and others3,4 have suggested that personality is the strongest risk factor for these lesions and for diagnostic purposes patients can be constructively divided into "overdoers" and "underdoers" of the vocal world.
The vocal overdoer as defined above has an innate drive toward a high degree of talkativeness and loudness. When this innate drive to speak is coupled with an external pull or need to speak such as in an occupation like teaching or acting, vocal overuse becomes very likely.
Vocal underdoers innately have a low degree of talkativeness and loudness. When this is coupled with minimal extrinsic need to speak, such as an occupation like computer programming or when living alone, the person may suffer from muscle deconditioning disorders (bowing/presbyphonia). This deconditioning may become even more apparent when a vocal underdoer is placed in an environment requiring a large degree of voice use. They may develop the seemingly paradoxical "voice fatigue syndrome" consisting of laryngeal discomfort, lack of vocal projection and a voice that fades quickly with use while having evidence of vocal fold bowing on laryngeal exam.
To summarize, people who use the voice extensively will be the most likely to suffer damage from continuous vibratory stress on the mucosa. On the other hand, they should have robust laryngeal musculature. Persons with the converse, taciturn personality, will likely have normal mucosa, but may suffer from decreased bulk of the intrinsic laryngeal muscles or with sudden increased use from the "voice fatigue syndrome". The first group are the "overdoers" of the vocal world and the second group the "underdoers".
To elicit whether a patient is an overdoer or an underdoer, a 7 point Likert self rating scale has been used for 15 years to elicit from the patient their perception of their innate degree of talkativeness and loudness. A seven point scale was chosen because it allows a person to quickly place themselves at the extremes of the scale: 1 and 7 or it allows self designation as average (4). It also allows the choices of "near the extremes" (2 or 6), or nearly average, but headed in one direction or the other (3 or 5). This self rating by patients of their place on the overdoer/underdoer continuum is one of the most useful elements of a voice history 3,4,5. It is particularly useful when the diagnostician also uses symptom complexes (eg. those symptoms typically experienced by persons with benign mucosal disease on the one hand or bowing and atrophy on the other) to match diagnosis. 6
