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Nonorganic Habitual Dysphonia and Autonomic Dysfunction
Journal of Voice Vol. 16, No. 4, pp. 549–559 © 2002 The Voice Foundation
Nonorganic Habitual Dysphonia and Autonomic Dysfunction Lize Demmink-Geertman and Philippe Henri Dejonckere The Institute of Phoniatrics, University Medical Center Utrecht, Utrecht, The Netherlands
Summary: The present study was designed to test the hypothesis that there is a relation between nonorganic habitual dysphonia and subjective experience of dysfunction of the autonomic nervous system (neurovegetative lability). Eightythree patients (65 women and 18 men) with a nonorganic voice disorder and a matched control group answered a questionnaire of 46 questions. One question replicated in different terms and six nonrelevant questions point out that the inquiry forms were answered in a consistent way. It appears that female patients in all age categories with a nonorganic habitual dysphonia report significantly more autonomic symptoms and complaints than healthy controls. This hypothesis cannot be confirmed for the male subgroup. Key Words: Nonorganic habitual dysphonia—Functional dysphonia—Autonomic nervous system—Vegetative functions—Anxiety—Stress.
stant internal environment (homeostasis). It also participates in appropriate coordinated responses to external stimuli: an extreme example of this regulation is the “fight-or-flight response” that occurs when a threat intensively activates the sympathetic nervous system, causing a variety of responses, as release of adrenal hormones, increase of heart rate and blood pressure, dilatation of bronchioles, inhibition of intestinal mobility and secretion, piloerection, constriction of cutaneous blood vessels, and so forth. Normally, this fight-or-flight response is an uncommon event, except if the function of the autonomic system becomes disturbed and overexcitable. The effectors are smooth muscle, cardiac muscle, and glands. Effects concern, among other things, heart rate, arterioles (constriction or dilation), bronchial muscles and glands, stomachal and intestinal motility and secretion, skin (pilomotor muscles and sweat glands), salivary, lacrymal and nasopharyngeal glands, genitourinary tract, and nervous system (tinnitus, dizziness). Adrenergic and cholinergic impulses generate different, mainly antagonistic ef-
INTRODUCTION The autonomic nervous system The term autonomic nervous system (or vegetative nervous system, or visceral motor system) usually refers to the sympathetic and parasympathetic nervous systems, and generally includes the enteric nervous system. The autonomic nervous system also includes central components, as the thalamus and the higher levels of the limbic system, which are associated with emotions and with many visceral behaviors, such as feeding, drinking, thermoregulation, and so forth.1 Like most organs, the larynx is reached by the sympathetic and parasympathetic fibers through the laryngeal vascular supply. The main function of the autonomic nervous system seems to assist the body in maintaining a conAccepted for publication April 16, 2002. Address correspondence and reprint requests to P. H. Dejonckere, MD, PhD, The Institute of Phoniatrics, University Medical Center Utrecht, AZU F. 02.504, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. e-mail : [email protected]
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fects. Accompanying the autonomic motor fibers in peripheral nerves are afferent fibers that originate from sensory receptors in the viscera. Many of these receptors trigger reflexes, but the activity of some receptors evokes sensory experiences, such as pain, hunger, thirst, nausea, a sense of visceral distention, and so forth.1,2 Stress and anxiety Animal experiments have suggested that stress may cause loss of hypothalamic control over sympathetic innervation, resulting in a relative dominance of the parasympathetic system.3,4 In humans, the limbic system controls emotional behavior in part by activation of the autonomic nervous system.1 Autonomic symptoms are known to be associated with anxiety.2 For example, life situations that produce anxiety, hostility, guilt, or feelings of frustration and resentment can disturb the autonomic vascular balance.5 In the gastrointestinal tract, autonomic dysfunction may take the form of nausea, vomiting, belching, distress from gas, and epigastric pain resulting from diarrhea and constipation. The cardiovascular system responds to stress with tachycardia and changes in rhythm, and neurocirculatory asthenia characterized by breathlessness, fatigability, palpitations, trembling, fainting, dizziness, and so forth.6 Relation with nonorganic voice disorders As a lot of patients with voice problems are struggling with emotional problems as well, several authors suggest an association between functional voice disorders and stress or anxiety. Morrison and Rammage7 emphasize that emotion—mainly anxiety—is the intervening variable between psychological factors and the physically altered laryngeal muscle tone that actually produces the dysphonia. Also Aronson8 states that laryngeal muscles are exquisitely sensitive to emotional stress, and that the responsible factors are anxiety, anger, irritability, impatience, frustration, and depression. Cause or effect ? Among respiratory reactions, the hyperventilation syndrome is generally associated with anxiety.9 However, excessive breathing can also be due to glottal air leakage. Overbreathing induces hypocapnia and alkalosis, and causes lightheadedness, palpitations, numbness, and tingling both periorally and in the extremities, and so forth. Now, hyperventilation Journal of Voice, Vol. 16, No. 4, 2002
seems to disappear once a patient has been successfully treated with antipanic medication. Also, behavioral breathing retraining treatments may decrease the frequency of panic attacks.10 According to Chapell,11 respiration mediates stress: slow, deep, regular, diaphragmatic-abdominal breathing is associated with low subjective and objective stress. In contrast, fast, shallow, irregular, thoracic breathing is associated with hyperarousal, fight/flight reactions of the sympathic system and stress, and may result in hyperventilation. Ley12 considers that breathing can be viewed as an independent variable that affects emotion, cognition and behavior as well as a dependent variable that reflects changes in emotion, cognition, and behavior. Breathing is an autonomic response that increases by increases in metabolic demand or by emotions or thoughts that give rise to emotions. Otherwise voluntary changes in breathing can affect our thoughts and feelings. This makes breathing a vital function that is under both voluntary as well as autonomic control. This applies for respiration at rest as well as during moving and/or speaking. Another example of interrelationship is provided by Cooke et al.13 They tested the esophageal dysmotility in a group of patients with noncardiac chest pain during hyperventilation provocation. Hyperventilation was associated with a significant fall in mean distal peristaltic amplitude and mean duration. It induced diffuse spasms in some patients and nonspecific motility disorders in others. Some patients reproduced chest pain, but in none did this coincide with important changes in peristaltic amplitude, duration, or frequency. They conclude that there must be a relationship between hyperventilation and esophageal motility. Because these disorders are often reported together, they may interact to produce chest pain, although overbreathing rarely produces chest pain via its effects on the esophagus. A last example can be found in Castell et al14 who contend that head position affects on both the upper esophageal sphincter (UES) and the pharynx. Too much head extension diminishes UES relaxation and has various effects such as aerophagy and reflux. Several patients with voice problems exhibit deviant head posture. Reaction to stress Each individual is equipped with a variety of adaptive mechanisms strengthened or weakened by the
NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION individual’s knowledge and experience as well as his physical condition and emotional mood, so it is not surprising that reaction to stress will be variable.10 Hypothesis In the present study, we attempt to verify the hypothesis that a link exists between nonorganic habitual dysphonia and complaints/manifestations of autonomic dysfunction, either connected or not connected with voice production, by comparing the prevalence of such complaints and symptoms in a group of patients diagnosed with nonorganic habitual dysphonia and in a group of matched control subjects. Gender and age categories are considered separately. Nonorganic dysphonia refers to impairment of voice production in the absence of mucosal or neurogenic disease of the larynx.15,16 It must be clear that this definition involves a lot of possible criticism, for exammple, about subtle structural changes or hormonal/pharmacological effects, particularly at the beginning phase of an evolutive process. However, a large part of possible misdiagnoses may be eliminated by a medical control exam after a few months and intercurrent functional voice therapy. In the absence of any identifiable organic disorder, dysphonia logically needs to be a product of altered laryngeal physiology during phonation. It is widely accepted that the disordered physiology commonly results from an inadequate balance in laryngeal muscle tension.17 In the past, typical laryngoscopic features of muscle tension dysphonia have been described,18 but recent research leads to some caution in the interpretation of clinical features of hyperfunction.19 Therefore, we preferred this definition for the inclusion criterion: the presence of a voice complaint and of a perceptual deviance in voice production, but the absence of any identifiable structural change in the larynx or systemic organic etiology. SUBJECTS AND METHODS Subjects The patient group consists of 83 subjects (65 females; 18 males), all of them with a voice complaint and a perceptual deviance in voice production, and the diagnosis of nonorganic habitual dysphonia. This diagnosis was made after a complete ENT examination, and exclusion of any identifiable structural change in the larynx. Hormonal, pharmacological,
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mutational and spasmodic dysphonias, as well as psychogenic aphonia were also excluded. “Habitual” points out that the voice problem had to be present for at least several months. All patients were referred to a speech therapist for treatment. All patients were also medically controlled after treatment, a few months later, in order to confirm the absence of any identifiable (and possibly evolutive) structural change in the larynx or systemic organic etiology. The age span was 18 to 77 years. A control group, consisting also of 84 subjects, was built up by having recourse to social relations of the speech-therapists themselves, and of their patients. All controls were free of voice problems or complaints, and the subgroups were matched for gender and age with the subgroups of voice patients. All participants were informed that this research concerned the prevalence of some specific associated complaints in voice patients. Only a very few subjects who were asked to participate did not accept. Table 1 shows the gender and age characteristics of both patients and controls. Method Both patients and controls were requested to fill in a questionnaire consisting of 46 complaints or symptoms, to be answered only with “yes,” for present, or “no” for absent (see Table 2). This questionnaire actually consisted of four subsets, unknown to the respondents. A first subset (22 questions) inquired about manifestations/complaints on the autonomic level without obvious relation to voice function or voice organs. A second subset (16 questions) also concerned manifestations/complaints on the autonomic level, but with a more or less obvious connection with voice TABLE 1. Gender and Age Characteristics of Patients and Controls Subgroup
Patients
Controls
Women 15–34 years
20
21
Women 35–54 years
31
29
Women 55 years and more
14
16
9
8
Men 15–44 years Men 45 years and more Total
9
10
83
84
Journal of Voice, Vol. 16, No. 4, 2002
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LIZE DEMMINK–GEERTMAN AND PHILIPPE HENRI DEJONCKERE TABLE 2. List of Symptoms/Complaints Number “Yes” in Patients
Number “Yes” in Controls
Neurovegetative
40
25
p = 0.022
Cold feet
Neurovegetative
45
42
NS
3
Excessive transpiration
Neurovegetative
31
10
p < 0.00l
4
Excessive sensitiveness to coldness
Neurovegetative
37
26
NS
5
Excessive sensitiveness to heat
Neurovegetative
27
21
NS
6
Diarrhea
Neurovegetative
20
9
p = 0.038
7
Constipation
Neurovegetative
24
9
p = 0.006
8
Puffiness
Neurovegetative
35
10
p < .001
9
Aerophagia
Neurovegetative
17
2
p = .001
10
Nausea
Neurovegetative
22
3
p < .001
11
Lack of appetite
Nonrelevant
9
3
NS
12
Eructations
Neurovegetative
30
14
No.
Complaint
Type
1
Cold hands
2
Significance Level
p = 0.007
13
Hiccups
Neurovegetative
26
10
p = 0.004
14
Heartburn
Neurovegetative
23
11
p = 0.031
15
Dizziness
Neurovegetative
46
14
p < 0.001
16
Tinnitus
Neurovegetative
25
11
p = 0.013
17
Dancing spots before the eyes
Neurovegetative
38
23
p = 0.02l
18
Difficult concentration
Neurovegetative
34
13
p < 0.001
19
Disturbed sleep
Neurovegetative
39
19
p = 0.002
20
Lack of energy
Neurovegetative
36
15
p = 0.001 p < 0.00l
21
Feelings of psychic tension
Reliability control
47
23
22
Renal problems
Nonrelevant
4
0
NS
23
Need of constantly swallowing
Voice related
33
2
p < 0.001
24
Sore throat
Voice related
44
9
p < 0.001
25
Hyperventilation
Voice related
21
2
p < 0.00l
26
Specific allergy
Nonrelevant
31
19
NS
27
Frequent sneezing
Voice related
32
12
p = 0.001
28
Fluctuating nose obstruction
Voice related
44
24
p = 0.002
29
Difficulty breathing through the nose at rest
Voice related
16
9
NS
30
Habitual mouth breathing at rest
Voice related
26
18
NS
31
Hearing loss
Nonrelevant
23
14
NS
32
Feelings of tension in the head while speaking
Voice related
17
2
p = 0.001
33
Headache
Nonrelevant
39
25
p = 0.033
34
Constant need to yawn
Voice related
23
10
p = 0.018
35
Gnashing of teeth
Voice related
11
3
p = 0.031
36
Temporomandibular pain or discomfort
Voice related
15
6
p = 0.033
37
Neck pain (while or after speaking)
Voice related
48
21
p < 0.001
38
Chest discomfort (while or after speaking)
Voice related
29
3
p < 0.001
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NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION
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Table 2. continued Number “Yes” in Patients
Number “Yes” in Controls
Voice related
46
2
p < 0.001
Frequent throat clearing
Voice related
40
11
p < 0.001
Chronic illness
Nonrelevant
18
8
No.
Complaint
Type
39
Fatigability when speaking
40 41
Significance Level
NS
42
Palpitations
Neurovegetative
33
6
p < 0.000
43
Social (communicative) handicap
Voice related
12
3
p = 0.029
44
Nail biting
Neurovegetative
19
17
45
Sensation of extreme tiredness
Neurovegetative
21
5
p = 0.001
46
Feelings of mental stress
Reliability control
45
22
p < 0.001
NS
Significance level: Pearson chi-square test with continuity correction (Yates). Abbreviation: NS, not significant.
function and/or voice organs (airway, breathing, articulation). A third smaller subset (6 questions) dealt with nonrelevant complaints, that is, without direct relation either to neurovegetative or to voice aspects. Finally, one question (number 21) was replicated, formulated in different words (question number 46). Question 21 was counted together with the first subset. Table 2 provides an overview of all symptoms/ complaints, and indicates for each one its category. The only possible responses were “yes” if the symptom was present and “no” if the symptom was absent. The present study is thus based, for the autonomic symptoms, exclusively on the subjective experience of the voice patients and control subjects, without involving psychophysiological testing. However, subsets 3 (irrelevant symptoms/complaints) and 4 (replication with different formulation) were intended as a check for validity and consistency. Statistics All data were analyzed with SPSS 9 (Statistical Package for Social Sciences). The positive responses in patients and controls were compared using the ttest, as distributions look quite normal. For each question, the statistical comparison of positive and negative responses in patients and controls was made with a chi-square test with Yate’s correction and a critical significance level of p < 0.05. In case of small subgroups, SPSS automatically shifts to Fisher’s exact test. A Cohen kappa was computed for checking consistency of responses to questions 21 and 46. A
chi-square test with Yate’s correction was also used for comparing patients and controls within subgroups based on gender or age. RESULTS Figures 1, 2, and 3 show the histograms of total positive responses for the complaints/symptoms pertaining, respectively, to neurovegetative aspects, to neurovegetative aspects connected with voice, and to nonneurovegetative aspects. For the first subset (symptoms/complaints on the autonomic level without obvious relation to voice function or voice organs), patients responded affirmatively an average of 8.05 times (SD 3.98) and controls 3.75 times (SD 2.26) (p < 0.000001). In 18 out of 22 questions, the excess of positive responses in patients compared with controls is statistically significant (Table 2). For the second subset (symptoms/complaints on the autonomic level, but with a more or less obvious connection with voice function and/or voice organs), patients responded affirmatively an average of 5.51 times (SD 2.89) and controls 1.64 times (SD 1.32) (p < 0.000001). In 14 out of 16 questions, the excess of positive responses in patients compared with controls is statistically significant (Table 2). For the third subset (symptoms/complaints, that is, without direct relation either to neurovegetative or to voice aspects), the discrepancy appears less obvious, although still clearly significant: patients responded affirmatively an average of 1.49 times (SD 1.12) and Journal of Voice, Vol. 16, No. 4, 2002
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FIGURE 1. Histogram of total positive responses for the complaints/symptoms pertaining to neurovegetative aspects, in patient and control group.
FIGURE 2. Histogram of total positive responses for the complaints/symptoms pertaining to neurovegetative aspects connected with voice, in patient and control group.
FIGURE 3. Histogram of total positive responses for the complaints/symptoms pertaining to nonneurovegetative aspects, in patient and control group. Journal of Voice, Vol. 16, No. 4, 2002
NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION controls 0.82 times (SD 0.75) (p = 0.00001). For only one question was the excess of positive responses in patients compared with controls weakly significant (Table 2). The contingency table of the “double question” “Feelings of psychic tension” (number 21) versus “Feelings of mental stress“ (number 46) testing for the consistency of answering, shows no statistically significant difference between the ratio of positive and negative responses in patients and controls (chisquare not significant) (Table 3). The percentage of agreement is 80%. Cohen kappa is 0.59, pointing out “moderate” to “substantial” strength of agreement. TABLE 3. Contingency Table of the Responses for the “Double” Question 46:yes
46:no
21:yes
52 (31%)
19 (11%)
21:no
14 (8%)
82 (49%)
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However, for question 21 as well as question 46, there is a clearly significant excess of positive responses in the patient group (chi-square: p < 0.001). Question 21 was incorporated in the first subset. The differences in amounts of subjects with more and less positive responses was also compared within different subgroups of patients and controls. For the first subset (symptoms/complaints on the autonomic level without obvious relation to voice function or voice organs), the excess of patients with at least seven positive responses (versus controls) within the female subgroup is highly significant, while it lacks statistical significance within the male subgroup (Table 4) For the second subset (symptoms/complaints on the autonomic level, but with a more or less obvious connection with voice function and/or voice organs), the excess of patients with at least 4 positive responses (versus controls) within the female subgroup is highly significant, while it lacks statistical significance within the male subgroup (Table 5). For the first subset, the excess of female patients with at least seven positive responses (vs. fe-
TABLE 4. Contingency Table Comparing Male and Female Subgroups for Symptoms/Complaints on the Autonomic Level Without Obvious Relation to Voice Function or Voice Organs 0–6 positive responses
7 or more positive responses.
Female controls Female patients
57 14
9 51 (p < 0.001)
Male controls Male patients
18 13
0 5 (p = 0.054 : NS)
Abbreviation: NS, not significant.
TABLE 5. Contingency Table Comparing Male and Female Subgroups for Symptoms/Complaints on the Autonomic Level, but with a More or Less Obvious Connection with Voice Function and/or Voice Organs 0–3 positive responses
4 or more positive responses
Female controls Female patients
63 10
3 55 (p < 0.001)
Male controls Male patients
14 12
4 6 (p = 0.71 : NS)
Abbreviation: NS, not significant. Journal of Voice, Vol. 16, No. 4, 2002
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male controls) remains highly significant within each age-defined subgroup (Table 6). For the second subset, the excess of female patients with at least four positive responses is also highly significant within each age-defined subgroup (Table 7).
in patients compared with controls is weakly significant (Table 2). Nevertheless, patients responded affirmatively an average of 1.49 times (SD 1.12) and controls 0.82 times (SD 0.75); albeit a small difference, it is clearly significant (p = 0.00001). This indicates that either functional voice patients are more sensitive to the subjective experience of autonomic dysfunction, or that they may be more prone to complain, or that the range of somatic manifestations is still larger than what has been considered as autonomic dysfunction. In fact, headache, and especially migraine, is for some authors included within the possible manifestations of chronic stress and tension, thus possibly also related to autonomic dysfunction.20 Further, the duplicated question shows that the inquiry forms were answered in a consistent way.
DISCUSSION Validity and consistency check with “dummy” and replicated questions Ideally, such “dummy” or nonrelevant questions (i.e., referring to symptoms/complaints without direct relation either to neurovegetative or to voice aspects), should be similarly answered by both the patients and the control groups. For only one single question (headache), the excess of positive responses
TABLE 6. Contingency Table Comparing Female Subgroups Based on Age for Symptoms/Complaints on the Autonomic Level Without Obvious Relation to Voice Function or Voice Organs 0–6 positive responses
7 or more positive responses
Female controls 15–34 years Female patients 15–34 years
18 3
3 17 (p < 0.001)
Female controls 35–54 years Female patients 35–54 years
24 8
5 23 (p < 0.001)
Female controls 55 years and over Female patients 55 years and over
15 3
1 11 (p < 0.001)
TABLE 7. Contingency Table Comparing Female Subgroups Based on Age for Symptoms/Complaints on the Autonomic Level, but with a More or Less Obvious Connection with Voice Function and/or Voice Organs 0–3 positive responses
4 or more positive responses
Female controls 15–34 years Female patients 15–34 years
18 3
3 17 (p < 0.001)
Female controls 35–54 years Female patients 35–54 years
27 4
2 27 (p < 0.001)
Female controls 55 years and over Female patients 55 years and over
Journal of Voice, Vol. 16, No. 4, 2002
16 2
0 12 (p < 0.001)
NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION The nature of the link Globally, our hypothesis that a link exists between nonorganic habitual dysphonia and complaints/manifestations of autonomic dysfunction, either connected or not with voice production, is largely validated for females, as the number of positive answers is significantly higher in functional voice patients than in matched controls. However, although they provide evidence for a link, these data do not directly answer the question of whether autonomic dysfunction should be considered causal, correlational, or consequential of the voice dysfunction. Nonorganic voice disorders are frequently assumed to be a manifestation of one or more types of psychological disequilibrium, especially anxiety and stress.20 Stress may be considered the set of emotional, cognitive, and physiological reactions to psychological demands and challenges, largely influenced by an individual’s coping ability. Voice is a very sensitive indicator of emotions, attitudes, and role assumptions.7 The way a person feels physically and emotionally is often directly reflected in the quality of the voice. The resultant voice symptoms may simply be the result of a whole body tension causing a more specific hypertonicity of the laryngeal muscles causing a tension dysphonia.21 Also Nichol, Morrison, and Rammage22 suggest that “tensional symptoms arise from the overactivity of autonomic and voluntary nervous systems in individuals who are unduly aroused and anxious.” According to these authors, such overactivity leads to hypertonicity of the intrinsic and extrinsic laryngeal muscles, and to dysphonia. Conversely, impairment of the voice is a distressing experience for most patients, and their frustration or anger may still increase musculoskeletal tension and worsen vocal production. The stressor might be either an external or an internal perception. According to Caputo Rosen and Sataloff,20 the sequence of the events is as follows: A memory, image, or thought is interpreted as danger, and the cortex responds, sending signals to the limbic system which adds emotional tone to the experience. The limbic system stimulates the hypothalamus, which regulates the autonomic nervous system. Impulses are also sent to the pituitary gland (hormonal regulation), and to the adrenal medullae (release of epinephrine and norepinephrine).
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By this way stress can generate numerous physical consequences. Through the autonomic nervous system, it may induce changes in airway mucus, saliva flow, heart rate, gastric acid production, skin temperature, secretions, and so forth, expressing as a wide scale of complaints. Still according to Caputo Rosen and Sataloff,20 more severe or prolonged stress is also commonly associated with increased muscle tension, particularly in the head and neck, chronic fatigue, reflux laryngitis, gastrointestinal manifestations, and numerous pain syndromes. Individual vulnerability is obviously an important factor. Vulnerability could be influenced by personality characteristics: Roy et al23 compared female voice patients diagnosed as functional dysphonia with a medical outpatient control group, and found in female voice patients an elevated degree of emotional maladjustment, with significantly higher scores on hypochondriasis and psychasthenia scales. It is interesting that despite symptom improvement after voice therapy, the subjects in this study with functional dysphonia continued to exhibit poor levels of adaptative functioning, which may represent traitlike vulnerability. Gender differences Nonorganic voice disorders are predominant in female patients,23 as are voice disorders in general. In the case of voice loading, women report more voice problems than men.24 Several physical or physiological gender differences, as mean speaking frequency, dorsal closure of the glottis, shape of the vocal fold edge, and lubrication possibly play a role.25 Recently, interesting gender differences in the distribution of hyaluronic acid within the vocal fold provided new biomechanical insights.26 Furthermore, the female larynx, being subject to hormone-mediated effects, is possibly rendered more vulnerable.27 Some endocrine as well as neurovegetative connections with behavior have been documented: A study by Frankenhaeuser et al28 on the effects of gender and occupational status on stress and “unwinding” showed that the after-work systolic blood pressure and epinephrine levels of female managers were distinguished from their male counterparts, with the former measure remaining elevated after work and the latter increasing. Several studies, but not all, indicate larger cortisol responses to public speaking challenges among men, Journal of Voice, Vol. 16, No. 4, 2002
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but on the other hand, women seem to be more responsive to the social nuances of the task situation, such as expressions of support and threats of withdrawal.29 The preliminary indications of gender differences in the influence of socially meaningful stimuli on endocrine homeostasis is clearly an understudied but potentially important area for psychophysiological research.30 For the future, such findings could provide some insight into possible explanations connecting the pathogenesis of dysphonia, especially when thinking in the scope of genomics, and particularly in terms of patterns of gene expression, regulated by soluble factors surrounding the cell, as endocrine secretions. CONCLUSION Our data provide evidence for a link, in females of all age categories, between nonorganic habitual dysphonia and subjective experience of autonomic dysfunction, either connected or not with voice production. This link has not been found in male patients. It seems likely to consider nonorganic habitual dysphonia as a possible manifestation of stress and anxiety, with overactivity of the autonomic nervous system in female, individually vulnerable patients. All age categories seem to be concerned in approximately the same way. The voice disorder seems to occur within a broader scale of complaints and symptoms, and the frustration elicited by the voice impairment may obviously reinforce the stress. The sensitivity of these patients to the subjective experience of autonomic dysfunction may also be increased. These concepts seem of major importance for better understanding and improving functional voice therapy. REFERENCES 1. Underdown ED. Physiology. 4th ed. St. Louis, Mo: Mosby Inc; 1998. 2. Gelder M, Gath D, Mayou R, Cowen P. Oxford Textbook of Psychiatry. Oxford: Oxford University Press; 1996. 3. Eccles R, Lee RL. The influence of the hypothalamus on the sympathic innervation of the nasal vasculature of the cat. Acta Otol Laryngol. 1981;91:127–134. 4. Gerth van Wijk R, de Graaf - in ‘t Veld C, Garrelds IM. Nasal hyperreactivity. Rhinology. 1999;37:50–55. 5. Fairbanks DNF. Nonallergic Rhinitis. In: Cummings, CW, et al, eds. Otolaryngology—Head and Neck Surgery. St. Louis, Mo: The C.V. Mosby Company; 1986:663–672. Journal of Voice, Vol. 16, No. 4, 2002
6. Kolb LC. The psychoneuroses. In: Beeson PB, McDermott WWB. Textbook of Medicine. Philadelphia, Pa: Saunders Company Post; 1961. 7. Morrison M, Rammage L. The Management of Voice Disorders. London: Chapman & Hall Medical, 1994:113–114. 8. Aronson AE. Clinical Voice Disorders. New York, NY: Thieme Inc; 1985:132–133. 9. Sadock B J, Sadock VA. Comprehensive Textbook of Psychiatry. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000. 10. Hales RE, Yudofski SC, Talbott JA. Textbook of Psychiatry. London: American Psychiatric Press, Inc; 1999. 11. Chapell MS. Inner speech and respiration: toward a possible mechanism of stress reduction. Percept & Motor Skills. 1994;79:803–811. 12. Ley R. An introduction to the psychophysiology of breathing. Biofeedback Self-Regul. 1994;19:95–96. 13. Cooke RA, Anggiansah A, Wang J, Chambers JB, Owen W. Hyperventilation and esophageal dysmotility in patients with noncardiac chest pain. Am J Gastroenterol. 1996;91: 480–484. 14. Castell JA, Castell DO, Schulz AR, Georgeson S. Effect of head position on the dynamics of the upper esophageal sphincter and pharynx. Dysphagia. 1993;8:1–6. 15. Murphy AT. Functional Voice Disorders. Englewood Cliffs, NJ: Prentice Hall; 1964. 16. Bridger MWM, Epstain R. Functional voice disorders: a review of 109 patients J Laryngol Otol. 1983;97:1145–1148. 17. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991;24:1059–1073. 18. Morrison MD, Nichol H, Rammage LA. Diagnostic criteria in functional dysphonia. Laryngoscope 1986;96:1–8. 19. Sama A, Carding PN, Price S, Kelly P, Wilson JA. The clinical features of functional dysphonia. Laryngoscope. 2001; 111:458–463. 20. Caputo Rosen DRN, Sataloff RT. Psychology of Voice Disorders. San Diego, Calif: Singular Publishing Group, Inc.; 1997. 21. Stemple JC, Glaze LE, Gerdeman BK. Clinical Voice Pathology. 2nd ed. San Diego, Calif. Singular Publishing Group; 1995. 22. Nichol H, Morrison MD, Rammage LA. Interdisciplinary approach to functional voice disorders: the psychiatrist’s role. Otolaryngol Head Neck Surg. 1993;108:643–647. 23. Roy N, McGrory JJ, Tasko SM, Bless DM, Heisey D, Ford CN. Psychological correlates of functional dysphonia: an investigation using the Minnesota Multiphasic Personality Inventory. J Voice. 1997;11:443–451. 24. Smith E, Kirchner HL, Taylor M, Hoffman H, Lemke JH. Voice problems among teachers: differences by gender and teaching characteristics. J Voice 1998;12:328–334. 25. Dejonckere PH. Gender differences in the prevalence of occupational voice disorders. In: Dejonckere PH, ed. Occupational Voice: Care & Cure. The Hague: Kugler Publications 2001:11–20. 26. Butler JE, Hammond TH, Gray SD. Gender-related differences of hyaluronic acid distribution in the human vocal fold. Laryngoscope. 2001:111:907–911.
NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION 27. Chagnon F, Stone RE Jr. Nodules and polyps. In: Brown WS, Vinson BP, Crary MA, eds. Organic Voice Disorders. San Diego, Calif: Singular Publishing Group; 1996:219–244. 28. Frankenhaeuser M, Lundberg U, Fredrikson M, et al. Stress on and off the job as related to sex and occupational status in white-collar workers. J Organ Behav. 1989;10:321– 346.
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29. Kirschbaum C, Wust S, Hellhammer D. Consistent sex differences in cortisol responses to psychological stress. Psychosom Med 1992;54:648–657. 30. Lovallo WR, Thomas, TL Stress hormones in psychophysiological resarch. In: Cacioppo JT, Tassinary LG, Bernstson GG, eds. Handbook of Psychophysiology. 2nd ed. Cambridge, UK: Cambridge University Press; 2000:342–367.
Journal of Voice, Vol. 16, No. 4, 2002
Nonorganic Habitual Dysphonia and Autonomic Dysfunction Lize Demmink-Geertman and Philippe Henri Dejonckere The Institute of Phoniatrics, University Medical Center Utrecht, Utrecht, The Netherlands
Summary: The present study was designed to test the hypothesis that there is a relation between nonorganic habitual dysphonia and subjective experience of dysfunction of the autonomic nervous system (neurovegetative lability). Eightythree patients (65 women and 18 men) with a nonorganic voice disorder and a matched control group answered a questionnaire of 46 questions. One question replicated in different terms and six nonrelevant questions point out that the inquiry forms were answered in a consistent way. It appears that female patients in all age categories with a nonorganic habitual dysphonia report significantly more autonomic symptoms and complaints than healthy controls. This hypothesis cannot be confirmed for the male subgroup. Key Words: Nonorganic habitual dysphonia—Functional dysphonia—Autonomic nervous system—Vegetative functions—Anxiety—Stress.
stant internal environment (homeostasis). It also participates in appropriate coordinated responses to external stimuli: an extreme example of this regulation is the “fight-or-flight response” that occurs when a threat intensively activates the sympathetic nervous system, causing a variety of responses, as release of adrenal hormones, increase of heart rate and blood pressure, dilatation of bronchioles, inhibition of intestinal mobility and secretion, piloerection, constriction of cutaneous blood vessels, and so forth. Normally, this fight-or-flight response is an uncommon event, except if the function of the autonomic system becomes disturbed and overexcitable. The effectors are smooth muscle, cardiac muscle, and glands. Effects concern, among other things, heart rate, arterioles (constriction or dilation), bronchial muscles and glands, stomachal and intestinal motility and secretion, skin (pilomotor muscles and sweat glands), salivary, lacrymal and nasopharyngeal glands, genitourinary tract, and nervous system (tinnitus, dizziness). Adrenergic and cholinergic impulses generate different, mainly antagonistic ef-
INTRODUCTION The autonomic nervous system The term autonomic nervous system (or vegetative nervous system, or visceral motor system) usually refers to the sympathetic and parasympathetic nervous systems, and generally includes the enteric nervous system. The autonomic nervous system also includes central components, as the thalamus and the higher levels of the limbic system, which are associated with emotions and with many visceral behaviors, such as feeding, drinking, thermoregulation, and so forth.1 Like most organs, the larynx is reached by the sympathetic and parasympathetic fibers through the laryngeal vascular supply. The main function of the autonomic nervous system seems to assist the body in maintaining a conAccepted for publication April 16, 2002. Address correspondence and reprint requests to P. H. Dejonckere, MD, PhD, The Institute of Phoniatrics, University Medical Center Utrecht, AZU F. 02.504, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. e-mail : [email protected]
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fects. Accompanying the autonomic motor fibers in peripheral nerves are afferent fibers that originate from sensory receptors in the viscera. Many of these receptors trigger reflexes, but the activity of some receptors evokes sensory experiences, such as pain, hunger, thirst, nausea, a sense of visceral distention, and so forth.1,2 Stress and anxiety Animal experiments have suggested that stress may cause loss of hypothalamic control over sympathetic innervation, resulting in a relative dominance of the parasympathetic system.3,4 In humans, the limbic system controls emotional behavior in part by activation of the autonomic nervous system.1 Autonomic symptoms are known to be associated with anxiety.2 For example, life situations that produce anxiety, hostility, guilt, or feelings of frustration and resentment can disturb the autonomic vascular balance.5 In the gastrointestinal tract, autonomic dysfunction may take the form of nausea, vomiting, belching, distress from gas, and epigastric pain resulting from diarrhea and constipation. The cardiovascular system responds to stress with tachycardia and changes in rhythm, and neurocirculatory asthenia characterized by breathlessness, fatigability, palpitations, trembling, fainting, dizziness, and so forth.6 Relation with nonorganic voice disorders As a lot of patients with voice problems are struggling with emotional problems as well, several authors suggest an association between functional voice disorders and stress or anxiety. Morrison and Rammage7 emphasize that emotion—mainly anxiety—is the intervening variable between psychological factors and the physically altered laryngeal muscle tone that actually produces the dysphonia. Also Aronson8 states that laryngeal muscles are exquisitely sensitive to emotional stress, and that the responsible factors are anxiety, anger, irritability, impatience, frustration, and depression. Cause or effect ? Among respiratory reactions, the hyperventilation syndrome is generally associated with anxiety.9 However, excessive breathing can also be due to glottal air leakage. Overbreathing induces hypocapnia and alkalosis, and causes lightheadedness, palpitations, numbness, and tingling both periorally and in the extremities, and so forth. Now, hyperventilation Journal of Voice, Vol. 16, No. 4, 2002
seems to disappear once a patient has been successfully treated with antipanic medication. Also, behavioral breathing retraining treatments may decrease the frequency of panic attacks.10 According to Chapell,11 respiration mediates stress: slow, deep, regular, diaphragmatic-abdominal breathing is associated with low subjective and objective stress. In contrast, fast, shallow, irregular, thoracic breathing is associated with hyperarousal, fight/flight reactions of the sympathic system and stress, and may result in hyperventilation. Ley12 considers that breathing can be viewed as an independent variable that affects emotion, cognition and behavior as well as a dependent variable that reflects changes in emotion, cognition, and behavior. Breathing is an autonomic response that increases by increases in metabolic demand or by emotions or thoughts that give rise to emotions. Otherwise voluntary changes in breathing can affect our thoughts and feelings. This makes breathing a vital function that is under both voluntary as well as autonomic control. This applies for respiration at rest as well as during moving and/or speaking. Another example of interrelationship is provided by Cooke et al.13 They tested the esophageal dysmotility in a group of patients with noncardiac chest pain during hyperventilation provocation. Hyperventilation was associated with a significant fall in mean distal peristaltic amplitude and mean duration. It induced diffuse spasms in some patients and nonspecific motility disorders in others. Some patients reproduced chest pain, but in none did this coincide with important changes in peristaltic amplitude, duration, or frequency. They conclude that there must be a relationship between hyperventilation and esophageal motility. Because these disorders are often reported together, they may interact to produce chest pain, although overbreathing rarely produces chest pain via its effects on the esophagus. A last example can be found in Castell et al14 who contend that head position affects on both the upper esophageal sphincter (UES) and the pharynx. Too much head extension diminishes UES relaxation and has various effects such as aerophagy and reflux. Several patients with voice problems exhibit deviant head posture. Reaction to stress Each individual is equipped with a variety of adaptive mechanisms strengthened or weakened by the
NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION individual’s knowledge and experience as well as his physical condition and emotional mood, so it is not surprising that reaction to stress will be variable.10 Hypothesis In the present study, we attempt to verify the hypothesis that a link exists between nonorganic habitual dysphonia and complaints/manifestations of autonomic dysfunction, either connected or not connected with voice production, by comparing the prevalence of such complaints and symptoms in a group of patients diagnosed with nonorganic habitual dysphonia and in a group of matched control subjects. Gender and age categories are considered separately. Nonorganic dysphonia refers to impairment of voice production in the absence of mucosal or neurogenic disease of the larynx.15,16 It must be clear that this definition involves a lot of possible criticism, for exammple, about subtle structural changes or hormonal/pharmacological effects, particularly at the beginning phase of an evolutive process. However, a large part of possible misdiagnoses may be eliminated by a medical control exam after a few months and intercurrent functional voice therapy. In the absence of any identifiable organic disorder, dysphonia logically needs to be a product of altered laryngeal physiology during phonation. It is widely accepted that the disordered physiology commonly results from an inadequate balance in laryngeal muscle tension.17 In the past, typical laryngoscopic features of muscle tension dysphonia have been described,18 but recent research leads to some caution in the interpretation of clinical features of hyperfunction.19 Therefore, we preferred this definition for the inclusion criterion: the presence of a voice complaint and of a perceptual deviance in voice production, but the absence of any identifiable structural change in the larynx or systemic organic etiology. SUBJECTS AND METHODS Subjects The patient group consists of 83 subjects (65 females; 18 males), all of them with a voice complaint and a perceptual deviance in voice production, and the diagnosis of nonorganic habitual dysphonia. This diagnosis was made after a complete ENT examination, and exclusion of any identifiable structural change in the larynx. Hormonal, pharmacological,
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mutational and spasmodic dysphonias, as well as psychogenic aphonia were also excluded. “Habitual” points out that the voice problem had to be present for at least several months. All patients were referred to a speech therapist for treatment. All patients were also medically controlled after treatment, a few months later, in order to confirm the absence of any identifiable (and possibly evolutive) structural change in the larynx or systemic organic etiology. The age span was 18 to 77 years. A control group, consisting also of 84 subjects, was built up by having recourse to social relations of the speech-therapists themselves, and of their patients. All controls were free of voice problems or complaints, and the subgroups were matched for gender and age with the subgroups of voice patients. All participants were informed that this research concerned the prevalence of some specific associated complaints in voice patients. Only a very few subjects who were asked to participate did not accept. Table 1 shows the gender and age characteristics of both patients and controls. Method Both patients and controls were requested to fill in a questionnaire consisting of 46 complaints or symptoms, to be answered only with “yes,” for present, or “no” for absent (see Table 2). This questionnaire actually consisted of four subsets, unknown to the respondents. A first subset (22 questions) inquired about manifestations/complaints on the autonomic level without obvious relation to voice function or voice organs. A second subset (16 questions) also concerned manifestations/complaints on the autonomic level, but with a more or less obvious connection with voice TABLE 1. Gender and Age Characteristics of Patients and Controls Subgroup
Patients
Controls
Women 15–34 years
20
21
Women 35–54 years
31
29
Women 55 years and more
14
16
9
8
Men 15–44 years Men 45 years and more Total
9
10
83
84
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LIZE DEMMINK–GEERTMAN AND PHILIPPE HENRI DEJONCKERE TABLE 2. List of Symptoms/Complaints Number “Yes” in Patients
Number “Yes” in Controls
Neurovegetative
40
25
p = 0.022
Cold feet
Neurovegetative
45
42
NS
3
Excessive transpiration
Neurovegetative
31
10
p < 0.00l
4
Excessive sensitiveness to coldness
Neurovegetative
37
26
NS
5
Excessive sensitiveness to heat
Neurovegetative
27
21
NS
6
Diarrhea
Neurovegetative
20
9
p = 0.038
7
Constipation
Neurovegetative
24
9
p = 0.006
8
Puffiness
Neurovegetative
35
10
p < .001
9
Aerophagia
Neurovegetative
17
2
p = .001
10
Nausea
Neurovegetative
22
3
p < .001
11
Lack of appetite
Nonrelevant
9
3
NS
12
Eructations
Neurovegetative
30
14
No.
Complaint
Type
1
Cold hands
2
Significance Level
p = 0.007
13
Hiccups
Neurovegetative
26
10
p = 0.004
14
Heartburn
Neurovegetative
23
11
p = 0.031
15
Dizziness
Neurovegetative
46
14
p < 0.001
16
Tinnitus
Neurovegetative
25
11
p = 0.013
17
Dancing spots before the eyes
Neurovegetative
38
23
p = 0.02l
18
Difficult concentration
Neurovegetative
34
13
p < 0.001
19
Disturbed sleep
Neurovegetative
39
19
p = 0.002
20
Lack of energy
Neurovegetative
36
15
p = 0.001 p < 0.00l
21
Feelings of psychic tension
Reliability control
47
23
22
Renal problems
Nonrelevant
4
0
NS
23
Need of constantly swallowing
Voice related
33
2
p < 0.001
24
Sore throat
Voice related
44
9
p < 0.001
25
Hyperventilation
Voice related
21
2
p < 0.00l
26
Specific allergy
Nonrelevant
31
19
NS
27
Frequent sneezing
Voice related
32
12
p = 0.001
28
Fluctuating nose obstruction
Voice related
44
24
p = 0.002
29
Difficulty breathing through the nose at rest
Voice related
16
9
NS
30
Habitual mouth breathing at rest
Voice related
26
18
NS
31
Hearing loss
Nonrelevant
23
14
NS
32
Feelings of tension in the head while speaking
Voice related
17
2
p = 0.001
33
Headache
Nonrelevant
39
25
p = 0.033
34
Constant need to yawn
Voice related
23
10
p = 0.018
35
Gnashing of teeth
Voice related
11
3
p = 0.031
36
Temporomandibular pain or discomfort
Voice related
15
6
p = 0.033
37
Neck pain (while or after speaking)
Voice related
48
21
p < 0.001
38
Chest discomfort (while or after speaking)
Voice related
29
3
p < 0.001
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NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION
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Table 2. continued Number “Yes” in Patients
Number “Yes” in Controls
Voice related
46
2
p < 0.001
Frequent throat clearing
Voice related
40
11
p < 0.001
Chronic illness
Nonrelevant
18
8
No.
Complaint
Type
39
Fatigability when speaking
40 41
Significance Level
NS
42
Palpitations
Neurovegetative
33
6
p < 0.000
43
Social (communicative) handicap
Voice related
12
3
p = 0.029
44
Nail biting
Neurovegetative
19
17
45
Sensation of extreme tiredness
Neurovegetative
21
5
p = 0.001
46
Feelings of mental stress
Reliability control
45
22
p < 0.001
NS
Significance level: Pearson chi-square test with continuity correction (Yates). Abbreviation: NS, not significant.
function and/or voice organs (airway, breathing, articulation). A third smaller subset (6 questions) dealt with nonrelevant complaints, that is, without direct relation either to neurovegetative or to voice aspects. Finally, one question (number 21) was replicated, formulated in different words (question number 46). Question 21 was counted together with the first subset. Table 2 provides an overview of all symptoms/ complaints, and indicates for each one its category. The only possible responses were “yes” if the symptom was present and “no” if the symptom was absent. The present study is thus based, for the autonomic symptoms, exclusively on the subjective experience of the voice patients and control subjects, without involving psychophysiological testing. However, subsets 3 (irrelevant symptoms/complaints) and 4 (replication with different formulation) were intended as a check for validity and consistency. Statistics All data were analyzed with SPSS 9 (Statistical Package for Social Sciences). The positive responses in patients and controls were compared using the ttest, as distributions look quite normal. For each question, the statistical comparison of positive and negative responses in patients and controls was made with a chi-square test with Yate’s correction and a critical significance level of p < 0.05. In case of small subgroups, SPSS automatically shifts to Fisher’s exact test. A Cohen kappa was computed for checking consistency of responses to questions 21 and 46. A
chi-square test with Yate’s correction was also used for comparing patients and controls within subgroups based on gender or age. RESULTS Figures 1, 2, and 3 show the histograms of total positive responses for the complaints/symptoms pertaining, respectively, to neurovegetative aspects, to neurovegetative aspects connected with voice, and to nonneurovegetative aspects. For the first subset (symptoms/complaints on the autonomic level without obvious relation to voice function or voice organs), patients responded affirmatively an average of 8.05 times (SD 3.98) and controls 3.75 times (SD 2.26) (p < 0.000001). In 18 out of 22 questions, the excess of positive responses in patients compared with controls is statistically significant (Table 2). For the second subset (symptoms/complaints on the autonomic level, but with a more or less obvious connection with voice function and/or voice organs), patients responded affirmatively an average of 5.51 times (SD 2.89) and controls 1.64 times (SD 1.32) (p < 0.000001). In 14 out of 16 questions, the excess of positive responses in patients compared with controls is statistically significant (Table 2). For the third subset (symptoms/complaints, that is, without direct relation either to neurovegetative or to voice aspects), the discrepancy appears less obvious, although still clearly significant: patients responded affirmatively an average of 1.49 times (SD 1.12) and Journal of Voice, Vol. 16, No. 4, 2002
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LIZE DEMMINK–GEERTMAN AND PHILIPPE HENRI DEJONCKERE
FIGURE 1. Histogram of total positive responses for the complaints/symptoms pertaining to neurovegetative aspects, in patient and control group.
FIGURE 2. Histogram of total positive responses for the complaints/symptoms pertaining to neurovegetative aspects connected with voice, in patient and control group.
FIGURE 3. Histogram of total positive responses for the complaints/symptoms pertaining to nonneurovegetative aspects, in patient and control group. Journal of Voice, Vol. 16, No. 4, 2002
NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION controls 0.82 times (SD 0.75) (p = 0.00001). For only one question was the excess of positive responses in patients compared with controls weakly significant (Table 2). The contingency table of the “double question” “Feelings of psychic tension” (number 21) versus “Feelings of mental stress“ (number 46) testing for the consistency of answering, shows no statistically significant difference between the ratio of positive and negative responses in patients and controls (chisquare not significant) (Table 3). The percentage of agreement is 80%. Cohen kappa is 0.59, pointing out “moderate” to “substantial” strength of agreement. TABLE 3. Contingency Table of the Responses for the “Double” Question 46:yes
46:no
21:yes
52 (31%)
19 (11%)
21:no
14 (8%)
82 (49%)
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However, for question 21 as well as question 46, there is a clearly significant excess of positive responses in the patient group (chi-square: p < 0.001). Question 21 was incorporated in the first subset. The differences in amounts of subjects with more and less positive responses was also compared within different subgroups of patients and controls. For the first subset (symptoms/complaints on the autonomic level without obvious relation to voice function or voice organs), the excess of patients with at least seven positive responses (versus controls) within the female subgroup is highly significant, while it lacks statistical significance within the male subgroup (Table 4) For the second subset (symptoms/complaints on the autonomic level, but with a more or less obvious connection with voice function and/or voice organs), the excess of patients with at least 4 positive responses (versus controls) within the female subgroup is highly significant, while it lacks statistical significance within the male subgroup (Table 5). For the first subset, the excess of female patients with at least seven positive responses (vs. fe-
TABLE 4. Contingency Table Comparing Male and Female Subgroups for Symptoms/Complaints on the Autonomic Level Without Obvious Relation to Voice Function or Voice Organs 0–6 positive responses
7 or more positive responses.
Female controls Female patients
57 14
9 51 (p < 0.001)
Male controls Male patients
18 13
0 5 (p = 0.054 : NS)
Abbreviation: NS, not significant.
TABLE 5. Contingency Table Comparing Male and Female Subgroups for Symptoms/Complaints on the Autonomic Level, but with a More or Less Obvious Connection with Voice Function and/or Voice Organs 0–3 positive responses
4 or more positive responses
Female controls Female patients
63 10
3 55 (p < 0.001)
Male controls Male patients
14 12
4 6 (p = 0.71 : NS)
Abbreviation: NS, not significant. Journal of Voice, Vol. 16, No. 4, 2002
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LIZE DEMMINK–GEERTMAN AND PHILIPPE HENRI DEJONCKERE
male controls) remains highly significant within each age-defined subgroup (Table 6). For the second subset, the excess of female patients with at least four positive responses is also highly significant within each age-defined subgroup (Table 7).
in patients compared with controls is weakly significant (Table 2). Nevertheless, patients responded affirmatively an average of 1.49 times (SD 1.12) and controls 0.82 times (SD 0.75); albeit a small difference, it is clearly significant (p = 0.00001). This indicates that either functional voice patients are more sensitive to the subjective experience of autonomic dysfunction, or that they may be more prone to complain, or that the range of somatic manifestations is still larger than what has been considered as autonomic dysfunction. In fact, headache, and especially migraine, is for some authors included within the possible manifestations of chronic stress and tension, thus possibly also related to autonomic dysfunction.20 Further, the duplicated question shows that the inquiry forms were answered in a consistent way.
DISCUSSION Validity and consistency check with “dummy” and replicated questions Ideally, such “dummy” or nonrelevant questions (i.e., referring to symptoms/complaints without direct relation either to neurovegetative or to voice aspects), should be similarly answered by both the patients and the control groups. For only one single question (headache), the excess of positive responses
TABLE 6. Contingency Table Comparing Female Subgroups Based on Age for Symptoms/Complaints on the Autonomic Level Without Obvious Relation to Voice Function or Voice Organs 0–6 positive responses
7 or more positive responses
Female controls 15–34 years Female patients 15–34 years
18 3
3 17 (p < 0.001)
Female controls 35–54 years Female patients 35–54 years
24 8
5 23 (p < 0.001)
Female controls 55 years and over Female patients 55 years and over
15 3
1 11 (p < 0.001)
TABLE 7. Contingency Table Comparing Female Subgroups Based on Age for Symptoms/Complaints on the Autonomic Level, but with a More or Less Obvious Connection with Voice Function and/or Voice Organs 0–3 positive responses
4 or more positive responses
Female controls 15–34 years Female patients 15–34 years
18 3
3 17 (p < 0.001)
Female controls 35–54 years Female patients 35–54 years
27 4
2 27 (p < 0.001)
Female controls 55 years and over Female patients 55 years and over
Journal of Voice, Vol. 16, No. 4, 2002
16 2
0 12 (p < 0.001)
NONORGANIC HABITUAL DYSPHONIA AND AUTONOMIC DYSFUNCTION The nature of the link Globally, our hypothesis that a link exists between nonorganic habitual dysphonia and complaints/manifestations of autonomic dysfunction, either connected or not with voice production, is largely validated for females, as the number of positive answers is significantly higher in functional voice patients than in matched controls. However, although they provide evidence for a link, these data do not directly answer the question of whether autonomic dysfunction should be considered causal, correlational, or consequential of the voice dysfunction. Nonorganic voice disorders are frequently assumed to be a manifestation of one or more types of psychological disequilibrium, especially anxiety and stress.20 Stress may be considered the set of emotional, cognitive, and physiological reactions to psychological demands and challenges, largely influenced by an individual’s coping ability. Voice is a very sensitive indicator of emotions, attitudes, and role assumptions.7 The way a person feels physically and emotionally is often directly reflected in the quality of the voice. The resultant voice symptoms may simply be the result of a whole body tension causing a more specific hypertonicity of the laryngeal muscles causing a tension dysphonia.21 Also Nichol, Morrison, and Rammage22 suggest that “tensional symptoms arise from the overactivity of autonomic and voluntary nervous systems in individuals who are unduly aroused and anxious.” According to these authors, such overactivity leads to hypertonicity of the intrinsic and extrinsic laryngeal muscles, and to dysphonia. Conversely, impairment of the voice is a distressing experience for most patients, and their frustration or anger may still increase musculoskeletal tension and worsen vocal production. The stressor might be either an external or an internal perception. According to Caputo Rosen and Sataloff,20 the sequence of the events is as follows: A memory, image, or thought is interpreted as danger, and the cortex responds, sending signals to the limbic system which adds emotional tone to the experience. The limbic system stimulates the hypothalamus, which regulates the autonomic nervous system. Impulses are also sent to the pituitary gland (hormonal regulation), and to the adrenal medullae (release of epinephrine and norepinephrine).
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By this way stress can generate numerous physical consequences. Through the autonomic nervous system, it may induce changes in airway mucus, saliva flow, heart rate, gastric acid production, skin temperature, secretions, and so forth, expressing as a wide scale of complaints. Still according to Caputo Rosen and Sataloff,20 more severe or prolonged stress is also commonly associated with increased muscle tension, particularly in the head and neck, chronic fatigue, reflux laryngitis, gastrointestinal manifestations, and numerous pain syndromes. Individual vulnerability is obviously an important factor. Vulnerability could be influenced by personality characteristics: Roy et al23 compared female voice patients diagnosed as functional dysphonia with a medical outpatient control group, and found in female voice patients an elevated degree of emotional maladjustment, with significantly higher scores on hypochondriasis and psychasthenia scales. It is interesting that despite symptom improvement after voice therapy, the subjects in this study with functional dysphonia continued to exhibit poor levels of adaptative functioning, which may represent traitlike vulnerability. Gender differences Nonorganic voice disorders are predominant in female patients,23 as are voice disorders in general. In the case of voice loading, women report more voice problems than men.24 Several physical or physiological gender differences, as mean speaking frequency, dorsal closure of the glottis, shape of the vocal fold edge, and lubrication possibly play a role.25 Recently, interesting gender differences in the distribution of hyaluronic acid within the vocal fold provided new biomechanical insights.26 Furthermore, the female larynx, being subject to hormone-mediated effects, is possibly rendered more vulnerable.27 Some endocrine as well as neurovegetative connections with behavior have been documented: A study by Frankenhaeuser et al28 on the effects of gender and occupational status on stress and “unwinding” showed that the after-work systolic blood pressure and epinephrine levels of female managers were distinguished from their male counterparts, with the former measure remaining elevated after work and the latter increasing. Several studies, but not all, indicate larger cortisol responses to public speaking challenges among men, Journal of Voice, Vol. 16, No. 4, 2002
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but on the other hand, women seem to be more responsive to the social nuances of the task situation, such as expressions of support and threats of withdrawal.29 The preliminary indications of gender differences in the influence of socially meaningful stimuli on endocrine homeostasis is clearly an understudied but potentially important area for psychophysiological research.30 For the future, such findings could provide some insight into possible explanations connecting the pathogenesis of dysphonia, especially when thinking in the scope of genomics, and particularly in terms of patterns of gene expression, regulated by soluble factors surrounding the cell, as endocrine secretions. CONCLUSION Our data provide evidence for a link, in females of all age categories, between nonorganic habitual dysphonia and subjective experience of autonomic dysfunction, either connected or not with voice production. This link has not been found in male patients. It seems likely to consider nonorganic habitual dysphonia as a possible manifestation of stress and anxiety, with overactivity of the autonomic nervous system in female, individually vulnerable patients. All age categories seem to be concerned in approximately the same way. The voice disorder seems to occur within a broader scale of complaints and symptoms, and the frustration elicited by the voice impairment may obviously reinforce the stress. The sensitivity of these patients to the subjective experience of autonomic dysfunction may also be increased. These concepts seem of major importance for better understanding and improving functional voice therapy. REFERENCES 1. Underdown ED. Physiology. 4th ed. St. Louis, Mo: Mosby Inc; 1998. 2. Gelder M, Gath D, Mayou R, Cowen P. Oxford Textbook of Psychiatry. Oxford: Oxford University Press; 1996. 3. Eccles R, Lee RL. The influence of the hypothalamus on the sympathic innervation of the nasal vasculature of the cat. Acta Otol Laryngol. 1981;91:127–134. 4. Gerth van Wijk R, de Graaf - in ‘t Veld C, Garrelds IM. Nasal hyperreactivity. Rhinology. 1999;37:50–55. 5. Fairbanks DNF. Nonallergic Rhinitis. In: Cummings, CW, et al, eds. Otolaryngology—Head and Neck Surgery. St. Louis, Mo: The C.V. Mosby Company; 1986:663–672. Journal of Voice, Vol. 16, No. 4, 2002
6. Kolb LC. The psychoneuroses. In: Beeson PB, McDermott WWB. Textbook of Medicine. Philadelphia, Pa: Saunders Company Post; 1961. 7. Morrison M, Rammage L. The Management of Voice Disorders. London: Chapman & Hall Medical, 1994:113–114. 8. Aronson AE. Clinical Voice Disorders. New York, NY: Thieme Inc; 1985:132–133. 9. Sadock B J, Sadock VA. Comprehensive Textbook of Psychiatry. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000. 10. Hales RE, Yudofski SC, Talbott JA. Textbook of Psychiatry. London: American Psychiatric Press, Inc; 1999. 11. Chapell MS. Inner speech and respiration: toward a possible mechanism of stress reduction. Percept & Motor Skills. 1994;79:803–811. 12. Ley R. An introduction to the psychophysiology of breathing. Biofeedback Self-Regul. 1994;19:95–96. 13. Cooke RA, Anggiansah A, Wang J, Chambers JB, Owen W. Hyperventilation and esophageal dysmotility in patients with noncardiac chest pain. Am J Gastroenterol. 1996;91: 480–484. 14. Castell JA, Castell DO, Schulz AR, Georgeson S. Effect of head position on the dynamics of the upper esophageal sphincter and pharynx. Dysphagia. 1993;8:1–6. 15. Murphy AT. Functional Voice Disorders. Englewood Cliffs, NJ: Prentice Hall; 1964. 16. Bridger MWM, Epstain R. Functional voice disorders: a review of 109 patients J Laryngol Otol. 1983;97:1145–1148. 17. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North Am. 1991;24:1059–1073. 18. Morrison MD, Nichol H, Rammage LA. Diagnostic criteria in functional dysphonia. Laryngoscope 1986;96:1–8. 19. Sama A, Carding PN, Price S, Kelly P, Wilson JA. The clinical features of functional dysphonia. Laryngoscope. 2001; 111:458–463. 20. Caputo Rosen DRN, Sataloff RT. Psychology of Voice Disorders. San Diego, Calif: Singular Publishing Group, Inc.; 1997. 21. Stemple JC, Glaze LE, Gerdeman BK. Clinical Voice Pathology. 2nd ed. San Diego, Calif. Singular Publishing Group; 1995. 22. Nichol H, Morrison MD, Rammage LA. Interdisciplinary approach to functional voice disorders: the psychiatrist’s role. Otolaryngol Head Neck Surg. 1993;108:643–647. 23. Roy N, McGrory JJ, Tasko SM, Bless DM, Heisey D, Ford CN. Psychological correlates of functional dysphonia: an investigation using the Minnesota Multiphasic Personality Inventory. J Voice. 1997;11:443–451. 24. Smith E, Kirchner HL, Taylor M, Hoffman H, Lemke JH. Voice problems among teachers: differences by gender and teaching characteristics. J Voice 1998;12:328–334. 25. Dejonckere PH. Gender differences in the prevalence of occupational voice disorders. In: Dejonckere PH, ed. Occupational Voice: Care & Cure. The Hague: Kugler Publications 2001:11–20. 26. Butler JE, Hammond TH, Gray SD. Gender-related differences of hyaluronic acid distribution in the human vocal fold. Laryngoscope. 2001:111:907–911.
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