Patients with Selected Voice Disorders Are Subject to Psychiatric Problems

Contact: Kenneth Satterfield(703) 519-1563[email protected]303-228-8460 (9/7-9/12)

PATIENTS WITH SELECTED VOICE DISORDERS ARE SUBJECT TO PSYCHIATRIC PROBLEMS

Researchers suggest further interdisciplinary research between voice specialists, psychiatrists and psychologists is needed.

Denver, CO -- Psychological factors including personality traits and psychiatric illness may be causally related to voice disorders or may be a consequence of vocal dysfunction. Failure to recognize coexistent psychopathology may result not only in errors in voice diagnosis, but may delay treatment and impair long-term cure rates.

Previous research on this subject area has investigated personality variables that may predispose individuals to the development of voice pathology. Findings revealed that personality variables and their behavioral consequences could contribute to voice disorders. A model of predispositional personality types for functional dysphonia and vocal nodules has been established; evaluations of individuals with psychogenic dysphonia found that they share certain neurotic personality traits and social anxiety.

Little is known about the prevalence of major psychiatric illnesses in patients with voice disorders. The purpose of this study was to examine the prevalence of psychiatric illness in patients with voice disorders. This information would complement the research on personality factors described above, leading to a more complete understanding of the interaction between psychopathology and voice disorders.

Natasha Mirza MD, Cesar Ruiz MA-CCC/SLP, Eric D. Baum MD, Jeffrey Staab MD, all with the University of Pennsylvania Medical Center, Philadelphia, PA, authored "Psychiatric Problems in Patients with Voice Disorders." Their findings were presented at the American Academy of Otolaryngology--Head and Neck Surgery Foundation Annual Meeting/OTO Expo being held September 9-12, 2001, at the Colorado Convention Center, Denver, CO.

Methodology: From January to June 2001, 51 consecutive patients presenting to the voice practice were screened for a diagnosis of voice disorders and psychiatric/psychological problems. Patients were administered the:

Voice Handicap Index: a recently developed 30-item self-assessment questionnaire that queries patients about the severity of their physical voice symptoms, as well as functional impairment and general emotional reactions to their voice pathology.

Basic Symptom Inventory, (BSI -- 53): a patient self-report consisting of 53 questions about psychological and physical symptoms {Derogatis}. Patients grade the severity of each symptom from 0 (symptom not present) to 4 (extreme severity). The BSI -- 53 identifies psychiatric patients with clinically significant psychological distress, indicative of an active psychiatric disorder). This gives a reliable estimate of the prevalence of psychopathology in a patient population.

Patients were all examined in the outpatient setting. Patients were grouped into five categories of voice disorders: (1) functional voice disorders, including patients with reflux laryngitis, (2) spasmodic dysphonia, (a spasmodic contraction of the intrinsic muscles of the larynx excited by attempted phonation) (3) vocal cord paralysis, (4) vocal nodules and (5) malignancies of the cords. If two or more diagnoses coexisted, the predominant voice diagnosis was used in the study. A psychiatrist on the voice team evaluated the BSI results, and a speech language pathologist graded the VHI.

Results: Forty-seven of 51 patients (28 women and 19 men with an average age of 49) completed all assessments. Seventeen patients (36.2 percent) had functional dysphonia; 14 (29.8 percent) had spasmodic dysphonia; 11 (23.4 percent) had vocal cord paralysis; three (6.4 percent) had polyps or nodules; and two (4.3 percent) had a malignancy. Because of their number, patients with polyps and malignancies and were excluded from further analyses. There were more women than men in the functional (11/17) and spasmodic dysphonia (10/14) groups, compared to the paralysis (5/11) group, but this difference was not statistically significant. There were no differences in the average age of patients among the groups. The duration of voice complaints for all patients ranged from two weeks to several years.

The prevalence of major psychiatric cases varied considerably among the groups, from a low of seven percent (1/14) for spasmodic dysphonia, to 29.4 percent (5/17) for functional dysphonia, to a high of 63.6 percent (7/11) for vocal cord. (This compares with previous studies that measured psychiatric cases in patients with cancer (35.1 percent), non-cardiac chest pain (48 percent), and medically stable cirrhosis (50 percent)). Key findings included:

* In the spasmodic dysphonia group, there were several moderate, negative correlations (r = -0.42 to -0.57) between the severity of voice and psychiatric symptoms. Those who rated their voice symptoms higher reported less depression, distrust, estrangement from others, and phobic avoidance, though the severity of these psychological symptoms was in the non-pathological range.

* All five patients with functional dysphonia who had a positive BSI reported high levels of interpersonal sensitivity (e.g., feelings being easily hurt) and/or estrangement from or distrust of others. In four of five cases, these symptoms exceeded the levels of anxiety and depression.

* The patients with vocal cord paralysis and psychopathology had symptom profiles consistent with an agitated or anxious depression. Their levels of anxiety, irritability, and somatic preoccupation correlated moderately (r = 0.45 to 0.54) with the severity of their voice symptoms on the physical domain of the VHI.

Conclusion: The researchers suggest their study adds to an emerging literature on the relationship between voice disorders, personality variables, and major psychiatric illnesses. It reinforces recent findings that spasmodic dysphonia is a neurological and/or laryngological disorder, while functional dysphonia may be associated with a distinct set of underlying personality vulnerabilities. Patients with vocal cord paralysis may be at risk for subsequent psychiatric problems. They believe the relationship between psychiatric conditions and voice disorders is complex and warrants further interdisciplinary research between voice specialists, psychiatrists and psychologists. The identification of otolaryngologic-psychiatric interactions is critical for the proper management of these conditions.

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