Psychological Distress in Patients With Voice Disorders

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Original Paper

Folia Phoniatr Logop 2011;63:281–288

DOI: 10.1159/000324641

Psychological Distress in Patients with Benign Voice Disorders

Nora Siupsinskiene a, b Artūras Razbadauskas a Laimis Dubosas a

a Faculty of Health Sciences, University of Klaipeda, Klaipeda , and b Department of Otolaryngology,

Hospital of Lithuanian University of Health Sciences, Kaunas , Lithuania

voice disorders using a simple HADS tool to identify those

patients who might benefit from a more psychologically

based approach to therapy. Copyright © 2011 S. Karger AG, Basel

Introduction

Voice disorders and mental health are closely connect-ed. Several studies suggest that dysphonia, defined as an altered quality of voice, is often accompanied by symp-toms of psychological distress [1, 2] . Psychogenic causes and an increased tension of the intrinsic and extrinsic la-ryngeal muscles, in response to psychological conflict, anxiety, depression or inhibited psychoemotional expres-sion, are presumed to be one end of the spectrum of pos-sible factors leading to the development of functional voice problems [3] . In addition, advanced laryngeal dis-orders such as laryngeal cancer and recurrent papilloma-tosis cause psychological distress, resulting in the forma-tion of a vicious cycle [4, 5] . Dysphonic patients frequent-ly report symptoms of psychological distress such as anxiety and depression [6, 7] . Increased state and trait anxiety is one of the most frequently mentioned features of patients with nonorganic dysphonia and vocal fold (VF) nodules [1, 3, 6, 7] . Despite overall interest in this field, only a few studies have been conducted to assess differences in the current state of psychological distress

Key Words

Anxiety � Depression � Hospital Anxiety and Depression

Scale � Gender � Voice disorders

Abstract

Objective: The aims of this study were to investigate the fre-

quency of anxiety and depression in patients with benign

voice disorders with respect to gender and diagnosis and to

determine correlations between psychological distress and

some sociodemographic factors and the Voice Handicap In-

dex (VHI). Methods: Psychological distress was assessed for

437 consecutive adult patients with benign voice disorders

and 88 healthy controls by a standardized Hospital Anxiety

and Depression Scale (HADS). In addition, sociodemograph-

ic factors, unhealthy habits and VHI were investigated. Re-sults: Mild to severe HADS-Anxiety scores were seen in 42.1%

of the whole patient group, while mild to severe HADS-De-

pression scores were seen in only 19.2% of patients. The anx-

iety rate rather than the depression rate in voice patients was

found to be significantly higher compared to controls (p !

0.05). Female patients expressed more anxiety than males.

HADS-Anxiety scores were similar for most benign voice dis-

orders. The worst depression scores were found in patients

with vocal fold paralysis. Higher psychological distress was

significantly related to female gender, older age, less educa-

tion and higher VHI scores. Conclusions: We recommend

screening for psychological distress in patients with benign

Published online: March 24, 2011

Nora Siupsinskiene, MD, Dr. habil. Department of Otolaryngology Hospital of Lithuanian University of Health Sciences Eiveniu 2, LT–90000 Kaunas (Lithuania) Tel. +370 37 326 247, E-Mail norai_s @ yahoo.com

© 2011 S. Karger AG, Basel1021–7762/11/0636–0281$38.00/0

Accessible online at:www.karger.com/fpl

Siupsinskiene /Razbadauskas /Dubosas Folia Phoniatr Logop 2011;63:281–288282

among various laryngeal diseases [1, 2, 8] . A recent study conducted by Dietrich et al. [8] is the only report to date that comprehensively investigated the frequency of anxi-ety and depression using the Hospital Anxiety and De-pression Scale (HADS) for patients with common voice disorders with respect to diagnosis and gender. The data are consistent with suggestions that anxiety and depres-sion may be common among some patients with muscle tension dysphonia, paradoxical VF movement disorder and benign VF lesions and that this distress may be more common for women than for men. However, individual variability in the data set was large, and no specific role of these mental health issues for the assessed voice disor-ders was stated. On the whole, the assessment of psycho-logical distress is an important issue, but a major segment of the studies on the frequency of psychological distress among patients with voice disorders is devoted to selected patient groups, e.g. patients with nonorganic dysphonia, while the data on psychological distress in patients with benign VF lesions and tumors or chronic inflammation are sparse and insufficient [4, 5, 8–10] . Further investiga-tions on how anxiety and depression may distribute across various voice disorders and across genders in a large sample could add more information on the preva-lence of psychological distress among dysphonic patients with a wider spectrum of voice disorders and could lead to better treatment options for selected patients.

The aim of the present study was threefold: first, to investigate the frequency of anxiety and depression in pa-tients with benign voice disorders versus healthy voice controls using a standardized approach; second, to assess differences in the distribution of anxiety and depression based on gender and diagnosis, and third, to determine the correlation between psychological distress (anxiety and depression) and sociodemographic factors, un-healthy habits and a Voice Handicap Index (VHI).

Subjects and Methods

Subjects The study included 437 consecutive adult patients, 18 years

and older, with newly diagnosed benign voice disorders (voice patients group), who presented to the outpatient voice laboratory of Kaunas Medical University Hospital between January 2001 and August 2004. As controls, 88 vocally healthy subjects of similar ages to the study group were included. Subjects were excluded if they were suspected of having laryngeal carcinoma or had been diagnosed with acute upper respiratory tract infections or airway obstruction at the time of examination. Patients with sulcus vo-calis, mucosal bridges, or VF cysts also were excluded because of insufficient numbers for the analysis of both genders. The pa-

tients with benign voice disorders were divided into seven sub-groups based on their primary diagnoses: Reinke’s edema; VF nodules; VF polyps; laryngeal papillomatosis; laryngopharyngeal reflux (LPR); VF paralysis and nonorganic dysphonia. Diagnoses were made by a laryngologist (S.N.) based on history, characteris-tic symptoms, clinical examination and telescopic videolaryngos-copies using a rigid 70° endoscope (Kay Elemetrics, Lincoln Park, N.J., USA) and standard diagnostic criteria in the identification of the conditions of interest for the study [11] . Diagnosis of Reinke’s edema was based on the observation of edematous swell-ing of the VF upper or both upper and lower surfaces, VF nodules and VF polyps – on observation of benign-appearing unilateral or bilateral lesions in the mid-membranous part of the VFs. Di-agnosis of papillomatosis was made based on the observation of papilloma-like masses localized in the larynx with supporting histological evidence; LPR was diagnosed on the basis of charac-teristic symptoms, positive reflux finding scores showing inflam-mation of the larynx or histological or erosive esophagitis accord-ing to the Los Angeles classification of upper gastrointestinal en-doscopy and a positive response to empirical 3-month proton pump inhibitor treatment [10, 12] . The diagnosis of VF paralysis was made in patients with unilateral VF immobility, which was caused primarily by thyroidectomy (77% of cases), but also by in-fection (9%), neck trauma (7%) and unknown etiologies (7%). The diagnosis of nonorganic dysphonia was based on patient history, voice complaints, signs of muscle tension of the head and neck and the absence of organic laryngeal pathology during (video)laryn-goscopy [3, 11] . Most patients in the nonorganic dysphonia sub-group were diagnosed as having primary muscle tension dyspho-nia (84%).

The vocally healthy subjects were recruited from adult volun-teers with healthy voices in a wide range of hospital staff and med-ical students. Vocally healthy subjects had no complaints, no his-tory of otolaryngological problems or voice surgery and no or-ganic pathology of the VFs during a comprehensive phoniatric examination. Eighty-eight adults randomly selected from a list of 207 vocally healthy subjects composed the healthy control group.

Methods An original questionnaire was used to gather information

about subjects’ professions, smoking (subjects were considered to be smokers if they smoked at least one cigarette per day), alcohol consumption (subjects were considered to be alcohol consumers if they consumed alcohol at least a few times per month), and level of voice training (subjects were considered to have trained voices if they had received voice training at least 2 h per week for 2 years).

Written informed consent was obtained from all subjects. The protocol was approved by the Ethics Committee of Kaunas Uni-versity of Medicine, Lithuania.

Hospital Anxiety and Depression Scale Psychological distress was measured by the HADS – a self-

rated standardized scale designed to detect psychological distress from the preceding week in physically ill patients in the general medicine setting [13] . The HADS contained a 14-item question-naire with two separate 7-item sections and four response catego-ry subscales that addressed symptoms of generalized anxiety (HADS-Anxiety) or depression (HADS-Depression), the latter being composed of reflections of the state of anhedonia. Each of

Psychological Distress and Voice Disorders

Folia Phoniatr Logop 2011;63:281–288 283

the two scale scores ranged from 0 (no symptoms) to 21 (maxi-mum of distress) points. HADS has been validated and culturally adopted in various countries, including Lithuania, and is consid-ered to be a reliable, valid and simple screening tool to assess the level of anxiety and depression [14, 15] . In its current form, the HADS is now divided into four ranges: normal (0–7 points), mild (8–10), moderate (11–15), and severe (16–21). Patients showing moderate or severe scores in either the anxiety or depression sub-scales (cutoff 6 11) could be defined as ‘potentially’ clinically sig-nificant cases [14] .

Voice Handicap Index The VHI was assessed using a validated questionnaire that

measures the impact of voice problems on a person’s life [16] . The questionnaire is composed of 30 questions, with ratings from 0 (never) to 4 (always). The VHI generates a total score (ranging from 0–120) and three subscale scores: functional, physical, and emotional (each ranging from 0–40).

Statistical Analysis Statistical analysis was performed with SPSS 10 for Windows

(SPSS Corp., Chicago, Ill., USA). The Student’s two-tailed t test was used for two-group comparisons of normally distributed quantitative parameters, and the Mann-Whitney U test was used for non-normally distributed parametric data. More than two groups were compared with one-way ANOVAs, which are relative robust against deviations of normality and unequal sample size [17] . The post-hoc LSD criterion for multiple comparisons was used. Additionally, the number of cases across and within each patient group was converted to gender-adjusted z scores, using the mean of healthy subjects; z scores were considered noteworthy if they exceeded this mean by 6 1 standard deviation (SD). � 2 -test and Fisher’s exact test were used for nonparametric data analysis. Correlation analysis was made with Spearman’s correlation coef-ficient (r). Significance was evaluated at p ! 0.05.

Results

Sociodemographic Data

The 437 adult patients with benign voice disorders in-cluded 284 (65.0%) females and 153 (35.0%) males aged from 18 to 81 years (mean: 41.8 8 13.2 years). Sixty-nine of the selected patients (32 females and 37 males) had Reinke’s edema, 51 (41 female and 10 males) had VF nod-ules, 84 (36 females and 48 males) had VF polyps, 27 (11 females and 16 males) had laryngeal papillomatosis, 88 (72 females and 16 males) had LPR, 44 (38 females and 6 males) had VF paralysis and 74 (54 females and 20 males) had nonorganic dysphonia. Thirty-one percent of the pa-tients were professional voice users (teachers, actresses, singers, or managers). The control group consisted of 88 vocally healthy subjects, including 64 (72.7%) females and 24 (27.3%) males aged from 24 to 67 years (mean 39.1

8 10.9 years). Voice patients and controls were similar in age and gender, alcohol consumption and smoker pro-portions (p 1 0.05). Similarly, 82.9% of patients and 77.2% of controls had untrained voices (p 1 0.05). Most of the voice patients (59.2%) and control group subjects (89.9%) were office employees; 7.1% of patients and 5.7% of con-trols were students, 26.7% of patients and 4.5% of controls were workers, and the rest (7.1%) were pensioners.

HADS Analysis

Whole Sample The mean anxiety score for the whole patient group

was higher than the depression score, but both scores were significantly higher compared to the control group [6.9 8 4.1 versus 4.8 8 3.4 points (HADS-Anxiety), p ! 0.0001, and 4.3 8 3.6 versus 3.0 8 2.9 points (HADS-Depression), p = 0.001, respectively, table 1] . Gender-ad-justed z scores for the whole sample also indicated that 40.0% of individuals in the patient group showed devia-tions from normal on anxiety scores, and 30.4% of voice patients showed deviations in their depression scores. The analysis of HADS severity grade distributions clear-ly indicated a higher prevalence of anxiety in the voice patient group. The analysis further showed that 42.1% of patients had mild to severe anxiety (cutoff 6 8) compared to 18.2% of the healthy subjects (p = 0.0001), a trend op-posite that of the depression scores: mild to severe depres-sion scores were found in 19.2% of patients, which was similar to control group results (11.4% of healthy subjects, p 1 0.05). Potentially clinically significant cases that dem-onstrated moderate to severe HADS scores for anxiety (cutoff 6 11) were found in 19.5% of the whole voice pa-tient group; 7.8% of this group had similar scores for de-pression.

Gender Effect in the Data. With respect to the whole voice patient group, the mean anxiety and depression scores, when analyzed separately for male and female voice patients, were significantly higher compared to the same-gender controls (p ! 0.05), but both anxiety and depression scores were significantly higher for females than for males (p ! 0.05, table 1 ). A gender-adjusted HADS-Anxiety z-score analysis also indicated a slightly higher percentage of deviations from normal for female patients (41.5%) in comparison with male patients (37.3%). A HADS-Depression z-score analysis revealed similar re-sults for patients of both genders: 29.2% of females and 32.6% of males were found to deviate from the norm. An analysis across HADS severity grades provided stronger


evidence of a possible gender effect in the data. A higher percentage of mild to severe anxiety was clearly diag-nosed for female patients (48.3%) in comparison with males (30.7%, p ! 0.05), and 22.9% of female and 13.1% of male patients showed clinically significant levels of anxi-ety. An analysis of gender effects on HADS depression severity showed slightly but not significantly higher per-centages of patients diagnosed as having mild to severe depression for females (22.2%) in comparison with males (13.8%, p 1 0.05). Only 8.5% of female patients and 6.6% of male patients showed clinically significant levels of signs of depression.

Diagnosis Effects in the Data W hole Sample. The data on anxiety and depression

mean scores, z scores and HADS severity grade scores by diagnosis and gender are summarized in tables 2 and 3 . Overall, the mean anxiety scores were significantly high-er for patients of both genders in the pooled data set than for controls using post-hoc pairwise comparisons with LSD adjustment (p ! 0.005) in all but one diagnostic sub-group: patients with VF polyps. The mean scores for anx-iety were highest in patients with laryngeal papillomato-sis (8.6 8 3.9), VF paralysis (8.0 8 3.9) and LPR (7.4 8

4.1), and lowest in patients with VF polyps (5.5 8 4.2, table 2 ). The latter diagnostic subgroup showed signifi-cantly lower mean anxiety scores in comparison with all other diagnostic subgroups with the exception of Rein-ke’s edema. Mean depression scores in the pooled data set were significantly higher in comparison with controls only for three of seven investigated patient subgroups: VF paralysis (6.5 8 3.6), Reinke’s edema (4.7 8 3.7) and LPR (4.7 8 3.8) versus controls (3.0 8 2.9, p ! 0.005, table 3 ). Only patients with VF paralysis showed significantly higher mean depression scores in comparison with the other diagnostic subgroups (p ! 0.05). None of the other comparisons approached significance. Results similar to means we found on converted z scores and on the sever-ity grade distribution analysis of both HADS subscales ( tables 2 , 3 ).

Gender Effects in the Data. Detailed information on gender effects in the data is shown in tables 2 and 3 . Com-parable to the pooled data, mean anxiety scores were higher than depression scores for patients with various benign voice disorders and differed significantly from controls in all but the VF polyp subgroup for females (p ! 0.005) and in four of seven diagnostic subgroups for males (Reinke’s edema, VF nodules, VF polyps and papil-

Table 1. Scores from the HADS for the whole voice patient group and healthy controls by gender

Psychological status Females Males A ll

patients(n = 284)

controls(n = 64)

pvalue

patients(n = 153)

controls(n = 24)

pvalue

patients( n = 437)

controls(n = 88)

pvalue

HADS-AnxietyMean 8 SD 7.684.1 5.383.3 <0.001c 5.884.0 3.483.4 0.008c 6.9 84.1 4.883.4 0.001c

z score ≥1 SD above norma, n (%) 118 (41.5) 12 (18.8) 0.001d 57 (37.3) 6 (25.0) 0.244 175 (40.0) 18 (20.5) 0.001d

Grades, n (%)Normal (0–7) 147 (51.7) 51 (79.7) 106 (69.3) 21 (87.5) 253 (57.9) 72 (81.8)Mild (8–10) 72 (25.4) 6 (9.4) 0.001d 27 (17.6) 2 (8.3) 0.322 99 (22.7) 8 (9.1) 0.001d

Moderate (11–15)b 60 (21.1) 7 (10.9) 18 (11.8) 1 (4.2) 78 (17.8) 8 (9.1)Severe (16–21)b 5 (1.8) – 2 (1.3) – 7 (1.6) –

HADS-DepressionMean 8 SD 4.683.6 3.482.9 0.009c 3.883.5 2.182.7 0.018c 4.383.6 3.082.9 0.001c

z score ≥1 SD above norma, n (%) 83 (29.2) 10 (15.6) 0.026d 50 (32.6) 4 (16.7) 0.113 133 (30.4) 14 (15.9) 0.006d

Grades, n (%)Normal (0–7)Mild (8–10)

221 (77.8)39 (13.7)

56 (87.5)5 (7.8) 0.221

132 (86.2)11 (7.2)

22 (91.7)2 (8.3) 0.643

353 (80.8)50 (11.4)

78 (88.6)7 (8.0) 0.333

Moderate (11–15)b 24 (8.5) 3 (4.7) 9 (5.9) – 33 (7.6) 3 (3.4)Severe (16–21)b – – 1 (0.7) – 1 (0.2) –

a N orm calculated from healthy controls. b Clinically significant anxiety or depression cases represent the number of subjects scoring ≥11 on anxiety or depression scales. c Statistically significant difference between patient and control groups with t test, significance level p < 0.05. d Statistically significant difference between patient and control groups with �2-test, significance level p < 0.05.



lomatosis, p ! 0.05). Mean depression scores differed sig-nificantly from controls in three diagnostic subgroups (Reinke’s edema, LPR and VF paralysis) for females, and in two diagnostic subgroups (Reinke’s edema and papil-lomatosis) for males (p ! 0.05). Multiple comparisons of mean anxiety scores between patient diagnostic sub-groups showed that female patients with VF polyps had significantly lower mean anxiety scores than all other di-agnostic subgroups with the exception of patients with VF nodules, whereas male patients with laryngeal pap-illomatosis showed significantly higher mean anxiety scores than patients with Reinke’s edema, VF polyps and nonorganic dysphonia (p ! 0.05). Female patients with VF paralysis had significantly higher mean depression scores than all other diagnostic subgroups (p ! 0.05) ex-cept for patients with Reinke’s edema, but male patients failed to show significant differences between diagnostic subgroup scores. Analysis of the distribution of HADS

severity grades showed that the percentage of patients with mild to severe anxiety was higher for females than males in five of seven investigated diagnostic subgroups, and mild to severe depression in all diagnostic subgroups, but significant differences between the results for both genders were found only for anxiety scores in two diag-nostic subgroups of patients: female patients with Rein-ke’s edema and nonorganic dysphonia showed higher rates of deviating anxiety scores in comparison with their male counterparts (p ! 0.05).

Correlation Analysis

Correlations between the severity of psychological dis-tress and sociodemographic characteristics (gender, age, profession, voice training, and experience of stressful events), unhealthy habits (smoking, alcohol consump-

Table 2. Anxiety scores from the HADS by separate voice disorder subgroups and gender

HADS-Anxiety scores Reinke’sedema

VFnodules

VFpolyps

Papillo-matosis

LPR VFparalysis

Nonorganicdysphonia

Females, n 32 41 36 11 72 38 54Mean 8 SD 8.383.3c 7.184.1c 3.884.2 9.184.3c 7.784.1c 8.583.9c 7.584.1c

z score ≥1 SD above norma, n (%) 15 (46.9)c 16 (39.0)c 10 (27.8) 6 (54.5)c 27 (37.5)c 22 (57.9)c 22 (40.7)c

Grades, n (%)Normal (0–7) 12 (37.5) 25 (61.0) 26 (72.2) 5 (45.4) 38 (52.7) 13 (34.2) 28 (51.8)Mild (8–10) 15 (46.9)c 8 (19.5) 6 (16.7) 2 (18.2)c 13 (18.1)c 15 (39.5)c 13 (24.1)c

Moderate (11–15)b 4 (12.5) 7 (17.1) 4 (11.1) 3 (27.3) 20 (27.8) 9 (23.7) 13 (24.1) Severe (16–21)b 1 (3.1) 1 (2.4) – 1 (9.1) 1 (1.4) 1 (2.6) –

Males, n 37 10 48 16 16 6 20Mean 8 SD 5.584.6c 7.183.2c 5.484.3c 8.283.7c 5.683.7 4.782.4 4.982.5z score ≥1 SD above norma, n (%) 12 (32.4) 5 (50.0) 16 (33.3) 11 (68.8)c 6 (37.5) 1 (16.7) 6 (30.0)Grades, n (%)

Normal (0–7)Mild (8–10)

26 (70.3)6 (16.2)

6 (60.0)2 (20.0)

34 (70.8)6 (12.5)

8 (50.0)4 (25.0)c

10 (62.5)5 (31.3)

5 (83.3)1 (16.7)

17 (85.0)3 (15.0)

Moderate (11–15)b 3 (8.1) 2 (20.0) 8 (16.7) 4 (25.0) 1 (6.2) – –Severe (16–21)b 2 (5.4) – – – – – –

All, n 69 51 84 27 88 44 74Mean 8 SD 6.784.3c 7.183.9c 5.584.2 8.683.9c 7.484.1c 8.083.9c 6.883.9c

z score ≥1 SD above norma, n (%) 27 (39.1)c 21 (41.2)c 26 (31.0) 17 (63.0)c 33 (37.5)c 23 (52.3)c 28 (37.8)c

Grades, n (%)Normal (0–7) 38 (55.2) 31 (60.8) 60 (71.4) 13 (48.2) 48 (54.5) 18 (40.8) 45 (60.8)Mild (8–10) 21 (30.4)c 10 (19.6)c 12 (14.3) 6 (22.2)c 18 (20.5)c 16 (36.4)c 16 (21.6)c

Moderate (11–15)b 7 (10.1) 9 (17.6) 12 (14.3) 7 (25.9) 21 (23.9) 9 (20.5) 13 (17.6)Severe (16–21)b 3 (4.3) 1 (2.0) – 1 (3.7) 1 (1.1) 1 (2.3) –

a Norm calculated from healthy controls. b Clinically significant anxiety or depression cases represent the number of subjects scor-ing ≥11 on anxiety or depression scales. c Statistically significant difference between patient and control groups by using the post hoc LSD criterion for multiple comparisons; significance level p < 0.05.


tion) and VHI were determined. The correlation analysis showed a significant but mild relationship between the severity of anxiety and gender (r = –0.22, p ! 0.0001), profession (r = 0.12, p = 0.032) and total VHI (r = 0.23, p = 0.001). Anxiety was also correlated significantly but mildly with all three VHI subscales, functional (r = 0.18, p = 0.007), physical (r = 0.19, p = 0.004), and emotional (r = 0.27, p = 0.0001). Increases in anxiety scores were sig-nificantly associated with female gender, less education and a higher perception of voice handicap. The higher depression scores were mildly but significantly depen-dent on female gender (r = –0.12, p = 0.013), older age (r = 0.20, p = 0.001), voice training (r = –0.12, p = 0.015), and higher VHI scores in the total (r = 0.17, p = 0.008), functional (r = 0.14, p = 0.042), physical (r = 0.17, p = 0.011), and emotional (r = 0.19, p = 0.005) subscales. No other significant relationships were found.

Discussion

The primary aim of this study was to investigate the frequency of anxiety and depression in patients with a wide spectrum of benign voice disorders compared to healthy voice controls using a standardized approach. The results of the current study showed that the preva-lence of psychological morbidity in patients with benign voice disorders based on HADS severity grade scores (cutoff 6 8) was found to be high at 42.1% (184 of 437) for anxiety and lower at 19.2% (84 of 437) for depression compared to norms and differ significantly from controls only for anxiety frequency score (p = 0.0001). Accord-ingly, clinically significant levels of anxiety (cutoff 6 11) were found in 19.5% (85 of 437) of the whole voice patient group, a level that is 2.5 times higher than that of depres-sion (7.8%, 34 of 437 cases). A gender-adjusted z-score analysis showed similar results for anxiety (40.0% of the

Table 3. Depression scores from the HADS by separate voice disorder subgroups and gender

HADS-Depression scores Reinke’sedema

VFnodules

VF polyps Papillo-matosis

LPR VFparalysis

Nonorganicdysphonia

Females, n 32 41 36 11 72 38 54Mean 8 SD 5.283.9c 3.583.1 4.283.3 3.882.4 4.983.9c 6.783.6c 3.882.9z score ≥1 SD above norma, n (%) 11 (34.4)c 9 (22.0) 8 (22.2) 2 (18.2) 21 (29.2) 22 (57.9)c 10 (18.5)Grades, n (%)

Normal (0–7) 23 (71.9) 35 (85.4) 30 (83.3) 9 (81.8) 54 (75.0) 25 (65.8) 45 (83.3)Mild (8–10) 4 (12.5)c 5 (12.2) 5 (13.9) 2 (18.2) 9 (12.5)c 7 (18.4)c 7 (13.0)Moderate (11–15)b 5 (15.6) 1 (2.4) 1 (2.8) – 9 (12.5) 6 (15.8) 2 (3.7)Severe (16–21)b – – – – – – –

Males, n 37 10 48 16 16 6 20Mean 8 SD 4.383.6c 2.582.5 3.483.8 4.883.3c 3.983.2 4.783.4 3.382.9z score ≥1 SD above norma, n (%) 13 (35.1) 3 (30.0) 13 (27.1) 8 (50.0) 5 (31.3) 3 (50.0) 5 (25.0)Grades, n (%)

Normal (0–7) 30 (81.1) 10 (100.0) 42 (87.5) 14 (87.5) 13 (81.2) 5 (83.3) 18 (90.0)Mild (8–10) 4 (10.8) – 3 (6.2) – 3 (18.8) – 1 (5.0)Moderate (11–15)b 3 (8.1) – 2 (4.2) 2 (12.5) – 1 (16.7) 1 (5.0)Severe (16–21)b – – 1 (2.1) – – – –

All, n 69 51 84 27 88 44 74Mean 8 SD 4.783.7c 3.383.0 3.783.6 4.482.9 4.783.8c 6.583.6c 3.782.9z score ≥1 SD above norma, n (%) 24 (34.8)c 12 (23.5) 21 (25.0) 10 (37.0) 26 (29.5)c 25 (56.8)c 15 (20.3) Grades, n (%)

Normal (0–7) 53 (76.8) 45 (88.2) 72 (85.7) 23 (85.2) 67 (76.2) 30 (68.2) 63 (85.1)Mild (8–10) 8 (11.6)c 5 (9.8) 8 (9.5) 2 (7.4) 12 (13.6)c 7 (15.9)c 8 (10.8)Moderate (11–15)b 8 (11.6) 1 (2.0) 3 (3.6) 2 (7.4) 9 (10.2) 7 (15.9) 3 (4.1)Severe (16–21)b – – 1 (1.2) – – – –

a Norm calculated from healthy controls. b Clinically significant anxiety or depression cases represent the number of subjects scor-ing ≥11 on anxiety or depression scales. c Statistically significant difference between patient and control groups by using the post hoc LSD criterion for multiple comparisons; significance level p < 0.05.



whole patient group) and higher levels of deviation from normal in depression (30.4% of the whole patient group) in comparison with HADS severity grade results. The reason for such discrepancies lies in the different cutoffs for psychological morbidity. Overall, anxiety appeared to be more common for the pooled voice patients set than did depression. According to the literature, elevated states of anxiety as measured by the HADS, which represents generalized anxiety symptoms, are connected with re-ported trait anxiety (personality traits such as introver-sion and neuroticism) for the patients with benign voice disorders, especially for those suffering from nonorganic dysphonia [1, 4, 6, 7, 9] . Specific personality traits might lead to muscularly inhibited voice production and result in elevated laryngeal tension and primary development of nonorganic dysphonia. Additionally, abusive, vocally aggressive behaviors in part determined by specific per-sonality traits may lead to the formation of secondary be-nign VF lesions [7, 9] . A higher overall prevalence of anx-iety than depression for voice patients in the current study also may be due to the larger sample of females (65% of patients), who tended to demonstrate higher anxiety scores in previous research [7, 8] .

The second aim of this study was to assess differences in the distribution of anxiety and depression scores based on gender and diagnosis. Analysis of the gender effects across HADS severity grades for the whole patient group provided the strongest evidence of a possible gender ef-fect on the data in comparison with the mean score and gender-adjusted z-score analyses and clearly showed that female patients were diagnosed with mild to severe anxi-ety significantly more often than were male patients of similar ages (48.3 versus 30.7% of the whole voice patient group). The same tendency was found also for clinically significant anxiety cases: 22.9% for female patients versus 13.1% for male patients. In contrast, the depression scores were similar for patients of both genders. Only up to 9% of patients of either gender were found to have clinically significant levels of signs of depression. These tendencies were also found in the analysis of separate voice disor-ders. Higher levels of psychological distress in females may be due to stresses perceived in a stronger way in their life and job (more females than males demonstrated ele-vated stress measured by current psychometric stan-dards) and some personality characteristics (women with dysphonia tended to have higher neuroticism scores) [1, 6–8] . When psychological distress was assessed among separate diagnostic voice patient subgroups, it was deter-mined that the intensity and frequency of anxiety were similar for most patient diagnosis subgroups with the ex-

ception of patients with VF polyps. Bearing in mind that the diagnosis of VF polyps generally has a good prognosis and good outcomes, that could play an important role in the more stable psychoemotional status of such patients, which is similar to that of healthy subjects. The worst de-pression scores were found in patients with VF paralysis, who demonstrated a significantly higher mean HADS depression score in comparison with the other diagnostic subgroups. Depression cases were stated for one third for such patients. According to our data, it is likely that ele-vated psychological distress could be as much a conse-quence of some voice disorders as a cause of them. La-ryngeal papillomatosis, VF paralysis and LPR diagnosis achieved the highest anxiety scores in the present study due to the chronic, complicated nature of these disorders when secondary psychological distress might be expected more than primary. These voice disorders are serious and frustrating with life-threatening complications, long-term treatment, and often insufficient treatment out-comes [4, 10, 12, 18] . These factors could lead to second-ary psychological distress. Although cross-study com-parisons can hardly be made because of the design and sample variability, our results based on the mean and converted z-score analyses are partially comparable with those from Dietrich et al. [8] , where 160 patients with common voice disorders were investigated, excluding pa-tients with VF paralysis. Our results showed an anxiety and depression rate that was at least double the reported scores for this patient subgroup. One of the reasons for such a difference may be that the subgroups were not unique with regard to subdiagnoses and causes of the dis-order. Another reason may be the younger age of our study patients of the VF paralysis subgroup (46.3 8 13.5 versus 60.4 8 18.4 years). Previous data showed that el-derly individuals tend to perceive less stress than young-er people [8] . On the basis of psychological distress inten-sity and frequency for dysphonic patients, our results could also be comparable to those of Millar et al. [2] .

The last aim of our study was to determine a correla-tion between the severity of anxiety and depression with sociodemographic characteristics, unhealthy habits and the VHI. It was established that increased anxiety scores were significantly but weakly related to female gender, less education and higher scores on the total VHI and all three VHI domains of voice patients. The higher depres-sion scores were significantly but weakly dependent on female gender, older age, the presence of voice training and increases in perceived voice handicap.

It has been established that besides personality pecu-liarities and lack of parents’ attention in childhood, poor


social and economic conditions and insignificant scien-tific achievements are common risk factors for the devel-opment of psychic and somatic disorders [19, 20] . A link between neuroticism and a tendency toward illness is formed due to impaired sympathetic-adrenomedullary and hypothalamic-pituitary-adrenal reactivity. Less edu-cated representatives of the lowest social class are more psychologically vulnerable. It is not surprising that those patients with higher perceived VHI scores, indicating an impaired ability to use their voices in common, social and work-related situations, had more psychological distress symptoms. Previous research showed that the VHI level is dependent on the severity of the voice dysfunction, and the highest VHI scores demonstrated patients with neu-rogenic impairments and severe structural abnormalities (cancer, Reinke’s edema) [18, 21] . Thus, the findings of the present study, showing that the severity of psychological distress on HADS positively correlated with the severity of the voice handicap equally for the total score and for all three domains, add valuable information indicating that the level of psychological distress is related to voice

dysfunction rather than to the type of voice disorder. The relationship of depression with gender and age has been confirmed by other investigators [22] . It is likely that voice disorders in voice professionals could cause both social and professional relationship impairments result-ing in more severe psychological distress.

Limitations of our study could be attributed to its cross-sectional design. Such a study design cannot give informa-tion about possible causal relationships between psycho-logical distress symptoms such as anxiety or depression and voice disorders that were investigated in this study; instead, they might reflect the current state of the psycho-logical distress. Further longitudinal studies with large cohort sizes and wide ranges of voice disorders are needed to evaluate the causative role of the psychological factor.

Disclosure Statement

The authors have no financial support or funding disclosure to declare.

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Psychological Distress in Patients With Voice Disorders