stiffening the spine to avoid anticipated jolts. Interestingly, fear-of-movement scores did not correlate with EMG levels, suggesting that long-standing guarding can become automatic and decoupled from conscious fear, sustaining dysfunction through altered motor patterns (1).
Situating the “guarded larynx” within established neurophysiology, the authors propose that it may reflect dysregulated activity of the laryngeal adductor reflex otherwise known as LAR. LAR is a brainstem-mediated airway-protective circuit in which mechanical or chemical stimulation of supraglottic mucosa (afferent: internal branch of the superior laryngeal nerve) elicits rapid vocal-fold adduction via nucleus ambiguus outputs to the recurrent laryngeal nerve (efferent) (39, 40, 41). The LAR exhibits robust early (R1) and later (R2) components that persist during volitional phonation and breathing, implying limited cortical gating and a reflexive priority over concurrent motor goals (40, 42).
When the inside of the larynx is touched or irritated, it automatically triggers the LAR, which closes the vocal folds to protect the airway. Scientists have found that this reflex happens in two quick stages: R1 (the fast reflex) is the first, very quick response, happening in about 20 milliseconds. It is controlled entirely by the brainstem, not the thinking brain. It causes the vocal folds to snap shut instantly to prevent anything from going into the lungs. It is automatic and can’t really be stopped by choice. R2 (the slower reflex) happens a little later - around 60–80 milliseconds after the stimulus. It’s a slower, longer-lasting muscle response that helps keep the folds closed or stabilises the larynx. This part of the reflex can be influenced by a conscious process, but it still mostly happens automatically.
Across “laryngeal dysfunction” syndromes like chronic refractory cough, paradoxical vocal fold motion/inducible laryngeal obstruction, and muscle tension dysphonia, converging evidence documents heightened laryngopharyngeal sensitivity and exaggerated airway-protective reflex activity, with measurable sensory hyperresponsiveness and clinically meaningful response to behavioural modulation (43, 44, 45). Framing the concept of laryngeal guarding as an emergent state of LAR hyperexcitability or disinhibition therefore offers a biologically coherent bridge from observed behavioural bracing to a sensorimotor loop that couples volitional laryngeal control with autonomic brainstem defence programmes (39, 40).
Task fMRI observation using inhaled capsaicin demonstrates a reproducible cortical network for airway irritation and the urge-to-cough centred on the anterior insula, anterior mid-cingulate cortex, primary somatosensory cortex, supplementary motor area, orbitofrontal cortex and cerebellum (with prefrontal recruitment during cognitive modulation). This network encodes threat appraisal and premotor set for protective behaviours, offering a plausible supramedullary scaffold onto which brainstem LAR output (R1/R2) can be amplified or gated during “guarded” laryngeal states (47, 48, 49).It is worth noting as a methodological failure that direct fMRI capture of the earliest LAR activity (R1) is limited by timing and brainstem artefacts; nevertheless, convergent fMRI evidence across cough, suppression, speech and swallowing shows the supramedullary circuits that likely gate and bias the reflex, providing a systems-neuroscience context for the guarded larynx model (45, 46, 47).
Across other fMRI studies, there is a trend where healthy participants tend to down-regulate cough via dorsomedial prefrontal and anterior mid-cingulate control networks, whereas patients with cough hypersensitivity show impaired suppression and usually a blunted activation of these forebrain inhibitory nodes (48, 49, 50). Conceptually then, the same failure of top-down control could permit reflexive laryngeal adduction to intrude during speech or quiet breathing, presenting phenotypically as a “guarded” larynx as the authors suggest.
In more extreme manifestations of this phenomenon, the neurological habits will alter functional activity in a more drastic and sometimes catastrophic manner. In FND, the brain’s generative model itself becomes the lesion, creating the conditions for the presentation of a Functional Neurological Disorder. FND includes the more deeply embedded behaviours within a complex biopsychosocial context. For example, Ludwig et al.’s meta-analysis found that exposure to stressful life events and maltreatment is markedly higher in FND than in either neurological or psychiatric controls, reinforcing the role of threat-learning in symptom genesis (39). This threat-based motor-adaptation loop therefore spans musculoskeletal pain, voice disorders, and full-blown FND in the potential for guarding behaviours.
Steinruecke et al (52) conducted a systematic review & meta-analysis around pain and how it relates to FND. Across 64 studies (n = 4,272), 55% of adults with FND reported chronic pain, a prevalence exceeding that in matched neurological controls. Pain was especially frequent in functional movement disorders (61%) and often precipitated emergency presentations, suggesting an early, possibly causal, role in the presence of FND. Pain was correlated with greater limb weakness and poorer long-term recovery, implying that protective bracing or avoidance may perpetuate functional motor deficits, although the authors explain that explicit electromyographic studies of guarding remain lacking. Interestingly, despite widespread use of psychotherapy and physiotherapy, most trials failed to relieve pain. From the Steinruecke et al study, comorbid complex regional pain syndrome (22%), irritable bowel syndrome (16%) and fibromyalgia (10%) were common with FND, reinforcing mechanistic convergence between FND and disorders where guarding and threat appraisal dominate.
In the field of voice, primary muscle tension dysphonia (MTD) and functional neurological voice disorder (FNVD) appear to share a common, threat-based motor-adaptation loop that is conceptually identical to the fear-avoidance cycle described in chronic pain. An integrative review of 100 studies on MTD concludes that “physiologically or psychologically aversive stimuli” prompt a defensive up-regulation of laryngeal muscle activity; this guarding response can persist long after danger has passed, becoming self-perpetuating through altered sensorimotor feedback (53). The authors explicitly frame MTD as an idiosyncratic strategy to control perceived threat, mirroring the cognitive-behavioural fear-avoidance model originally developed for musculoskeletal pain (54).
Experimental work by van Mersbergen, Patrick and Glaze (55) deepens this picture. When participants with functional dysphonia imagined socially threatening scenes, they showed significantly higher subjective fear yet lower facial EMG reactivity than social-anxiety controls—akin to a “freeze” posture. They simultaneously reported greater post-imagery vocal effort across all conditions, implying that heightened internal vigilance rather than overt arousal drives laryngeal co-contraction. Crucially, fear was present without overt avoidance, suggesting that early intervention should target the cognitive appraisal (“I might fail”) before habitual guarding evolves into frank phonatory avoidance.
Clinic-based studies confirm that these threat appraisals translate into real-world restrictions. In a cross-sectional cohort of 197 new voice-clinic patients, one-third met the requirements for anxiety, depression or somatisation. The recorded qualitative themes exposed a fear of occupational fallout and feeling “unheard” as pivotal stressors (56). A follow-up qualitative study of patients with diagnosed MTD mapped these fears onto concrete coping patterns such as trigger avoidance, voice-saving ‘rituals’ and social withdrawal. Importantly, higher perceived control over voice symptoms neutralised distress.
Trauma-linked FNVD provides an extreme of this spectrum of voice disorder. Baker (57) showed that psychogenic aphonia often emerges after events where speaking was dangerous or futile, echoing the “conflict over speaking out” construct. Here, voice loss functions as both shield and negative reinforcer: it blocks re-exposure to threat but simultaneously cements the guarding pattern. Neurological case-series data endorse this fear-guard model at the level of FND. Chung et al. (58) report that functional speech and voice disorders characteristically show ‘struggle behaviour’, exaggerated facial and laryngeal contraction that escalates with effort yet melts away under distraction, a signature of goal-directed but maladaptive guarding. High suggestibility and rapid reversibility parallel the “rapid gains after confrontation” seen in graded exposure for other FND subtypes, further underscoring the relevance of a fear-avoidance lens.
Choking under pressure refers to a noticeable decline in performance that occurs not because of a lack of ability, but due to anxiety and the weight of high-stakes situations (59). It happens when someone who is normally capable underperforms when it matters most. This drop can be sudden and is often linked to increased self-doubt and overthinking (60). Though commonly associated with sports, choking can also occur in academics, public speaking, or any situation where expectations are high. The ‘freeze’ response is a reaction to a perceived threat in the environment. The use of the ‘choke’ metaphor has particular poignancy for the voice user under pressure in performance.
Performing artists have a higher incidence of mental health challenges. Clements (61) conducted a scoping review to investigate factors related to poor mental health and well-being within the performing arts sector. The review shows us something of the precarious nature of work in the industry; irregular hours, low income, and limited job security, present as significant stressors. These challenges are exacerbated by cultural pressures, such as aesthetic ideals and power imbalances in professional relationships. The COVID-19 pandemic further amplified these issues, with many performers reporting heightened anxiety, depression, and financial instability during this period. The study also identifies systemic barriers to mental health support, such as financial constraints, stigma, and a lack of industry-specific services. Recommendations from this review include better education on coping strategies, improving access to mental health services, and addressing structural inequalities within the sector.
In Volume XX of his complete psychological works, Freud spoke about “Signal Anxiety” or “bleeding before the cut” (62). As children, he says, we can play with other children and work out what is dangerous and what is safe. This learning informs our responses in adulthood, although we may not always be accurate judges of safety. Signal Anxiety is the first mention we have of what we might now call Anticipatory Anxiety or Future Tripping. Instead of trusting in learned safety, we imagine a future danger. Learned danger of the unknown is common in the anticipatory anxiety process as the voice user has no blueprint for what is safe, particularly if they did not explore play in this way as a child. These concepts are relevant to our writing here because guarding is the product of anticipatory anxiety. There is often no life-threatening danger; often, the danger is created (or, in the case of abuse, recreated) within the individual because of an imagined enemy or consequence. Drawing on the theoretical and developmental roots of the fear of falling, Perlman explored the defensive, adaptive, characterological, intrapsychic, and relational aspects of holding (63). The paper also considers grounding as a foundational condition that creates a relational space safe enough to allow surrender into the fear of falling. In doing so, it highlights how the act of holding, in whatever adaptive form it takes, serves to preserve attachment and protect the life force of the human being.
Finally, we must address Music Performance Anxiety (MPA) concerning guarding or anticipatory behaviours. MPA is defined as “the experience of persisting, distressful apprehension about and/or actual impairment of performance skills in a public context, to a degree unwarranted given the individual’s musical aptitude, training, and level of preparation” (64, as cited in 65). This condition manifests through mental, physiological, and behavioural symptoms, including negative emotions, increased heart rate, and tremors, which can significantly impact musicians’ performance quality and overall well-being. There is a prevalence of MPA among musicians, with reports indicating that a substantial number of both professional and student musicians experience significant levels of performance-related anxiety (66). The severity of MPA can lead to impaired performance and may even cause individuals to abandon their musical careers if not adequately addressed. MPA may well be a contributing factor to a guarded larynx, with the perception of an anticipatory anxiety component.
The Popkirov et al (67) review dismantles the traditional “physical-versus-psychological” split by showing that complex regional pain syndrome and FND share a single biopsychosocial engine driven by nociceptive input, predictive coding, learning and attention. Early after injury, protective redistribution of muscle activity stiffens and slows movement; if threat expectations persist, this state becomes habitual through negative reinforcement, hypervigilance and kinesiophobia, yielding chronic co-contraction that mirrors classical guarding. Pain-related fear, catastrophising and phobic anxiety predict disability in complex regional pain syndrome and are treated effectively with graded exposure protocols borrowed from anxiety therapy; these same top-down processes are now central to FND rehabilitation. Education that frames symptoms as a reversible “software” problem, coupled with physiotherapy that challenges avoidance and retrains movement, improves function even in long-standing cases, underscoring the therapeutic value of addressing guarding behaviour and cognitive-affective drivers together (67).
Differing from the psychiatric and clinical psychology stance of the Diagnostic Statistical Manual of Mental Disorders, personality is not always ‘disordered’. In fact, we all have varying levels of personality ‘function’ and thus operate from a spectrum of neurosis in our day to day lives. Roy and Bless (68) advanced a “trait theory” in which there are some enduring dispositions: stress reactivity, introversion to extraversion, and social dominance. According to this work, there is a bias for these individuals toward specific vocal pathologies: patients with functional dysphonia tended to be introverted, stress reactive, alienated, and unhappy for example, whereas those with vocal nodules were more socially dominant and socially aggressive, although often with an underlying anxiety element. Dietrich et al. (69) extended this dispositional lens by demonstrating that a sizeable minority of patients with common voice disorders report elevated stress, anxiety, and depression, and by proposing a psychobiological framework in which personality-driven stress creates extra laryngeal muscle activity. Together, these studies suggest that personality variables are not merely consequences of dysphonia but rather part of its causal architecture.
Before that, we have some earlier psychogenic accounts that pointed toward “structural” patterns in the personality organisation of patients. Butcher (70) described individuals with psychogenic voice disorder as typically free of major psychopathology, yet despite this, they were burdened by: interpersonal conflict, low self-esteem, responsibility overload, and powerlessness, coupled with difficulty voicing feelings. These were all features consistent with overcontrolled, self-silencing styles rather than the outdated ideas of hysteria. Elias et al. (71), after surveying clinical practice, emphasised the need for speech therapists to systematically assess such psychosocial configurations, implying that therapeutic structure (alliance, education, graded voicing) must be tailored to these personality constellations.
Contemporary guidance reframes these traits within a biopsychosocial management model. Baker et al. (72) recommend targeting illness beliefs, self-directed attention, and abnormal movement patterns. Through education, CBT-informed strategies, and symptom modulation, Baker et al. shows how we can effect change across the FND patient caseload. In the field of clinical psychology, Aldridge-Waddon et al. (73) synthesised 39 case control studies (N = 4,740). They found consistently higher depression (SMD ≈ 0.50), state anxiety (≈ 0.58), trait anxiety (≈ 0.52), health anxiety (≈ 0.57), and neuroticism (≈ 0.47) in people with voice disorders compared with controls, updating the ideas from Butcher’s 1995 research that there is a substantial psychological burden. Aldridge-Waddon et al. reported no reliable differences between functional and organic voice disorder groups on these measures and argued for routine clinical psychology input within multidisciplinary voice services. Building on this body of work, King (74, 75) argues in theoretical and case study accounts that functional voice loss occurs within our personality and how we identify with it. This is linked with the time after the occurrence of a voice problem, where there is a period of grieving the previous voice (74). There is also a case study consideration from King (75) where he offers an account to help us understand what might cause a flare up in a chronic presentation of vocal FND. Here he began looking at how the roles we play, either as a professional performer or as a member of a family, society or group can bring about psychological conflict and ultimately voicelessness.
Otto Dix (German, 1891-1969), Half-Nude, 1926
Oil and tempera on panel, 73.1 x 54.9 cm (28 3/4 x 21 5/8 in.)
Private Collection, Courtesy Neue Galerie New York
© 2025 Artists Rights Society (ARS), New York / VG Bild-Kunst, Bonn for Otto Dix
As the term ‘guarded’ has not yet been used in publications with reference to laryngeal function, this section is intended as a practical guide for clinicians, teachers and voice users. The evidence from the review section is applied to voice use in a theoretical construct, arising from the authors’ experience in working with higher functioning voice problems.
The literature exposes something important for us to consider in the voice studio, and this is the difference between guarding as a behaviour and guarding as a reflex. Guarding behaviours appear to be self-limiting, unconscious states in the musculoskeletal system. Guarding reflexes appear to be more immediate reactions to a fear avoidance response. In the singing studio, we are going to be subject to people experiencing both guarding behaviours and guarding reflexes simultaneously. The skill of uncovering the guarded behaviour may well lie in an in-depth psychological process. The ability to navigate the guarding reflex may well be more cognitive and behavioural in its intervention.
If somebody has “survived” or been coping with their voice problem for a long time, this may well result in the guarding behaviour. If the episode is more acute, and has certain, more immediate environmental triggers, the singer may be subject to the reflex of guarding instead of the behaviour. The skill of changing the relationship to the guarding reflex lies in creating a safe environment by which this voice user can experience their voice freely, and almost certainly differently. As we have seen from the literature, a great deal of anticipatory anxiety can influence the guarding reflex, therefore a stable and consistent environmental setting is required for meaningful change in this case. In terms of shifting the guarding behaviour, there may need to be some purposeful, yet safe unbalancing. The person must experience themselves differently, which ultimately shifts them out of their pattern of behaviour. The authors agree that changing a guarding behaviour probably requires more time and more resources to elicit meaningful change; the therapeutic intervention will need to be trained in holistic understanding of this mind-body interaction.
A Guarded Larynx, Muscle Tension Dysphonia and Functional Neurological Voice Disorder all have overlapping causes and presentations. From the literature, the authors consider that MTD is more to do with the conscious use, misuse and habits of the voice user. FNVD is often a more unconscious or psychosomatic presentation with physiological symptoms (76). The guarding reflex occurs when conscious use and unconscious processes arise at once from fear of injury or pain, leading to mostly non-pathologic holding patterns. In lay terms, this is when singers get into a bit of a muddle, without an obvious cause. Overlap occurs when both are present, e.g., guarding against injury and fear of ‘causing damage’, leading to holding patterns. These may be released with physical work and rebalancing of technique. In some cases, there is little need to fully address the underlying psychological behaviours; in other cases the undoing of the muddle will need a psychotherapeutic frame (77).
Ultimately, if someone has a guarded larynx, they may not be getting the help they need. We live our life and use our voice by ‘coping’ with various interactions and experiences. Some people have anxious or repressed coping styles which invariably lead them to anxiety inducing or repressive strategies. If the coping style is coded as anxious, the voice user is probably more likely to develop FNVD (78). In functional voice disorders, then, the larynx becomes a convenient focus point for guarding behaviour because dysphonia is both audible and difficult to disprove, allowing the individual to avoid emotionally threatening or evaluative situations without overtly violating social contracts.
Voice users may become over-sensitised to sensations in the throat. These could be from a previous upper respiratory tract infection, or from laryngopharyngeal reflux, or they may have some other psychogenic root. The symptoms will be classed as persistent throat symptoms and may include soreness, burning, scratchiness, globus, or aching. If endoscopic assessment shows no visible pathology, the recommendation will be for rehabilitation work with a Speech and Language Pathologist/Therapist or a Singing Rehabilitation Specialist. It is important to recognise that the presenting symptoms will almost always be exacerbated by a guarding reflex or behaviour. Pain or discomfort with an unknown aetiology is distressing for the person; additionally, there is the fear of causing potential damage with voice use. Guarding behaviours are inevitable in these circumstances.
We saw from Olugbade’s research that the extent of the fear of injury is the primary predictor for individual management of the response (5). Perhaps the relationship between guarding, pain, and emotion is most likely to be addressed effectively by intervening at the unconscious, anxious level rather than with painkillers.
This falls into the area of secondary MTD. If a patient has a vocal fold pathology such as nodules, a cyst, polyp or sulcus, rehabilitation work with or without surgery can often help the vocal folds to return to a healthy and functional state. Rehabilitation work will address functional habits such as patterns of unnecessary laryngeal constriction. The patient may be discharged with a completely healthy larynx and revised vocal habits. However, even after successful rehabilitation, there will inevitably be some residual fear of a repeat voice issue in the future. The person may become hypervigilant about any symptoms, feelings and sounds. Hypervigilant awareness will elicit laryngeal guarding. This alone can be enough to lead to further voice problems.
This can also include behaviour arising due to chronic cough. If either rapid inhalation or phonation can trigger a cough, the person may withhold the easy flow of air through the glottis. This type of hypervigilance will result in a generalised guarding response in both laryngeal flexibility and breathing patterns.
Hypermobility of some sort is prevalent in a proportion of performing artists; we would expect to observe this in somewhere in excess of 40% of performers (33, 35). Hypermobility brings with it a fear of injury and pain, and the attendant muscular holding patterns of guarding. This physical holding will be accompanied by an emotional wariness and a low level of chronic anxiety; the world does not feel like a safe place for the hypermobile individual. If the larynx has a greater than average flexibility (large pitch range, ease and facility with runs and riffs), it follows that it is also more vulnerable to injury. If this physical vulnerability is coupled with a higher level of anxiety, it is easy to see how laryngeal guarding will be more prevalent in the hypermobile population.
Guarding may also emerge from professional voice users’ misdirected attempt to pace output and forestall fatigue. Stage singers, for instance, often ‘mark’ during a rehearsal. This might look or sound like producing a softer, sometimes octave-lower rendition while preserving the dramatic contour of full-voice production. If marking is done with an inappropriate technique, instead of reducing muscular load, it can paradoxically heighten laryngeal tension, replacing efficient power modulation with protective bracing. An analogous pattern is seen in occupational speakers who adopt breathy or whispered phonation to “save” the voice; the resulting glottal insufficiency increases airflow demands and drives compensatory strain, thereby reproducing the very fatigue and discomfort the strategy was meant to prevent. These examples illustrate how well-meaning self-regulation can devolve into maladaptive guarding if it is not scaffolded by precise motor-learning principles and real-time somatosensory feedback.
By contrast, another singer may consciously pride themseIf on “pushing through” by teaching all day and performing each night despite escalating hoarseness. The gratification lies in the narrative of stoic endurance (“the show must go on”), not in external rewards; indeed, offers of rest elicit irritation because they threaten the moral calculus that suffering equals worthiness (78). This might also land them into a more conscious experience of muscle tension dysphonia; however, it could well be the laryngeal guarding which is preventing optimal voice function and necessitating the ‘push-through’. Ultimately, this leads us to a complex relationship with performers’ voices and their role in the performing arts in general, an industry where abuse is rife, and the performer’s safety often comes last in a long list of profiteering and occupational hazards (80).
Conflict Over Speaking Out (COSO) is a recognised contributor to FNVD (81, 82), as a significant situation arising from the Life Events and Difficulties Schedule (LEDS). The individual may have been ignored in the home or the workplace, as a child they may have been asked to keep quiet. A traumatic event where their voice may have been silenced or ignored can also lead to COSO, where voice loss of some sort is part of the PTSD (57). The traumatic event can be a violent assault on the individual, including domestic violence, rape, mugging, and strangulation during sex. Or the person could have observed such activity, and their voice was not heard. There are numerous possible events: physical trauma injuries such as sporting or road traffic accidents, experiences in war or conflict, or even natural disasters can have a lasting effect on people’s voices. Essence of the COSO construct is a triad of consideration - perceived responsibility to the other or others - consequences of speaking out and as significantly - consequences of not speaking out. It is not just ambivalence or being asked to be quiet, rather, there are consequences either way. Performers experiencing COSO have a compounding and complicated relationship to hierarchical structures, too. There is often a sense of the ‘replaceability’ in shows, and so performers are frequently left voiceless as working professionals to serve the show rather than themselves.
Misono et al.’s (83) cross-sectional survey of 196 first-time voice-clinic attendees expands the COSO narrative and quantifies the “cost of silence.” Because distress severity was unrelated to laryngeal diagnosis or acoustic handicap, the data support a top-down, not purely anatomical, aetiology, aligning with FND models in which threat predictions, rather than tissue damage, drive protective motor patterns. Second, the qualitative themes reveal how COSO is enacted in everyday life. Asked what makes the voice problem hardest, patients most often cited (i) being unheard or misunderstood (16%), (ii) feared loss of occupational identity (16%), and (iii) effortful, fatiguing speech (12%). Overt emotions such as fear or embarrassment were mentioned far less, suggesting that the conflict is experienced more as pragmatic risk-calculation than as raw affect.
We might be best placed working towards a graded exposure of perceived occupational threat (because threat-to-job was the dominant theme). The use of behavioural experiments or role-play (e.g., simulated meetings with safety-nets) might be designed to disconfirm predicted social penalties, analogous to fear-avoidant rehab in CRPS/FND. We might also do well to consider an appropriate somatisation focus, after all in Misono’s study, the somatic symptoms exceeded either depression or anxiety, implying that interventions must legitimise bodily sensations rather than pathologise them, fostering interoceptive accuracy and reducing defensive co-contraction of the phonatory muscles (83).
So far, we have discussed guarding in the context of the voice output. This may be a physical protection against potential pain or damage, and in this instance, any arising fear is from a potential injury or discomfort caused by the voice user. Alternatively, it may be an emotional protection against how the voice is perceived and received by others; the perceived threat is from the others’ perception of the voice quality, or the message conveyed by the voice.
There will also be protective ‘character’ armour in place if an individual feels threatened while they are using their voice. This threat may be in the form of negative comments from a conductor or director, it could be critical feedback from a coach or a colleague. For any public speaker, they will be sensitive to and affected by the subtle reactions of the audience. This triggers not only guarding and protective manoeuvres but 'try harder' strategies, which can snowball into straining and over projecting; enjoyment in performance shifts rapidly to a heightened sympathetic nervous response. In this instance, the fear is from a potential external threat to identity or self. The protection is necessary for self-preservation, yet the guarding action will further negatively impact all vocal output.
Psychophysiological resilience can be defined as the capacity of an organism to restore neuro-autonomic homeostasis rapidly after a threat-induced perturbation of the nervous system (84). Individuals who score lower on validated resilience indices display a markedly greater susceptibility to anxiety and mood disorders, suggesting that reduced “bounce-back” potential is a generic vulnerability factor across psychopathologies (85). If we stay with the thought of input/ output as it relates to guarding, and the protective mechanism that consequently grabs hold, then it is pertinent to discuss how to aid in a voice user’s overall emotional and nervous reflexivity. When resilience is compromised, the laryngeal guarding/threat-response ceases to be a momentary, reflexive defence and evolves into a persistent, low-grade co-contraction of the phonatory musculature. Because this chronic state of guarding maintains a state of autonomic hyper-arousal, it is important to note that any effective voice rehabilitation will incorporate explicit down-regulation of the client’s nervous system state as a core treatment intervention. This could be achieved through breathing exercises, humming or low stakes vocalisation where the input/output guarding does not yet take hold.
In FVND, secondary gain refers to the external benefits a person receives as a result of experiencing physical or psychological symptoms, even if those symptoms are not consciously fabricated. These benefits can reinforce and maintain the symptoms, making them harder to resolve. For the voice user, a secondary gain can be either receiving attention or avoiding a situation. A professional singer who catastrophises imminent vocal criticism may welcome an acute bout of dysphonia before a high-stakes audition; the illness legitimises withdrawal and preserves self-esteem while attracting empathic support from peers (15, 74). The guarding behaviour is again linked to fear, protection and projection; the reward or gain is likely to lead to a repeated pattern response.
Sensitive questioning can help the client to realise the connection between any events or experiences and the current functional state of the voice. If there are relational patterns or expectations from others on the way the client lives their life, sings or uses their voice, then voice rehabilitation may well be enough to address the links and establish appropriate vocal boundaries. In cases of PTSD or deeper psychological work, voice rehabilitation needs to take place alongside appropriate psychotherapeutic work (86). It is most important that the unconscious nature of these physical and behavioural responses is emphasised, as any therapeutic work is ultimately seeking to bring the unknown, known. The voice user will be more likely to be able to accept and move on with their life if there is no blame or shame attached to the initial cause. This unconditional state could also help curb any further development of the voice issue.
Much information can be elicited from listening to the voice quality through the pitch range. Below is a non-comprehensive list of ideas and observations from the authors, and by no means represents the only way to orient your whole practice.
These illustrations are not diagnostic; they are suggested as examples of possible links between the psychological state and the guarding reflex. Individual coping styles are ways of managing stress or difficult situations. These coping styles are related to dispositional personality structures; the mechanisms can be passive/avoidant, such as withdrawal or getting stuck, or they can create a protective barrier. These patterns can be adaptive or maladaptive, they often begin with an adaptive or beneficial function, and then become habitual as a maladaptive behaviour (87).
It is important not to always assume a psychological cause for a voice problem; the psychological complexity may have arisen solely from the distress of having a dysfunctional voice or from unpleasant physical sensations associated with the throat and larynx (72). It is normally best practice to begin by intervening at the symptomatic level and see what arises in the dynamic because of this work. A pragmatic, reverse-engineering sequence typically commences with semi-occluded or resonant vocal tasks that foster effortless, low-impact phonation. These allow for less guarding, low stakes and often feel achievable. These auditory-motor exercises are coupled with micro-movement release techniques, such as cervical rolls or shoulder spirals, to interrupt rigid postural sets, thus interrupting any physical guarding patterns elsewhere in the system. Gentle, consensual manual therapy (delivered either by a trained therapist or through directed self-massage) can potentiate the effect by providing proprioceptive feedback that disconfirms the need for any hypertonic defence. As the confidence in the voice user hopefully returns and interoceptive threat predictions are updated, sympathetic drive diminishes, guarding behaviour extinguishes, and laryngeal biomechanics resume a more economical pattern of function.
Guarding and the symptoms which evolve from this are a multi-layered phenomenon. The voice user may not be aware of the physical sensations of holding. They may not link these physical responses to emotional or psychological events or dispositions. The relationships between the biomechanical, the psychological and the social elements of the whole are non-linear. The voice exists all at once, and like a pancake, you cannot extract the eggs once it has been fried, and neither can we truly isolate any part of the voice to remove or change by itself. Because of this complexity, management of this in a rehabilitation context is often most effectively carried out within an interdisciplinary team of practitioners.
‘Letting down the guard’ will shift the voice user to a state of vulnerability; this has to be managed within what they perceive as a safe space, a safe space as defined and consented to by the client, not by the practitioner. The rehabilitation work here does not need to unravel the whole picture, and indeed, this would be an impossible and often unethical task. It is a gradual process of deepening awareness. Physical changes will enable emotional shifts, either within or outside of conscious awareness.
How do we demarcate the differences between a guarded larynx, MTD or FNVD? There is more that unites these diagnoses than differentiates or distances them from one another. So, whether or not someone is at the guarded end of the continuum or the completely aphonic FNVD end of the continuum, the idea remains the same: how do we help this person make something that is an unconscious behaviour or reflex, into a conscious choice?
Figure 2, the basic spectrum of laryngeal guarding
Table 1, An explanation of the guarding spectrum
| Segment | Key features & theoretical links |
| Contextual Guarding Reflex | Rapid, automatic co-contraction that stiffens the airway during threat (e.g., glottic closure in startle). Serves a short-term defensive role and normally extinguishes once danger passes. |
| Guarded Behaviour (Fear-Avoidance) | Anticipatory bracing of neck and laryngeal muscles driven by catastrophic predictions (“If I speak, I’ll fail / be judged”). Mirrors musculoskeletal fear-avoidance models; sustained vigilance keeps the system sensitised. |
| Primary Muscle Tension Dysphonia | Habitual hyper-functional voice production with no structural lesion. Guarding becomes the default motor plan, reinforced by somatic focus and performance anxiety; reversible with cognitive-motor retraining. |
| Aphonic FNVD | Voice output collapses entirely despite intact anatomy. Reflects an extreme, maladaptive end-point of the guarding spectrum in which motor inhibition is context-locked to perceived threat or conflict over speaking out (COSO). |
In summary, this review establishes the concept of “laryngeal guarding” as a multidimensional phenomenon, encompassing rapid, reflexive muscle co-contractions and more enduring, anticipatory behaviours driven by fear-avoidant processes (53, 67). By mapping guarding onto a visual continuum from contextual reflexes to habitual bracing and, at its extreme, functional neurological voice disorder, clinicians and educators can better conceptualise and classify voice presentations that lack overt structural pathology but are not extreme enough to be classified as FNVD.
This article addresses the importance of a biopsychosocial approach (19) that integrates sensory-motor retraining, graded‐exposure techniques borrowed from chronic pain rehabilitation, and a suggestion for the inclusion of targeted psychotherapeutic strategies to address underlying anxiety and maladaptive beliefs. Early identification of guarding patterns through careful history-taking throughout sessions may prevent the transition from transient reflexive stiffening to entrenched muscle tension dysphonia or aphonic presentations. This concept of making the unconscious conscious is the core voice of this paper.
Future research could operationalise laryngeal guarding with standardised, reproducible metrics, such as quantifiable EMG thresholds or other quantitative measures. Prospective cohort and interventional trials are needed to validate the continuum model, determine the efficacy of combined voice‐motor and psychological interventions, and refine clinical pathways for functional voice disorders. Above all, by giving a voice to the guarded larynx, we aim to stimulate empirical inquiry and improve multidisciplinary management of this entirely common yet under-recognised presentation.
The Authors would like to acknowledge the guidance with this paper they have received from Professor Janet Baker.