The dysphonic voice heard by me,you and it: differential associations with personality and psychological distress

Voice production is subject to and indicative of psychological status. The precise relationships of voice disorders and psychological variables remain unclear. We compared the correlations of self-reported and more objective measures of voice quality in dysphonic patients with personality, coping, affect and somatization. Two hundred and four subjects participating in a randomized, controlled trial of speech therapy underwent self-report, observer rating and computer acoustic analysis of voice quality. These three indices of voice quality were compared with regard to their correlations with individual differences in neuroticism, alexithymia, negative emotion coping, anxiety, depression, neurotic symptoms, medically unexplained symptoms and quality of life. Significant correlations were observed between self-reported voice problems and all of the personality/coping and clinical psychological distress measures. People who reported more voice problems had: higher neuroticism and alexithymia; a tendency to use emotion-oriented coping; more psychological distress; poorer quality of life; and more past medically unexplained symptoms. Expert voice rating correlated weakly with neurotic disturbance, quality of life and previous medically unexplained symptoms. Objective voice assessment (amplitude perturbation) showed no significant associations with any psychological measure. The strongest associations of psychological variables and voice measures are with self-report measures. This suggests that it is in part the patients' perception of their own voice quality which accounts for the association of voice production and psychological factors in subjects presenting to voice clinics.     

Cognitive behavioral therapy for functional dysphonia: a pilot study

OBJECTIVES: We sought to investigate whether a brief period of training in cognitive behavioral therapy (CBT) can improve the treatment of functional dysphonia by a speech and language therapist and ameliorate the psychological distress associated with this condition. METHODS: In a consecutive cohort design, a speech and language therapist treated a small cohort (n = 15) of dysphonic patients with voice therapy alone. After a brief period of CBT training, she treated the next cohort of dysphonic patients (n = 13) with CBT-enhanced voice therapy. Pretreatment and posttreatment measures were taken of voice quality and voice-related quality of life. The General Health Questionnaire 28 and the Hospital Anxiety and Depression Scale were used to assess psychological distress and general well-being. RESULTS: All voice measures improved significantly in both cohorts. Both groups improved significantly on the General Health Questionnaire 28, with the CBT group improving significantly more than the control group. Only the CBT group improved significantly on the Hospital Anxiety and Depression Scale (depression subscale). CONCLUSIONS: Despite limitations of size, design, and between-group baseline differences, the results support the hypothesis that the addition of CBT skills to existing voice therapy is both feasible and clinically effective in the treatment of functional dysphonia.     

How we do it: adjunctive intravenous midazolam: diagnosis and treatment of therapy‐resistant muscle tension dysphonia

? Dysphonic patients with muscle tension are common at voice clinics. The majority respond to intensive vocal therapy. ? A small number of cases remain resistant to intensive vocal therapy. ? We have used intravenous midazolam to enhance therapy‐resistant dysphonic patients’ self‐monitoring, their self‐awareness and to change fixed patterns. ? Six of seven patients were discharged with restoration of normal voice 1 month after treatment.     

Personality traits and psychological factors in voice pathology: a foundation for future research.

It has been argued that personality, emotions, and psychological problems contribute to or are primary causes of voice disorders and that voice disorders in turn create psychological problems and personality effects. This article (a) briefly reviews the literature surrounding the role of psychological and personality processes in individuals with functional dysphonia (FD), vocal nodules (VN), and spasmodic dysphonia (SD); (b) provides an overview of recent concepts in personality and trait structure; and (c) summarizes the fundamental tenets of a theoretical synthesis proposed by Roy and Bless (2000) to explain the dispositional bases of FD and VN. This theory links FD and VN to the signal sensitivities and behavioral response biases of neurotic introverts and neurotic extraverts, respectively. In a companion article, the merits of the Roy and Bless theory are evaluated.     

The reliability and validity of patient self‐rating of their own voice quality

Objectives: To provide preliminary data on the reliability and validity of dysphonic patients rating their own voice quality. Design: Prospective reliability/validity assessment of voice ratings in dysphonic patients. Setting: The Royal Free Hampstead NHS Primary Care Trust. Participants: Thirty‐five adult dysphonia patients recruited from ENT referrals to a speech and language therapy department. Exclusion criteria were (i) a hearing impairment which may affect auditory discrimination and (ii) a diagnosis of cognitive impairment which may affect task comprehension. Main outcome measures: Patient intra‐rater reliability was assessed by test–retest ratings, using G (Grade), R (Rough), B (Breathy), A (Asthenic), S (Strained) (GRBAS). Validity was assessed by comparing (i) patient–clinician inter‐rater reliability, (ii) patients’ GRBAS ratings with their Vocal Performance Questionnaire (VPQ) responses. Result: (i) Patients had lower intrarater reliability than clinicians (for G of GRBAS, kappa = 0.51 versus 0.74); (ii) patients consistently rated their voices more severely than clinicians (for G of GRBAS, mean rating = 1.4 versus 1.0); (iii) clinician–patient inter‐rater agreement was no better than chance (paired t‐test, all P < 0.05); (iv) patient ratings correlated significantly with vocal performance scores (r > 0.4, P < 0.05). Conclusions: Patients appear to have good validity and consistency using GRBAS as a self‐perception tool. However, validity measured in terms of agreement with clinician ratings is poor. Voice patients may rate what they perceive rather than what they hear. Disagreement between patient and clinician ratings has implications for therapy aims, prognosis, patient expectations and outcomes. Where disagreement persists, the clinician may have to determine whether therapy priorities need redesigning to reflect patients’ perceived needs, or to evaluate whether patient perceptions and expectations are unrealistic.     

Psychological assessment of patients with Menière's disease

The objective of this study was to evaluate daily stressors, coping, personality, physical and mental health, and quality of life in Menière patients. 110 consecutive patients with definite Menière's disease were assessed using the Dutch Daily Hassles List, Coping Inventory for Stressful Situations (CISS), Symptoms Checklist 90 (SCL-90), NEO Five Factor Inventory (NEO-FFI), General Health Questionnaire (GHQ-12), and the Short Form Health Survey 36 (SF-36). Duration and subjective severity of symptoms were scored using a self-report questionnaire. It was shown that Menière patients had more daily stressors, used certain coping strategies less often, and had more psychopathology (e.g. anxiety and depression), and a worse quality of life compared to healthy reference groups. No abnormalities in personality were found. Patients with more severe symptoms had more psychopathology and a worse quality of life than patients with mild symptoms. The psychological profile of Menière patients seems comparable to patients with other chronic diseases. The outcomes should be used to intensify psychological support in patients with this disabling disease.     

Exploring the relationship between severity of dysphonia and voice‐related quality of life

Objectives: To explore whether severity and/or consistency of dysphonia are linked to voice‐related quality of life. Design: Cross‐sectional study. Setting: Specialist voice clinics, University Teaching Hospital. Participants: Sixty adult patients attending with a primary complaint of dysphonia. Exclusion criteria were those below 16 years of age, transexual patients and those with a persistent dysphonia of >2 years. Main outcome measures: Voice‐related quality of life as assessed by VoiSS. Explanatory factors: Severity of dysphonia as judged by perceptual ratings of voice (GRBAS); a visual analogue scale to judge best, worst and today's voice. Results: There was a highly significant correlation between perceptual dysphonia severity as assessed by GRBAS and the total, impairment and emotional subsets of the VoiSS questionnaire (r from 0.48 to 0.64). There was a similar and highly significant correlation between best, worst and today's self‐rated voice and the total, impairment and emotional subsets of the VoiSS questionnaire (r from ?0.40 to ?0.60). However, none of the self‐rated parameters was demonstrably better at explaining the effect on quality of life. Conclusions: An increasingly negative effect on quality of life appears to be associated with an increase in the severity of dysphonia. Further research on the role of quality of life measures in the assessment and treatment of dysphonia would be of value.     

Psychological coping style versus disease extent,tumour treatment and quality of life in successfully treated head and neck squamous cell carcinoma patients

Objectives: To study self‐reported coping style by the COPE questionnaire and the association to tumour node distant metastasis (TNM) stage, received treatment and health‐related quality of life (HRQoL) in a population of successfully treated head and neck squamous cell carcinoma (HNSCC) patients. Design: Disease free HNSCC patients were interviewed during a regular outpatient visit to the Department. Setting: All patients <80 years who had been diagnosed with HNSCC, in Western Norway, in the period from 1992 to 1997 and who were disease free in the year 2000 were included. Main outcome measures: The HNSCC patients were studied by the European organization for research and treatment of cancer quality of life (QoL) questionnaire and by the COPE questionnaire from which coping styles profiles were extracted. Clinical and socio‐demographic variables were also gathered. Results: Level of problem focused coping style was associated with the T stage and whether or not the patient was given neck radiotherapy. An avoidance‐focused coping style was generally associated with lowered HRQoL. Employment of emotional focused coping was associated with low HRQoL among the patients treated with surgery only, and associated with increased HRQoL among patients treated with radiation therapy only. The associations between HRQoL and coping style levels were stronger for HRQoL indexes reflecting cognitive/emotional function than for HRQoL indexes reflecting physical function. Conclusions: In former HNSCC patients, level of problem focused coping style was associated with the T stage and if given neck radiotherapy. Level of avoidance coping was inversely associated with the HRQoL, and level of emotional coping was associated with HRQoL in a complex manner.     

Validation of a voice prosthesis questionnaire to assess valved speech and its related issues in patients following total laryngectomy

Objectives: To establish the reliability and validity of a new self‐administered questionnaire to assess valved speech and its related issues in patients who have undergone a total laryngectomy operation. Design: Cross‐sectional psychometric validation study. Setting: Tertiary cancer care centre. Patients: We identified sixty‐one total laryngectomy patients with no sign of recurrent disease and using voice prothesis from the speech and language therapy database of the Royal Marsden Hospital. The patients were assessed using a postal self‐administered voice prosthesis questionnaire concerning the voice valve and it's related issues. Patients were also asked to complete the University of Michigan voice related quality of life and University of Washington head and neck quality of life (version 4) questionnaires. Main outcome measures: Test‐retest and internal consistency reliability; content; criterion and construct validity. Results: We received completed questionnaires from fifty‐one of the sixty‐one total laryngectomy patients identified for the study providing a response rate of 84%. The median age of the group was 65 years (range: 40–85) with thirty‐seven males and fourteen females. The internal consistency reliability using the Cronbach's alpha coefficient was 0.87 (range: 0.85 to 0.89). Test‐retest reliablility showed that more than 75% of patients had a score on re‐test that was within 1 point of their original score. Content validity was ensured during the design process. The median Spearman correlation coefficient was 0.25 for convergent construct validity with the University of Washington head and neck quality of life questionnaire and 0.64 for criterion valididty on comparison with the University of Michigan voice related quality of life scale. Conclusions: The voice prosthesis questionnaire is the first validated and reliable self‐administered questionnaire designed specifically for evaluating valved speech and its related issues in patients who have undergone total laryngectomy. The voice prosthesis questionnaire has significant utility for audit, outcomes research and monitoring in this unique group of patients.     

The Voice Symptom Scale (VoiSS) and the Vocal Handicap Index (VHI): a comparison of structure and content

Self report measures of voice function are in frequent use, but have had inadequate psychometric evaluation. We aimed to perform a substantial factor analysis of two measures of voice impairment, the Voice Symptom Scale (VoiSS) and the Voice Handicap Index (VHI). Both the 30-item questionnaires were completed by 319 dysphonic voice clinic attenders (99M, 220F). Principal components analysis confirmed that both instruments reflected general voice abnormality. The VoiSS comprised three factors - impairment (15 items), emotional (8 items) and related physical symptoms (7 items) - each with a good internal consistency. Analysis of the VHI suggested that it contains only two subscales. When a three-factor solution was imposed on the data, analysis failed to support the currently advised three 10-item subscale interpretations. Instead, we found a physical (voice impairment) domain (8 items), a psychosocial domain (14 items) and a factor with 8 items related to difficulty in being heard. The VHI requires further statistical refinement to identify its subscale structure. The VoiSS was developed from 800 subjects and is psychometrically the most robust and extensively validated self report voice measure available.     

Personality, choice of coping and T stage predict level of distress in head and neck cancer patients during follow-up

The aim of the present study was to investigate to what extent TNM stage, treatment level, personality, choice of coping, mood and health-related quality of life (HRQoL) scores predicted distress as measured by general health questionnaire (GHQ) in successfully treated head and neck squamous cell carcinoma (HNSCC) patients. All patients younger than 80?years who had been diagnosed with HNSCC in western Norway in the period from 1992 to 1997, and who had survived until 1999, were sampled. Ninety-six patients (90% response rate) were included 48?±?2?months after diagnosis. We determined personality by the Eysenck personality inventory, coping by the COPE questionnaire; HRQoL by EORTC QLQ questionnaire; and mood by Beck depression inventory (BDI). Fifty-five of 58 eligible patients were interviewed a second time 47?±?1?months after the first interview where neuroticism and GHQ-30 questionnaires were answered. Both HRQoL [explained variance (EV), 9–40%] and BDI (EV 26–30%) scores predicted the GHQ scores. Numerical T stage was inversely associated with GHQ scores (EV ~10%). High neuroticism generally predicted high GHQ scores (EV 16–28%). Avoidance focused, problem focused, drinking to cope predicted GHQ scores (EV 8–14%) and high alcohol consumption (EV ~8%) predicted GHQ scores. The present association pattern could still be shown when adjusted for gender, age and educational level when studied by multiple regression analyses. In conclusion, lowered HRQoL, low mood, a high T stage, high alcohol consumption, high neuroticism, coping by avoidance and coping by problem solving directly predicted worse distress as measured by high GHQ scores, whereas neuroticism was also associated with GHQ through choice of coping.     

Voice activity and participation profile: assessing the impact of voice disorders on daily activities.

Traditional clinical voice evaluation focuses primarily on the severity of voice impairment, with little emphasis on the impact of voice disorders on the individual's quality of life. This study reports the development of a 28-item assessment tool that evaluates the perception of voice problem, activity limitation, and participation restriction using the International Classification of Impairments, Disabilities and Handicaps-2 Beta-1 concept (World Health Organization, 1997). The questionnaire was administered to 40 subjects with dysphonia and 40 control subjects with normal voices. Results showed that the dysphonic group reported significantly more severe voice problems, limitation in daily voice activities, and restricted participation in these activities than the control group. The study also showed that the perception of a voice problem by the dysphonic subjects correlated positively with the perception of limitation in voice activities and restricted participation. However, the self-perceived voice problem had little correlation with the degree of voice-quality impairment measured acoustically and perceptually by speech pathologists. The data also showed that the aggregate scores of activity limitation and participation restriction were positively correlated, and the extent of activity limitation and participation restriction was similar in all except the job area. These findings highlight the importance of identifying and quantifying the impact of dysphonia on the individual's quality of life in the clinical management of voice disorders.     

Observations of benefit finding in head and neck cancer patients

The management of head and neck cancer (HNC) can lead to potentially severe physical, functional and psychological disturbances. As a result, many HNC patients develop symptoms of depression following diagnosis and treatment. Finding benefit in a disease and its treatment can reduce the symptoms of depression and enhance quality of life (QOL). 92 patients from the Head and Neck Cancer Clinic at Auckland Hospital completed measures of unmet needs and quality of life at diagnosis, and completed measures of benefit finding, coping, fear of recurrence and depression 12–18 months later. Patients reported at least moderate benefit finding in the majority of areas. More benefit finding was predicted by the presence of more advanced disease, Maori/Pacific Island ethnicity, lower baseline QOL, and the use of active coping strategies. These findings support the view that screening for QOL at diagnosis and facilitating the development of coping skills may lead to improved benefit finding and psychological adjustment in people with head and neck cancer. Identification of the factors that facilitate benefit finding may assist management of patients after treatment for HNC.     

The reliability and sensitivity to change of acoustic measures of voice quality

This study aimed to evaluate the reliability and sensitivity to change of three commonly used acoustic parameters as measured by the Multi-Dimensional Voice Programme (MDVP); jitter, shimmer and noise-to-harmonic ratio. A total of 231 subjects' voices were recorded and analysed. The sample comprised 145 dysphonic patients who received intervention (surgery or voice therapy), 36 dysphonic patients who received no intervention, and 50 non-dysphonic (normal) subjects. All voices were recorded and analysed on two occasions (before and after treatment, or test-retest assessment) using a standard procedure. These data were analysed using standard psychometric procedures for assessing reliability and responsiveness. The acoustic analysis measures demonstrated poor to moderate reliability and effect size with respect to their sensitivity to change. Caution should be exercised in the injudicious use of computer-based acoustic analysis systems as an isolated measure of voice outcome in any clinical trial of interventions aimed at improving voice quality.     

Self‐assessment of voice therapy for chronic dysphonia

Self‐assessment of voice therapy for chronic dysphonia The effects of voice therapy in a group of chronically dysphonic patients are determined using two quality‐of‐life (QOL) instruments: the Voice Handicap Index (VHI), and a simple three‐item outcome scale (three visual analogue scales). Both instruments measure changes in the quality of the voice itself and in the extent of impairment resulting from the dysphonia as experienced by the patient in social and occupational settings. Statistical tests conducted on pre‐ and post‐treatment data indicated significant improvements on both instruments for the group as a whole. At the individual level, however, the effects were diverse. For roughly 50% of the subjects, a significant improvement could be established. The positive changes as measured with the three‐item scale were greater than those measured with the VHI. The results suggest that the two QOL instruments measure slightly different aspects of the subjective perception of the therapy effects. In order to obtain a general evaluation of the patient's handicap, it may suffice to ask some simple questions.     

Cross-cultural adaptation and validation of the Chinese Voice Handicap Index-10

OBJECTIVES/HYPOTHESIS: Recent developments in voice assessment propose the use of quality of life measurements. The Voice Handicap Index (VHI) is one of the most psychometrically robust and well-studied instruments among the various instruments for measuring quality of life. Two versions of VHI (VHI-30 and VHI-10) have been shown to be valid instruments for distinguishing dysphonic from nondysphonic individuals and also for documenting treatment effect for dysphonic patients. The VHI has been used worldwide; however, the psychometric properties of the Chinese version of VHI remains untested. This study aimed to investigate such properties of the Chinese VHI-30 and VHI-10 in the Hong Kong Chinese population. STUDY DESIGN: Psychometric analysis of the Chinese VHI-30 and VHI-10 in dysphonic patients and control subjects. METHODS: The original VHI-30 was translated into Chinese and was completed by 131 dysphonic patients and 54 nondysphonic individuals. The dysphonic patients also self-rated their dysphonic severity. RESULTS: Results showed high test-retest reliability and high item-total correlation for both Chinese VHI-30 and VHI-10. Both Chinese versions could be used to distinguish different dysphonic groups and between dysphonic and nondysphonic groups. Significant correlation was found between the VHI scores and the patients' self-rated dysphonic severity. CONCLUSION: The present study supported the original three-factorial structures of the VHI-30 and the use of the VHI for the Chinese population. It is shown that the Chinese VHI-10 is a strong representation of VHI-30 and is recommended for use in clinics because of its validity and ease of use by patients.     

Patient-reported problems associated with dysphonia

In the UK there has been little assessment of the efficacy of therapy for patients with dysphonia. Current objective assessment methods (e.g. acoustical analysis) do not correlate well with patient symptoms. Existing subjective measures are based on clinical impression. To date, no measure has been based on the patient’s experience and the aim of this study was to explore the difficulties that patients encounter as a consequence of their illness or disability. One hundred and thirty-three dysphonic patients completed an open-ended questionnaire where they were asked to make a list of the problems they experienced due to their voice disorder. Responses were categorized using the WHO International Classification of Impairments, Disabilities and Handicaps. A total number of 467 problems were listed: 60% impairments, 26% disabilities and 14% were handicap related. The six major impairments related to altered voice and throat symptoms. Although the majority of disabilities resulted from lack of projection and clarity, the most frequently reported was singing. Reported handicaps encompassed psychological, emotional and employment-related difficulties and effects on family and friends. People with dysphonia experience social, lifestyle and employment difficulties as a consequence of their voice disorder. Responses to the open-ended questionnaire have considerable practical applications in targeting more comprehensive treatment strategies.     

The quality of life impact of dysphonia

Dysphonia can affect social life and employment, but formal studies of its general health impact are lacking. The aims of this study were (i) to compare self-rated general health status as measured by the SF-36 in a large cohort of dysphonic patients with those from normative groups; and (ii) to examine the differential impact of dysphonia on the various health status domains. The 163 dysphonic voice clinic attendees (38 men, 125 women) were drawn from recruits to a prospective trial of speech therapy efficacy. The Short-Form 36 (SF-36) scores were compared with published data on 744 age-matched healthy controls. Patients with dysphonia had significantly poorer self-reported health than the controls on all eight SF-36 subscales (limitation of physical activity P < 0.05; other seven, all P < 0.001, Student's t-test). We thus conclude that dysphonia in patients without obvious laryngeal disease has an adverse impact on all health status subscales as measured by the SF-36. The study provides further evidence for the inclusion quality of life measures in otolaryngology baseline and outcome assessments.     

The dysphonia severity index: an objective measure of vocal quality based on a multiparameter approach.

The vocal quality of a patient is modeled by means of a Dysphonia Severity Index (DSI), which is designed to establish an objective and quantitative correlate of the perceived vocal quality. The DSI is based on the weighted combination of the following selected set of voice measurements: highest frequency (F(0)-High in Hz), lowest intensity (I-Low in dB), maximum phonation time (MPT in s), and jitter (%). The DSI is derived from a multivariate analysis of 387 subjects with the goal of describing, purely based on objective measures, the perceived voice quality. It is constructed as DSI = 0.13 x MPT + 0.0053 x F(0)-High - 0.26 x I-Low - 1.18 x Jitter (%) + 12.4. The DSI for perceptually normal voices equals +5 and for severely dysphonic voices -5. The more negative the patient's index, the worse is his or her vocal quality. As such, the DSI is especially useful to evaluate therapeutic evolution of dysphonic patients. Additionally, there is a high correlation between the DSI and the Voice Handicap Index score.     

Quality of life and voice handicap of laryngectomees using tracheoesophageal substitute voice

BACKGROUND: Health-related quality of life (QoL) and subjective health have become popular constructs for the evaluation of both efficacy and efficiency of diagnostic and therapeutic procedures in medicine. QoL is considered a multidimensional construct encompassing physical, mental and social facets of life. It is an accepted outcome parameter not only in international classification systems such as ICIDH and ICF, but as well in clinical guidelines and disease management programs. Measuring quality of life allows for comparison of different diseases though it certainly lacks disease specific aspects. Thus, it has to be assumed that in patients with distinct functional deficits QoL cannot cover all aspects that are important for the individual patient. This study focuses on laryngectomies and their self-evaluation of post-laryngectomy speech. It is well known that these patients experience a decreased QoL compared to patients after partial laryngectomy or healthy persons. In this study, the impact of voice restoration on the laryngectomies' QoL was evaluated. PATIENTS AND METHODS: In 20 male laryngectomies aged 62 +/- 8 years, relations between QoL and voice handicap were evaluated using two instruments as proposed in the international literature, i. e. the Short-Form Health Survey (SF-36) and the Voice Handicap Index (VHI). All patients had successfully been using tracheoesophageal substitute voice for at least one year. Complete data sets were available from all patients. Data were analysed using Microsoft Excel and Sigma Plot, Jandel Corp. software packages. RESULTS: Results of both the SF-36 and the VHI reveal wide interindividual ranges. There are statistically significant correlations (p < 0.05) between the SF-36's scales General Health and Vitality and the VHI, whereas no correlations were found between social and psychological scales and the voice handicap. DISCUSSION: Wide ranges of the data obtained reveal that obviously both health related quality of life and voice handicap are not affected in a group specific way. So, both tests are of clinical value to depict individual aspects of wellbeing after laryngectomy. The combination of VHI and SF-36 illuminates correlations between general and special subjective aspects. Strikingly, the laryngectomies' social and psychological status is not related to their voice handicap. Data allow for conclusion that laryngectomies' substitute voice problems do not affect social aspects of quality of life in a disease specific way, at least as long as voice restoration was successful at all.