Reconsidering the role of psychosocial factors in functional dysphonia

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.

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.

Effects of Virtual Instruction on Educators' Voices During the COVID-19 Pandemic

INTRODUCTION

Resulting from the COVID-19 pandemic, professionals in the United States were mandated to work virtually from home to protect the health needs of the population. The shift in setting and ergonomic factors posed a threat to the vocal health of workers, and more specifically, to those whose professions inflict significant vocal load, such as educators. This study compared the symptoms of vocal tract discomfort and self-perceived voice handicap in full-time educators between face-to-face and virtual settings. Additionally, this study sought to identify relationships between specific environmental factors and levels of discomfort.

METHODS

A cross-sectional research study was conducted by distributing an online survey to 223 individuals who identified as full-time educators. This survey collected data on vocal tract symptoms during both face-to-face and virtual instruction, environmental factors of virtual work setting, personal vocal health habits, and self-perceived voice handicap in each setting.

RESULTS

In this sample population, the shift to a virtual work setting did not result in a significant increase in the number of vocal discomfort symptoms or an increase in vocal handicap. However, environmental factors such as air quality and water intake had the strongest correlation with levels of vocal tract discomfort.

CONCLUSION

It is beneficial to provide resources to full-time educators regarding the risk of voice disorders and the impact of environmental factors on vocal health.

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.

Understanding, Recognizing, and Managing Functional Speech Disorders: Current Thinking Illustrated With a Case Series

PURPOSE

Functional speech disorders (FSDs), a subtype of functional neurological disorders, are distinguishable from neurogenic motor speech disorders based on their clinical features, clinical course, and response to treatment. However, their differential diagnosis and management can be challenging. FSDs are not well understood, but growing evidence suggests a biopsychosocial basis distinct from structural lesions that cause neurogenic motor speech disorders.

METHOD AND RESULTS

Following an overview of FSDs, four patients are described to illustrate the range of clinical manifestations, biopsychosocial contexts, and responses to treatment of FSDs. The path to differential diagnosis is discussed, with particular attention to positive features that led to the FSD diagnosis. Approaches to education, counseling, and management are discussed.

CONCLUSIONS

This case series demonstrates that FSDs can present with a variety of manifestations including dysfluencies, articulation errors, dysphonia, rate and prosodic abnormalities, and combinations of disruptions in speech subsystems. FSDs may present in the context of known recent or remote physical or psychosocial trauma or, as in many cases, in the absence of an identifiable triggering event. FSDs are recognizable by positive clinical features and should not be considered a diagnosis of exclusion. With appropriate identification, counseling, and treatment, FSDs may resolve, sometimes rapidly; in some cases, treatment may be prolonged or ineffective.

Perceptions regarding communicative participation in individuals receiving botulinum toxin injections for laryngeal dystonia

BACKGROUND

Laryngeal dystonia (LD), or spasmodic dysphonia (SD), is a neurological disorder characterized by focal dystonia or involuntary spasms of the laryngeal muscles and associated voice symptoms. It is typically treated with injection of botulinum toxin (BoNT) that weakens the affected muscles.

AIMS

The primary purpose of this qualitative study was to explore participants' experience of living with LD and BoNT treatment. The secondary purpose was to examine those experiences as a function of participants' scores on the Communicative Participation Item Bank (CPIB). Results will enhance our understanding of restrictions in communicative participation, assist in planning intervention targeting these restrictions and aid in clinical interpretation of CPIB scores.

METHODS & PROCEDURES

Semi-structured interviews using a phenomenological tradition and focusing on BoNT treatment and communicative participation were conducted with 26 people with LD who are on established BoNT treatment regimens. Interviews were recorded, transcribed, coded and analysed inductively. Participants were categorized by CPIB scores into groups ranging from none to extensive participation restrictions. Both self- and expert ratings of voice were obtained.

OUTCOMES & RESULTS

Participants with different levels of CPIB scores had different experiences related to communicative participation in the context of BoNT treatment. These differences were organized into the following topics: BoNT and voice; attitudes toward participation; coping strategies; and advice. For all participants except those in the least restricted and most restricted groups, expert ratings of voice did not relate to CPIB scores.

CONCLUSIONS & IMPLICATIONS

Although most participants report improved voice with BoNT treatment, many participants experienced lingering restrictions in communicative participation, some to a severe extent. Participants reported coping with these restrictions in many ways; some of these strategies were more successful than others. Those with restricted participation recommended more support for daily life and the emotional toll of LD, as well as support for family members. This support might be offered by speech-language pathologists.

WHAT THIS PAPER ADDS

What is already known on the subject Participants with different levels of CPIB scores had different experiences related to communicative participation in the context of BoNT treatment. What this study adds to the existing knowledge Although most participants report improved voice with BoNT treatment, many participants experienced lingering restrictions in communicative participation, some to a severe extent. What are the potential or actual clinical implications of this work? SLP services that take a participation-focused approach to intervention and use multi-factorial approaches to help clients maximize their life participation in the context of LD are well within the SLP scope of practice. SLPs can help clients find and use their optimal voices within the constraints of the dystonia and BoNT effects.

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.

Use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial

OBJECTIVE

To assess the use of proton pump inhibitors (PPIs) to treat persistent throat symptoms.

DESIGN

Pragmatic, double blind, placebo controlled, randomised trial.

SETTING

Eight ear, nose, and throat outpatient clinics, United Kingdom.

PARTICIPANTS

346 patients aged 18 years or older with persistent throat symptoms who were randomised according to recruiting centre and baseline severity of symptoms (mild or severe): 172 to lansoprazole and 174 to placebo.

INTERVENTION

Random blinded allocation (1:1) to either 30 mg lansoprazole twice daily or matched placebo twice daily for 16 weeks.

MAIN OUTCOME MEASURES

Primary outcome was symptomatic response at 16 weeks measured using the total reflux symptom index (RSI) score. Secondary outcomes included symptom response at 12 months, quality of life, and throat appearances.

RESULTS

Of 1427 patients initially screened for eligibility, 346 were recruited. The mean age of the study sample was 52.2 (SD 13.7) years, 196 (57%) were women, and 162 (47%) had severe symptoms at presentation; these characteristics were balanced across treatment arms. The primary analysis was performed on 220 patients who completed the primary outcome measure within a window of 14-20 weeks. Mean RSI scores were similar between treatment arms at baseline: lansoprazole 22.0 (95% confidence interval 20.4 to 23.6) and placebo 21.7 (20.5 to 23.0). Improvements (reduction in RSI score) were observed in both groups-score at 16 weeks: lansoprazole 17.4 (15.5 to19.4) and placebo 15.6 (13.8 to 17.3). No statistically significant difference was found between the treatment arms: estimated difference 1.9 points (95% confidence interval -0.3 to 4.2 points; P=0.096) adjusted for site and baseline symptom severity. Lansoprazole showed no benefits over placebo for any secondary outcome measure, including RSI scores at 12 months: lansoprazole 16.0 (13.6 to 18.4) and placebo 13.6 (11.7 to 15.5): estimated difference 2.4 points (-0.6 to 5.4 points).

CONCLUSIONS

No evidence was found of benefit from PPI treatment in patients with persistent throat symptoms. RSI scores were similar between the lansoprazole and placebo groups after 16 weeks of treatment and at the 12 month follow-up.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN38578686 and EudraCT 2013-004249-17.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

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.

A possible association between dysphonia and sleep duration: A cross-sectional study based on the Korean National Health and nutrition examination surveys from 2010 to 2012

BACKGROUND

Sleep is important in terms of good general health and appropriate sleep duration has been linked to quality-of-life. Dysphonia may impair communication and social relationships, and is thus also closely related to quality-of-life. No large-scale, cross-sectional epidemiological study of a sample representative of the population of an entire country has yet assessed the possible existence of a relationship between sleep duration and dysphonia.

METHODS

We investigated a possible association between subjective voice problems and self-reported sleep duration in South Korean subjects using 2010-2012 data from the Korean National Health and Nutrition Examination Survey (KNHANES). Cross-sectional data on 17,806 adults (7,578 males and 10,228 females) over the age of 19 years who completed the KNHANES were analyzed. All participants reported voice problems (if present) and their daily average sleep duration using a self-reporting questionnaire. Sleep duration was classified into five categories as follows: ≤5, 6, 7, 8, and ≥9 h/day.

RESULTS

The overall prevalence of dysphonia was 6.8%; 5.7% in males and 7.7% in females. The prevalence for dysphonia by sleep duration exhibited a U-shape, with the lowest point being at sleep duration of 7-8h. After adjustment for covariates (age, sex, smoking status, alcohol consumption, regular exercise, low income, high-level education), a sleep duration of ≤5 h (OR = 1.454; 95% CI, 1.153-1.832) and a sleep duration of ≥9 h (OR = 1.365; 95% CI, 1.017-1.832) were significantly associated with dysphonia, compared to a sleep duration of 7 h. In terms of gender, males who slept for ≥9 h were at a 2-fold (OR = 2.028; 95% CI, 1.22-3.35) higher odds for dysphonia (p<0.05) compared to those who slept for 7 h. A sleep duration ≤5 h was associated with a 1.6-fold (OR = 1.574; 95% CI, 1.203-2.247) higher odds of dysphonia ≥3 weeks in duration (long-term dysphonia).

CONCLUSIONS

This is the first study to show that both short and long sleep duration were significantly associated with the development of dysphonia. The association between sleep duration and dysphonia was more marked in males than females. A sleep duration ≤5 h had a significant impact on the prevalence of long-term dysphonia.

Pragmatic detection of anxiety and depression in a prospective cohort of voice outpatient clinic attenders

OBJECTIVE

To evaluate diagnostic performance of the emotional domain of the VoiSS questionnaire compared with the Hospital Anxiety and Depression Scale (HADS).

DESIGN

Cross-sectional questionnaire study.

SETTING

Tertiary referral centre voice clinic.

PARTICIPANTS

210 consecutive voice clinic patients.

MAIN OUTCOME MEASURES

Screening with VoiSS and HADS questionnaires. Paired comparison, correlation, multinomial logistic regression and receiver-operating characteristic (ROC) curve analysis.

RESULTS

A total of 177 returned complete data sets. Ninety-six patients (54.2%) had functional dysphonia, and 81 (45.8%) had organic laryngeal disorders. Mean total VoiSS score = 39.7/120 (standard deviation (sd) 22.2). Mean emotional VoiSS subscale = 7.6/22 (sd 7.5). Mean HADS anxiety = 6.5/21 (sd 5.2) and depression mean = 7.1/21 (sd 4.8). There were 35 (20%) borderline anxiety and/or depression scores and 30 (17%) scores considered positive for 'caseness'. There was strong correlation between emotional VoiSS and HADS anxiety (Spearman's Rho = 0.68, P < 0.001) and HADS depression (Spearman's Rho = 0.62, P < 0.001). ROC curve analysis exhibited significant association between emotional VoiSS and HADS 'caseness' (area under curve = 0.88). In addition, functional dysphonia patients had lower mean VoiSS and HADS scores than patients with identifiable laryngeal abnormalities.

CONCLUSION

The VoiSS emotional subscale strongly correlates with HADS anxiety and depression scores and could be used as a measure of psychological distress. This could allow targeted psychological strategies, without additional psychometric questionnaires. Functional dysphonia has less association with psychological distress than certain organic laryngological disorders.

Risk Factors for the Incidence of Perceived Voice Disorders in Elementary and Middle School Teachers

OBJECTIVE/HYPOTHESIS

This study aimed to identify risk factors for the incidence of perceived voice disorders in teachers, specifically related to the influence of common mental disorders.

DESIGN

This is a longitudinal quantitative study conducted in municipal schools.

METHOD

We performed a data analysis of 469 teachers, reassessed 3 years after an initial study. The Voice Handicap Index was used to measure the impact of a probable voice problem with a cutoff value of 19 points. Mental disorder symptomatology was measured by the Self-Reporting Questionnaire (20 items), with a cutoff value of eight points. Bivariate analysis was conducted through Poisson regression to verify proportion differences in the occurrence of perceived voice disorders among the study's different categories of independent variables. The same technique of Poisson regression was used to assess risk factors for perceived voice disorder incidence in a specific hierarchic model.

RESULTS

The incidence of a perceived voice disorder was 17.1%. Teachers who lectured in fourth grade and below presented a risk of 20% less than those who lectured from the fifth grade up (P = 0.046). Teachers who reported taking a leave of absence because of their voice had a 32% more chance of a probable perceived voice disorder (P = 0.024). Teachers who presented a common mental disorder had twice the risk of perceived voice disorder (P > 0.001).

CONCLUSIONS

This study concluded that teachers presented a higher risk of developing a perceived voice disorder when they have the following features: lectured from fifth grade up, have gone on leave because of their voice, and showed behavior indicative of common mental disorder.

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.

Functional dysphonia: strategies to improve patient outcomes

Functional dysphonia (FD) refers to a voice problem in the absence of a physical condition. It is a multifaceted voice disorder. There is no consensus with regard to its definition and inclusion criteria for diagnosis. FD has many predisposing and precipitating factors, which may include genetic susceptibility, psychological traits, and the vocal behavior itself. The assessment of voice disorders should be multidimensional. In addition to the clinical examination, auditory-perceptual, acoustic, and self-assessment analyses are very important. Self-assessment was introduced in the field of voice 25 years ago and has produced a major impact in the clinical and scientific scenario. The choice of treatment for FD is vocal rehabilitation by means of direct therapy; however, compliance has been an issue, except for cases of functional aphonia or when an intensive training is administered. Nevertheless, there are currently no controlled studies that have explored the different options of treatment regimens for these patients. Strategies to improve patient outcome involve proper multidisciplinary diagnosis in order to exclude neurological and psychiatric disorders, careful voice documentation with quantitative measurement and qualitative description of the vocal deviation for comparison after treatment, acoustic evaluation to gather data on the mechanism involved in voice production, self-assessment questionnaires to map the impact of the voice problem on the basis of the patient’s perspective, referral to psychological evaluation in cases of suspected clinical anxiety and/or depression, identification of dysfunctional coping strategies, self-regulation data to assist patients with their vocal load, and direct and intensive vocal rehabilitation to reduce psychological resistance and to reassure patient’s recovery. An international multicentric effort, involving a large population of voice-disordered patients with no physical pathology, could produce enough data for achieving a consensus regarding this complex problem.

Behavioral Dysphonia and Depression in Elementary School Teachers

OBJECTIVE/HYPOTHESIS

To verify the relationship between behavioral dysphonia and current depressive episodes in municipal elementary school teachers. We hypothesize that teachers with behavioral dysphonia will be more susceptible to psychiatric disorders.

DESIGN

Cross-sectional study, quantitative, conducted across municipal schools in both rural and urban regions of Pelotas.

METHOD

Five-hundred seventy-five teachers from urban and rural areas of the same Brazilian state were included. The full version of the Voice Handicap Index validated into Brazilian Portuguese was used to determine the presence of behavioral dysphonia. A profile of vocal behaviors was also used to quantify the number of phonotraumatic events. In addition, the Mini-International Neuropsychiatric Interview was used to determine current episodes of depression. Data were analyzed via correlative studies using chi-square and Poisson regression analyses.

RESULTS

Across all teachers, the prevalence of dysphonia was 33.9% and 55% reported that they had already taken a leave because of their voice. Those teachers with a current depressive episode had a higher rate of dysphonia compared with those without depression (prevalence ratio [PR] 1.66; P < 0.000). Teachers who presented with a risk of serious vocal problems had a prevalence ratio of 2.58, indicating a greater proportion of dysphonia, whereas teachers classified as champions of abuse were five times more likely compared with those teachers with behaved or candidates for voice problems.

CONCLUSIONS

There is an association between behavioral dysphonia and current depressive episodes in elementary school teachers.

Estudo de caso: disfonia psicogênica

Disfonia funcional psicogênica possui relação com aspectos psicológicos. O tipo de voz, a articulação e a fluência são sensíveis às oscilações psicológicas. Uma voz em ajuste de falsete paralítico, caracterizada como uma voz de pitch extremamente agudo pode ser encontrada em casos de disfonias psicogênicas. Em qualquer quadro psicogênico é essencial um diagnóstico diferencial, a fim de viabilizar um tratamento fonoaudiológico e médico adequados e efetivos. O prognóstico de uma alteração psicogênica geralmente é bom. O quadro de disfonia psicogênica é mais comum no sexo feminino. O objetivo desse estudo é apresentar a evolução terapêutica de um indivíduo com disfonia psicogênica. A.J.O., 45 anos, sexo masculino, compareceu ao Ambulatório de Avaliação e Terapia de Voz encaminhado por médico otorrinolaringologista. Trouxe a queixa vocal "pela manhã a voz está perfeita, conforme o dia passa, a voz fica fina". Realizou avaliação fonoaudiológica em 18 de abril de 2013, com laudo médico de "mobilidade reduzida de prega vocal esquerda". Tratamento com técnica de sons disparadores, com modificação direta nos sintomas e evolução rápida. Demonstrou-se satisfeito com sua qualidade vocal. Em casos de suspeita de disfonias psicogênicas de conversão, devem-se descartar alterações orgânicas, sendo essencial uma avaliação fonoaudiológica que auxilie no diagnóstico diferencial e provas terapêuticas que incentivem o paciente.

Medically unexplained symptoms and somatisation in ENT

Background:

Somatisation has been described as the perception of a physiological event influenced by emotion.

Method:

A review of the medical literature was carried out using the following Medical Subject Headings: somatisation (which identified 357 articles), medically unexplained symptoms (749 articles), unexplained or idiopathic dizziness (142 articles), tinnitus (360 articles), catarrh (1068 articles) and globus pharyngeus (3114 articles).

Results:

Up to 40 per cent of out-patient attendances have medically unexplainable symptoms. In ENT clinics, this includes patients with dizziness, tinnitus, ‘pseudo’ eustachian tube dysfunction, being ‘unable to hear’, catarrh and postnasal drip, atypical facial pain, globus pharyngeus, and functional dysphonia. Medical explanations of these symptoms often differ from patients' perceptions. Demonstrating normal test results and providing reassurance have little effect on patients' doubts and anxieties. Consultations that recognise the symptoms and their impact, and offer a tangible and involving explanation are more likely to satisfy and empower patients.

Conclusion:

The treatment of medically unexplained symptoms has changed in recent years; there is now more emphasis on psychological factors due to an association with anxiety and depression.

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.