The prevalence of major psychiatric pathologies in patients with voice disorders

Ear, Nose & Throat Journal, Oct, 2003 by Natasha Mirza, Cesar Ruiz, Eric D. Baum, Jeffrey P. Staab

Abstract

We conducted a study of 47 patients with various voice disorders to determine the prevalence of concomitant psychopathology. The prevalence of psychiatric symptoms varied considerably among patients with the three most common voice disorders: 63.6% among patients with vocal fold paralysis, 29.4% among those with functional dysphonia, and 7.1% among those with spasmodic dysphonia. Levels of anxiety and depression correlated moderately with the severity of voice symptoms in patients with vocal fold paralysis, but not in those with functional or spasmodic dysphonia. Certain abnormal personality traits--including interpersonal sensitivity and distrust of others--were more common among patients with functional dysphonia. The low rate of psychopathology among patients with spasmodic dysphonia is consistent with rates reported in previous investigations. Our findings suggest that the prevalence of psychopathology in patients with voice disorders varies according to the specific voice diagnosis, as does the relationship between specific psychiatric and voice symptoms.

Introduction

Psychological factors--including personality traits and psychiatric illness--can be either a cause or a consequence of voice disorders. Failure to recognize coexistent psychopathology can result not only in misdiagnosis of voice problems, but in treatment delay and a reduction in long-term cure rates.

Most of the research in this area has been focused on personality variables that may predispose individuals to the development of voice pathology. Almost 50 years ago, Moses described the complex interaction between voice production, personality, and emotional dynamics. (1) Research by Roy et al has begun to identify different personality profiles for individuals with functional dysphonia, vocal nodules, spasmodic dysphonia, and vocal fold paralysis. (2) These researchers have found that personality variables and their behavioral consequences may contribute to the development of such voice disorders. They also have proposed a model of personality types that are predisposed to functional dysphonia and vocal nodules. Aronson et al (3) and Gerritsma (4) also evaluated patients with psychogenic dysphonia and 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. Historically, most medically unexplained voice disturbances have been conceptualized as conversion disorders, although the data are largely theoretical and anecdotal. More recent investigations have focused on the possibility that patients with voice disorders--particularly functional dysphonia--develop a conditioned hypersensitivity to pharyngeal and laryngeal sensations, suggesting that hypersensitivity to somatic sensations may play a critical role in anxiety disorders. (5) Depression and anxiety disorders also may develop as a consequence of voice pathology, but only limited data address this possibility.

The purpose of our study was to examine the prevalence of major psychiatric illness in patients with voice disorders. We believe that such information can complement research on the personality factors described earlier and lead to a more complete understanding of the interaction between psychopathology and voice disorders.

Patients and methods

Between Jan. 1 and June 30, 2001, we screened 51 consecutive patients who came to the voice practice of the lead author (N.M.). Our goal was to look for an association between their voice disorders and psychopathology. Both new and returning patients were included; the duration of their voice complaints ranged from 2 weeks to several years. All were examined in the outpatient setting. Information on only one visit was recorded for the purposes of this study, and post-treatment results were not included in the final analysis.

Patients underwent a complete otolaryngologic examination and were then grouped into one of five categories, based on the type of their voice disorder: (1) functional voice disorders, including reflux laryngitis, (2) spasmodic dysphonia, (3) vocal fold paralysis, (4) vocal fold nodules, and (5) vocal fold malignancies. When a patient had two or more voice conditions, the predominant diagnosis was used for the purposes of this study. Patients were then assessed by the Voice Handicap Index (VHI) (6) and the Brief Symptom Inventory (BSI). (7)

The VHI is a recently developed screening aid. VHI values are determined on the basis of answers to a 30-item self-assessment questionnaire regarding the severity of physical voice symptoms, the degree of functional impairment, and general emotional reactions to voice pathology (10 questions each). Patients rate the frequency of each of their symptoms on a scale from 0 (never) to 4 (always). The VHI produces three separate scores--all ranging from 0 to 40--for the physical, functional, and emotional domains of the VHI.

The BSI is also a self-report in which patients answer 53 questions about their psychological and physical symptoms. Patients grade the severity of each symptom from 0 (not present) to 4 (extremely severe). The BSI includes nine subscales and three global scales, each with established population norms. A BSI is considered positive when scores on two or more subscales or on at least one global scale exceed their respective population norms by more than one standard deviation. When used in this way, the BSI identifies "psychiatric caseness" (i.e., the presence of clinically significant psychological distress that is indicative of an active psychiatric disorder). The BSI provides a reliable estimate of the prevalence of psychopathology in a given population. Symptom profiles reflecting the major categories of psychiatric illnesses (e.g., depressive disorders) can be derived from subscale items. The BSI features excellent internal consistency, external validity, and test-retest reliability. It has been used to estimate the prevalence of psychiatric disorders in patients with a variety of physical ailments (8-11) as well as those with medically unexplained physical symptoms. (12)