One significant part of the voice history is to determine the innate level of talkativeness of an individual. Further information is available in our publication in the Journal of Voice.
- Robert W. Bastian, MD
- Loyola School of Medicine, 2160 S.W. 1st Ave., Maywood, IL, 60153-3304 (708) 216-9183
- James P. Thomas, MD
- 909 NW 18th Avenue, Portland, OR 97209-2324 (503) 478-1845
- Presented at the 29th Annual Symposium: Care of the Professional Voice, Philadelphia, PA, June 30, 2000
- This paper was written during Dr. Thomas' fellowship with Dr. Bastian.
Patients presenting with benign mucosal disturbances such as nodules and polyps frequently describe themselves as innately talkative. Others, with conditions such as bowing or "voice fatigue syndrome" often describe themselves as taciturn.
To determine the degree of correlation between self-rating scales of talkativeness and loudness and various types of voice disorders.
Prospective cohort and case control studies using Likert Scale ratings and their ability to predict laryngeal disease.
One clinic of a university laryngology/voice practice in Chicago, Illinois.
974 total patients consisting of two subgroups. The cohort study includes 430 consecutive patients presenting to the senior author with voice complaints from December 1995 through December 1998. The case control study adds 544 consecutive patients referred to the same examiner from January 1988 through December 1998 for vocal fold examination prior to thyroid, parathyroid, and carotid surgery.
Main Outcome Measures
Patient responses on 7 point Likert self-rating scales of talkativeness and loudness were compared with laryngeal disease.
More than 70% of patients subsequently found to have mucosal lesions clearly associated with vibratory trauma will rate themselves as highly talkative. Conversely, those with bowing tend to describe themselves as relatively untalkative.
Use of a simple self-rating scale of vocal loudness and talkativeness during history taking can separate patients into categories of vocal overdoers and vocal underdoers. This process can reliably orient the examiner to the types of voice disorders likely to be diagnosed subsequently during vocal capability testing and laryngeal examination. The high degree of talkativeness and loudness seen in vocal overdoers correlates well with mucosal disorders such as nodules, polyps, capillary ectasia, epidermoid inclusion cysts and hemorrhage. The low degree of talkativeness and loudness seen in vocal underdoers correlates well with disorders such as bowing and voice fatigue syndrome.
larynx, vocal nodules, vocal polyps, vocal fold bowing, hoarseness, behavior, vocal trauma, vocal abuse, personality
One might speculate that an average amount of vocal use should lead to a healthy larynx. Overuse could cause problems associated with the surface epithelium (mucosal disease) and underuse could cause problems associated with loss of muscle bulk (deconditioning). This reasoning might be inferred by analogy to other situations. The epithelium on one's hands is typically supple and functions well in gripping things. Overuse causes first an injury to the epithelium (swelling, blisters) and later a reaction (callous formation). Certain injuries of the larynx follow a similar mechanism of overuse. People who use the voice extensively will be most likely to suffer from continuous vibratory stresses on the mucosa (causing swelling and injuries such as mucosal hemorrhage) and a later reaction (polyps, nodules)1. On the other hand, they should have a robust laryngeal musculature.
Underuse problems might be inferred from the muscle loss that takes place in an extremity when placed in a cast. Underuse leads to muscle atrophy. The laryngeal equivalent would be vocal fold bowing. Persons with a taciturn personality will likely have normal mucosa, but may suffer from decreased bulk of the intrinsic laryngeal musculature or with the paradoxical "voice fatigue syndrome." While this is speculation, observations by Bastian 2 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
Primary group, cohort study
This group consists of all patients presenting seeking treatment for laryngeal complaints from December 1995 through December 1998. 430 charts with laryngeal complaints were reviewed. Data extracted included the self rating score for talkativeness and for loudness, age, sex, chief complaint and diagnosis.
All patients were asked to rate themselves prior to laryngeal examination, via intake questionaire and confirmatory interview on two parameters: talkativeness and loudness. Each uses a seven point scale. To score talkativeness, 1 represents a quiet untalkative person, 4 represents an averagely talkative person and 7 represents an extremely talkative person. Next, 1 represents marked soft spokenness, 4 averagely loud spoken and 7 very loud spoken.
During face to face history taking, they are asked to confirm their response. Questions that help the clinician confirm an accurate response include: "Is this number you chose, your life-long innate degree of talkativeness? Remember, this is not the amount of talking required of you by work or lifestyle." "If I asked your friends and family, would they agree with the answer here? Since your family is with you, may I ask them if they agree with your answer?" "This number should represent your degree of talkativeness in a comfortable social setting." These additional promptings help the patient better understand the intent of the question and they are allowed to change their initial answer. Occasionally, though surprisingly infrequently, it will appear to the examiner that the patient is not quite in touch with their inner drive to speak. In this practice, the actual rating is not changed, though the actual amount of talkativeness perceived by the physician is still considered in making a diagnosis. Some patients circle two adjacent numbers and cannot peg themselves to one particular number. For example, if they choose both a 6 and a 7, saying they are somewhere in the middle of these numbers, the answer is coded as 6.5. For purposes of this study the Likert scale was treated as a continuous variable.
Pre neck surgery: case control study
Patients (with no voice complaint) undergoing a pre-neck surgery laryngeal evaluation from January 1988 through December 1998 were asked to self rate their talkativeness and loudness prior to laryngeal examination. This included all evaluations performed during the senior authors residence at Loyola Medical School from January 1988 through December 1998. Patients were being screened for laryngeal problems prior to thyroid, parathyroid or carotid surgeries. 544 charts were reviewed. Data extracted included the self rating score for talkativeness and for loudness, age, sex, chief complaint and diagnosis. The identical approach to obtaining data for the cohort study was utilized.
All patients in both groups were then subgrouped (catergorized) by type of laryngeal disease (see table1) as determined by using the three part examination described by Bastian4.
Data were analyzed with StatView 5.0 by SAS Institute Inc., 1992-1998. Unpaired t-tests were used to determine differences in age and gender between the two groups. ANOVA was utilized for evaluating group differences in the areas of talkativeness and loudness. Scheffe and Fishers PLSD were used to determine where significant differences occurred. A simple regressionwas utilized to determine the relationship between talkativeness and loudness. Stepwise regressions were used to determine the relationship between talkativeness, loudness and disease.
Mucosal disease and other laryngeal disease peaked in the 40 years old age group. Deconditioning and postmenopausal endocrine disorders peaked in the 70 year old age group. While patients with voice complaints have a high female:male ratio, thyroid disease has an even higher female:male ratio. The control group is thus not an entirely normal population but the 14% incidence of mucosal disease in women and 10% in men might represent a first approximation of the incidence in a larger population. If this ratio of 1.4:1 incidence is correct, then the incidence of 2.6:1 in a laryngeal clinic might suggest that women are more sensitive to the effects of a mucosal disorder. Additionally the people with mucosal disease in the control group typically did not have voice complaints. Mucosal disease is a benign disorder that only requires treatment for symptoms.
Talkativeness-loudness and laryngeal disorders
The results from this study demonstrate that level of patient talkativeness and vocal loudness can be placed on a continuum. A high degree of talkativeness and loudness correlate with laryngeal mucosal disorders such as nodules, polyps, capillary ectasias and hemorrhage. A person with a strong inner drive to talk tends to be socially gregarious. They often gravitate toward careers that capitalize on their innate sociality. Singing, acting and sales are examples of occupations that utilize the voice extensively and people with this strong inner drive to speak will often be most happy in careers of this type. Because this drive is innate, the tendency to talk will be just as evident during off work hours as well. They will be comfortable in the company of other talkers. When this innate "pull from within" is coupled with an extrinsic need to speak such as at the workplace "pull from without", these patients may be termed "vocal overdoers".
In this study, personality as defined by high levels of talkativeness and loudness is correlated with the type of laryngeal disorder the patient suffers from. Determining where a patient belongs on the vocal overdoer/underdoer continuum is valuable and highly orienting information for the clinician since it focuses the diagnostic process, including the physical examination of the larynx. Additionally it directs treatment at the etiology of the disorder. Since more than 80% of patients subsequently found to have mucosal disease will rate their talkativeness as a 6 or 7, this rating provides a strong clue to the clinician to look for mucosal disease symptoms on the remainder of the history. The laryngeal exam can be very focused on the mucosal surface if the lesion is not initially obvious.
An underdoer lacks the inner drive to speak. They are comfortable with long periods of silence. They will tend to gravitate toward careers that do not require social interaction. Computer programming, accounting, library work, laboratory research are examples of careers that may not require much speaking at all. These people may be quite happy in the quiet of their home after work. A patient defined as a vocal underdoer by the combination of lower than average talkativeness, lower than average loudness (a 4 or less on the scales) and little "pull from without" to talk will more likely have a deconditioning or muscle atrophy type disorder. Time of life may also affect the "pull from without" and an elderly person living alone may have long periods of vocal inactivity and have little need to speak. A patient with lower than average talkativeness and loudness combined with a strong "pull from without" will more likely suffer from voice fatigue syndrome. Also, while vocal bowing can be treated surgically, when the etiology of the disorder rests in part or whole on the patient status as an underdoer, behavioral management such as voice building is always given first chance.
Though the average rating by patients eventually found to have a deconditioning type of disorder is 4.1 and other laryngeal disorders and normal patients more often rate themselves near a 5, there is less discrimination between these groups than between overdoers with mucosal disease and other laryngeal disorders.
It is interesting to note that few people rate themselves a 1 or a 2 on these seven point scales. Perhaps these scales do not have a bell shaped distribution or perhaps people with little drive or need to talk would not recognize or seek treatment for a voice disorder if they had one. 8% of patients undergoing neck surgery had evidence of a deconditioning disorder. Of these 30% rated themselves a 3 or less. Perhaps patients with deconditioning disorders seek medical care less often than a talkative person with a mucosal disorder would.
After the diagnosis, these overdoer and underdoer characteristics can be useful information for the patient, the laryngologist and the speech therapist. Mucosal disease can, and often should be treated surgically, but if the patient with mucosal disease is, as usual a vocal overdoer, then behavioral management always comes first. Behavioral modification should be directed at lifestyle management for the vocal overdoer. This priority of treatment allows the patient the opportunity to heal the lesion and/or prepare them for surgery with a reduced chance of recurrence after the surgery. For example, a laryngologist may surgically remove a polyp for a patient that answers a "7" and a "7" on talkativeness and loudness scales. Since these 7's represent behaviors, they will need behavioral management or the patient's talkativeness is likely to cause a disease recurrence. This is equally true for the underdoers who rates themselves as a "3" and a "3". Vocal exercises to get their voice usage up on a daily basis may increase intrinsic laryngeal muscle bulk or tone and correct their bowing or presbyphonia problem to the patients satisfaction.
The lack of correlation of these personality traits, talkativeness and loudness with other types of laryngeal disease (Tumor, trauma, etc.) suggests that while talkativeness and loudness do play a role in the development of mucosal and deconditioning disorders, they play less of a role in other laryngeal diseases. The statistical similarity of talkativeness and loudness between the "other" laryngeal disease group and a normal population group (pre-neck surgery) also suggests that this part of personality (talkativeness and loudness) does not play a major role in the development of these other types of laryngeal disease.
Two simple questions regarding loudness and talkativeness can play a key role in orienting the examiner to the laryngeal disorders of mucosal disease and muscle deconditioning.
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