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Psychological Aspects of Voice Disorders: The Role of the Voice Pathologist
By Lesley Mathieson
It is evident that there are psychological aspects of all voices, normal and disordered. Even if we try to disguise our emotional status, our voices frequently reveal our true feelings. The paralinguistic features of the voice are fundamental to communication and allow us to identify and convey the content of that communication beyond the words, grammar and syntax. Anxiety, love, tenderness and anger can all be transmitted by changes in vocal parameters while the words, if necessary, remain neutral and socially acceptable. These vocal changes have a powerful effect on the listener who, in turn, modifies vocal behaviour in response (Mathieson, 2001). It has to be remembered when considering disordered voices, therefore, that the psychological aspects of normal voices are not insignificant. This article considers the psychological aspects of voice disorders in general, not only voice disorders whose primary aetiology is psychogenic.
What is the role of the voice pathologist generally when treating individuals with voice disorders? The various aspects include:
- gathering information about the individual
- analysing and evaluating vocal tract behaviour and the vocal profile
- formulating and testing hypotheses as a basis for intervention
- setting treatment goals and selecting therapeutic strategies
- carrying out treatment
The aims of treatment are to cure or resolve the voice disorder when there is evidence that the aetiology or the symptomatology is reversible and to facilitate functionally satisfactory 'safe' voice. In cases of irreversible conditions, the aim is to achieve the best possible function.
In considering psychological aspects of voice disorders, it is useful to refer to the World Health Organisation International Classification of Disease-10 (WHO ICD-10), The Classification of Mental and Behavioural Disorders (1992). There are two classes which are probably most relevant to patients with voice disorders. These are 'Neurotic, stress-related and somatoform disorders' (which includes anxiety, depression and impaired insight, in the absence of any loss in perception of external reality) and 'Abnormalities of adult personality and behaviour'. The clinician has to bear in mind that psychological aspects of voice disorders might be primary (the cause of the voice disorder), concurrent (pre-existing or co-existing the voice disorder) or secondary (the result of the voice disorder). Or all three.
Several studies have explored the psychological status of individuals who have voice disorders. Roy, Bless and Heisey (2000) concluded that the majority of individuals with vocal fold nodules, in their study, were extraverts and that the majority of individuals with functional dysphonia (a term which means very different things to different people) were introverts. They noted that patients with spasmodic dysphonia and unilateral vocal fold paralysis, and the subjects in the control group, had no consistent personality differences. They concluded, therefore, that personality differences and their behavioural consequences contribute to functional dysphonia and to vocal nodules. White, Deary and Wilson (1997) found no significant personality traits between their three groups of subjects: a control group, patients with psychogenic voice disorders and patients with structural laryngeal changes. As might be expected, patients with psychogenic dysphonia had a greater degree of psychiatric disturbance than those in the other groups but, interestingly, one in three women with structural laryngeal changes showed similar psychiatric disturbance. No differences in personality traits were found between organic and functional groups of dysphonic individuals in a study by Millar, Deary, Wilson and Mackenzie (1999). Understandably, they found that dysphonic patients showed marked distress compared with norms but there were no differences in psychological distress whether the aetiology of the dysphonia was organic or functional. Little evidence of major psychiatric disturbance was found by House and Andrews (1987) in their study of 71 patients with diagnoses of functional dysphonia, but 33% had clinically diagnosable mood disorders, which were mainly anxiety states. Similarly, Butcher (1995) found that the majority of patients with psychogenic voice disorders were women who were experiencing high degrees of stress and above average musculoskeletal tension, rather than a conversion symptom.
There are various underlying issues that affect the clinician's management of these issues. Primarily, the patient wants resolution of the voice problem and as voice disorders cause stress it is reasonable to suppose that the patient's distress will usually diminish with successful treatment. Many individuals with voice disorders do not have more significant emotional issues than other people, other than those arising from the voice disorder. It is also worth remembering that many individuals with emotional problems or psychiatric disturbance do not have dysphonia. Consequently, it is not realistic for the voice pathologist to attempt to address all the emotional problems of a patient with a voice disorder, only those that are relevant to the disordered voice. It is essential for the clinician to carefully consider the division of time between therapeutic talking time and direct intervention in each treatment session while at all times maintaining appropriate sensitivity and professional distance, if treatment is to be successful.
With these issues in mind, the role of the voice pathologist in respect of the psychological aspects of voice disorders can be summarised as follows:
- to cure the voice disorder or to achieve maximum vocal function
- to ascertain to what extent the psychological aspects are primary, concomitant or secondary; or a combination of any of the three
- to retain appropriate professional distance in conjunction withsensitivity and professional warmth - to recognise when psychological aspects are beyond our competencies as individuals or as voice pathologists
- to provide direct treatment for vocal symptoms
- to counsel/'talk'
- to constantly monitor the balance of the whole intervention
- to address the psychological aspects as an integral part of the voicetherapy pathway
- to make appropriate decisions about discharge or onward referral.
Lesley Mathieson DipCST, FRCSLT is Visiting Lecturer in Voice Pathology at the University of Reading and is former president of the British Voice Association.
Butcher P (1995) Psychological processes in psychogenic voice disorder. Eur J Disord Commun 30(4):467-74
House A, Andrews HB(1987) The psychiatric and social characteristics of patients with functional dysphonia. J Psychosom Res 31(4):483-90
Mathieson, L (2001) Greene and Mathieson's The Voice and Its Disorders (6th edition) London: Whurr
Millar A, Deary IJ, Wilson JA, MacKenzie K (1999) Is an organic/functional distinction psychologically meaningful in patients with dysphonia? J Psychosom Res (Jun;46(6):497-505)
Nichol H, Morrison MD, Rammage LA (1993) Interdisciplinary approach to functional voice disorders: the psychiatrist's role. Otolaryngol Head Neck Surg Jun;108(6):643-7
Roy N, Bless DM, Heisey D (2000) Personality and voice disorders: a superfactor trait analysis. J Speech Lang Hear Res Jun;43(3):749-68
Scott S, Robinson K, Wilson JA, MacKenzie K (1997) Patient-reported problems associated with dysphonia. Clin Otolaryngol Feb;22(1):37-40
White A, Deary IJ, Wilson JA (1997) Psychiatric disturbance and personality traits in dysphonic patients. Eur J Disord Commun 32(3 Spec No): 307-14
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