Marked depression and anxiety in patients with functional dysphonia
Introduction
An abnormal voice exists when quality, pitch, loudness, or flexibility differs from the voices of others of similar age, sex, and cultural groups. Functional dysphonia should be diagnosed when the voice is abnormal despite normal laryngeal anatomy and physiology (Aronson, 1990). In DSM-IV (American Psychiatric Association, 1994), functional dysphonia is included among the “somatoform disorders, conversion disorder with motor symptom or deficit” (300.11). The common feature of somatoform disorders is the presence of physical symptoms that suggest a general medical condition but are not fully explained by a general medical condition, by another mental disorder, or by the direct effects of a substance. The symptoms must cause clinically significant distress or impairment in occupational, social, or other areas of functioning (American Psychiatric Association, 1994).
Conversion disorder involves unexplained symptoms of deficits affecting voluntary motor or sensory functions that suggest a neurological or other general medical condition. Conversion disorder appears to be more frequent in women than men, with reported ratios varying from 2:1 to 10:1. The age of onset of conversion disorder ranges from late childhood to early adulthood and is generally acute, but a gradual increase in the severity of symptoms may also occur. Recurrence is common, affecting one-fifth to one-quarter of the individuals within 1 year, and once an episode recurs, more are likely to follow (American Psychiatric Association, 1994).
The prevalence rate of dysphonia without largyngeal pathology is about 8% among patients with dysphonia. Patients with functional dysphonia often reported dependence on the voice in their professional life (Herrington-Hall et al., 1988). In their study of a sample of dysphonic patients with a normal larynx, Herrington-Hall et al. (1988) found occupations that not only could lead to voice abuse such as teaching, but also occupations that have not been traditionally linked to a high risk for voice problems, such as factory work or housekeeping.
The etiology of functional dysphonia is still unclear, but psychological factors are assumed to play an important role. Morrison et al. (1986) indicated that cases of functional dysphonia “while being of psychological and social etiology, have their final common path in the production of dysphonia, the misuse of the voluntary muscles associated with phonation.” Otherwise, there is no direct correlation between the various psychiatric diagnoses that are made and the type of functional dysphonia (Wilson et al., 1995).
It seems that a tendency to somatize psychological conflicts (Nichol et al., 1993) predisposes patients to functional dysphonia (Millar et al., 1999). Matas (1991) described a case report of a 46-year-old unemployed female whose speech had become so difficult to understand that she was forced to communicate through writing. A psychiatric assessment showed that the conversion symptom represented a defense against anxiety and fear. Moreover, in general, there are relatively few studies about the relation between conversion disorder and depression (Binzer and Esemann, 1998, Cybulska, 1997) and even fewer studies about conversion disorder and anxiety (Kohl, 1998).
In the present study, we screened for psychiatric disorders [aside from the psychiatric diagnosis “somatoform disorders, conversion disorder” (300.11)] and for self-rated symptoms of depression and anxiety in patients with functional dysphonia and compared them with healthy controls, matched by sex, age, and occupation. Because we expected an influence of co-morbid psychiatric diagnoses on the self-reported symptoms of depression and anxiety, we analyzed multivariate differences between patients and controls with the co-morbid psychiatric diagnoses as covariates.
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Subjects
Sixty-one patients with functional dysphonia were consecutively recruited and examined at the Department of Phoniatrics and Logopedics of the University—Ear, Nose and Throat—Clinic of Vienna. The patient sample consisted of 48 (79%) female and 13 (21%) male patients. Sex distribution showed a significant majority of female patients (χ2=20.082, df=1, P≤0.0001), which is consistent with the literature (American Psychiatric Association, 1994, Herrington-Hall et al., 1988).
All of the patients
Psychiatric evaluation
Forty-three percent of the patients with functional dysphonia did not receive an additional psychiatric diagnosis (lifetime or current diagnosis). They just fulfilled DSM-IV-criteria for somatoform disorders, conversion disorder (300.11). Twenty patients (33%) had mood disorders (four major depressive disorder, nine dysthymic disorder, and seven depressive disorders not otherwise specified), and 12 patients (20%) had clinical anxiety disorders (three panic disorder, two specific phobia, five
Discussion
Functional dysphonia as a change of voice quality such as huskiness, hoarseness or croaking is characterized by normal laryngoscopic findings, and it is diagnosed (American Psychiatric Association, 1994) as “somatoform disorders, conversion disorder with motor symptom or deficit” (300.11).
In the present study we screened patients with functional dysphonia for psychiatric disorders other than 300.11 and for self-rated symptoms of depression and anxiety, and we compared them with healthy
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