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Psychogenic stress as a possible etiological factor in non-organic dysphonia
International Congress Series 1240 (2003) 1251 – 1256
Psychogenic stress as a possible etiological factor in non-organic dysphonia M.N. Kotby *, M. Baraka, S.R. El Sady, M. Ghanem, R. Shoeib Unit of Phoniatrics, ENT Department, Ain Shams University Specialized Hospital, El-Khalifa El-Maamoon St., Cairo, Egypt
Abstract Psychogenic background of non-organic dysphonia has been suspected for some time. The purpose of this study is to assess cases of non-organic voice disorders in order to elucidate the role of psychogenic stress in the pathogenesis of this clinical entity. To reach our goal, 100 non-organic voice disorder patients were subjected to both voice and psychiatric protocols of assessment and the results obtained were compared with the results of 50 normal individuals whom subjected to the same protocols of assessment. The results showed that there was a highly significant difference between both groups as regards the scales of psychiatric tests. Conclusion: there is evident psychogenic background for some types of non-organic voice disorders, namely, incomplete mutation, phonasthenia and nonorganic aphonia. This may necessitate a combined therapy program of behavior readjustment voice therapy as well as psychiatric management for these cases to get best results and avoid relapse. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Psychogenic stress; Non-organic dysphonia
1. Introduction Voice problems in the absence of identifiable structural or neurological pathology are commonly labeled non-organic (functional) voice disorders. Etiological classification of voice pathology is of clinical significance since it enables a clinician to select the proper line of treatment. There are several classification of group of voice disorders. Perello [1] has classified non-organic voice disorders into phononeurosis (psychogenic aphonia/ dysphonia and spasmodic dysphonia) and phonoponosis (hyper- and hypokinetic dysphonia). Milutinovic [2] has modified this classification by excluding spasmodic dysphonia from the category of phononeurosis for its possible organic background and including in * Corresponding author. Tel.: +20-4031653. E-mail address: [email protected] (M.N. Kotby). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00858-6
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this group mutational disorders, which has an apparent psychosomatic basis. Morrison et al. [3] have classified non-organic voice disorders into muscular tension dysphonia, psychogenic dysphonia and spasmodic dysphonia. Kotby [4] has classified non-organic voice disorder into habitual and psychogenic voice disorders. Voice production may be affected by the emotional and psychological state of the individual. A psychogenic background of non-organic voice disorders has been suspected for some time [5]. The aim of this study is to assess cases of non-organic voice disorders in order to elucidate the role of psychogenic stress in the pathogenesis of this clinical entity.
2. Subjects and methods This study was conducted on two groups of subjects. Group I included 100 patients (52 males with mean age of 46.7 years and 48 females with mean age of 33.8 years) diagnosed as non-organic voice disorders. Group II (control group) consisted of 50 normal individuals (28 males with mean age 49.3 years and 22 females with mean age 38.6 years). They were selected randomly from members not suffering any voice disorders. Each individual of both groups was subjected to the following protocol of assessment. 2.1. A full voice evaluation: (Kotby [4]) This includes the following steps: (I) Elementary diagnostic procedures: patient interview, auditory perceptual assessment (APA) by the clinician and preliminary laryngeal visualization (mirror laryngoscopy). (II) Clinical diagnostic aids: augmentation and documentation of the glottic picture and voice recording. (III) Instrumental diagnostic measures: aerodynamic and acoustic measures. 2.2. Psychiatric evaluation The following tests were chosen on the grounds that they may highlight psychological aspects relevant to voice disorders. (1) The Social Readjustment Rating Questionnaire [6]. (2) Symptoms checklist [7].
Table 1 Comparison between group I and group II as regard the Social Readjustment Rating Scale [6] Stressful life events
Group I (n = 100) Group II (n = 50) p < 0.001 (HS).
No.
Percentage (%)
66 4
66 8
M.N. Kotby et al. / International Congress Series 1240 (2003) 1251–1256
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Table 2 Comparison between group I (n = 100) and group II (n = 50) as regards Symptom Checklist (SCL—[7]) Group I
Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism
Group II
No.
Percentage (%)
No.
Percentage (%)
53 3 18 14 52 8 6 0 0
53 3 18 14 52 8 6 0 0
8 1 5 2 3 3 2 0 0
16 2 10 4 6 6 4 0 0
p
Significance
< 0.001 > 0.05 > 0.05 > 0.05 < 0.001 > 0.05 > 0.05 > 0.05 > 0.05
HS NS NS NS HS NS NS NS NS
(3) Composite International Diagnostic Interview (CIDI) [8]. (4) Hamilton Anxiety Rating Scale [9]. (5) Hysteria (Hy) and hypochondriasis (Hs) scales of Minnesota Multiphasic Personality Inventory (MMPI) [10].
3. Statistical analysis t-Test was used to compare the mean values of quantitative parameters of both groups. Chi-square test was used to compare results of psychiatric tests.
4. Results The comparison between group I and group II as regard Social Readjustment Rating Scale is shown in Table 1, Symptom Checklist in Table 2, Composite International
Table 3 Comparison between group I (n = 100) and group II (n = 50) as regards Composite International Diagnostic Interview (CIDI) [8] Group I
Psychogenic pain disorder Somatization Hypochondriasis Generalized anxiety Dissociative Depression Obsessive compulsive
Group II
No.
Percentage (%)
No.
Percentage (%)
30 42 43 50 12 13 16
30 42 43 50 12 13 16
6 1 5 11 0 6 9
12 2 10 22 0 12 18
p
Significance
< 0.05 < 0.001 < 0.001 < 0.001 < 0.05 > 0.05 > 0.05
S HS HS HS S NS NS
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Table 4 Comparison between group I and group II as regards Hamilton Anxiety Rating Scale (1959) Group I
No anxiety Mild anxiety Moderate anxiety Severe anxiety
Group II
No.
Percentage (%)
No.
Percentage (%)
57 14 27 2
57 14 27 2
47 3 0 0
94 6 0 0
p < 0.001 (HS).
Diagnostic Interview in Table 3, Hamilton Anxiety Rating scale in Table 4 and hysteria and hypochondriasis assessed by MMPI in Table 5. 4.1. Comparison between each subgroup of non-organic voice disorders and control group as regard psychiatric tests Comparison between hyperfunctional childhood dysphonia and control group. All scales of psychiatric tests showed nonsignificant difference ( p>0.05). Comparison between incomplete mutation and control group. Hypochondriasis scales of CIDI and MMPI showed highly significant difference ( p < 0.001). Comparison between phonasthenia and control group. All scales showed highly significant difference ( p < 0.001) except: obsessive compulsive disorders, interpersonal sensitivity, depression, hostility, phobic anxiety, paranoid ideation and psychoticism scales of SCL. Dissociative reaction, depression and obsessive compulsive disorder (OCD) scales of CIDI showed nonsignificant difference ( p>0.05). Comparison between hyperfunctional dysphonia and control group. All scales showed nonsignificant values ( p>0.05) except estimation of presence of stressful life events by Social Readjustment Rating Scale which showed highly significant value ( p < 0.001). Comparison between non-organic aphonia and control group. All scales ranged between significant ( p < 0.05) and highly significant values ( p < 0.001) except obsessive compulsive disorders, hostility, phobic anxiety, paranoid ideation and psychoticism scales which showed nonsignificant values ( p>0.05).
Table 5 Comparison between group I and group II as regards Minnesota Multiphasic Personality Inventory (MMPI) scales for assessment of hysteria and hypochondriasis
Group I (n = 100) Group II (n = 50) p < 0.001 (HS).
Hysteria (Hy) + ve
Hypochondriasis (Hs) + ve
No.
Percentage (%)
No.
Percentage (%)
36 3
36 6
49 3
49 6
M.N. Kotby et al. / International Congress Series 1240 (2003) 1251–1256
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5. Discussion Better knowledge about the role of psychogenic stress in the pathogenesis of nonorganic voice disorders may improve our understanding of voice control mechanisms and also may help in designing effective therapeutic programs for these conditions. To reach our goal, it was a must to apply a proposed scheme of assessment of psychological profile of the patients of non-organic voice disorders. Depending on the hypothesis that patients presenting with this category of voice disorders, the authors [11,12] postulated that the dominance of stressful life events, anxiety, somatization, hypochondriasis, hysteria and depression should be considered in the search of psychogenic implication in the pathogenesis of non-organic voice disorders. In spite of the fact that the whole group showed certain general tendencies of psychogenic background, it is mandatory to have a closer look on the significance of the psychogenic changes in the various etiological subgroups of non-organic voice disorders. 5.1. In hyperfunctional childhood dysphonia The insignificant scales of psychological tests may strongly indicate that increased vocal demand is the only etiological factor in this category. 5.2. Incomplete mutation The high significance of hypochondriasis scale goes with their common comment about their new unacceptable deep voice, which is pathological and indicates serious illness of the larynx. 5.3. In phonasthenia The highly significant association with stressful life events, somatization, generalized anxiety disorder, hysteria, hypochondriasis and psychogenic pain disorder may open the way for the strong psychogenic etiological background of phonasthenia. 5.4. In hyperfunctional dysphonia Stressful life events may produce a certain degree of musculoskeletal tension of both laryngeal and respiratory muscles that may explain the occurrence of hyperfunctional dysphonia. Psychological distress may be secondary to dysphonia, being the direct result of a dysfunctional state. 5.5. In non-organic aphonia The highly significant association with the scales of psychiatric tests may indicate the role of psychogenic stress factors in the pathogenesis of this disorder. These are supported by the results of Ref. [12].
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6. Conclusion We can conclude that there is evident psychogenic background for some types of nonorganic voice disorders, namely, incomplete mutation, phonasthenia and non-organic aphonia. This may necessitate a combined therapy program of behavior readjustment voice therapy as well as psychiatric management for these cases to get best results and avoid relapse.
References [1] J. Perello, La theorie muco-ondulatoire de la phonation, Annales d’Oto-Laryngologie 79 (1962) 722 – 725. [2] Z. Milutinovic, Classification of voice pathology, Folia Phoniatrica et Logopaedica 48 (1996) 301 – 308. [3] M. Morrison, H. Nichol, L.A. Rammage, Diagnostic criteria in functional dysphonia, Laryngoscope 4 (1986) 1 – 8. [4] M.N. Kotby, Voice disorders: recent diagnostic advances, Egyptian Journal of Otolaryngology 3 (1) (1986) 69 – 98. [5] A.E. Aronson, Clinical Voice Disorders: An Interdisciplinary Approach, 2nd ed., Thieme-Stratton, New York, 1985. [6] T.H. Holmes, R.M. Rahe, The social readjustment rating scale, Journal of Psychosomatic Research 11 (1967) 213 – 218. [7] A.A. El-Behary, Symptom Check List (SCL-90), El-Nahda Library, 1984. [8] Composite International Diagnostic Interview, World Health Organization, CoreVersion 1.1, 1993. [9] M. Hamilton, The assessment of anxiety states by rating, British Medical Journal (1959) 20. [10] L.K. Melaika, Minnesota Multiphasic Personality Inventory (MMPI), El-Nahda Library, Cairo, Egypt, 1969. [11] A.O. House, H.B. Andrews, The psychiatric and social characteristics of patients with. [12] N. Roy, D.M. Bless, D. Heisey, Personality and Voice Disorders: A Superfactor Trait Analysis, NCVS Status and Progress Report-14, 2000 September, pp. 203 – 219.
Psychogenic stress as a possible etiological factor in non-organic dysphonia M.N. Kotby *, M. Baraka, S.R. El Sady, M. Ghanem, R. Shoeib Unit of Phoniatrics, ENT Department, Ain Shams University Specialized Hospital, El-Khalifa El-Maamoon St., Cairo, Egypt
Abstract Psychogenic background of non-organic dysphonia has been suspected for some time. The purpose of this study is to assess cases of non-organic voice disorders in order to elucidate the role of psychogenic stress in the pathogenesis of this clinical entity. To reach our goal, 100 non-organic voice disorder patients were subjected to both voice and psychiatric protocols of assessment and the results obtained were compared with the results of 50 normal individuals whom subjected to the same protocols of assessment. The results showed that there was a highly significant difference between both groups as regards the scales of psychiatric tests. Conclusion: there is evident psychogenic background for some types of non-organic voice disorders, namely, incomplete mutation, phonasthenia and nonorganic aphonia. This may necessitate a combined therapy program of behavior readjustment voice therapy as well as psychiatric management for these cases to get best results and avoid relapse. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Psychogenic stress; Non-organic dysphonia
1. Introduction Voice problems in the absence of identifiable structural or neurological pathology are commonly labeled non-organic (functional) voice disorders. Etiological classification of voice pathology is of clinical significance since it enables a clinician to select the proper line of treatment. There are several classification of group of voice disorders. Perello [1] has classified non-organic voice disorders into phononeurosis (psychogenic aphonia/ dysphonia and spasmodic dysphonia) and phonoponosis (hyper- and hypokinetic dysphonia). Milutinovic [2] has modified this classification by excluding spasmodic dysphonia from the category of phononeurosis for its possible organic background and including in * Corresponding author. Tel.: +20-4031653. E-mail address: [email protected] (M.N. Kotby). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00858-6
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M.N. Kotby et al. / International Congress Series 1240 (2003) 1251–1256
this group mutational disorders, which has an apparent psychosomatic basis. Morrison et al. [3] have classified non-organic voice disorders into muscular tension dysphonia, psychogenic dysphonia and spasmodic dysphonia. Kotby [4] has classified non-organic voice disorder into habitual and psychogenic voice disorders. Voice production may be affected by the emotional and psychological state of the individual. A psychogenic background of non-organic voice disorders has been suspected for some time [5]. The aim of this study is to assess cases of non-organic voice disorders in order to elucidate the role of psychogenic stress in the pathogenesis of this clinical entity.
2. Subjects and methods This study was conducted on two groups of subjects. Group I included 100 patients (52 males with mean age of 46.7 years and 48 females with mean age of 33.8 years) diagnosed as non-organic voice disorders. Group II (control group) consisted of 50 normal individuals (28 males with mean age 49.3 years and 22 females with mean age 38.6 years). They were selected randomly from members not suffering any voice disorders. Each individual of both groups was subjected to the following protocol of assessment. 2.1. A full voice evaluation: (Kotby [4]) This includes the following steps: (I) Elementary diagnostic procedures: patient interview, auditory perceptual assessment (APA) by the clinician and preliminary laryngeal visualization (mirror laryngoscopy). (II) Clinical diagnostic aids: augmentation and documentation of the glottic picture and voice recording. (III) Instrumental diagnostic measures: aerodynamic and acoustic measures. 2.2. Psychiatric evaluation The following tests were chosen on the grounds that they may highlight psychological aspects relevant to voice disorders. (1) The Social Readjustment Rating Questionnaire [6]. (2) Symptoms checklist [7].
Table 1 Comparison between group I and group II as regard the Social Readjustment Rating Scale [6] Stressful life events
Group I (n = 100) Group II (n = 50) p < 0.001 (HS).
No.
Percentage (%)
66 4
66 8
M.N. Kotby et al. / International Congress Series 1240 (2003) 1251–1256
1253
Table 2 Comparison between group I (n = 100) and group II (n = 50) as regards Symptom Checklist (SCL—[7]) Group I
Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism
Group II
No.
Percentage (%)
No.
Percentage (%)
53 3 18 14 52 8 6 0 0
53 3 18 14 52 8 6 0 0
8 1 5 2 3 3 2 0 0
16 2 10 4 6 6 4 0 0
p
Significance
< 0.001 > 0.05 > 0.05 > 0.05 < 0.001 > 0.05 > 0.05 > 0.05 > 0.05
HS NS NS NS HS NS NS NS NS
(3) Composite International Diagnostic Interview (CIDI) [8]. (4) Hamilton Anxiety Rating Scale [9]. (5) Hysteria (Hy) and hypochondriasis (Hs) scales of Minnesota Multiphasic Personality Inventory (MMPI) [10].
3. Statistical analysis t-Test was used to compare the mean values of quantitative parameters of both groups. Chi-square test was used to compare results of psychiatric tests.
4. Results The comparison between group I and group II as regard Social Readjustment Rating Scale is shown in Table 1, Symptom Checklist in Table 2, Composite International
Table 3 Comparison between group I (n = 100) and group II (n = 50) as regards Composite International Diagnostic Interview (CIDI) [8] Group I
Psychogenic pain disorder Somatization Hypochondriasis Generalized anxiety Dissociative Depression Obsessive compulsive
Group II
No.
Percentage (%)
No.
Percentage (%)
30 42 43 50 12 13 16
30 42 43 50 12 13 16
6 1 5 11 0 6 9
12 2 10 22 0 12 18
p
Significance
< 0.05 < 0.001 < 0.001 < 0.001 < 0.05 > 0.05 > 0.05
S HS HS HS S NS NS
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Table 4 Comparison between group I and group II as regards Hamilton Anxiety Rating Scale (1959) Group I
No anxiety Mild anxiety Moderate anxiety Severe anxiety
Group II
No.
Percentage (%)
No.
Percentage (%)
57 14 27 2
57 14 27 2
47 3 0 0
94 6 0 0
p < 0.001 (HS).
Diagnostic Interview in Table 3, Hamilton Anxiety Rating scale in Table 4 and hysteria and hypochondriasis assessed by MMPI in Table 5. 4.1. Comparison between each subgroup of non-organic voice disorders and control group as regard psychiatric tests Comparison between hyperfunctional childhood dysphonia and control group. All scales of psychiatric tests showed nonsignificant difference ( p>0.05). Comparison between incomplete mutation and control group. Hypochondriasis scales of CIDI and MMPI showed highly significant difference ( p < 0.001). Comparison between phonasthenia and control group. All scales showed highly significant difference ( p < 0.001) except: obsessive compulsive disorders, interpersonal sensitivity, depression, hostility, phobic anxiety, paranoid ideation and psychoticism scales of SCL. Dissociative reaction, depression and obsessive compulsive disorder (OCD) scales of CIDI showed nonsignificant difference ( p>0.05). Comparison between hyperfunctional dysphonia and control group. All scales showed nonsignificant values ( p>0.05) except estimation of presence of stressful life events by Social Readjustment Rating Scale which showed highly significant value ( p < 0.001). Comparison between non-organic aphonia and control group. All scales ranged between significant ( p < 0.05) and highly significant values ( p < 0.001) except obsessive compulsive disorders, hostility, phobic anxiety, paranoid ideation and psychoticism scales which showed nonsignificant values ( p>0.05).
Table 5 Comparison between group I and group II as regards Minnesota Multiphasic Personality Inventory (MMPI) scales for assessment of hysteria and hypochondriasis
Group I (n = 100) Group II (n = 50) p < 0.001 (HS).
Hysteria (Hy) + ve
Hypochondriasis (Hs) + ve
No.
Percentage (%)
No.
Percentage (%)
36 3
36 6
49 3
49 6
M.N. Kotby et al. / International Congress Series 1240 (2003) 1251–1256
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5. Discussion Better knowledge about the role of psychogenic stress in the pathogenesis of nonorganic voice disorders may improve our understanding of voice control mechanisms and also may help in designing effective therapeutic programs for these conditions. To reach our goal, it was a must to apply a proposed scheme of assessment of psychological profile of the patients of non-organic voice disorders. Depending on the hypothesis that patients presenting with this category of voice disorders, the authors [11,12] postulated that the dominance of stressful life events, anxiety, somatization, hypochondriasis, hysteria and depression should be considered in the search of psychogenic implication in the pathogenesis of non-organic voice disorders. In spite of the fact that the whole group showed certain general tendencies of psychogenic background, it is mandatory to have a closer look on the significance of the psychogenic changes in the various etiological subgroups of non-organic voice disorders. 5.1. In hyperfunctional childhood dysphonia The insignificant scales of psychological tests may strongly indicate that increased vocal demand is the only etiological factor in this category. 5.2. Incomplete mutation The high significance of hypochondriasis scale goes with their common comment about their new unacceptable deep voice, which is pathological and indicates serious illness of the larynx. 5.3. In phonasthenia The highly significant association with stressful life events, somatization, generalized anxiety disorder, hysteria, hypochondriasis and psychogenic pain disorder may open the way for the strong psychogenic etiological background of phonasthenia. 5.4. In hyperfunctional dysphonia Stressful life events may produce a certain degree of musculoskeletal tension of both laryngeal and respiratory muscles that may explain the occurrence of hyperfunctional dysphonia. Psychological distress may be secondary to dysphonia, being the direct result of a dysfunctional state. 5.5. In non-organic aphonia The highly significant association with the scales of psychiatric tests may indicate the role of psychogenic stress factors in the pathogenesis of this disorder. These are supported by the results of Ref. [12].
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M.N. Kotby et al. / International Congress Series 1240 (2003) 1251–1256
6. Conclusion We can conclude that there is evident psychogenic background for some types of nonorganic voice disorders, namely, incomplete mutation, phonasthenia and non-organic aphonia. This may necessitate a combined therapy program of behavior readjustment voice therapy as well as psychiatric management for these cases to get best results and avoid relapse.
References [1] J. Perello, La theorie muco-ondulatoire de la phonation, Annales d’Oto-Laryngologie 79 (1962) 722 – 725. [2] Z. Milutinovic, Classification of voice pathology, Folia Phoniatrica et Logopaedica 48 (1996) 301 – 308. [3] M. Morrison, H. Nichol, L.A. Rammage, Diagnostic criteria in functional dysphonia, Laryngoscope 4 (1986) 1 – 8. [4] M.N. Kotby, Voice disorders: recent diagnostic advances, Egyptian Journal of Otolaryngology 3 (1) (1986) 69 – 98. [5] A.E. Aronson, Clinical Voice Disorders: An Interdisciplinary Approach, 2nd ed., Thieme-Stratton, New York, 1985. [6] T.H. Holmes, R.M. Rahe, The social readjustment rating scale, Journal of Psychosomatic Research 11 (1967) 213 – 218. [7] A.A. El-Behary, Symptom Check List (SCL-90), El-Nahda Library, 1984. [8] Composite International Diagnostic Interview, World Health Organization, CoreVersion 1.1, 1993. [9] M. Hamilton, The assessment of anxiety states by rating, British Medical Journal (1959) 20. [10] L.K. Melaika, Minnesota Multiphasic Personality Inventory (MMPI), El-Nahda Library, Cairo, Egypt, 1969. [11] A.O. House, H.B. Andrews, The psychiatric and social characteristics of patients with. [12] N. Roy, D.M. Bless, D. Heisey, Personality and Voice Disorders: A Superfactor Trait Analysis, NCVS Status and Progress Report-14, 2000 September, pp. 203 – 219.