Publicação
Psychological features of functional voice disorders
| Resumo: | Functional voice disorders (FVDs) are common vocal pathologies in the ENT outpatient clinics, with incidence ranging from 10% to 40% of the total patients with voice disorders. They have a female predominance (3:1) and are more frequent between the third and fifth decades of life. FVDs are characterized by apparently normal laryngeal anatomy and physiology while the patients present significant impairment in vocal and life qualities. The Diagnostic Classification System for Voice Disorders (DCSVD) proposed by Baker et al. in 2007 considers the existence of physiological, behavioral (abuse or misuse) and psychosocial (depression, anxiety and personality disorders) factors in their etiology, and recognizes and values the existence of three different types of FVDs. According to this system, patients with FVDs were classified as: psychogenic (PVD) in the absence of a structural or neurological pathology or as muscle tension voice disorders (MTVDs), a condition characterized by abnormal laryngeal tension. MTVDs can be subdivided in primary muscle tension voice disorders (MTVD1) with the vocal folds presenting an incomplete vocal fold closure, or as secondary muscle tension voice disorders (MTVD2), when the inadequate vocal technique and excessive phonatory effort leads to the development of benign vocal fold lesions (e.g., vocal nodules or polyps). Objectives An exploratory, descriptive, and cross-sectional study with a purposive sampling was developed to analyze the relationship between psychological features and functional voice disorders (FVDs). The three presentations of FVDs were characterized from a psychological perspective. The sociodemographic characteristics were identified, and an evaluation of vocal quality and its impact on quality of life have been performed. Methods The procedure took place in the Department of Ear, Nose, Throat, Voice and Communication Disorders of the Santa Maria Hospital (HSM), and Otolaryngology University Clinic of the Faculty of Medicine of the University of Lisbon, The recruitment of patients was made by ENT specialists or residents and/or by speech therapists, who accompanied these patients. The videolaryngoscopy using rigid endoscope or flexible fiberscope was used for the diagnosis and classification of each patient with FVDs. For the characterization of the subjects, a clinical history was made based on a semi-structured interview designed to collect information related to sociodemographic characteristics, health behaviors, vocal and psychological data (Study 1). The incidence of affective and anxiety disorders and the severity of depression and anxiety symptoms were analyzed with the Mini International Neuropsychiatric Interview (MINI) and both Hamilton Rating Scales (HAM-D for depression and HARS for anxiety), respectively (Study 2). The Millon Multiaxial Inventory (MCMI-II) was used to determine the personality profile of patients with FVDs and to identify the personality traits and disorders acting as vulnerability factors for their development (Study 3). Affective temperaments were assessed with the Temperament Evaluation of Memphis, Pisa, Paris and San Diego - Auto questionnaire (TEMPS-A) (Study 4). Vocal acoustic evaluation was made using Praat software (Study 5). Means of fundamental frequency (F0) and that of the first formant (F1) for the sustained vowels /i/, /a/ and /u/ were compared within groups and with normative database for Portuguese population (normal and dysphonic). The Voice Handicap Index (VHI-30) was used to evaluate the self-perception of quality of life and impairment associated to functional, physical and emotional vocal domains (Study 6). Results A total of 83 females, aged between 18 and 83 and with a mean age of 52.51 years (standard deviation = 14.27), were eligible for inclusion. Patients were clustered into three groups: PVD group with 39 patients (47%), MTVD1 group with 16 patients (19%), and MTVD2 group with 28 patients (34%). Our sample was constituted by patients with 3rd cycle (PVD and MTVD1) or secondary level (MTVD2) education, with an active professional life (≈ 60%) and most were married (Study 1). Nearly half of the patients were attending speech therapy sessions and 24.1% were receiving mental health treatments (psychology, psychiatric or both). FVDs patients noted as frequent the vocal fatigue and intensity changes in percentages greater than 87.5%. Dysphonia was also reported and variability existed in the comparison of groups (PVD = 89.7%, MTVD1 = 68.8% and MTVD2 = 100.0%). From the three groups, the group of patients with primary muscle tension voice disorders (MTVD1) had a higher incidence of current major depression and mood with psychotic symptoms as lifetime panic disorder, current generalized anxiety and panic disorder with agoraphobia (Study 2). These patients (MTVD1) also presented worse severity levels of depression (moderate) and anxiety (mild) compared to the patients from the two other groups (PVD and MTVD2) that were evaluated as having mild depression and anxiety at “normal range” of severity. In the group of patients with psychogenic voice disorders (PVD) the suicidal risk was prevalent, either at the level of incidence or severity. Obsessive-compulsive personality disorder as well as narcisistic, dependent and avoidant traits were prevalent among groups (Study 3). Paranoid as personality trait and as a personality disorder were most frequent among patients with psychogenic (PVD) and primary muscle tension (MTVD1) voice disorders. When depression and anxiety levels were set at a mean value, schizoid and schizotypal personality disorders appeared associated with PVD. Depressive and anxious temperaments were found at mild or moderate levels among FVDs patients (Study 4). PVD patients revealed vulnerability for depressive temperament when levels of depression and anxiety were statistically controlled. Our results were in consonance with the referenced data, with MTVD1 presenting high means F0 and MTVD2 low means F0, with the difference being more pronounced in the sustained vowel /u/ (Study 5). For the first formant (F1), statistical differences were found for the three vowels: /i/ and /u/ (PVD and MTVD1, and between MTVD1 and MTVD2 groups) and in the vowel /a/ (MTVD1 and MTVD2 groups), with MTVD1 to reached higher frequency means. In cough intensity, PVD and MTVD2 did not revealed differences between them. FVDs patients reported a moderate impairment in quality of life with high mean values in the physical subscale (Study 6). The MTVD1 had a significant statistical handicap in the functional subscale compared to the two other groups (PVD and MTVD2). Conclusions Our work underlines the relationship between psychological features and functional voice disorders. The incidence of affective and anxiety disorders, the severity of depression and anxiety symptoms and the personality disorders identified in our sample highlights the importance of its assessment in these patients. The common and the specific characteristics of FVDs groups were identified, revealing that their differences go beyond anatomo-functional presentations and voice quality, a condition that supports the classification system applied. Together these characteristics have clinical and therapeutic implications. The vocal multidisciplinary assessment should integrate ENT specialists, speech therapists and the psychologist. This evaluation makes it possible to determine whether the treatment should primarily focus on the physical, behavioral and/or emotional processes involved in vocal production. The psychologist has to identify, understand, and manage the psychological features on which the vocal symptom is based or linked to, ensuring the promotion of a better quality of life. |
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| Autores principais: | Andrea, Mafalda Bordalo |
| Assunto: | Functional voice disorders Psychogenic voice disorders Primary muscle tension voice disorders Secondary muscle tension voice disorders Psychological features Teses de doutoramento - 2018 |
| Ano: | 2018 |
| País: | Portugal |
| Tipo de documento: | tese de doutoramento |
| Tipo de acesso: | acesso aberto |
| Instituição associada: | Universidade de Lisboa |
| Idioma: | inglês |
| Origem: | Repositório da Universidade de Lisboa |
| Resumo: | Functional voice disorders (FVDs) are common vocal pathologies in the ENT outpatient clinics, with incidence ranging from 10% to 40% of the total patients with voice disorders. They have a female predominance (3:1) and are more frequent between the third and fifth decades of life. FVDs are characterized by apparently normal laryngeal anatomy and physiology while the patients present significant impairment in vocal and life qualities. The Diagnostic Classification System for Voice Disorders (DCSVD) proposed by Baker et al. in 2007 considers the existence of physiological, behavioral (abuse or misuse) and psychosocial (depression, anxiety and personality disorders) factors in their etiology, and recognizes and values the existence of three different types of FVDs. According to this system, patients with FVDs were classified as: psychogenic (PVD) in the absence of a structural or neurological pathology or as muscle tension voice disorders (MTVDs), a condition characterized by abnormal laryngeal tension. MTVDs can be subdivided in primary muscle tension voice disorders (MTVD1) with the vocal folds presenting an incomplete vocal fold closure, or as secondary muscle tension voice disorders (MTVD2), when the inadequate vocal technique and excessive phonatory effort leads to the development of benign vocal fold lesions (e.g., vocal nodules or polyps). Objectives An exploratory, descriptive, and cross-sectional study with a purposive sampling was developed to analyze the relationship between psychological features and functional voice disorders (FVDs). The three presentations of FVDs were characterized from a psychological perspective. The sociodemographic characteristics were identified, and an evaluation of vocal quality and its impact on quality of life have been performed. Methods The procedure took place in the Department of Ear, Nose, Throat, Voice and Communication Disorders of the Santa Maria Hospital (HSM), and Otolaryngology University Clinic of the Faculty of Medicine of the University of Lisbon, The recruitment of patients was made by ENT specialists or residents and/or by speech therapists, who accompanied these patients. The videolaryngoscopy using rigid endoscope or flexible fiberscope was used for the diagnosis and classification of each patient with FVDs. For the characterization of the subjects, a clinical history was made based on a semi-structured interview designed to collect information related to sociodemographic characteristics, health behaviors, vocal and psychological data (Study 1). The incidence of affective and anxiety disorders and the severity of depression and anxiety symptoms were analyzed with the Mini International Neuropsychiatric Interview (MINI) and both Hamilton Rating Scales (HAM-D for depression and HARS for anxiety), respectively (Study 2). The Millon Multiaxial Inventory (MCMI-II) was used to determine the personality profile of patients with FVDs and to identify the personality traits and disorders acting as vulnerability factors for their development (Study 3). Affective temperaments were assessed with the Temperament Evaluation of Memphis, Pisa, Paris and San Diego - Auto questionnaire (TEMPS-A) (Study 4). Vocal acoustic evaluation was made using Praat software (Study 5). Means of fundamental frequency (F0) and that of the first formant (F1) for the sustained vowels /i/, /a/ and /u/ were compared within groups and with normative database for Portuguese population (normal and dysphonic). The Voice Handicap Index (VHI-30) was used to evaluate the self-perception of quality of life and impairment associated to functional, physical and emotional vocal domains (Study 6). Results A total of 83 females, aged between 18 and 83 and with a mean age of 52.51 years (standard deviation = 14.27), were eligible for inclusion. Patients were clustered into three groups: PVD group with 39 patients (47%), MTVD1 group with 16 patients (19%), and MTVD2 group with 28 patients (34%). Our sample was constituted by patients with 3rd cycle (PVD and MTVD1) or secondary level (MTVD2) education, with an active professional life (≈ 60%) and most were married (Study 1). Nearly half of the patients were attending speech therapy sessions and 24.1% were receiving mental health treatments (psychology, psychiatric or both). FVDs patients noted as frequent the vocal fatigue and intensity changes in percentages greater than 87.5%. Dysphonia was also reported and variability existed in the comparison of groups (PVD = 89.7%, MTVD1 = 68.8% and MTVD2 = 100.0%). From the three groups, the group of patients with primary muscle tension voice disorders (MTVD1) had a higher incidence of current major depression and mood with psychotic symptoms as lifetime panic disorder, current generalized anxiety and panic disorder with agoraphobia (Study 2). These patients (MTVD1) also presented worse severity levels of depression (moderate) and anxiety (mild) compared to the patients from the two other groups (PVD and MTVD2) that were evaluated as having mild depression and anxiety at “normal range” of severity. In the group of patients with psychogenic voice disorders (PVD) the suicidal risk was prevalent, either at the level of incidence or severity. Obsessive-compulsive personality disorder as well as narcisistic, dependent and avoidant traits were prevalent among groups (Study 3). Paranoid as personality trait and as a personality disorder were most frequent among patients with psychogenic (PVD) and primary muscle tension (MTVD1) voice disorders. When depression and anxiety levels were set at a mean value, schizoid and schizotypal personality disorders appeared associated with PVD. Depressive and anxious temperaments were found at mild or moderate levels among FVDs patients (Study 4). PVD patients revealed vulnerability for depressive temperament when levels of depression and anxiety were statistically controlled. Our results were in consonance with the referenced data, with MTVD1 presenting high means F0 and MTVD2 low means F0, with the difference being more pronounced in the sustained vowel /u/ (Study 5). For the first formant (F1), statistical differences were found for the three vowels: /i/ and /u/ (PVD and MTVD1, and between MTVD1 and MTVD2 groups) and in the vowel /a/ (MTVD1 and MTVD2 groups), with MTVD1 to reached higher frequency means. In cough intensity, PVD and MTVD2 did not revealed differences between them. FVDs patients reported a moderate impairment in quality of life with high mean values in the physical subscale (Study 6). The MTVD1 had a significant statistical handicap in the functional subscale compared to the two other groups (PVD and MTVD2). Conclusions Our work underlines the relationship between psychological features and functional voice disorders. The incidence of affective and anxiety disorders, the severity of depression and anxiety symptoms and the personality disorders identified in our sample highlights the importance of its assessment in these patients. The common and the specific characteristics of FVDs groups were identified, revealing that their differences go beyond anatomo-functional presentations and voice quality, a condition that supports the classification system applied. Together these characteristics have clinical and therapeutic implications. The vocal multidisciplinary assessment should integrate ENT specialists, speech therapists and the psychologist. This evaluation makes it possible to determine whether the treatment should primarily focus on the physical, behavioral and/or emotional processes involved in vocal production. The psychologist has to identify, understand, and manage the psychological features on which the vocal symptom is based or linked to, ensuring the promotion of a better quality of life. |
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