The prevalence of major psychiatric pathologies in patients with voice disorders.

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)

Results

Complete assessments were available for 47 patients--28 women and 19 men, aged 22 to 84 years (mean: 49.1 [+ or -] 15.4). Seventeen patients (36.2%) had functional dysphonia, 14 (29.8%) had spasmodic dysphonia, 11 (23.4%) had vocal fold paralysis, three (6.4%) had vocal fold polyps or nodules, and two (4.3%) had a vocal fold malignancy (figure 1). Because of the small numbers, patients in the latter two groups were excluded from further analysis.

[FIGURE 1 OMITTED]

More women than men had functional dysphonia (11 and 6, respectively) and spasmodic dysphonia (10 vs 4), and more men than women had vocal fold paralysis (6 vs 5), but none of these differences was statistically significant. There was no difference in the mean ages of the three groups.

The prevalence of major psychiatric disorders varied considerably among the groups: 63.6% (7/11) among those with vocal fold paralysis, 29.4% (5/17) among those with functional dysphonia, and 7.1% (1/14) among patients with spasmodic dysphonia (chi squared = 9.23; degree of freedom = 2; p<0.01) (figure 2). By comparison, others have found that the prevalence of major psychiatric disorders was 35.1% among a large group of cancer patients, (11) 48% among patients with noncardiac chest pain, (12) and 50% among patients with medically stable cirrhosis. (9)

Analysis of the three VHI domains (physical, functional, and emotional) and the nine BSI subscales revealed no statistically significant positive correlations. In fact, in the spasmodic dysphonia group, there were several moderately 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. Even so, the degree of these psychological symptoms was still in the nonpathologic range, indicating that these statistical correlations had little clinical significance.

In contrast, all five patients with functional dysphonia who had a positive BSI reported high levels of interpersonal hypersensitivity (e.g., their feelings were easily hurt) and/or estrangement from or distrust of others. In four of these five patients, these interpersonal symptoms exceeded the levels of anxiety and depression.

The symptom profiles of the seven patients with vocal fold paralysis and psychopathology were consistent with anxiety and depression. Their levels of anxiety, irritability, and somatic preoccupation were moderately correlated (r = 0.45 to 0.54) with the severity of voice symptoms reported on the VHI physical domain.

Discussion

The results of our study complement and extend previous work on the interactions between psychological variables and voice pathology. Previous investigations have identified personality variables that are important risk factors for the development and persistence of certain types of voice pathologies. Our goal was not to define the personality traits associated with vocal pathologies, but to examine the coexistence of voice disorders with major psychiatric illnesses.

Spasmodic dysphonia. The rate of clinically significant psychopathology was quite low for the group of patients with spasmodic dysphonia (7.1%) and consistent with data from emerging research on the biologic etiology of this disorder. As measured by the BSI, all but one of these patients were well adjusted psychologically and able to engage the support of others in the face of their vocal pathology. Furthermore, the absence of clinically meaningful correlations between their voice and psychiatric symptoms suggested that there was no significant causal relationship.

Functional dysphonia. At first glance, the moderate prevalence rate of major psychiatric illness in the functional dysphonia group (29.4%) was surprising, especially in light of the higher rates of psychopathology seen in other medical populations and considering the long-held theories about the psychogenic etiology of these conditions. However, a closer analysis found that the results of our study complement previous work. The BSI is not designed to provide a personality profile, yet the major psychological symptoms reported by functionally dysphonic patients with a positive BSI were indeed relevant personality variables (interpersonal sensitivity, estrangement, mistrust). These are the types of symptoms one would expect to see in a neurotic introvert under stressful situations. Roy and Bless associated this personality type with functional dysphonia. (5) Furthermore, these personality variables were more dominant than other psychological symptoms, which reinforces the theory that the connection between psychopathology and functional dysphonia is within the realm of personality vulnerabilities rather than major psychiatric disorders.

Vocal fold paralysis. The rate of major psychiatric illness among patients with vocal fold paralysis in our study (63.6%) was higher than that reported by Roy et al. (2) In their study, they found no clinically significant depression in patients with vocal fold paralysis. However, they used only a single measure of depression rather than a broader screening tool such as the BSI, and they did not report the severity of voice pathology. In our study, patients with vocal fold paralysis had high rates of major depression mixed with anxiety. The levels of dysphoria, irritability, anxiety, and somatic preoccupation were directly proportional to the severity of voice symptoms. These findings suggest that their psychiatric illness developed secondary to vocal fold dysfunction because there is no plausible mechanism by which depression can initiate true paralysis of the vocal folds. Nevertheless, active psychopathology may exacerbate the morbidity arising from vocal fold paralysis and prolong recovery from dysphonia, which emphasizes the need for prompt recognition and treatment of psychiatric symptoms in these patients. (13) Further research is needed to clarify this relationship.

The BSI proved to be a simple tool to assess psychiatric disorders in patients with voice pathology. It can be included easily as a routine part of voice assessments to identify patients with coexisting psychopathology who need further psychiatric investigation, support, and treatment.

Our report adds to the emerging literature on the relationship between voice disorders, personality variables, and major psychiatric illnesses. It reinforces recent findings that spasmodic dysphonia is a neurologic and/or laryngologic disorder and that functional dysphonia may be associated with a distinct set of underlying personality vulnerabilities. Patients with vocal told paralysis may be at significant risk for psychiatric sequelae. The relationship between psychiatric conditions and voice disorders is complex and warrants further interdisciplinary research by voice specialists, psychiatrists, and psychologists. A more sophisticated understanding of otolaryngologic and psychiatric interactions is critical for the proper management of these conditions.

Functional dysphonia      36.2%
Spasmodic dysphonia       29.8%
Vocal fold paralysis      23.4%
Vocal fold nodules         6.4%
Vocal fold malignancy      4.3%

Figure 1. Chart illustrates the distribution of voice disorders in
the 47 evaluable patients.

Note: Table made from pie chart.

                         Patients with            Patients without
                      psychiatric diagnosis     psychiatric diagnosis

Functional
dysphonia                     29.4%

Spasmodic
dysphonia                      7.1%

Vocal fold
paralysis                     63.6%

Figure 2. Graph shows the numbers of the 42 evaluable patients
with the three most common types of voice disorder who did and
did not have concomitant psychiatric disorders.

References

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(10.) Grassi L, Righi R, Makoui S, et al. Illness behavior, emotional stress and psychosocial factors among asymptomatic HIV-infected patients. Psychother Psychosom 1999:68:31-8.

(11.) Zabora J, BrintzenhofeSzoc K, Curbow B, et al. The prevalence of psychological distress by cancer site. Psychooncology 2001:111:19-28.

(12.) Kane FJ Jr., Strohlein J, Harper RG. Noncardiac chest pain in patients with heart disease. South Med J 1991:84:847-52.

(13.) White A, Deary IJ, Wilson JA. Psychiatric disturbance and personality traits in dysphonic patients. Eur J Disord Commun 1997:32:307-14.

From the Department of Otorhinolaryngology--Head and Neck Surgery (Dr. Mirza, Mr. Ruiz, Dr. Baum, and Dr. Staab), and the Department of Psychiatry (Dr. Staab), University of Pennsylvania, Philadelphia.

Reprint requests: Natasha Mirza, MD, Department of Otorhinolaryngology--Head and Neck Surgery, 5 Ravdin, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Originally presented at a poster session during the annual meeting of the American Academy of Otolaryngology--Head and Neck Surgery, Sept. 9-12, 2001; Denver.