The role of psychogenic and psychosocial factors in the development of functional voice disorders

Eclectic Voice Therapy Program in Hyperfunctional Voice Disorders: Evidence from Multidimensional Vocal Profiling

PURPOSE

Hyperfunctional voice disorder (HFVD) is a disorder of multifactorial origin. It can be speculated that an eclectic voice therapy program that uses combinatory approaches could bring about better efficiency of voice in these individuals. Nevertheless, very less attempts have been made to examine the efficacy of eclectic voice therapy using multidimensional voice outcome measures in the treatment of HFVD.

METHOD

Ten individuals with HFVD in the age range of 20-55years attended Comprehensive Voice Habilitation Program (CVHP), an eclectic voice therapy approach for 15 sessions spread across 3weeks. A stroboscopy examination was performed at the baseline and post-therapy to track the changes in laryngeal functions. Further, perceptual voice analysis, Acoustic Voice Quality Index (AVQI), and Voice Handicap Index in Kannada (VHI-K) were obtained at the baseline, post-therapy, and two follow-ups to report the therapy outcomes. Related samples Friedman's Two-way Analysis of Variance by Ranks and Wilcoxon Signed Rank Test were used to note the pre-post and follow-up changes in voice outcomes.

RESULTS

Stroboscopy findings revealed significant improvement in movement patterns of the vocal folds and a reduction in ventricular hyperadduction. Perceptual ratings and AVQI scores decreased in post-therapy and follow-up evaluations indicating a decrease in dysphonia severity over time. In addition, a significant decrease in VHI-K scores indicated the alleviation of self-perceived disability/handicap.

CONCLUSION

The current study provided preliminary evidence to support the efficacy of eclectic voice therapy in HFVD by documenting significant changes in the voice-related outcome measures.

A Comparison of Voice and Psychotherapeutic Treatments for Adults With Functional Voice Disorders: A Systematic Review

OBJECTIVE

To examine the effect of traditional voice therapy and cognitive therapy on the voice and client-wellbeing outcomes in adults with functional voice disorders (FVD).

METHODS

A systematic review of English articles was conducted using Medline (Ovid), Embase (Elsevier), CINAHL (Ebsco), The Cochrane Central Register of Controlled Trials (CENTRAL), PsychInfo (Ebsco) and Speechbite from inception to current date. Additional studies were identified through bibliographies and authors were contacted when further information was required from an article. All study designs were included with pretest/posttest outcome measures related to voice. Independent extraction of studies was completed by three authors using predefined data fields and quality assessment tools.

RESULTS

Outcomes of 23 studies (2 RCTs and 21 cohort or case studies) are summarised using a narrative style due to heterogeneity of interventions and outcome scales used. Overall research quality of included studies was low, with many cohort and case studies lacking controls, blinding and robust outcome measures.

CONCLUSIONS

There are some benefits to pairing cognitive behavioural therapy (CBT) with traditional voice therapy for FVD including improved voice quality, psychosocial wellbeing and prevention of relapse. It is feasible to train speech-language pathologists (SLPs) in CBT-enhanced voice therapy. Further high-quality research is needed, however, to guide the clinical implementation of CBT for the management of FVD.

The efficiency of the DoctorVox voice therapy technique in conversion dysphonia and aphonia

OBJECTIVE

The main purpose of this study was to retrospectively evaluate the efficiency of DoctorVox voice therapy in psychogenic dysphonia or aphonia patients, and to share the mid- to long-term results of the method.

METHODS

The study was carried out on patients who underwent DoctorVox voice therapy for psychogenic dysphonia or aphonia between January 2015 and September 2019. The evaluation methods used were: the Voice Handicap Index-10; the grade, roughness, breathiness, asthenia and strain ('GRBAS') scale; and videolaryngostroboscopy recordings.

RESULTS

The mean Voice Handicap Index-10 values of the patients were 30.91 ± 2.97 before treatment, 8.14 ± 3.82 after treatment, and 3.36 ± 1.78 in the final follow-up examination. The grade, roughness, breathiness, asthenia and strain scale scores were: 9 ± 0.67 pre-treatment, 0.78 ± 0.80 post-treatment, and 0.57 ± 0.64 at the final follow up.

CONCLUSION

DoctorVox voice therapy seems to be an efficient treatment method for psychogenic dysphonia or aphonia; it helps develop phonatory muscle functions, using multidimensional biofeedback mechanisms, and increases the patients' therapy adherence.

Voice Acoustic Parameters as Predictors of Depression

OBJECTIVE

To analyze whether voice acoustic parameters are discriminant and predictive in patients with and without depression.

METHODS

Observational case-control study. The following instruments were administered to the participants: Self-Reporting Questionnaire (SRQ-20), Beck Depression Inventory-Second Edition (BDI-II), Voice Symptom Scale (VoiSS) and voice collection for subsequent extraction of the following acoustic parameters: mean, mode and standard deviation (SD) of the fundamental frequency (F0); jitter; shimmer; glottal to noise excitation ratio (GNE); cepstral peak prominence-smoothed (CPPS); and spectral tilt. A total of 144 individuals participated in the study: 54 patients diagnosed with depression (case group) and 90 without a diagnosis of depression (control group).

RESULTS

The means of the acoustic parameters showed differences between the groups: F0 (SD), jitter, and shimmer values were high, while values for GNE, CPPS and spectral tilt were lower in the case group than in the control group. There was a significant association between BDI-II and jitter, shimmer, CPPS, and spectral tilt and between CPPS and the class of antidepressants used. The multiple linear regression model showed that jitter and CPPS were predictors of depression, as measured by the BDI-II.

CONCLUSION

Acoustic parameters were able to discriminate between patients with and without depression and were associated with BDI-II scores. The class of antidepressants used was associated with CPPS, and the jitter and CPPS parameters were able to predict the presence of depression, as measured by the BDI-II clinical score.

An eclectic Voice Therapy Program for the Treatment of Hyperfunctional Voice Disorders (HFVD)

PURPOSE

An eclectic voice therapy program includes sequenced and structured set of exercises combining direct and indirect intervention methods. Tailor-made exercise prescription with specific cultural adaptations are needed to provide a holistic change to voice quality.1 This study detailed the construction of an exercise prescription for participants with hyperfunctional voice disorder [HFVD] in the Indian context.

METHOD

The exercise program was developed based on literature related to vocal therapy approaches and delivery methods. Adaptations were introduced to a selected set of exercises. Five voice experts verified the exercises and their prescription for content and feasibility of use in the Indian context. Modification suggested by the experts were included for framing the final version of the exercise program. This structured therapy program was planned for 6 weeks (30 minutes duration/session offered individually twice per week, with a gap of two days between sessions in a week) with the goals to improve voice quality, flexibility, and endurance while speaking. Five participants with HFVD partook in the study for pilot testing. Stroboscopy, perceptual voice analysis, Dysphonia Severity Index (DSI) and Vocal Fatigue Index in Tamil (VFI-T) were used to report the therapy outcomes. Participants' report on the learning process and generalization of the program were documented. Wilcoxon-signed rank test was used to test the pre-post outcome measures.

RESULTS

An eclectic voice therapy program, i.e., Comprehensive Voice Habilitation Program [CVHP] was constructed and it included vocal hygiene instructions, warm-up & cool-down, easy onset, resonant voice, and carry over exercises. Participants completed the program in 14-18 sessions (over 7 to 9 weeks of therapy). All participants showed significant changes in vocal fold movement patterns, reduction in ventricular hyperadduction, overall grade of voice quality, DSI and VFI-T. Participants reported that pictorial illustrations, feedback, and monitoring sheets were useful in learning the exercises.

CONCLUSION

CVHP showed significant change in the voice-related outcome measures and was a viable program for treating HFVD.

Functional Speech and Voice Disorders: Approaches to Diagnosis and Treatment

Historically, formal training for speech-language therapists (SLTs) in the area of functional speech and voice disorders (FSVD) has been limited, as has the body of empirical research in this content area. Recent efforts in the field have codified expert opinions on best practices for diagnosing and treating FSVD and have begun to demonstrate positive treatment outcomes. To provide comprehensive interventions for these complex conditions at the intersection of neurology, psychiatry, and other medical specialties, the SLT must not only build knowledge of diagnostic strategies and components of symptomatic treatment in FSVD but also embrace behavior change techniques and counseling strategies.

Initial Theoretical Discussion of Identity as Barrier and Facilitator in Voice Habilitation and Rehabilitation

OBJECTIVES

The purpose of this paper is to review seminal identity theories grounded in social psychology and one concept from voice science and explain how this group may point to identity factors facilitating or impeding voice habilitation and rehabilitation.

METHODS

Identity theories from the social psychology literature (Dramaturgical Theory, Self-Categorization Theory, Self-Determination Theory, Identity Negotiation Theory) and vocal congruence are described. Concepts are synthesized with voice science research to explore potential identity-behavior relations at play in voice habilitation and rehabilitation.

RESULTS

Applicable concepts from social psychology and voice science suggest identity-related processes by which a client may or may not develop a voice difference/disorder, seek intervention, and achieve goals in intervention. A bidirectional relationship between identity and behavior has been well-established in the social psychology literature. However, the relevance of vocal behavior has yet to be formally examined within this literature. Importantly, although connections between behavioral tendencies and voice disorders as well as the contribution of identity to gender-affirming voice treatment have been established in the voice science literature, the consideration of identity's possible role in voice habilitation and rehabilitation in cis gender individuals has thus far been scant.

CONCLUSIONS

Research into identity and voice habilitation and rehabilitation may help to improve voice intervention outcomes. A possible adjunct to human studies is agent-based modeling or other computational approaches to assess the myriad factors that may be relevant within this line of inquiry.

Clinical Psychology and Voice Disorders: A Meta-Analytic Review of Studies Assessing Psychological Characteristics Across Individuals With and Without Voice Disorders

OBJECTIVES

Clinical voice disorders are heterogenous conditions capturing problems with voice production and control. Psychological conceptualizations of voice disorders posit that mood, anxiety, and personality characteristics contribute to the development and maintenance of voice symptoms. This review brings together research comparing these psychological characteristics across groups with and without voice disorders, with the aim of profiling group differences.

METHODS

A systematic search of PubMed, CINAHL, Ovid (PsycInfo, MEDLINE, Embase), and Web of Science databases was conducted, with studies required to assess psychological characteristics between samples with and without voice disorders. Relative study quality and risk of bias were formally evaluated, synthesizing results via meta-analysis (estimating standardized mean difference; SMD) and narrative synthesis.

RESULTS

Thirty-nine studies (N = 4740) were reviewed. Marked psychological differences were observed between case-control groups, including significantly higher self-reported features of depression (SMD = 0.50), state anxiety (SMD = 0.58), trait anxiety (SMD = 0.52), health anxiety (SMD = 0.57), and neuroticism (SMD = 0.47) in voice disorder groups. However, less consistent patterns of difference were observed between voice disorder types, including minimal quantitative differences between functional and organic diagnoses.

CONCLUSIONS

Findings underline and formulate the psychological features associated with experiencing a voice disorder, indicating individuals with voice disorders present with considerable psychological needs that may benefit from clinical psychology input.

Intersection of Mental Health and Dysphonia: A Scoping Review

OBJECTIVE

Previous research has indicated that voice disorders frequently co-occur with mental health disorders, which may influence voice treatment seeking behavior and effectiveness. Our goal is to characterize the existing literature on the relationship between voice disorders and mental health and to investigate nuances related to mental health and voice disorder diagnosis.

DATA SOURCES

Ovid MEDLINE, ProQuest PsycINFO, and Web of Science.

REVIEW METHODS

Using the PRISMA protocol, a scoping review was performed. Databases searched included: Ovid MEDLINE, ProQuest PsycINFO, and Web of Science. Our inclusion criteria were all adults seen in an outpatient setting for voice and mental health disorders, excluding those with a prior history of head and neck surgery, cancers, radiation, or developmental anomalies, and certain mental health disorders. Results were screened by two independent screeners for inclusion. Data were then extracted and analyzed to present key findings and characteristics.

RESULTS

A total of 156 articles, with publication dates ranging from 1938 to 2021, were included in the analysis, with females and teachers being the most described population groups. The most frequently studied laryngeal disorders were dysphonia (n = 107, 68.6%), globus (n = 33, 21.2%), and dysphonia with globus (n = 16, 10.2%). The two most common mental health disorders found in the included studies were anxiety disorders (n = 123, 78.8%) and mood disorders (n = 111, 71.2%). The Voice Handicap Index was the most used tool to gather data on voice disorders (n = 36, 23.1%), while the Hospital Anxiety and Depression Scale was the most used tool to gather data on mental health disorders (n = 20, 12.8%). The populations studied within the included articles were predominately female and worked in educational occupations. Race and ethnicity was only reported for 10.2% of included articles (n = 16) and the most commonly studied race was White/Caucasian (n = 13, 8.3%).

CONCLUSION

Our scoping review of the current literature on mental health and voice disorders reveals an intersection between the conditions. The current literature represents change over time in terms of terminology that recognizes the patient's individualized experience of mental health and laryngeal conditions. However, there is still a great deal of homogeneity in the studied patient populations in terms of race and gender, with patterns and gaps that require further investigation.

Copingstrategien und Stimme – Einfluss von Stressbewältigungsstrategien auf stimmliche Missempfindungen und die stimmbezogene Lebensqualität bei Patient*innen mit Dysphonien

Strategien zur Stressbewältigung (Coping) sind für die Rehabilitation von Stimmpatient*innen von großer Bedeutung. Es fehlen jedoch aktuelle Evidenzen, die Zusammenhänge zwischen Copingstrategien und Dysphonien ausreichend belegen. Mithilfe einer Online-Befragung wurden erwachsene Stimmpatient*innen zum Grad der stimmlichen Missempfindung mittels der deutschen Fassung der Vocal Tract Discomfort Scale (VTD), der stimmbezogenen Lebensqualität mit dem Voice-Related Quality of Life-Fragebogen (VRQOL) und ihrem Umgang mit Stresssituationen im Coping-Inventar zum Umgang mit Stress-Situationen (CISS) befragt.

Es lagen 72 gültige Fragebögen vor. Signifikante Korrelationen bestanden zwischen Aussagen, die mit maladaptivem Coping assoziiert sind und Werten der VTD bzw. des VRQOL. In Regressionsanalysen konnten maladaptive Copingstrategien als Prädiktor für den Grad der stimmlichen Missempfindung identifiziert werden. In der Stimmtherapie sollte zukünftig berücksichtigt werden, welche Rolle maladaptives Coping im individuellen Fall spielt.

Integrative Review and Framework of Suggested Mechanisms in Primary Muscle Tension Dysphonia

PURPOSE

Despite the high prevalence of primary muscle tension dysphonia (MTD-1), its underlying mechanisms and their interrelationships have yet to be fully identified. The objectives of this integrative review were (a) to describe and classify the suggested underlying mechanisms for MTD-1, (b) to appraise the empirical evidence supporting each of the proposed mechanisms, and (c) to summarize the information in an integrative model.

METHOD

PubMed, Scopus, and CINAHL were searched for all publications pertaining to muscle tension dysphonia. Papers were retained if they included theoretical or empirical data pertaining to underlying mechanisms of MTD-1. A total of 921 papers initially qualified for screening, of which 100 remained for consideration in this review. Underlying mechanisms of MTD-1 were extracted using a consensus approach.

RESULTS

Seven broad categories of putative mechanisms involved in MTD-1 were identified: psychosocial, autonomic, sensorimotor, respiratory, postural, inflammatory, and neuromuscular. These categories were further divided into 19 subcategories detailed in the body of this review article. Based on the reviewed evidence, our proposed integrative model presents MTD-1 as an idiosyncratic motor adaptation to physiological perturbation or perceived threat. Under this model, physiologically or psychologically aversive stimuli can instigate a series of motor adaptations at multiple levels of the nervous system, ultimately disturbing muscle activation patterns and their biomechanical outcomes. Importantly, these adaptations appear to have the potential to become chronic even after threatening stimuli are withdrawn.

CONCLUSIONS

The proposed model highlights the importance of personalized rehabilitation in MTD-1 treatment. Limitations of the literature are discussed to provide guidance for future research aimed at improving our understanding of MTD-1.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19586065.

Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide

There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.

Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy

Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.

Effectiveness of Intensive Voice Therapy Versus Weekly Therapy for Muscle Tension Dysphonia: A Noninferiority Randomised Controlled Trial With Nested Focus Group

OBJECTIVES

To investigate the noninferiority of intensive voice therapy and compare its effects with weekly voice therapy on multidimensional outcomes of voice and well-being, satisfaction, and attendance in people with muscle tension dysphonia (MTD). The study further aimed to explore clinician's perceptions of barriers and enablers to implementation of intensive therapy.

STUDY DESIGN

Noninferiority randomised controlled trial with nested focus group.

METHODS

Twenty adults with MTD were randomised to receive either weekly voice therapy (1 hour per week for 8 weeks) or intensive voice therapy (1 hour, 4 days per week for 2 weeks). Participants were assessed by a blinded assessor twice before treatment, once post treatment and once at 4 weeks follow up on the primary outcome measure VHI and a range of secondary auditory-perceptual, acoustic, and patient (i.e., VoiSS, satisfaction) and clinician reported outcome measures (i.e., AusTOMs, attendance rates). Five Speech Language Pathologists also participated in a focus group to explore barriers and enablers to implementing intensive therapy, with questions and analyses guided by the Theoretical Domains Framework.

RESULTS

While noninferiority for the primary outcome measure VHI was not confirmed, secondary outcome measures revealed comparable within group clinically important improvements for VoiSS and the AusTOMs, as well as selected acoustic and auditory-perceptual measures for both groups. A trend of more improvements being maintained in the intensive group was identified. Comparably high satisfaction and attendance was also found between groups. Clinicians reported more enablers than barriers to providing intensive therapy which included beliefs that it led to greater progression and consolidation of patient learning, was supported by the local context and was associated with positive emotions. Barriers related to difficulties with booking and scheduling and the belief that intensive therapy was not for all patients.

CONCLUSIONS

While the current study was likely underpowered to establish non-inferiority of intensive therapy, secondary outcomes suggested that intensive therapy may produce comparable benefits to voice, wellbeing, satisfaction and attendance compared to weekly therapy and may be a viable therapy option for individuals with MTD. When implementing intensive therapy, clinicians should consider patient's preferences and availability, as well as systems which allow for flexible booking and therapy provision for patients. Clear recommendations for future research including the use of a larger sample and telehealth are also provided.

Cognitive, Emotional, and Social Influences on Voice Production Elicited by Three Different Stroop Tasks

INTRODUCTION

The effects of emotion and cognition have been of interest to voice clinicians and research given the known correlations between psychological states and voice disorders. However, most voice research techniques investigate one psychological state at a time and do not necessarily consider other psychological states or the combination of two or more states occurring simultaneously. The purpose of this study is to employ three Stroop tasks, all known to elicit different psychological states, during a voice study to determine whether separate psychological states have a variable effect on vocalizations.

METHODS

Fifteen female participants were instructed to view a word on a computer screen and say the name of the color of the font of that word. Words were part of a Color Stroop, Emotional Stroop, or Taboo Stroop paradigm and designed to elicit cognitive, emotional, or the combination of cognitive/emotional interference. Behavioral measures of response time and acoustic measures of frequency, intensity, and noise ratio were extracted from each stimulus.

RESULTS

Participants had significantly greater response times for all experimental conditions compared to baseline. Additionally, intensity range was significantly less, and average fundamental frequency and cepstral peak prominence were significantly greater than baseline. However, there was no distinct pattern of response for any condition.

DISCUSSION/CONCLUSION

Although there are definite changes in vocalizations when participants were engaged in higher cognitive or emotional processing, no acoustic signatures for these separate conditions exist. These findings suggest that more specific acoustic measures or additional measures such as physiological or self-report may be necessary to parse out the differential effect on the voice in these three conditions.

Translation, Cross-Cultural Validation of the Voice Handicap Index (VHI-30) in Slovak Language

PURPOSE

The objective of the study is to verify the psychometric properties of Voice Handicap Index (VHI-30) in Slovak language.

METHODS

Original VHI-30 has been translated into the Slovak language. Fifty-two dysphonic individuals and 104 individuals of the control group without voice disorders were included in the study. Item to total correlation, internal consistency (Cronbach's alpha coefficient α and split-half coefficient), test-retest reliability (correlation coefficient), and validity of VHI 30 (Kruskal-Wallis test) were analyzed.

RESULTS

Item analysis proved that questionnaire items have a good to excellent correlation to the total score (0.42-0.87, P < 0.05). Good internal consistency was proved by calculating Cronbach's alpha coefficient (0.88, P < 0.05) and split-half correlation for the Total score in VHI (0.997, P < 0.05). Test-retest reliability was found to be strong (0.86, P < 0.05). Validity results of Slovak VHI suggests that total mean scores of control group were significantly lower than total mean scores of dysphonic groups (structural, neurogenic, inflammatory, functional, and nonspecified). Total mean scores indicated no statistically significant difference between dysphonic groups (P < 0.05). The cut-off value of 21 points was determined by Receiver Operating Characteristics (ROC) analysis.

CONCLUSION

The results of the study proved that the Slovak VHI-30 is a reliable and valid tool. It is useful for assessing disadvantage related to voice disorders from the patient's perspective.

Functional connectivity of PAG with core limbic system and laryngeal cortico-motor structures during human phonation

Previous studies in animals and humans suggest the periaqueductal grey region (PAG) is a final integration station between the brain and laryngeal musculature during phonation. To date, a limited number of functional magnetic neuroimaging (fMRI) studies have examined the functional connectivity of the PAG during volitional human phonation. An event-related, stimulus-induced, volitional movement paradigm was used to examine neural activity during sustained vocalization in neurologically healthy adults and was compared to controlled exhalation through the nose. The contrast of vocalization greater than controlled expiration revealed activation of bilateral auditory cortex, dorsal and ventral laryngeal motor areas (dLMA and vLMA) (p < 0.05, corrected), and suggested activation of the cerbellum, insula, dorsomedial prefrontal cortex (dmPFC), amygdala, and PAG. The functionally defined PAG cluster was used as a seed region for psychophysiological interaction analysis (PPI) to identify regions with greater functional connectivity with PAG during volitional vocalization, while the above functionally defined amygdala cluster was used in an ROI PPI analysis. Whole-brain results revealed increased functional connectivity of the PAG with left vLMA during voicing, relative to controlled expiration, while trend-level evidence was observed for increased PAG/amygdala coupling during voicing (p = 0.07, uncorrected). Diffusion tensor imaging (DTI) analysis confirmed structural connectivity between PAG and vLMA. The present study sheds further light on neural mechanisms of volitional vocalization that include multiple inputs from both limbic and motor structures to PAG. Future studies should include investigation of how these neural mechanisms are affected in individuals with voice disorders during volitional vocalization.

A psychosocial intervention for the management of functional dysphonia: complex intervention development and pilot randomised trial

BACKGROUND

Medically unexplained loss or alteration of voice-functional dysphonia-is the commonest presentation to speech and language therapists (SLTs). Besides the impact on personal and work life, functional dysphonia is also associated with increased levels of anxiety and depression and poor general health. Voice therapy delivered by SLTs improves voice but not these associated symptoms. The aims of this research were the systematic development of a complex intervention to improve the treatment of functional dysphonia, and the trialling of this intervention for feasibility and acceptability to SLTs and patients in a randomised pilot study.

METHODS

A theoretical model of medically unexplained symptoms (MUS) was elaborated through literature review and synthesis. This was initially applied as an assessment format in a series of patient interviews. Data from this stage and a small consecutive cohort study were used to design and refine a brief cognitive behavioural therapy (CBT) training intervention for a SLT. This was then implemented in an external pilot patient randomised trial where one SLT delivered standard voice therapy or voice therapy plus CBT to 74 patients. The primary outcomes were of the acceptability of the intervention to patients and the SLT, and the feasibility of changing the SLT's clinical practice through a brief training. This was measured through monitoring treatment flow and through structured analysis of the content of intervention for treatment fidelity and inter-treatment contamination.

RESULTS

As measured by treatment flow, the intervention was as acceptable as standard voice therapy to patients. Analysis of treatment content showed that the SLT was able to conduct a complex CBT formulation and deliver novel treatment strategies for fatigue, sleep, anxiety and depression in the majority of patients. On pre-post measures of voice and quality of life, patients in both treatment arms improved.

CONCLUSION

These interventions were acceptable to patients. Emotional and psychosocial issues presented routinely in the study patient group and CBT techniques were used, deliberately and inadvertently, in both treatment arms. This CBT "contamination" of the voice therapy only arm reflects the chief limitation of the study: one therapist delivered both treatments.

TRIAL REGISTRATION

Registered with the ISRCTN under the title: Training a Speech and Language Therapist in Cognitive Behavioural Therapy to treat Functional Dysphonia - A Randomised Controlled Trial.Trial Identifier: ISRCTN20582523 Registered 19/05/2010; retrospectively registered. http://www.isrctn.com/ISRCTN20582523.

Investigating the Role of Salivary Cortisol on Vocal Symptoms

PURPOSE

We investigated whether participants who reported more often occurring vocal symptoms showed higher salivary cortisol levels and if such possible associations were different for men and women.

METHOD

The participants (N = 170; men n = 49, women n = 121) consisted of a population-based sample of Finnish twins born between 1961 and 1989. The participants submitted saliva samples for hormone analysis and completed a web questionnaire including questions regarding the occurrence of 6 vocal symptoms during the past 12 months. The data were analyzed using the generalized estimated equations method.

RESULTS

A composite variable of the vocal symptoms showed a significant positive association with salivary cortisol levels (p < .001). Three of the 6 vocal symptoms were significantly associated with the level of cortisol when analyzed separately (p values less than .05). The results showed no gender difference regarding the effect of salivary cortisol on vocal symptoms.

CONCLUSIONS

There was a positive association between the occurrence of vocal symptoms and salivary cortisol levels. Participants with higher cortisol levels reported more often occurring vocal symptoms. This could have a connection to the influence of stress on vocal symptoms because stress is a known risk factor of vocal symptoms and salivary cortisol can be seen as a biomarker for stress.

Associations Between Vocal Symptoms and Genetic Variants in the Oxytocin Receptor and Arginine Vasopressin 1A Receptor Gene

PURPOSE

Oxytocin and arginine vasopressin are associated with different aspects of the stress response. As stress is regarded as a risk factor for vocal symptoms, we wanted to explore the association between the oxytocin receptor gene (OXTR) and arginine vasopressin 1A receptor gene (AVPR1A) single-nucleotide polymorphisms (SNPs) and vocal symptoms. We also wanted to explore whether such effects might be mediated by cortisol because oxytocin and vasopressin are associated with cortisol levels.

METHOD

A population-based sample (N = 657) of Finnish twins (born 1961-1989) completed a web questionnaire on the occurrence of vocal symptoms. A total of 170 participants submitted saliva samples for hormone analysis. A total of 20 OXTR and AVPR1A SNPs were analyzed.

RESULTS

Three OXTR polymorphisms (rs2270465, rs2268493, rs7632287) and 2 AVPR1A polymorphisms (rs1587097, rs1042615) showed nominal effects (p < .05) on vocal symptoms, of which 1 (rs1587097) remained significant after correcting for multiple testing (p = .003). We found potential mediation of the effect of the OXTR rs2268493 polymorphism on vocal symptoms through levels of cortisol.

CONCLUSIONS

The associations between variants of OXTR and AVPR1A and vocal symptoms indicate that oxytocin and vasopressin might influence vocal symptoms. The effect of oxytocin seems to be partly mediated through cortisol actions.

Assessment practices of Irish speech and language therapists in the evaluation of voice disorders

It is commonly accepted that the evaluation of voice disorders ought to include extensive perceptual, psychometric, and instrumental measurements. This serves to encapsulate the wide-reaching effects of such a disorder, from the physical impairment in voice production to the psycho-social impact of having a dysphonic voice. In spite of this, no international gold standard exists by which voice disorders should be evaluated, and so speech and language therapists (SLTs) are often tasked with developing an assessment battery for use in their own clinics. The purpose of this study is to determine whether the evaluation of voice disorders by Irish SLTs on a national scale is suitably comprehensive, with particular reference to the guidelines published by the European Laryngological Society. A total of 49 SLTs working in a variety of settings responded anonymously to an electronic survey regarding their assessment practices. Results indicate that therapists are comprehensive in non-instrumental evaluation of voice, but lack both access to and training in instrumental assessment techniques.

Relação entre os sintomas vocais, intensidade do desvio vocal e diagnóstico laríngeo em pacientes com distúrbios da voz

RESUMO Objetivo investigar se existe associação entre a frequência de ocorrência dos sintomas vocais, a intensidade do desvio vocal e o diagnóstico laríngeo em pacientes com diferentes distúrbios da voz. Métodos Participaram do estudo 330 pacientes com queixa vocal, distribuídos em cinco grupos de acordo com o diagnóstico laringológico: G1-sem lesão laríngea, G2-lesões benignas das pregas vocais, G3-distúrbio neurológico da voz, G4-fenda glótica sem causa orgânica ou neurológica e G5-distúrbio de voz secundário a refluxo gastroesofágico. Foram alocados em cinco grupos, de acordo com o diagnóstico laríngeo. Todos os participantes responderam à Escala de Sintomas Vocais (ESV) e gravaram a vogal /ɛ/ sustentada, que foi analisada quanto à intensidade do desvio vocal por meio de uma escala analógico-visual. Resultados Houve diferença nos escores total, de limitação e físico da ESV entre diferentes grupos diagnósticos. Pacientes com lesão na porção membranosa das pregas vocais apresentaram maior número de sintomas vocais em relação aos outros grupos diagnósticos. Observou-se correlação positiva entre a intensidade do desvio vocal e os escores total, de limitação e emocional da ESV. Pacientes com desvio vocal moderado e intenso apresentaram maior número de sintomas vocais que pacientes com vozes saudáveis ou com desvio leve. Conclusão Existe associação entre o diagnóstico laríngeo, a intensidade do desvio vocal e a frequência de ocorrência dos sintomas vocais. Pacientes com lesão benigna nas pregas vocais e com desvio vocal mais intenso apresentam maior frequência de sintomas vocais.

Transmasculine People's Voice Function: A Review of the Currently Available Evidence

OBJECTIVES

This study aims to evaluate the currently available discursive and empirical data relating to those aspects of transmasculine people's vocal situations that are not primarily gender-related, to identify restrictions to voice function that have been observed in this population, and to make suggestions for future voice research and clinical practice.

METHODS

We conducted a comprehensive review of the voice literature. Publications were identified by searching six electronic databases and bibliographies of relevant articles. Twenty-two publications met inclusion criteria. Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in transmasculine people. The quality of the evidence was appraised.

RESULTS

The extent and quality of studies investigating transmasculine people's voice function was found to be limited. There was mixed evidence to suggest that transmasculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality.

CONCLUSIONS

More research into the different factors and practices affecting transmasculine people's voice function that takes account of a range of parameters of voice function and considers participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.

Functional voice disorders: Clinical presentations and differential diagnosis

In this chapter, an overview of the heterogeneous group of functional voice disorders is given, including the psychogenic voice disorder (PVD) and hyperfunctional or muscle tension voice disorder (MTVD) subgroups. Reference is made to prevalence and demographic data, with empiric evidence for psychosocial factors commonly associated with the onset and maintenance of these disorders. Clinical features that distinguish between the different presentations of PVD and MTVD are described. While there are some shared characteristics, key differences between these two subgroups indicate that PVD more closely resembles the psychogenic movement disorders and a range of other functional neurologic disorders. Assessment procedures and auditory-perceptual features of the voice that distinguish these disorders from the neurologically based voice disorders are discussed, with case examples highlighting ambiguous features that may influence differential diagnosis. The clinical profiles of PVD and MTVD affirm approaches to clinical management by speech-language pathologists that integrate symptomatic behavioral voice therapy with "top-down" models of counseling or psychotherapy. They also support the proposition that PVD may be construed as a subtype of functional neurologic disorders.

The behavioural treatment of muscle tension voice disorders: A systematic review

PURPOSE

A systematic review of behavioural intervention for the treatment of adults with muscle tension voice disorders (MTVD).

METHOD

A search of 12 electronic databases and reference lists for studies published between the years 1990-2014 was conducted using the PRISMA guidelines. Inclusion and exclusion criteria included type of publication, participant characteristics, intervention, outcome measures and report of outcomes. Methodological quality rating scales and confidence in diagnostic scale supported the literature evaluation.

RESULT

Seven papers met the inclusion criteria. Significant improvement on at least one outcome measure was reported for all studies. Effect sizes were small-to-large. Methodological qualities of research were varied. No study explicitly reported treatment fidelity and cumulative intervention intensity could only be calculated for two out of seven studies. Outcome measures were used inconsistently and less than half of the measures had reported reliability values. Confidence in the accuracy of subject diagnosis on average was rated as low. Specific "active ingredients" for therapeutic change were not identified.

CONCLUSION

Voice therapy for the treatment of MTVD is associated with positive treatment outcomes; however, there is an obvious need for systematic and high quality research designs to expand the evidence base for the behavioural treatment of MTVD.

Psychobiological stress reactivity and personality in persons with high and low stressor-induced extralaryngeal reactivity

PURPOSE

The purpose of the study was to determine whether persons who responded with high stressor-induced extralaryngeal muscle activity in a stress reactivity protocol differed from those with low muscle activity on measures of emotional and autonomic cardiovascular reactivity and personality.

METHOD

Thirty-six vocally healthy women (18-35 years) were assigned to high and low extralaryngeal groups based on submental (SM) and infrahyoid (IH) surface electromyography (sEMG) recordings obtained during a stress reactivity protocol (high vs. low sEMGSM and sEMGIH, n = 18 per subgroup; Dietrich & Verdolini Abbott, 2012). Measures included assessments of basic fear and fear of public speaking, rumination, systolic blood pressure (SBP), and personality.

RESULTS

The high sEMGIH group reported significantly greater basic fear across experimental phases than did the low sEMGIH group (p = .036). However, the high sEMGSM and sEMGIH versus low sEMGSM and sEMGIH groups did not differ on fear of public speaking, rumination, or SBP across phases. Both high sEMGSM and sEMGIH groups were characterized by significantly lower scores on Extraversion (p < .001).

CONCLUSION

In combination with the authors' previous findings (Dietrich & Verdolini Abbott, 2012), the present findings provided robust evidence that low Extraversion was linked to stressor-induced changes in extralaryngeal functioning and that perceived fear played a contributing role.

Psychogenic dysphonia: diversity of clinical and vocal manifestations in a case series

Introduction

Objective

Methods

Results

Conclusions

Psychosocial risk factors which may differentiate between women with Functional Voice Disorder, Organic Voice Disorder and a Control group

This study aimed to explore psychosocial factors contributing to the development of functional voice disorders (FVD) and those differentiating between organic voice disorders (OVD) and a non-voice-disordered control group. A case-control study was undertaken of 194 women aged 18-80 years diagnosed with FVD (n = 73), OVD (n = 55), and controls (n = 66). FVD women were allocated into psychogenic voice disorder (PVD) (n = 37) and muscle tension voice disorder (MTVD) (n = 36) for sub-group analysis. Dependent variables included biographical and voice assessment data, the number and severity of life events and difficulties and conflict over speaking out (COSO) situations derived from the Life Events and Difficulties Schedule (LEDS), and psychological traits including emotional expressiveness scales. Four psychosocial components differentiated between the FVD and control group accounting for 84.9% of the variance: severe events, moderate events, severe COSO, and mild COSO difficulties. Severe events, severe and mild COSO difficulties differentiated between FVD and OVD groups, accounting for 80.5% of the variance. Moderate events differentiated between PVD and MTVD sub-groups, accounting for 58.9% of the variance. Psychological traits did not differentiate between groups. Stressful life events and COSO situations best differentiated FVD from OVD and control groups. More refined aetiological studies are needed to differentiate between PVD and MTVD.

Association between Anxiety, Type A Personality, and Treatment Outcome of Dysphonia due to Benign Causes

Objective

Dysphonia has been linked to psychosocial factors such as anxiety and personality type. The aim of this study is to determine whether these factors also affect the treatment outcome of benign dysphonia.

Study Design

Prospective case series.

Setting

Voice clinic of a tertiary otolaryngology clinic.

Subjects and Methods

Thirty-seven patients diagnosed with benign dysphonia over a 3-month period were included. Demographic data, the Voice Handicap Index–10 (VHI-10), Reflux Symptom Index (RSI), Clinical Anxiety Scale (CAS), and Bortner Personality Scale were recorded at presentation. After a period of treatment with lifestyle advice, proton pump inhibitors, and/or speech therapy, the VHI-10 and RSI were repeated.

Results

After standard dysphonia treatment, 18 patients who reported complete recovery were found to be significantly less anxious (lower CAS scores) than those who did not recover completely ( P = .023). However, there was no significant difference in number of complete recoveries between patients of personality types A and B ( P > .05). Multivariate regression showed that higher CAS scores had a negative influence on the amount of improvement of VHI-10 ( P = .026) but had no impact on RSI ( P = .148). Again, personality type had no influence on either RSI or VHI-10 improvement (both P > .05). An additional factor, older age, was found to predict negatively for the amount of RSI improvement ( P = .017), but no other predictive variables were identified.

Conclusion

This is the first study to show that psychosomatic factors may affect treatment outcome in patients with dysphonia due to benign causes. The benefit of adjunctive psycho-cognitive measures warrants further investigation.

Coping strategies in voice disorders of a Brazilian population

The purpose of this research is to explore coping strategies of individuals with and without vocal complaint and to examine relationships between the type of coping and vocal complaint; vocal symptoms; vocal self-assessment; perceptual analysis and states of depression, anxiety, and aspects related to self-esteem; and locus of control. One hundred seventy-eight subjects with (n=87) and without vocal (n=91) complaint completed the following analysis: identification and characterization questionnaire, vocal self-assessment, perceptual analysis, Voice Disability Coping Questionnaire (VDCQ)-Brazilian Version, Beck Depression Inventory, Rosenberg Self-esteem Scale, Spielberger State-Trait Anxiety Inventory, and Health Locus of Control Scale. Age (P=0.219) and sex (P=0.132) were similar for both groups. The groups were statistically different for the following vocal characterization: number of symptoms, voice complaint, vocal self-assessment, and perceptual analysis. Conversely, the groups did not differ on states of depression, anxiety, and aspects related to self-esteem; and locus of control. Mean coping scores for the group with vocal complaint was 51.86 and for the group without vocal complaint was 23.18. Furthermore, men and women did not differ on the coping strategies reported (P=0.750); however, individuals with vocal complaint reported statistically more strategies than the individuals without vocal complaint (P<0.001). Problem-focused strategies were more frequently reported by individuals with vocal complaint (46.7%). Coping results correlated (Spearman's r) positively with vocal perceptual analysis (P=0.036), depression (P=0.006), and anxiety (P=0.022), and correlated negatively with locus of control (P=0.001). No correlation was found between coping and the other variables studied. These findings indicate that people with vocal complaint use a variety of coping strategies, problem focused in particular, to deal with their voice problems. Coping results appear to be associated with perceptual characteristics of voice and some traits, such as depression, anxiety, and locus of control.

Relationship between Fatigue, Perfectionism, and Functional Dysphonia

Objectives. Increased levels of fatigue and perfectionism were noted during evaluation of cognitive behavioral therapy for the treatment of functional dysphonia. The investigators thus aimed to explore levels of general fatigue and perfectionism in patients with functional dysphonia and controls.

Study design. Case-control study.

Setting. Teaching hospital, United Kingdom.

Subjects and Methods. Patients recruited through speech therapy were asked to recruit a friend as a control, of the same sex and within 5 years of their age. An 11-point fatigue questionnaire, previously validated on a normal population, was analyzed using both Likert (0123) and bimodal (0011) systems, with a score greater than 4 on the bimodal system implying substantial fatigue. A 35-point perfectionism questionnaire was also completed and analyzed for “healthy” and “unhealthy” perfectionist traits.

Results. There were 75 cases and 62 controls. The mean fatigue score in patients with functional dysphonia was 17.0 and 14.4 for the controls (Likert, P = .009). Under the bimodal scoring system, the mean fatigue scores in functional dysphonia (5.10) and controls (3.01) were also significantly different ( P = .003). The mean perfectionism scores were 98.9 for patients with functional dysphonia and 91.2 for controls ( P = 0.043).

Conclusions. To the investigators’ knowledge, this is the first substantial report that fatigue and perfectionism scores are significantly elevated in functional dysphonia. Functional dysphonia is shown to be analogous to other medically unexplained physical symptoms that are also marked by generic somatopsychic distress and for which multiple factors are implicated in their onset and maintenance. This has implications for both research and treatment.

Disfonia psicogênica associada a outras doenças: desafio para o tratamento fonoaudiológico

TEMA: sucessos e dificuldades no tratamento de disfonia psicogênica. OBJETIVO: discutir as limitações da terapia fonoaudiológica para disfonia psicogênica associada a outras doenças. MÉTODO: foram utilizados protocolos de avaliação e registros de terapia para discussão do caso. RESULTADOS: a paciente chegou com importante alteração vocal e, após avaliação, diagnosticou-se disfonia psicogênica. O tratamento envolveu ativação vocal e modificação do ajuste fixado. Observaram-se mudanças positivas como estabilidade no padrão vocal, redução da rouquidão, aspereza, soprosidade e desconforto laríngeo e na qualidade de vida relacionada à voz, mas que não se sustentaram na medida em que houve piora dos outros problemas de saúde. CONCLUSÃO: o tratamento fonoaudiológico pode ser limitado, contudo desafiador, quando a disfonia psicogênica ocorre de maneira concomitante com outras doenças.

Opinião dos pais sobre a voz, características de comportamento e de personalidade de seus filhos

OBJETIVO: verificar como os pais percebem e descrevem seus filhos com relação à voz e às características de comportamento e personalidade. MÉTODOS: participaram do estudo 66 pais de crianças entre 6 e 9 anos, de ambos os sexos, os quais responderam a um questionário com 28 questões que investigavam características de voz, comportamento e personalidade de seus filhos. RESULTADOS: os resultados indicaram que a maioria dos pais (90,9%) se mostra satisfeita com o som da voz de seu filho(a). Somente 9,1% dos pais caracterizaram a voz de seu filho como sendo pior que a das demais crianças e 31,8% achou que seu filho(a) fala muito mais se comparado aos colegas. Aproximadamente um quarto (22,7%) dos pais observou que o volume de voz utilizado por seus filhos é aumentado. Os pais que caracterizaram seus filhos como sendo mais falantes também perceberam a voz deles como sendo mais aguda (p=0,013). O volume de voz aumentado mostrou correlação positiva com agitação (p=0,044), inquietação (p=0,005), sociabilidade (p=0,021), menos quantidade de horas dormidas (p=0,013) e extroversão (p=0,014). Crianças caracterizadas como sendo mais calmas (p=0,011) e menos argumentativas (p=0,044) são também menos falantes na comparação com outras crianças. CONCLUSÃO: em geral, os pais parecem perceber características vocais em seus filhos, têm forte tendência a considerar seus filhos sensíveis, observadores e exigentes quanto a si mesmos, além de perceberem relação entre volume de voz e características de comportamento e personalidade.

Women's voices: lost or mislaid, stolen or strayed?

It is estimated that disorders of voice affect 3-4% of people from all strata of Australian society and while some voice disorders may be caused by organic conditions, most patients are troubled by non-organic or functional voice disorders (FVD). As professionals dealing with these problems, we wonder about the role of strong negative emotions arising from stressful life experiences preceding onset, or dispositional factors that may influence ways in which an individual responds to such incidents. We wonder too, how these complex processes may be inter-related, and if this may account for one person misusing or damaging the voice, while another loses the voice altogether. Evidence for the possible relationship between negative emotions arising out of stressful events and onset of FVD in women is briefly presented. The findings suggest that women with FVD may have difficulty in the processing of negative emotions, and when considered in a wider socio-cultural perspective, it is proposed that some have temporarily lost their voices, while others have been rendered powerless and had their voices stifled. These findings serve as the foundation for a broader discussion about the possible implications for the speech pathology profession which might be at risk of losing its voice.

Current knowledge, controversies and future directions in hyperfunctional voice disorders

Taking the preceding five papers in this special issue of the International Journal of Speech-Language Pathology as a starting point, this paper synthesizes key aspects of hyperfunctional voice disorders (HFVD). Aetiological and contributing factors, defining features, prevention, assessment and intervention are canvassed, while controversial issues and future directions in research and clinical practice are discussed. Despite disagreements and inconsistencies in terminology surrounding HFVD, there is broad agreement that musculoskeletal tension is the hallmark of these voice disorders. There is also reasonable consensus that the pathogenesis and persistence of HFVD are associated with multiple and overlapping factors, some of which are likely to interact in as yet unknown ways. In addition to dysregulated laryngeal muscle functioning, key processes in the psychosocial and sensory domains are canvassed as likely contributors to HFVD. Vocal fatigue is considered as an intriguing relative of HFVD, the role of laryngopharyngeal reflux is debated and the proposition that particular individuals are psychologically and/or physiologically predisposed to HFVD is discussed. New directions in assessment highlight the use of client-centred measures to consider insider perspectives of psychological factors, vocal effort and vocal fatigue. Emerging psychosocial and physical-manipulative interventions are emphasized and the future educational needs of voice care professionals are considered.