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functional dysphonia
144
Psychologic factors in
functional dysphonia
A wide array of psychopathologic processes contributing
to voice symptom formation in FD has been proposed
[27,29]. The exquisite sensitivity and prolonged hyper
contraction of the intrinsic and extrinsic laryngeal
muscles, in response to stress, conflict, anxiety, depres
sion, or inhibited emotional expression, is frequently
cited as the common denominator underlying the major
ity of functional voice problems [7,30]. Other possible
mechanisms include, but are not limited to, conversion
reaction, hysteria, hypochondriasis, and various situ
ational conflicts or personality dispositions that also in
duce excess or dysregulated laryngeal musculoskeletal
tension [6,25,26,28]. However, research evidence to sup
port these various psychologic mechanisms has seldom
been provided. The empirical literature evaluating the
FD-psychology relationship is characterized by diver
gent results regarding the frequency and degree of spe
cific personality traits [6,31-34",35"], conversion reac
tion [6,36], and psychopathologic symptoms such as
depression and anxiety [6,31,34-,35-40]. Despite signifi
cant methodologic differences among these studies,
some interesting patterns do surface. These patterns
suggest a general trend tmvard elevated levels of (1) state
and trait anxiety, (2) depression, (3) somatic preoccu
pation/complaints, and (4) introversion in the FD popu
lation. Patients have been described as inhibited, stress
reactive, socially anxious, and nonassertive, with a ten
dency toward restraint [31,33,34,35",36]. The inter-
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Koufman JA, Blalock PO: Functional voice disorders. Otolaryngol Clin North
Am 1991,4:1059-1073.
Roy N, Bless OM, Heisey 0, et al.: Manual circum laryngeal therapy for func
tional dysphonia: an evaluation of short- and long-term treatment outcomes.
J Voice 1997, 11 :321-331.
Boone DR, McFarlane SC: The Voice and Voice Therapy, edn 6. Englewood
Cliffs, NJ: Prentice Hall, 2000.
Sama A, Carding PN, Price S, et al.: The clinical features of functional dys
phonia. Laryngoscope 2001. 111 :458-463.
This well-designed research article questions the clinical utility and validity of laryn
goscopic classification systems of FD. The laryngoscopic features commonly as
sociated with FD are frequently prevalent in nondysphonic controls and fail to dis
tinguish subjects with FD from normal subjects.
10 Carding P, Horsley I, Docherty G: A study of the effectiveness of voice
therapy in the treatment of 45 patients with non organic dysphonia. J Voice
1999,13:72-104.
11
12 Morrison MD, Rammage LA, Gilles MB, et al.: Muscular tension dysphonia.
J Otolaryngol 1983, 12:302-306.
13
14
Koufman JA, Blalock PO: Classification and approach to patients with func
tional voice disorders. Ann Otol Rhinol Laryngol1982, 91 :372-377.
15
Koufman JA, Blalock PO: Vocal fatigue and dysphonia in the professional
voice user: Bogart-Bacall syndrome. Laryngoscope 1988, 98:493-499.
Conclusions
Functional dysphonia-a VOIce disturbance in the ab
sence of structural or neurologic laryngeal pathological
factors-is an enigmatic and controversial voice disorder
that is frequently encountered in multidisciplinary voice
clinics. Recently, the term FD has been replaced in
some clinical circles by the diagnostic label "muscle ten
sion dysphonia," which serves to highlight excess, dvs
regulated, or imbalanced activity of the intrinsic and ex
trinsic laryngeal muscles as the proximal cause of the
observed dysphonia. Although many sources have been
cited as contributing to this muscle tension, specific per
sonality traits have been identified as important to its
development and maintenance. Voice therapy by an ex
perienced speech-language pathologist remains an efIec
tive short-term treatment for FD in the majority of cases,
but little is known regarding the long-term fate of such
treatment. Further research is needed to better under
stand the pathogenesis of FD, and factors contributing to
its successful management.
17
Roy N, Ford CN, Bless OM: Muscle tension dysphonia and spasmodic dys
phonia: the role of manual laryngeal tension reduction in diagnosis and treat
ment. Ann Otol Rhinol Laryngol1996, 105:851-856.
18
19
20
22
Roy N, Bless OM: Manual circum laryngeal techniques in the assessment and
treatment of voice disorders. Curr Opin Otolaryngol Head Neck Surg 1998,
6:151-155.
23
24
25
148
26
27
28
41
Roy N, Bless OM: Personality traits and psychological factors in voice pathol
ogy: a foundation for future research. J Speech Lang Hear Res 2000,
43:737-748.
This article provides a cursory review of the literature (circa 1998) pertaining to the
FD-psychology relationship. The fundamental tenets and predictions of the trait
theory are outlined.
42 Andersson K, Schalen L: Etiology and treatment of psychogenic voice disor
der: results of a follow-up study of thirty patients. J Voice 1998, 12:96-106.
43
44
tions.
29
45
30
House AO, Andrews HB: Life events and difficulties preceding the onset of
functional dysphonia. J Psychosom Res 1988, 32:311-319.
46
31
32
33
47
Stemple J: Voice Therapy: Clinical Studies, 2nd edn. San Diego: Singular
Publishing Group; 2000.
48
49
34
35
37
Deary IJ, Scott S, Wilson 1M, et al.: Personality and psychological distress in
dysphonia. Br J Health Psychol 1998, 2:333-341.
38
39
White A, Deary IJ, Wilson JA: Psychiatric disturbance and personality traits in
dysphonic patients. Eur J Dis Commun 1997, 32:121-128.
40
52
Peifang C: Massage for the treatment of voice ailments. J Trad Chinese Med
1991,11 :209-215.
53
54
55 Dworkin JP, Meleca RJ, Simpson ML, et al.: Use of topical lidocaine in the
treatment of muscle tension dysphonia. J Voice 2000, 14:567-574.
A novel approach for treating refractory cases of muscle tension dysphonia is
described.
56