Janet Baker

The role of psychogenic and psychosocial factors in the development of functional voice disorders

The primary objective of this discussion paper is to review the available evidence for the role of psychogenic and psychosocial factors in the development of functional voice disorders (FVD). Current theoretical models linking these factors to the aetiology of FVD and to vocal hyperfunction are then considered. Since there is a paucity of solid empirical evidence to date, general patterns of evidence derived from single case reports and case series are examined first, followed by those empirical studies using more sophisticated methodologies. The discussion is structured around a framework that includes the following psychosocial areas of enquiry: demographic profiles of individuals with FVD; stressful incidents preceding onset; personality traits; coping styles and psychiatric disorder. Current evidence and associated theoretical models suggest that cognitive, affective, neurophysiological and behavioural aspects culminate in the development of these complex voice disorders. The implications of these findings are discussed with respect to clinical practice and clinical training, with suggestions for future scientific research.

Development of a modified diagnostic classification system for voice disorders with inter-rater reliability study

Diversity in nomenclature and on-going dilemmas over the conceptual bases for the classification of voice disorders make it virtually impossible for the collation and accurate comparison of evidence-based data across different clinical settings. This has significant implications for treatment outcome studies. The first aim of this study was to develop a modified diagnostic classification system for voice disorders with clearly defined operational guidelines by which we might reliably distinguish voice disorders from one another. The second aim was to establish the face validity and reliability of the system as an effective diagnostic tool for the allocation of patients to different diagnostic groups for clinical and research purposes. After the Diagnostic Classification System for Voice Disorders (DCSVD) had been developed, it was used in an inter-rater reliability study for the independent assessment of 53 new consecutive patients referred to the Voice Analysis Clinics of three tertiary hospitals. There were three raters present for the assessment and diagnostic allocation of each patient. The high levels of inter-rater reliability suggest this may be a robust classification system that has good face validity and even at this early stage, strong construct validity.

Psychogenic voice disorders—heroes or hysterics? A brief overview with questions and discussion*

A brief overview of the field in relation to psychogenic voice disorders is given with reference to past and present terminology used, the common presentations seen, followed by the more subtle or ambiguous examples which may challenge our notions of psychogenic or clear-cut functional versus organic dichotomies. Issues related to aetiology, personality and psychological correlates are discussed, and a number of questions regarding the phenomenology of psychogenic dysphonia and its therapeutic resolution are raised. Since prevalence continues to be significantly in favour of women, it is suggested psychogenic voice disorder as a feminist issue might be worthy of our further consideration.

Psychogenic dysphonia: Peeling back the layers

Resolution of psychogenic dysphonia is often quick and effortless for client and therapist alike. In such instances, the therapeutic interventions are simple and straightforward, insights are reached without difficulty, and once normal voice has been established, resumption of dysphonia or other psychosomatic symptoms rarely occurs. Sometimes, however, psychogenic dysphonia is extremely difficult to overcome, requiring considerable time, effort, and determination on the part of the client, coupled with confident, skilled persistence and psychotherapeutic insight from the therapist. In such cases one feels a sense of working through many complex layers before obtaining satisfactory voice or reaching an understanding of the psychogenic factors that precipitated onset and/or maintenance of the dysphonia. Two cases that illustrate this involved process of peeling back the layers are presented. For resolution of severe psychogenic dysphonia, the therapist must be able to recognize and establish the complex relationship between the neurophysiological, intrapsychic, and interpersonal levels of function as they affect the clients voice and person, as a whole. This work requires considerable courage and skill on the part of the therapist to question, explore, change direction, and select alternative approaches. It is important that the problem can be resolved with a depth of understanding which is relevant for the client, and with due attention to the social context and wider systems of which he or she is a part.

Psychosocial risk factors which may differentiate between women with Functional Voice Disorder, Organic Voice Disorder and a Control group

Abstract This study aimed to explore psychosocial factors contributing to the development of functional voice disorders (FVD) and those differentiating between organic voice disorders (OVD) and a non-voice-disordered control group. A case-control study was undertaken of 194 women aged 18–80 years diagnosed with FVD (n = 73), OVD (n = 55), and controls (n = 66). FVD women were allocated into psychogenic voice disorder (PVD) (n = 37) and muscle tension voice disorder (MTVD) (n = 36) for sub-group analysis. Dependent variables included biographical and voice assessment data, the number and severity of life events and difficulties and conflict over speaking out (COSO) situations derived from the Life Events and Difficulties Schedule (LEDS), and psychological traits including emotional expressiveness scales. Four psychosocial components differentiated between the FVD and control group accounting for 84.9% of the variance: severe events, moderate events, severe COSO, and mild COSO difficulties. Severe events, severe and mild COSO difficulties differentiated between FVD and OVD groups, accounting for 80.5% of the variance. Moderate events differentiated between PVD and MTVD sub-groups, accounting for 58.9% of the variance. Psychological traits did not differentiate between groups. Stressful life events and COSO situations best differentiated FVD from OVD and control groups. More refined aetiological studies are needed to differentiate between PVD and MTVD.

Patterns of Emotional Expression and Responses to Health and Illness in Women With Functional Voice Disorders (MTVD) and a Comparison Group

OBJECTIVES To determine whether emotional expression, alexithymia, illness behavior, and coping strategies differed between women with muscle tension voice disorder (MTVD) and those without voice disorder and between women with and without mucosal pathology of the vocal folds, and to explore possible links between psychosocial constructs and clinical features in women with MTVD. STUDY DESIGN AND METHOD A within-subjects design matched 20 women with MTVD and 20 women without voice disorder on validated self-report measures of the psychosocial constructs. The effect of mucosal pathology was assessed using between-groups analyses. Correlations assessed relationships between psychosocial constructs and clinical features. RESULTS Comparisons between women with MTVD and those without voice disorder showed an elevated sense of illness identity and greater belief in the presence of somatic illness in women with MTVD. There was a trend toward women with MTVD showing lower levels of emotional awareness. Women without vocal fold pathology reported lower levels of emotional awareness than those with pathology, whereas women with pathology reported greater use of a mixed pattern of adaptive and maladaptive coping strategies than those with no pathology. Low vocal load was associated with higher scores on alexithymia, higher numbers of vocal symptoms were associated with the use of adaptive coping, and greater impact of symptoms was associated with higher levels of emotional awareness and greater belief in the presence of somatic illness. CONCLUSIONS These findings encourage further investigation of relationships between emotional awareness, illness behavior, and coping in women with functional voice disorders.

Women's voices: Lost or mislaid, stolen or strayed?

It is estimated that disorders of voice affect 3–4% of people from all strata of Australian society and while some voice disorders may be caused by organic conditions, most patients are troubled by non-organic or functional voice disorders (FVD). As professionals dealing with these problems, we wonder about the role of strong negative emotions arising from stressful life experiences preceding onset, or dispositional factors that may influence ways in which an individual responds to such incidents. We wonder too, how these complex processes may be inter-related, and if this may account for one person misusing or damaging the voice, while another loses the voice altogether. Evidence for the possible relationship between negative emotions arising out of stressful events and onset of FVD in women is briefly presented. The findings suggest that women with FVD may have difficulty in the processing of negative emotions, and when considered in a wider socio-cultural perspective, it is proposed that some have temporarily lost their voices, while others have been rendered powerless and had their voices stifled. These findings serve as the foundation for a broader discussion about the possible implications for the speech pathology profession which might be at risk of losing its voice.

Living with the altered self: A qualitative study of life after total laryngectomy

Abstract Total laryngectomy (TL), a life-preserving surgery, results in profound physical and communication changes for the individual. Physical and psychosocial adjustment to a TL is complex, and quality-of-life (QoL) measures have provided useful knowledge to assist clinical management. However, many tools were developed without considering the perspectives of people who have experienced TL. To improve understanding of the phenomena of living with TL, a qualitative study was conducted which explored the views and experiences of seven men and five women from a range of ages, geographical locations, and social situations who had undergone a TL. Data were collected through in-depth, semi-structured interviews, journals, and field notes, and analysed using a constructivist grounded theory approach and symbolic interactionism. The emergent concept was identifying with the altered self after TL as reflected in dynamic multi-level changes (physical, communication, and psycho-emotional) continuously interacting with intrinsic and extrinsic interpersonal factors including personal and socio-cultural constructs, e.g., age, gender, resilience, beliefs, and supports. This process affected the strategies these individuals used to negotiate their social experiences. The extent to which communication changes disrupted social roles affecting a persons sense of self appeared to relate to long-term adjustment.

Self‐expression and identity after total laryngectomy: Implications for support

To explore how individuals with a laryngectomy (IWL) from diverse backgrounds make meaning and adjust to the physical and functional changes from a total laryngectomy. To examine the extent primary supporters (PS) and health professionals (HP) are able to support IWL with the psychosocial and existential challenges rendered by a surgery that significantly impacts a persons talking, breathing, swallowing, and appearance.

The therapeutic relationship once established need never be broken.

In the lead article, Hersh () draws attention to the significant phase of ending therapy for clients and in particular, for their therapists. Hersh highlights three main tensions that underpin this process: real versus ideal endings, making and breaking of the therapeutic relationship, and balancing of respect for client autonomy over considerations of caseload and resources. In this paper, I offer a commentary on the first two of these issues by drawing upon my experience as a speech-language pathologist/family therapist specializing in voice, and as an academic fostering the development of student clinicians. This is then linked to parallel discussions in the recent psychoanalytic and psychotherapy literature. I support Hershs premise that the implicit processes and emotions associated with this final phase of therapy need to be made more explicit and suggest that this is more likely to occur when clinicians acknowledge that they too experience rewards and losses in the therapeutic relationship. I challenge the notion that any therapeutic relationship once established is ever entirely broken.