- Email: [email protected]
Personality, anxiety and functional dysphonia
Personality and Individual Differences 39 (2005) 1441–1449 www.elsevier.com/locate/paid
Personality, anxiety and functional dysphonia Ulrike Willinger a
a,*
, Harald N. Aschauer
b
University Ear, Nose and Throat Clinic, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria b Department of General Psychiatry, University Hospital for Psychiatry, Vienna, Austria Received 30 November 2004; accepted 14 June 2005 Available online 8 August 2005
Abstract Psychological factors are considered for the predisposition and perpetuation of functional dysphonia. In the present study 61 patients with functional dysphonia were compared with 61 healthy controls, matched by age, sex, and occupation with respect to CloningerÕs personality model, mood, and anxiety. The patients with functional dysphonia presented significantly higher scores than the healthy controls with respect to ‘‘harm avoidance’’ (HA); depressive symptoms; symptoms of unspecific and general anxiety; symptoms of specific anxiety concerning ‘‘health’’, ‘‘illness’’, and ‘‘extraversion versus introversion’’. No significant differences were found in ‘‘novelty seeking’’ (NS), ‘‘reward dependence’’ (RD), ‘‘persistence’’ (PE), or in state-anxiety and anxiety of social situations. These results were found considering univariate and multivariate analyses and confirm the relationship of psychological factors such as personality traits, mood, and anxiety on one hand and conversion disorder in general and functional dysphonia in particular on the other hand. This important relationship should be considered in the diagnostic and therapeutic interventions of functional dysphonia. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: Functional dysphonia; Conversion disorder; Symptoms of depression; Symptoms of anxiety; Personality
*
Corresponding author. Tel.: +43 1 40400 3335; fax: +43 1 40400 3332. E-mail address: [email protected] (U. Willinger).
0191-8869/$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2005.06.011
1442
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1. Introduction Functional dysphonia is described by complaints of vocal weakness and discomfort in the throat (Aronson, 1990) and complaints of voice change such as hoarseness, huskiness, and jerkiness in the absence of a structural or neurological abnormality of the larynx (Scott, Deary, Mackenzie, & Wilson, 1997; Wilson, Deary, Scott, & MacKenzie, 1995). In the ‘‘diagnostic and statistical manual of mental disorders (DSM-IV)’’ of the American Psychiatric Association (1994) functional dysphonia is diagnosed as ‘‘somatoform disorders, conversion disorder with motor symptom or deficit’’ (300.11). Psychological factors are considered for the predisposition and perpetuation of functional dysphonia: House and Andrews (1987) pointed out that a third of 71 patients with functional dysphonia received diagnoses of mood, anxiety, or adjustment disorders. In a previous analysis of the present data base we found that patients with functional dysphonia showed significantly higher scores than the healthy controls with respect to depressive symptoms, symptoms of unspecific and general anxiety, and symptoms of specific anxiety concerning health and somatic complains (Willinger, Vo¨lkl-Kernstock, & Aschauer, 2005). According to Andersson and Schalen (1998) it is generally accepted that functional dysphonia is a result of psychosocial stress. They stated that functional dysphonia may be interpreted as a somatic reaction to emotional problems, although the pathogenetic mechanisms are still far from being well understood. Many of the patients in their study seem to have poor abilities to cope with social stress; they expressed such features as helplessness and an inability to manage their life situation, assert themselves, and hold their own. The patients also had a poor social network and low professional status, and they complained of an inability to express themselves verbally. The authors proposed that functional dysphonia should be considered as a disorder of a particular aspect of communication—a disturbed capacity for emotional verbal expression. Mans (1993) considered the voice symptom as a creative achievement of the patient to cope with an internal conflict by using the ego function of speaking in the social context. So, functional dysphonics display a remarkable sensitivity and variability towards psychosocial factors and an often immediate connection with the underlying psychic conflict constellation (Mans, 1994). House and Andrews (1987) stated that a significantly high proportion of patients with functional dysphonia had experienced a difficulty or event that involved conflict over speaking out. Therefore, in the present study we were interested in the expression of symptoms of specific anxiety concerning illness and social situations. According to Nichol, Morrison, and Rammage (1993) personality factors may predispose the patient to dysphonia. Gerritsma (1991) reported that 41% of 82 aphonic and dysphonic patients had significantly high scores on a neuroticism scale. Kinzel, Biebl, and Rauchegger (1988) found alexithymic traits (inability to differentiate emotions sufficiently or to express them adequately in words, lack of fantasies, impoverished imagination, inability to cope with aggressions in an adequate way) in patients with functional dysphonia. House and Andrews (1987) however, suggest that functional dysphonia is usually not found in markedly abnormal personalities. The results as to the influence of personality traits on functional dysphonia seemed to be contradictory. However, in the present study we were interested in the impact of the ‘‘Unified Biosocial Personality Model’’ (Cloninger, 1987a; Cloninger, Svrakic, & Przybeck, 1993) on functional dysphonia as a conversion disorder (a subtype of somatoform disorder), because this kind of
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1443
personality model was investigated in patients with somatization disorder (another subtype of somatoform disorder) and higher scores of one dimension of the model (‘‘novelty seeking’’) were found in those patients (Battaglia, Bertella, Bajo, Politi, & Bellodi, 1998). Battaglia et al. (1998) stated that although somatization disorder is considered to be a prototype of a somatoform disorder, differences requiring further research may well exist between patients with somatization disorder and individuals with other clinical presentations of somatoform disorder. The ‘‘Unified Biosocial Personality Model’’ is a neurobiologically based operant learning model to guide the rational development of descriptors for temperament that was developed by Cloninger (Cloninger, 1987a; Cloninger et al., 1993). He hypothesized the four independent multifaceted, higher-order temperament dimensions ‘‘novelty seeking’’ (NS), ‘‘harm avoidance’’ (HA), ‘‘reward dependence’’ (RD), and ‘‘persistence’’ (PE). These four dimensions of personality seemed to be influenced by basic emotional dispositions, several studies showed different associations between mood disorders and anxiety on the one hand and NS, HA and RD on the other in psychiatric outpatients in general (Brown, Svrakic, Przybeck, & Cloninger, 1992), and especially in patients with social phobia (Kim & Hoover, 1996) and alcohol dependence (Meszaros et al., 1996) but also in non-psychiatric subjects (Krebs, Weyers, & Janke, 1998; Stewart, Ebmeier, & Deary, 2005). Personality dimensions such as NS and RD seemed to covariate only minimally with current mood and seemed to be independent of mood state and feelings, HA and the subscales of HA seemed to be influenced by depression and anxiety (Brown et al., 1992), significantly higher scores in HA and significantly lower scores in PE were found in patients with social phobia compared to healthy controls (Kim & Hoover, 1996). Therefore, the third aim of the present study was to analyze multivariate differences between the patients with functional dysphonia and the healthy controls with respect to personality, mood and anxiety. In detail, the following three research questions were considered: (1) Are there significant univariate differences between patients with functional dysphonia and healthy controls with respect to specific anxiety concerning illness and social situations? (2) Are there significant univariate differences between patients with functional dysphonia and healthy controls with respect to the four dimensions of CloningerÕs personality model? (3) Are there significant multivariate differences between patients with functional dysphonia and healthy controls with respect to the four dimensions of CloningerÕs personality model, mood and anxiety?
2. Methods 2.1. Subjects Sixty-one patients with complaints of vocal weakness and discomfort in the throat were consecutively recruited and examined at the Department of Phoniatrics and Logopedics of the University Ear, Nose and Throat Clinic of Vienna. All patients received laryngoscopic and phonic examinations for exclusion of organic impairment and fulfilled the DSM-IV (American Psychiatric Association, 1994) criteria of conversion disorder, mainly characterized by one or more symptoms or deficits affecting voluntary motor or sensory function without neurological or general
1444
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
medical condition, which are causing clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants of medical evaluation and are not intentionally produced or feigned. Sixty-one controls without voice pathology and without former ENT, phoniatric, speech or psychiatric treatment were recruited mainly at schools and kindergartens and through a circle of acquaintances of students and were matched for age, sex, and occupation. Both samples consisted of 48 (79%) female and 13 (21%) male patients. Consistent with the literature (American Psychiatric Association, 1994), sex distribution showed a significant majority of female patients (v2 = 20.082; df = 1; p 6 0.0001). The mean age of the patients and the controls when they entered the study was 36 years (SD = 13 years). About half of the patient sample and the control sample had a voice-demanding occupation—28% were teachers, 7% kindergarten teachers and 12% salespeople—and reported dependence on the voice in their professional life. All of the patients and controls participated voluntarily and without financial reward after informed consent was obtained. Selection procedure for the samples of patients and controls has been described in detail in a previous paper (Willinger et al., 2005). 2.2. Measures Anamnestic data regarding sociodemographic particulars; information about former treatments, including ENT, phoniatric (e.g. surgery of larynx), speech, and psychiatric treatments; details of onset; and course of functional dysphonia (e.g. duration, remissions) were evaluated according to a standardized interview. The ‘‘Unified Biosocial Personality Model’’, which is operationalized by the four temperamental dimensions ‘‘novelty seeking’’ (NS), ‘‘harm avoidance’’ (HA), ‘‘reward dependence’’ (RD), and ‘‘persistence’’ (PE), was measured by the German version (Aschauer et al., 1994) of the selfadministered ‘‘Tridimensional Personality Questionnaire’’ (TPQ) (Cloninger, 1987b). NS is defined by being quick-tempered, exploratory, excitable, curious, enthusiastic, exuberant, easily bored, impulsive, and disorderly. HA is covered by being cautious, careful, tense, fearful, apprehensive, nervous, timid, doubtful, discouraged, passive, insecure, negativistic, or pessimistic even in situations that do not worry other people. RD is defined by being tender-hearted, warm and loving, dedicated, sensitive, dependent, and sociable. PE is represented by being industrious, hard-working, persistent, and stable despite frustration and fatigue. The German version revealed Cronbachs alpha coefficients between 0.57 and 0.65, stability over time (3 months) between 0.62 and 0.79. External validity showed that 68% of patients with schizophrenia and healthy controls were classified correctly by NS and HA (Aschauer et al., 1994). Depressive symptoms were measured by the German version (Hautzinger, Bailer, Worall, & Keller, 1995) of the self-rated ‘‘Beck Depression Inventory’’ (Beck & Steer, 1987). Information about the symptoms of unspecific and generalized anxiety (e.g. ‘‘I feel insecure’’, ‘‘I feel anxious’’, ‘‘I feel nervous’’, ‘‘I am jittery’’) was obtained by means of the German version (Laux, Glanzmann, Schaffner, & Spielberger, 1981) of the self-ratable ‘‘State-Trait-Anxiety Inventory’’ (Spielberger, Gorusch, & Lushene, 1970), which enables anxiety to be quantified both as a time- and situation-related state (X1) and as a comparatively stable personality trait (X2). Information about the symptoms of specific anxiety concerning health and social interactions was assessed by the three different scales ‘‘somatic complaints’’ (FPI-8), ‘‘health concern’’ (FPI-9), and ‘‘extraversion versus introversion’’ (FPI-11) of the self-ratable ‘‘Freiburg Personality Inven-
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1445
tory’’ (Fahrenberg, Hampel, & Selg, 1994). ‘‘Somatic complaints’’ ranges from having many somatic complaints and being psychosomatically disturbed to having few somatic complaints and not being psychosomatically disturbed (e.g. ‘‘I often have a headache’’, ‘‘I sometimes have an accelerated heart rate’’, ‘‘I am often constipated’’, ‘‘I often have chest pain or discomfort’’). ‘‘Health concern’’ ranges from being afraid of illness, being conscious about health, and treating oneself with care not to be worried about health, being unconcerned about health, and feeling robust (e.g. ‘‘I am informed on the most widespread diseases and their first signs’’; ‘‘If I have a disease, I would like to consult a second doctor’’; ‘‘I consult a doctor regularly, also without serious complaints, only for caution’’; ‘‘I avoid eating unwashed fruits’’). ‘‘Extraversion versus introversion’’ ranges from being extraverted, sociable, impulsive, and enterprising to being introverted, reserved, reflective, and serious (e.g. ‘‘I am able to entertain a big society’’, ‘‘In society or at public events I prefer to be in the background’’, ‘‘I am very slow in contracting a new friendship’’). Information about anxiety concerning illness and social situations was obtained by means of the self-ratable ‘‘Interaction-Anxiety Questionnaire’’ (Becker, 1997). It consists of six different subscales that are summed up to two higher order factors. The first factor, ‘‘illness-anxiety’’, is covered by fear of physical injury, fear of illness, and fear of medical treatment (e.g. ‘‘How un-/pleasant is it for you . . .’’: ‘‘. . . if you are assuming that someone is following you in the darkness’’, ‘‘. . . if you are receiving anonymous letters with threats of physical violence’’, ‘‘. . . if you have to go to the hospital for some time’’, ‘‘. . . if you are standing in a group of persons and you notice that one of them has an infectious illness’’). The second factor, ‘‘anxiety of social situations’’ is covered by fear of social scenes, fear of transgressing social standards, anxiety over self-competence, and fear of social devaluation and inferiority (e.g. ‘‘How un-/pleasant is it for you . . .’’: ‘‘. . . if your boss is watching you while you are working’’, ‘‘. . . if you should speak in front of many people’’, ‘‘. . . if you remember that you once lied to your best friend’’, ‘‘. . . if you should complain about bad treatment in an restaurant’’, ‘‘. . . if you realize that other people are laughing about you’’). 2.3. Statistical analyses Distribution of sex within the patient sample was analyzed for significance by the chi-square test. Univariate group differences between patients and matched controls were tested for significance by univariate t-tests for paired samples. Discriminant analysis was used for multivariate group differences between patients and controls regarding those variables of the four personality traits, mood, and anxiety, which were significantly different between patients and controls in the univariate analyses of the present and a previous study (Willinger et al., 2005). The cut-off level for statistical significance was set at p < 0.05, 2-tailed. All statistical analyses were performed by SPSS for Windows, Version 10.0.
3. Results Patients with functional dysphonia scored significantly lower in ‘‘extraversion versus introversion’’ (t-value = 12.28; df = 56; p 6 0.001) and significantly higher in ‘‘fear of illness’’
1446
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
Table 1 Means, standard deviations and significance of personality traits, symptoms of anxiety and depression in patients with functional dysphonia and healthy controls Variables a
Novelty seeking (TPQ) Harm avoidance (TPQ)a Reward dependence (TPQ)a Persistence (TPQ)a Extraversion vs introversion (FPI-R)b Fear of illness (IAF)a Fear of social situations (IAF)a Depressive symptoms (BDI)a,c State-anxiety (STAI-X1)a,c Trait-anxiety (STAI-X2)a,c Somatic complaints (FPI-R)a,c Health concern (FPI-R)a,c
Patients (n = 61)
Controls (n = 61)
Mean
Mean
SD
Significance
SD
15.3 15.6 14.0 4.5
5.2 6.2 3.5 2.1
16.7 11.7 13.7 4.2
5.1 5.0 3.6 1.8
n.s. s. n.s. n.s.
7.8 83.6 121.6
2.4 13.1 18.9
11.9 78.3 116.5
0.7 10.6 19.6
s. s. n.s.
9.3 38.9 40.7 4.3 5.8
7.4 12.3 11.3 2.9 2.7
4.2 35.1 35.5 2.4 4.8
4.1 9.5 9.6 2.0 2.7
s. n.s. s. s. s.
s.: significant (p < 0.05), n.s.: not significant. a Higher values show higher tendencies in variables. b Higher values show more extraversion, lower values show more introversion. c See Willinger et al. (2005).
(t-value = 2.29; df = 58; p 6 0.026). No significant difference was found in ‘‘fear of social situations’’ (t-value = 1.58; df = 58; p = 0.119). Moreover, the patients showed significantly higher scores than healthy controls with respect to ‘‘harm avoidance’’ (t-value = 3.85; df = 58; p 6 0.001). No significant differences were found in NS (t-value = 1.47; df = 58; p = 0.146), RD (t-value = 0.4; df = 58; p = 0.69) and PE (t-value = 0.79; df = 58; p = 0.432). Numerical details of these results and of those previous statistical analyses of the present data (Willinger et al., 2005) which were used for the following discriminant analysis are given in Table 1. Multivariate group comparisons between the patients and the controls showed significant differences between the two groups (canonical correlation = 0.5; Wilks k = 0.8; v2 = 28.6; df = 7; p 6 0.0001). Seventy-three percentage of the patients and controls were classified correctly by personality, mood, and anxiety. The correlations between the discriminant variables and the standardized canonical discriminant function showed high values with respect to the depressive symptoms (r = 0.8), to specific anxiety concerning somatic complaints (r = 0.7), and HA (r = 0.6), modest values with respect to specific anxiety concerning illness (r = 0.4) and health (r = 0.4), and low values with respect to general anxiety (r = 0.2) and ‘‘extraversion versus introversion’’ (r = 0.008).
4. Discussion Personality factors may predispose patients to dysphonia (Nichol et al., 1993). In the current study we investigated patients with functional dysphonia and their control cohorts by means of the ‘‘Unified Biosocial Personality Model’’, operationalized by the TPQ. Significant differences
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1447
were found in one dimension of the TPQ, namely HA. Patients with functional dysphonia tend to be cautious, careful, tense, fearful, apprehensive, nervous, timid, doubtful, discouraged, passive, insecure, negativistic, and pessimistic even in situations that do not worry other people. In the other three temperament dimensions—NS, RD, and PE—there were no significant differences. Patients and controls seem to have similar tendencies towards intense excitement to novel stimuli, exploratory activity, reward, succor, and perseverance despite frustration and fatigue. In the literature there are contradictory results regarding personality in functional dysphonia. House and Andrews (1987) identified only 2 patients with personality disorder (histrionic) among 71 patients with functional dysphonia. Personality disorder may be too strong a criterion to look for; it may be better to look for characteristic personality traits. White, Deary, and Wilson (1997) stated that patients with functional dysphonia showed a greater degree of mild psychiatric disturbance but no significant differences in personality traits compared to patients with dysphonia associated with structural laryngeal abnormality and to ENT outpatient controls; patients with functional dysphonia did not show unusual levels of neuroticism, extraversion or hysteroid traits. Otherwise, according to Scott et al. (1997) psychological and social factors seem to play an important role in the initiation and perpetuation of functional dysphonia. Bauer (1991) found that functional dysphonia often appeared as an unspecific reaction to emotional disturbances. Gerritsma (1991) reported high scores in two scales, neuroticism and neurotic somatization, which measure the neurotic instability that manifests itself in the expression of psychoneurotic and functional physical complaints. According to Roy et al. (1997) the patients with functional dysphonia showed emotional adjustment problems despite successful voice management. These patients considered themselves as people who to a significantly greater degree than others deny good health and report a variety of vague somatic symptoms; are pessimistic, dissatisfied, sad, suspicious, interpersonally sensitive, diffusedly anxious, and confused; adhere rigidly to ideas and attitudes; and tend to engage in denial, withdraw socially, and be insecure and anxious when in contact with others. In the current study we found significant differences in anxiety concerning illness. The patients with functional dysphonia showed significantly higher scores than healthy controls with respect to fear of physical injury, fear of illness, and fear of medical treatment. We did not find any significant differences in fear of social situations, which encompasses fear of social scenes, fear of transgressing social standards, fear of inadequate self-competence, and fear of social devaluation and inferiority, but we did find such a difference regarding behavior in social situations: the patients with functional dysphonia considered themselves to be introverted, reserved, reflective, and serious. According to Nichol et al. (1993) the ‘‘. . . voice of an individual is a very sensitive indicator of attitudes, emotions, and role assumptions. It is a major component in social interactions. Therefore it is not surprising that impairments of voice function are not uncommon accompaniments of psychological conflicts’’. According to Butcher (1995) functional dysphonia arises mostly in women who tend to assume an above average number of responsibilities; who are frequently caught up in family and interpersonal relationship difficulties; who find it hard to express their emotions, especially negative feelings; and who have difficulties in asserting themselves. Inefficient assertiveness may contribute to feelings of powerlessness and helplessness which might be associated with emotional disturbance and conditions of anxiety and depression.
1448
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
Multivariate group comparisons between the patients and the controls showed significant differences between the two groups. Seventy-three percentage of the patients and controls were classified correctly by personality, mood, and anxiety, especially by depressive symptoms, somatic complaints, and HA. These results emphasized the relationship between personality, mood and anxiety which were found in several studies about associations between mood disorders and anxiety on the one hand and NS, HA and RD on the other (Brown et al., 1992; Kim & Hoover, 1996; Krebs et al., 1998; Meszaros et al., 1996; Stewart et al., 2005). However, the multivariate and univariate results indicate that personality, mood and anxiety should be considered not only in the diagnostic of functional dysphonia but also in the therapeutic interventions. Summing up: When compared to healthy controls, the patients with functional dysphonia showed a significantly higher tendency to respond intensely to aversive stimuli and to avoid punishment, novelty, and non-reward. Moreover, the patients presented significantly higher scores than the healthy controls with respect to specific anxiety concerning illness and social situations by reporting higher fear of physical injury, fear of illness, and fear of medical treatment and by considering themselves to be introverted, reserved, reflective, and serious. These results were found considering univariate and multivariate analyses and confirm the relationship of psychological factors such as personality traits and anxiety on one hand and conversion disorder in general and functional dysphonia in particular on the other hand. This important relationship should be considered in the diagnostic and therapeutic interventions of functional dysphonia.
References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Andersson, K., & Schalen, L. (1998). Etiology and treatment of psychogenic voice disorder: results of a follow-up study of thirty patients. Journal of Voice, 12, 96–106. Aronson, A. E. (1990). Clinical voice disorders (3rd ed.). New York: Thieme Inc. Aschauer, H. N., Meszaros, K., Willinger, U., Fischer, G., Berger, P., Reiter, E., et al. (1994). Tridimensional Personality Questionnaire: Ergebnisse zu Gu¨tekriterien der deutschen Version des Fragebogens. Neuropsychiatrie, 8, 177–181. Battaglia, M., Bertella, S., Bajo, S., Politi, E., & Bellodi, L. (1998). An investigation of the co-occurrence of panic and somatization disorders through temperamental variables. Psychosomatic Medicine, 60, 726–729. Bauer, H. H. (1991). Zur Definition psychogener Stimmsto¨rungen. Laryngo-Rhino-Otologie, 70, 102–104. Beck, A. T., & Steer, R. A. (1987). Beck depression inventory—manual. San Antonio: The Psychological Corporation. Becker, P. (1997). Interaktions-Angst-Fragebogen. Go¨ttingen: Beltz-Verlag. Brown, S. L., Svrakic, D. M., Przybeck, T. R., & Cloninger, C. R. (1992). The relationship of personality to mood and anxiety states: a dimensional approach. Journal of Psychiatric Research, 26, 197–211. Butcher, P. (1995). Psychological process in psychogenic voice disorder. European Journal of Disordered Communication, 30, 467–474. Cloninger, C. R. (1987a). A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry, 44, 573–588. Cloninger, C. R. (1987b). Tridimensional Personality Questionnaire (TPQ) (version 4). St Louis, MO: Washington University Medical School, Department of Psychiatry. Cloninger, C. R., Svrakic, D. M., & Przybeck, T. R. (1993). A psychobiological model of temperament and character. Archives of General Psychiatry, 50, 975–989.
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1449
Fahrenberg, J., Hampel, R., & Selg, H. (1994). Das Freiburger Perso¨nlichkeitsinventar (FPI). In Revidierte Fassung und teilweise gea¨nderte Fassung FPI-A1. Handanweisung. Go¨ttingen–Toronto–Zu¨rich: Verlag fu¨r Psychologie, Dr. C. J. Hogrefe. Gerritsma, E. J. (1991). An investigation into some personality characteristics of patients with psychogenic aphonia and dysphonia. Folia Phoniatrica, 43, 13–20. Hautzinger, M., Bailer, M., Worall, H., & Keller, F. (1995). Beck-Depressions-Inventar (BDI). Bern–Go¨ttingen– Toronto–Seattle: Verlag Hans Huber. House, A., & Andrews, H. (1987). The psychiatric and social characteristics of patients with functional dysphonia. Journal of Psychosomatic Research, 31, 483–490. Kim, S. W., & Hoover, K. M. (1996). Tridimensional personality questionnaire: assessment in patients with social phobia and a control group. Psychological Reports, 78, 43–49. Kinzel, J., Biebl, W., & Rauchegger, H. (1988). Functional aphonia. A conversion symptom as defensive mechanism against anxiety. Psychotherapy Psychosomatic, 49, 31–36. Krebs, H., Weyers, P., & Janke, W. (1998). Validation of the German version of CloningerÕs TPQ: replication and correlations with stress coping, mood measures and drug use. Personality and Individual Differences, 24, 805–814. Laux, L., Glanzmann, P., Schaffner, P., & Spielberger, C. D. (1981). Das State-Trait-Angstinventar. Theoretische Grundlagen und Handanweisung. Weinheim: Beltz Testgesellschaft. Mans, E. J. (1993). The psychosomatic interview in diagnosis of functional voice disorders. Folia Phoniatr Basel, 45, 105–111. Mans, E. J. (1994). Psychotherapeutic treatment of patients with functional voice disorders. Folia Phoniatrica Logopedica, 46, 1–8. Meszaros, K., Willinger, U., Fischer, G., Scho¨nbeck, G., Aschauer, H. N., & on behalf of The European Fluvoxamine in Alcoholism Study Group (1996). The tridimensional personality model: influencing variables in a sample of detoxified alcohol dependents. Comprehensive Psychiatry, 37, 109–114. Nichol, H., Morrison, M. D., & Rammage, L. A. (1993). Interdisciplinary approach to functional voice disorders: the psychiatristÕs role. Otolaryngology—Head and Neck Surgery, 108, 643–647. Roy, N., McGrory, J. J., Tasko, S. M., Bless, D. M., Heisey, D., & Ford, C. N. (1997). Psychological correlates of functional dysphonia: an investigation using the Minnesota Multiphasic Personality Inventory. Journal of Voice, 11, 443–451. Scott, S., Deary, I. J., Mackenzie, K., & Wilson, J. A. (1997). Functional dysphonia: a role for psychologists? Psychology, Health & Medicine, 2, 169–180. Spielberger, C. D., Gorusch, R. L., & Lushene, R. E. (1970). Manual for the state-trait anxiety inventory (STAI). Palo Alto: Consulting Psychologists Press Inc. Stewart, M. E., Ebmeier, K. P., & Deary, I. J. (2005). Personality correlates of happiness and sadness: EPQ-R and TPQ compared. Personality and Individual Differences, 38, 1085–1096. White, A., Deary, I. J., & Wilson, J. A. (1997). Psychiatric disturbance and personality traits in dysphonic patients. European Journal of Disordered Communication, 32, 307–314. Willinger, U., Vo¨lkl-Kernstock, S., & Aschauer, H. N. (2005). Marked depression and anxiety in patients with functional dysphonia. Psychiatry Research, 134, 85–91. Wilson, J. A., Deary, I. J., Scott, S., & MacKenzie, K. (1995). Functional dysphonia. British Medical Journal, 311, 1039–1040.
Personality, anxiety and functional dysphonia Ulrike Willinger a
a,*
, Harald N. Aschauer
b
University Ear, Nose and Throat Clinic, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria b Department of General Psychiatry, University Hospital for Psychiatry, Vienna, Austria Received 30 November 2004; accepted 14 June 2005 Available online 8 August 2005
Abstract Psychological factors are considered for the predisposition and perpetuation of functional dysphonia. In the present study 61 patients with functional dysphonia were compared with 61 healthy controls, matched by age, sex, and occupation with respect to CloningerÕs personality model, mood, and anxiety. The patients with functional dysphonia presented significantly higher scores than the healthy controls with respect to ‘‘harm avoidance’’ (HA); depressive symptoms; symptoms of unspecific and general anxiety; symptoms of specific anxiety concerning ‘‘health’’, ‘‘illness’’, and ‘‘extraversion versus introversion’’. No significant differences were found in ‘‘novelty seeking’’ (NS), ‘‘reward dependence’’ (RD), ‘‘persistence’’ (PE), or in state-anxiety and anxiety of social situations. These results were found considering univariate and multivariate analyses and confirm the relationship of psychological factors such as personality traits, mood, and anxiety on one hand and conversion disorder in general and functional dysphonia in particular on the other hand. This important relationship should be considered in the diagnostic and therapeutic interventions of functional dysphonia. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: Functional dysphonia; Conversion disorder; Symptoms of depression; Symptoms of anxiety; Personality
*
Corresponding author. Tel.: +43 1 40400 3335; fax: +43 1 40400 3332. E-mail address: [email protected] (U. Willinger).
0191-8869/$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2005.06.011
1442
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1. Introduction Functional dysphonia is described by complaints of vocal weakness and discomfort in the throat (Aronson, 1990) and complaints of voice change such as hoarseness, huskiness, and jerkiness in the absence of a structural or neurological abnormality of the larynx (Scott, Deary, Mackenzie, & Wilson, 1997; Wilson, Deary, Scott, & MacKenzie, 1995). In the ‘‘diagnostic and statistical manual of mental disorders (DSM-IV)’’ of the American Psychiatric Association (1994) functional dysphonia is diagnosed as ‘‘somatoform disorders, conversion disorder with motor symptom or deficit’’ (300.11). Psychological factors are considered for the predisposition and perpetuation of functional dysphonia: House and Andrews (1987) pointed out that a third of 71 patients with functional dysphonia received diagnoses of mood, anxiety, or adjustment disorders. In a previous analysis of the present data base we found that patients with functional dysphonia showed significantly higher scores than the healthy controls with respect to depressive symptoms, symptoms of unspecific and general anxiety, and symptoms of specific anxiety concerning health and somatic complains (Willinger, Vo¨lkl-Kernstock, & Aschauer, 2005). According to Andersson and Schalen (1998) it is generally accepted that functional dysphonia is a result of psychosocial stress. They stated that functional dysphonia may be interpreted as a somatic reaction to emotional problems, although the pathogenetic mechanisms are still far from being well understood. Many of the patients in their study seem to have poor abilities to cope with social stress; they expressed such features as helplessness and an inability to manage their life situation, assert themselves, and hold their own. The patients also had a poor social network and low professional status, and they complained of an inability to express themselves verbally. The authors proposed that functional dysphonia should be considered as a disorder of a particular aspect of communication—a disturbed capacity for emotional verbal expression. Mans (1993) considered the voice symptom as a creative achievement of the patient to cope with an internal conflict by using the ego function of speaking in the social context. So, functional dysphonics display a remarkable sensitivity and variability towards psychosocial factors and an often immediate connection with the underlying psychic conflict constellation (Mans, 1994). House and Andrews (1987) stated that a significantly high proportion of patients with functional dysphonia had experienced a difficulty or event that involved conflict over speaking out. Therefore, in the present study we were interested in the expression of symptoms of specific anxiety concerning illness and social situations. According to Nichol, Morrison, and Rammage (1993) personality factors may predispose the patient to dysphonia. Gerritsma (1991) reported that 41% of 82 aphonic and dysphonic patients had significantly high scores on a neuroticism scale. Kinzel, Biebl, and Rauchegger (1988) found alexithymic traits (inability to differentiate emotions sufficiently or to express them adequately in words, lack of fantasies, impoverished imagination, inability to cope with aggressions in an adequate way) in patients with functional dysphonia. House and Andrews (1987) however, suggest that functional dysphonia is usually not found in markedly abnormal personalities. The results as to the influence of personality traits on functional dysphonia seemed to be contradictory. However, in the present study we were interested in the impact of the ‘‘Unified Biosocial Personality Model’’ (Cloninger, 1987a; Cloninger, Svrakic, & Przybeck, 1993) on functional dysphonia as a conversion disorder (a subtype of somatoform disorder), because this kind of
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1443
personality model was investigated in patients with somatization disorder (another subtype of somatoform disorder) and higher scores of one dimension of the model (‘‘novelty seeking’’) were found in those patients (Battaglia, Bertella, Bajo, Politi, & Bellodi, 1998). Battaglia et al. (1998) stated that although somatization disorder is considered to be a prototype of a somatoform disorder, differences requiring further research may well exist between patients with somatization disorder and individuals with other clinical presentations of somatoform disorder. The ‘‘Unified Biosocial Personality Model’’ is a neurobiologically based operant learning model to guide the rational development of descriptors for temperament that was developed by Cloninger (Cloninger, 1987a; Cloninger et al., 1993). He hypothesized the four independent multifaceted, higher-order temperament dimensions ‘‘novelty seeking’’ (NS), ‘‘harm avoidance’’ (HA), ‘‘reward dependence’’ (RD), and ‘‘persistence’’ (PE). These four dimensions of personality seemed to be influenced by basic emotional dispositions, several studies showed different associations between mood disorders and anxiety on the one hand and NS, HA and RD on the other in psychiatric outpatients in general (Brown, Svrakic, Przybeck, & Cloninger, 1992), and especially in patients with social phobia (Kim & Hoover, 1996) and alcohol dependence (Meszaros et al., 1996) but also in non-psychiatric subjects (Krebs, Weyers, & Janke, 1998; Stewart, Ebmeier, & Deary, 2005). Personality dimensions such as NS and RD seemed to covariate only minimally with current mood and seemed to be independent of mood state and feelings, HA and the subscales of HA seemed to be influenced by depression and anxiety (Brown et al., 1992), significantly higher scores in HA and significantly lower scores in PE were found in patients with social phobia compared to healthy controls (Kim & Hoover, 1996). Therefore, the third aim of the present study was to analyze multivariate differences between the patients with functional dysphonia and the healthy controls with respect to personality, mood and anxiety. In detail, the following three research questions were considered: (1) Are there significant univariate differences between patients with functional dysphonia and healthy controls with respect to specific anxiety concerning illness and social situations? (2) Are there significant univariate differences between patients with functional dysphonia and healthy controls with respect to the four dimensions of CloningerÕs personality model? (3) Are there significant multivariate differences between patients with functional dysphonia and healthy controls with respect to the four dimensions of CloningerÕs personality model, mood and anxiety?
2. Methods 2.1. Subjects Sixty-one patients with complaints of vocal weakness and discomfort in the throat were consecutively recruited and examined at the Department of Phoniatrics and Logopedics of the University Ear, Nose and Throat Clinic of Vienna. All patients received laryngoscopic and phonic examinations for exclusion of organic impairment and fulfilled the DSM-IV (American Psychiatric Association, 1994) criteria of conversion disorder, mainly characterized by one or more symptoms or deficits affecting voluntary motor or sensory function without neurological or general
1444
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
medical condition, which are causing clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants of medical evaluation and are not intentionally produced or feigned. Sixty-one controls without voice pathology and without former ENT, phoniatric, speech or psychiatric treatment were recruited mainly at schools and kindergartens and through a circle of acquaintances of students and were matched for age, sex, and occupation. Both samples consisted of 48 (79%) female and 13 (21%) male patients. Consistent with the literature (American Psychiatric Association, 1994), sex distribution showed a significant majority of female patients (v2 = 20.082; df = 1; p 6 0.0001). The mean age of the patients and the controls when they entered the study was 36 years (SD = 13 years). About half of the patient sample and the control sample had a voice-demanding occupation—28% were teachers, 7% kindergarten teachers and 12% salespeople—and reported dependence on the voice in their professional life. All of the patients and controls participated voluntarily and without financial reward after informed consent was obtained. Selection procedure for the samples of patients and controls has been described in detail in a previous paper (Willinger et al., 2005). 2.2. Measures Anamnestic data regarding sociodemographic particulars; information about former treatments, including ENT, phoniatric (e.g. surgery of larynx), speech, and psychiatric treatments; details of onset; and course of functional dysphonia (e.g. duration, remissions) were evaluated according to a standardized interview. The ‘‘Unified Biosocial Personality Model’’, which is operationalized by the four temperamental dimensions ‘‘novelty seeking’’ (NS), ‘‘harm avoidance’’ (HA), ‘‘reward dependence’’ (RD), and ‘‘persistence’’ (PE), was measured by the German version (Aschauer et al., 1994) of the selfadministered ‘‘Tridimensional Personality Questionnaire’’ (TPQ) (Cloninger, 1987b). NS is defined by being quick-tempered, exploratory, excitable, curious, enthusiastic, exuberant, easily bored, impulsive, and disorderly. HA is covered by being cautious, careful, tense, fearful, apprehensive, nervous, timid, doubtful, discouraged, passive, insecure, negativistic, or pessimistic even in situations that do not worry other people. RD is defined by being tender-hearted, warm and loving, dedicated, sensitive, dependent, and sociable. PE is represented by being industrious, hard-working, persistent, and stable despite frustration and fatigue. The German version revealed Cronbachs alpha coefficients between 0.57 and 0.65, stability over time (3 months) between 0.62 and 0.79. External validity showed that 68% of patients with schizophrenia and healthy controls were classified correctly by NS and HA (Aschauer et al., 1994). Depressive symptoms were measured by the German version (Hautzinger, Bailer, Worall, & Keller, 1995) of the self-rated ‘‘Beck Depression Inventory’’ (Beck & Steer, 1987). Information about the symptoms of unspecific and generalized anxiety (e.g. ‘‘I feel insecure’’, ‘‘I feel anxious’’, ‘‘I feel nervous’’, ‘‘I am jittery’’) was obtained by means of the German version (Laux, Glanzmann, Schaffner, & Spielberger, 1981) of the self-ratable ‘‘State-Trait-Anxiety Inventory’’ (Spielberger, Gorusch, & Lushene, 1970), which enables anxiety to be quantified both as a time- and situation-related state (X1) and as a comparatively stable personality trait (X2). Information about the symptoms of specific anxiety concerning health and social interactions was assessed by the three different scales ‘‘somatic complaints’’ (FPI-8), ‘‘health concern’’ (FPI-9), and ‘‘extraversion versus introversion’’ (FPI-11) of the self-ratable ‘‘Freiburg Personality Inven-
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1445
tory’’ (Fahrenberg, Hampel, & Selg, 1994). ‘‘Somatic complaints’’ ranges from having many somatic complaints and being psychosomatically disturbed to having few somatic complaints and not being psychosomatically disturbed (e.g. ‘‘I often have a headache’’, ‘‘I sometimes have an accelerated heart rate’’, ‘‘I am often constipated’’, ‘‘I often have chest pain or discomfort’’). ‘‘Health concern’’ ranges from being afraid of illness, being conscious about health, and treating oneself with care not to be worried about health, being unconcerned about health, and feeling robust (e.g. ‘‘I am informed on the most widespread diseases and their first signs’’; ‘‘If I have a disease, I would like to consult a second doctor’’; ‘‘I consult a doctor regularly, also without serious complaints, only for caution’’; ‘‘I avoid eating unwashed fruits’’). ‘‘Extraversion versus introversion’’ ranges from being extraverted, sociable, impulsive, and enterprising to being introverted, reserved, reflective, and serious (e.g. ‘‘I am able to entertain a big society’’, ‘‘In society or at public events I prefer to be in the background’’, ‘‘I am very slow in contracting a new friendship’’). Information about anxiety concerning illness and social situations was obtained by means of the self-ratable ‘‘Interaction-Anxiety Questionnaire’’ (Becker, 1997). It consists of six different subscales that are summed up to two higher order factors. The first factor, ‘‘illness-anxiety’’, is covered by fear of physical injury, fear of illness, and fear of medical treatment (e.g. ‘‘How un-/pleasant is it for you . . .’’: ‘‘. . . if you are assuming that someone is following you in the darkness’’, ‘‘. . . if you are receiving anonymous letters with threats of physical violence’’, ‘‘. . . if you have to go to the hospital for some time’’, ‘‘. . . if you are standing in a group of persons and you notice that one of them has an infectious illness’’). The second factor, ‘‘anxiety of social situations’’ is covered by fear of social scenes, fear of transgressing social standards, anxiety over self-competence, and fear of social devaluation and inferiority (e.g. ‘‘How un-/pleasant is it for you . . .’’: ‘‘. . . if your boss is watching you while you are working’’, ‘‘. . . if you should speak in front of many people’’, ‘‘. . . if you remember that you once lied to your best friend’’, ‘‘. . . if you should complain about bad treatment in an restaurant’’, ‘‘. . . if you realize that other people are laughing about you’’). 2.3. Statistical analyses Distribution of sex within the patient sample was analyzed for significance by the chi-square test. Univariate group differences between patients and matched controls were tested for significance by univariate t-tests for paired samples. Discriminant analysis was used for multivariate group differences between patients and controls regarding those variables of the four personality traits, mood, and anxiety, which were significantly different between patients and controls in the univariate analyses of the present and a previous study (Willinger et al., 2005). The cut-off level for statistical significance was set at p < 0.05, 2-tailed. All statistical analyses were performed by SPSS for Windows, Version 10.0.
3. Results Patients with functional dysphonia scored significantly lower in ‘‘extraversion versus introversion’’ (t-value = 12.28; df = 56; p 6 0.001) and significantly higher in ‘‘fear of illness’’
1446
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
Table 1 Means, standard deviations and significance of personality traits, symptoms of anxiety and depression in patients with functional dysphonia and healthy controls Variables a
Novelty seeking (TPQ) Harm avoidance (TPQ)a Reward dependence (TPQ)a Persistence (TPQ)a Extraversion vs introversion (FPI-R)b Fear of illness (IAF)a Fear of social situations (IAF)a Depressive symptoms (BDI)a,c State-anxiety (STAI-X1)a,c Trait-anxiety (STAI-X2)a,c Somatic complaints (FPI-R)a,c Health concern (FPI-R)a,c
Patients (n = 61)
Controls (n = 61)
Mean
Mean
SD
Significance
SD
15.3 15.6 14.0 4.5
5.2 6.2 3.5 2.1
16.7 11.7 13.7 4.2
5.1 5.0 3.6 1.8
n.s. s. n.s. n.s.
7.8 83.6 121.6
2.4 13.1 18.9
11.9 78.3 116.5
0.7 10.6 19.6
s. s. n.s.
9.3 38.9 40.7 4.3 5.8
7.4 12.3 11.3 2.9 2.7
4.2 35.1 35.5 2.4 4.8
4.1 9.5 9.6 2.0 2.7
s. n.s. s. s. s.
s.: significant (p < 0.05), n.s.: not significant. a Higher values show higher tendencies in variables. b Higher values show more extraversion, lower values show more introversion. c See Willinger et al. (2005).
(t-value = 2.29; df = 58; p 6 0.026). No significant difference was found in ‘‘fear of social situations’’ (t-value = 1.58; df = 58; p = 0.119). Moreover, the patients showed significantly higher scores than healthy controls with respect to ‘‘harm avoidance’’ (t-value = 3.85; df = 58; p 6 0.001). No significant differences were found in NS (t-value = 1.47; df = 58; p = 0.146), RD (t-value = 0.4; df = 58; p = 0.69) and PE (t-value = 0.79; df = 58; p = 0.432). Numerical details of these results and of those previous statistical analyses of the present data (Willinger et al., 2005) which were used for the following discriminant analysis are given in Table 1. Multivariate group comparisons between the patients and the controls showed significant differences between the two groups (canonical correlation = 0.5; Wilks k = 0.8; v2 = 28.6; df = 7; p 6 0.0001). Seventy-three percentage of the patients and controls were classified correctly by personality, mood, and anxiety. The correlations between the discriminant variables and the standardized canonical discriminant function showed high values with respect to the depressive symptoms (r = 0.8), to specific anxiety concerning somatic complaints (r = 0.7), and HA (r = 0.6), modest values with respect to specific anxiety concerning illness (r = 0.4) and health (r = 0.4), and low values with respect to general anxiety (r = 0.2) and ‘‘extraversion versus introversion’’ (r = 0.008).
4. Discussion Personality factors may predispose patients to dysphonia (Nichol et al., 1993). In the current study we investigated patients with functional dysphonia and their control cohorts by means of the ‘‘Unified Biosocial Personality Model’’, operationalized by the TPQ. Significant differences
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1447
were found in one dimension of the TPQ, namely HA. Patients with functional dysphonia tend to be cautious, careful, tense, fearful, apprehensive, nervous, timid, doubtful, discouraged, passive, insecure, negativistic, and pessimistic even in situations that do not worry other people. In the other three temperament dimensions—NS, RD, and PE—there were no significant differences. Patients and controls seem to have similar tendencies towards intense excitement to novel stimuli, exploratory activity, reward, succor, and perseverance despite frustration and fatigue. In the literature there are contradictory results regarding personality in functional dysphonia. House and Andrews (1987) identified only 2 patients with personality disorder (histrionic) among 71 patients with functional dysphonia. Personality disorder may be too strong a criterion to look for; it may be better to look for characteristic personality traits. White, Deary, and Wilson (1997) stated that patients with functional dysphonia showed a greater degree of mild psychiatric disturbance but no significant differences in personality traits compared to patients with dysphonia associated with structural laryngeal abnormality and to ENT outpatient controls; patients with functional dysphonia did not show unusual levels of neuroticism, extraversion or hysteroid traits. Otherwise, according to Scott et al. (1997) psychological and social factors seem to play an important role in the initiation and perpetuation of functional dysphonia. Bauer (1991) found that functional dysphonia often appeared as an unspecific reaction to emotional disturbances. Gerritsma (1991) reported high scores in two scales, neuroticism and neurotic somatization, which measure the neurotic instability that manifests itself in the expression of psychoneurotic and functional physical complaints. According to Roy et al. (1997) the patients with functional dysphonia showed emotional adjustment problems despite successful voice management. These patients considered themselves as people who to a significantly greater degree than others deny good health and report a variety of vague somatic symptoms; are pessimistic, dissatisfied, sad, suspicious, interpersonally sensitive, diffusedly anxious, and confused; adhere rigidly to ideas and attitudes; and tend to engage in denial, withdraw socially, and be insecure and anxious when in contact with others. In the current study we found significant differences in anxiety concerning illness. The patients with functional dysphonia showed significantly higher scores than healthy controls with respect to fear of physical injury, fear of illness, and fear of medical treatment. We did not find any significant differences in fear of social situations, which encompasses fear of social scenes, fear of transgressing social standards, fear of inadequate self-competence, and fear of social devaluation and inferiority, but we did find such a difference regarding behavior in social situations: the patients with functional dysphonia considered themselves to be introverted, reserved, reflective, and serious. According to Nichol et al. (1993) the ‘‘. . . voice of an individual is a very sensitive indicator of attitudes, emotions, and role assumptions. It is a major component in social interactions. Therefore it is not surprising that impairments of voice function are not uncommon accompaniments of psychological conflicts’’. According to Butcher (1995) functional dysphonia arises mostly in women who tend to assume an above average number of responsibilities; who are frequently caught up in family and interpersonal relationship difficulties; who find it hard to express their emotions, especially negative feelings; and who have difficulties in asserting themselves. Inefficient assertiveness may contribute to feelings of powerlessness and helplessness which might be associated with emotional disturbance and conditions of anxiety and depression.
1448
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
Multivariate group comparisons between the patients and the controls showed significant differences between the two groups. Seventy-three percentage of the patients and controls were classified correctly by personality, mood, and anxiety, especially by depressive symptoms, somatic complaints, and HA. These results emphasized the relationship between personality, mood and anxiety which were found in several studies about associations between mood disorders and anxiety on the one hand and NS, HA and RD on the other (Brown et al., 1992; Kim & Hoover, 1996; Krebs et al., 1998; Meszaros et al., 1996; Stewart et al., 2005). However, the multivariate and univariate results indicate that personality, mood and anxiety should be considered not only in the diagnostic of functional dysphonia but also in the therapeutic interventions. Summing up: When compared to healthy controls, the patients with functional dysphonia showed a significantly higher tendency to respond intensely to aversive stimuli and to avoid punishment, novelty, and non-reward. Moreover, the patients presented significantly higher scores than the healthy controls with respect to specific anxiety concerning illness and social situations by reporting higher fear of physical injury, fear of illness, and fear of medical treatment and by considering themselves to be introverted, reserved, reflective, and serious. These results were found considering univariate and multivariate analyses and confirm the relationship of psychological factors such as personality traits and anxiety on one hand and conversion disorder in general and functional dysphonia in particular on the other hand. This important relationship should be considered in the diagnostic and therapeutic interventions of functional dysphonia.
References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Andersson, K., & Schalen, L. (1998). Etiology and treatment of psychogenic voice disorder: results of a follow-up study of thirty patients. Journal of Voice, 12, 96–106. Aronson, A. E. (1990). Clinical voice disorders (3rd ed.). New York: Thieme Inc. Aschauer, H. N., Meszaros, K., Willinger, U., Fischer, G., Berger, P., Reiter, E., et al. (1994). Tridimensional Personality Questionnaire: Ergebnisse zu Gu¨tekriterien der deutschen Version des Fragebogens. Neuropsychiatrie, 8, 177–181. Battaglia, M., Bertella, S., Bajo, S., Politi, E., & Bellodi, L. (1998). An investigation of the co-occurrence of panic and somatization disorders through temperamental variables. Psychosomatic Medicine, 60, 726–729. Bauer, H. H. (1991). Zur Definition psychogener Stimmsto¨rungen. Laryngo-Rhino-Otologie, 70, 102–104. Beck, A. T., & Steer, R. A. (1987). Beck depression inventory—manual. San Antonio: The Psychological Corporation. Becker, P. (1997). Interaktions-Angst-Fragebogen. Go¨ttingen: Beltz-Verlag. Brown, S. L., Svrakic, D. M., Przybeck, T. R., & Cloninger, C. R. (1992). The relationship of personality to mood and anxiety states: a dimensional approach. Journal of Psychiatric Research, 26, 197–211. Butcher, P. (1995). Psychological process in psychogenic voice disorder. European Journal of Disordered Communication, 30, 467–474. Cloninger, C. R. (1987a). A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry, 44, 573–588. Cloninger, C. R. (1987b). Tridimensional Personality Questionnaire (TPQ) (version 4). St Louis, MO: Washington University Medical School, Department of Psychiatry. Cloninger, C. R., Svrakic, D. M., & Przybeck, T. R. (1993). A psychobiological model of temperament and character. Archives of General Psychiatry, 50, 975–989.
U. Willinger, H.N. Aschauer / Personality and Individual Differences 39 (2005) 1441–1449
1449
Fahrenberg, J., Hampel, R., & Selg, H. (1994). Das Freiburger Perso¨nlichkeitsinventar (FPI). In Revidierte Fassung und teilweise gea¨nderte Fassung FPI-A1. Handanweisung. Go¨ttingen–Toronto–Zu¨rich: Verlag fu¨r Psychologie, Dr. C. J. Hogrefe. Gerritsma, E. J. (1991). An investigation into some personality characteristics of patients with psychogenic aphonia and dysphonia. Folia Phoniatrica, 43, 13–20. Hautzinger, M., Bailer, M., Worall, H., & Keller, F. (1995). Beck-Depressions-Inventar (BDI). Bern–Go¨ttingen– Toronto–Seattle: Verlag Hans Huber. House, A., & Andrews, H. (1987). The psychiatric and social characteristics of patients with functional dysphonia. Journal of Psychosomatic Research, 31, 483–490. Kim, S. W., & Hoover, K. M. (1996). Tridimensional personality questionnaire: assessment in patients with social phobia and a control group. Psychological Reports, 78, 43–49. Kinzel, J., Biebl, W., & Rauchegger, H. (1988). Functional aphonia. A conversion symptom as defensive mechanism against anxiety. Psychotherapy Psychosomatic, 49, 31–36. Krebs, H., Weyers, P., & Janke, W. (1998). Validation of the German version of CloningerÕs TPQ: replication and correlations with stress coping, mood measures and drug use. Personality and Individual Differences, 24, 805–814. Laux, L., Glanzmann, P., Schaffner, P., & Spielberger, C. D. (1981). Das State-Trait-Angstinventar. Theoretische Grundlagen und Handanweisung. Weinheim: Beltz Testgesellschaft. Mans, E. J. (1993). The psychosomatic interview in diagnosis of functional voice disorders. Folia Phoniatr Basel, 45, 105–111. Mans, E. J. (1994). Psychotherapeutic treatment of patients with functional voice disorders. Folia Phoniatrica Logopedica, 46, 1–8. Meszaros, K., Willinger, U., Fischer, G., Scho¨nbeck, G., Aschauer, H. N., & on behalf of The European Fluvoxamine in Alcoholism Study Group (1996). The tridimensional personality model: influencing variables in a sample of detoxified alcohol dependents. Comprehensive Psychiatry, 37, 109–114. Nichol, H., Morrison, M. D., & Rammage, L. A. (1993). Interdisciplinary approach to functional voice disorders: the psychiatristÕs role. Otolaryngology—Head and Neck Surgery, 108, 643–647. Roy, N., McGrory, J. J., Tasko, S. M., Bless, D. M., Heisey, D., & Ford, C. N. (1997). Psychological correlates of functional dysphonia: an investigation using the Minnesota Multiphasic Personality Inventory. Journal of Voice, 11, 443–451. Scott, S., Deary, I. J., Mackenzie, K., & Wilson, J. A. (1997). Functional dysphonia: a role for psychologists? Psychology, Health & Medicine, 2, 169–180. Spielberger, C. D., Gorusch, R. L., & Lushene, R. E. (1970). Manual for the state-trait anxiety inventory (STAI). Palo Alto: Consulting Psychologists Press Inc. Stewart, M. E., Ebmeier, K. P., & Deary, I. J. (2005). Personality correlates of happiness and sadness: EPQ-R and TPQ compared. Personality and Individual Differences, 38, 1085–1096. White, A., Deary, I. J., & Wilson, J. A. (1997). Psychiatric disturbance and personality traits in dysphonic patients. European Journal of Disordered Communication, 32, 307–314. Willinger, U., Vo¨lkl-Kernstock, S., & Aschauer, H. N. (2005). Marked depression and anxiety in patients with functional dysphonia. Psychiatry Research, 134, 85–91. Wilson, J. A., Deary, I. J., Scott, S., & MacKenzie, K. (1995). Functional dysphonia. British Medical Journal, 311, 1039–1040.