 Gradual onset can begin with the manifestation of a hoarse voice quality, which may later transform into a voice quality described as strained with breaks in phonation.These phonation breaks have been compared to stuttering in the past, but there is a lack of research in support of spasmodic dysphonia being classified as a fluency disorder.It is commonly reported by people with spasmodic dysphonia that symptoms almost only occur on vocal sounds that require phonation.