Janet Baker 1 , David I. Ben-Tovim 2 , Andrew Butcher 1 , Adrian Esterman 3 , Kristin McLaughlin 2

1 Flinders University, Speech Pathology and Audiology, Adelaide

2 Flinders Medical Centre, Epidemiology, Adelaide

3 University of South Australia, Nursing and Midwifery, Adelaide

Background: Current themes regarding etiology suggest Functional Voice Disorders (FVD) may develop in response to negative emotions following stressful life events, that personality traits may influence ways of coping and that FVD may reflect the suppression or repression of negative emotions. To date, the empirical evidence for these etiological hypotheses is scarce. Objectives: To examine the life events and difficulties experienced by women with FVD during the 12 months preceding onset, and to determine the women's patterns of emotional expression, coping style and attachment in close adult relationships. Methods: The study was a case-control design involving women 18-80 years of age, with a recently diagnosed FVD (n=73) or Organic Voice Disorder (OVD) (n=55), and a control group (n=66) with perceptually normal voices, broadly matched for age and occupation. Diagnosis was made with reference to the Diagnostic Classification System for Voice Disorders (DCSVD) developed for this project. Data collected as putative risk factors for FVD included the Life Events and Difficulties Schedule (LEDS) and Conflict Over Speaking Out (COSO) situations. Additional data included Attachment Style and five standardized self-report questionnaires targeting Coping Styles and Personality Traits related to emotional expressiveness. Results: Univariate analysis showed women with FVD in comparison to OVD and Controls experienced more severe events, major difficulties, COSO events and COSO difficulties. Psychological traits data showed FVD women reported: higher levels of anxiety, anger and depression; lower levels of optimism and social support; emotional expression-in; anxious rather then repressive coping style; more ambivalence over the expression of negative emotion; less emotional expressiveness in family of origin; more insecure and fearful attachment and a stronger history of violence, strangulation or sexual abuse. Logistic regression showed four major components to be predictive of FVD group in comparison to the control group accounting for 84.9% of the variance: severe events, moderate events, severe COSO and mild COSO difficulties. Personality traits were not predictive of FVD or control group, and no confounding was present. Conclusion: This is the largest and most definitive study of its kind to show the possible inter-relationship between stressful life events and difficulties, COSO situations and dispositional factors in the etiology of FVD in women. The results support clinicians incorporating psychotherapeutic approaches in the assessment and management of FVD.  

Key Words: Functional voice disorders, Organic voice disorders, Etiology, Life events and difficulties, Conflict over speaking out, Coping style, Attachment style, Emotional expressiveness, Emotion processing deficits.

Janet Baker 1 , Richard D. Lane 2

1 Flinders University, Speech Pathology and Audiology, Adelaide

2 University of Arizona, Psychiatry and Neuroscience, Tucson

In this discussion paper we draw upon findings reported earlier in this symposium (Baker J. Ben-Tovim, D.I., Butcher, A., Esterman, A., & Mclaughlin, K.) on the association between functional voice disorders (FVD) in women and the etiologic role of life stress, coping style and patterns of emotional expression. There are two distinct themes in these results for women with FVD relative to those with organic voice disorder or healthy controls. One involves a greater amount of emotional distress and negative affect arising in response to stressful and/or conflict over speaking out situations. The other suggests some kind of inhibition or alteration in the ability to process that emotional distress, which included both more recent as well as more remote, developmental factors.

The findings serve as a foundation for our discussion of how emotional distress and the relative failure to process it could result in FVD. The discussion focuses on the distinction between implicit and explicit emotional processes and their distinct neural substrates. It is proposed that FVD may arise when emotional distress cannot be adequately processed at the conscious level. This may be associated with an autonomic imbalance favoring sympathetic relative to vagal outflow, resulting in constriction of the intrinsic and extrinsic laryngeal muscles, increased tension in the vocal folds, and an attendant loss of voice. Bringing the emotional distress into conscious awareness in therapy can lead to a top-down modulation of emotional arousal associated with a shift in autonomic balance characterized by an increase in vagal tone (as determined by heart rate variability) and concomitant relaxation of the intrinsic and extrinsic laryngeal muscles. Thus, FVD may arise when emotional distress is persistent and yet remains largely implicit, whereas successful treatment of FVD involves a shift to explicit processing, which itself is associated with an increase in vagal tone. It is proposed this can be most readily achieved by assisting individuals to process their emotions and experience their feelings consciously through the use of language in a more differentiated way. In being able to process emotions at this more explicit level, such individuals are then able to make sense of their emotional response, both to themselves and in relation to others. The implications of this model are discussed in relation to the most appropriate therapeutic approaches needed for the long- term resolution of functional voice disorders, and to the optimal education and training for both undergraduate and postgraduate speech pathologists. We conclude with suggestions for further empirical testing of this model of emotion processing deficits in FVD. 

Key words: Functional Voice Disorders; Emotion processing deficits; Emotional processes and their neural substrates; Theoretical and causal models; Therapy for Functional Voice Disorders; Postgraduate education in counselling

  

  

 

  

Cate Madill 1 , Robert Heard 1 , Christine Sheard 1 , Ross Menzies 1

1 University of Sydney, Faculty of Health Sciences, Sydney

Geert Berghs 1 , Annemie Gielis 2 , Marian Vervoort 2 , Felix de Jong 2

1 singing teacher, , Bussum

2 Lab.Exp.ORL, Dep.ENT, Head and Neck Surgery, Leuven