Personality and Individual Dierences 39 (2005) 14411449

www.elsevier.com/locate/paid

Personality, anxiety and functional dysphonia

Ulrike Willinger
a

a,*

, Harald N. Aschauer

University Ear, Nose and Throat Clinic, Medical University of Vienna, Waehringer Guertel 18-20,
A-1090 Vienna, Austria
b
Department of General Psychiatry, University Hospital for Psychiatry, Vienna, Austria
Received 30 November 2004; accepted 14 June 2005
Available online 8 August 2005

Abstract
Psychological factors are considered for the predisposition and perpetuation of functional dysphonia. In
the present study 61 patients with functional dysphonia were compared with 61 healthy controls, matched
by age, sex, and occupation with respect to Cloningers personality model, mood, and anxiety.
The patients with functional dysphonia presented signicantly higher scores than the healthy controls
with respect to harm avoidance (HA); depressive symptoms; symptoms of unspecic and general anxiety;
symptoms of specic anxiety concerning health, illness, and extraversion versus introversion. No
signicant dierences were found in novelty seeking (NS), reward dependence (RD), persistence
(PE), or in state-anxiety and anxiety of social situations. These results were found considering univariate
and multivariate analyses and conrm the relationship of psychological factors such as personality traits,
mood, and anxiety on one hand and conversion disorder in general and functional dysphonia in particular
on the other hand. This important relationship should be considered in the diagnostic and therapeutic
interventions of functional dysphonia.
2005 Elsevier Ltd. All rights reserved.
Keywords: Functional dysphonia; Conversion disorder; Symptoms of depression; Symptoms of anxiety; Personality

Corresponding author. Tel.: +43 1 40400 3335; fax: +43 1 40400 3332.
E-mail address: ulrike.willinger@univie.ac.at (U. Willinger).

0191-8869/$ - see front matter 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.paid.2005.06.011

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U. Willinger, H.N. Aschauer / Personality and Individual Dierences 39 (2005) 14411449

1. Introduction
Functional dysphonia is described by complaints of vocal weakness and discomfort in the
throat (Aronson, 1990) and complaints of voice change such as hoarseness, huskiness, and jerkiness in the absence of a structural or neurological abnormality of the larynx (Scott, Deary, Mackenzie, & Wilson, 1997; Wilson, Deary, Scott, & MacKenzie, 1995).
In the diagnostic and statistical manual of mental disorders (DSM-IV) of the American Psychiatric Association (1994) functional dysphonia is diagnosed as somatoform disorders, conversion disorder with motor symptom or decit (300.11).
Psychological factors are considered for the predisposition and perpetuation of functional dysphonia: House and Andrews (1987) pointed out that a third of 71 patients with functional dysphonia received diagnoses of mood, anxiety, or adjustment disorders. In a previous analysis of the
present data base we found that patients with functional dysphonia showed signicantly higher
scores than the healthy controls with respect to depressive symptoms, symptoms of unspecic
and general anxiety, and symptoms of specic anxiety concerning health and somatic complains
(Willinger, Volkl-Kernstock, & Aschauer, 2005). According to Andersson and Schalen (1998) it is
generally accepted that functional dysphonia is a result of psychosocial stress. They stated that
functional dysphonia may be interpreted as a somatic reaction to emotional problems, although
the pathogenetic mechanisms are still far from being well understood. Many of the patients in
their study seem to have poor abilities to cope with social stress; they expressed such features
as helplessness and an inability to manage their life situation, assert themselves, and hold their
own. The patients also had a poor social network and low professional status, and they complained of an inability to express themselves verbally. The authors proposed that functional dysphonia should be considered as a disorder of a particular aspect of communicationa disturbed
capacity for emotional verbal expression.
Mans (1993) considered the voice symptom as a creative achievement of the patient to cope
with an internal conict by using the ego function of speaking in the social context. So, functional
dysphonics display a remarkable sensitivity and variability towards psychosocial factors and an
often immediate connection with the underlying psychic conict constellation (Mans, 1994).
House and Andrews (1987) stated that a signicantly high proportion of patients with functional
dysphonia had experienced a diculty or event that involved conict over speaking out. Therefore, in the present study we were interested in the expression of symptoms of specic anxiety concerning illness and social situations.
According to Nichol, Morrison, and Rammage (1993) personality factors may predispose the
patient to dysphonia. Gerritsma (1991) reported that 41% of 82 aphonic and dysphonic patients
had signicantly high scores on a neuroticism scale. Kinzel, Biebl, and Rauchegger (1988) found
alexithymic traits (inability to dierentiate emotions suciently or to express them adequately in
words, lack of fantasies, impoverished imagination, inability to cope with aggressions in an adequate way) in patients with functional dysphonia. House and Andrews (1987) however, suggest
that functional dysphonia is usually not found in markedly abnormal personalities.
The results as to the inuence of personality traits on functional dysphonia seemed to be contradictory. However, in the present study we were interested in the impact of the Unied Biosocial Personality Model (Cloninger, 1987a; Cloninger, Svrakic, & Przybeck, 1993) on functional
dysphonia as a conversion disorder (a subtype of somatoform disorder), because this kind of

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1443

personality model was investigated in patients with somatization disorder (another subtype of
somatoform disorder) and higher scores of one dimension of the model (novelty seeking) were
found in those patients (Battaglia, Bertella, Bajo, Politi, & Bellodi, 1998). Battaglia et al. (1998)
stated that although somatization disorder is considered to be a prototype of a somatoform disorder, dierences requiring further research may well exist between patients with somatization disorder and individuals with other clinical presentations of somatoform disorder.
The Unied Biosocial Personality Model is a neurobiologically based operant learning model
to guide the rational development of descriptors for temperament that was developed by Cloninger (Cloninger, 1987a; Cloninger et al., 1993). He hypothesized the four independent multifaceted,
higher-order temperament dimensions novelty seeking (NS), harm avoidance (HA), reward
dependence (RD), and persistence (PE). These four dimensions of personality seemed to be
inuenced by basic emotional dispositions, several studies showed dierent associations between
mood disorders and anxiety on the one hand and NS, HA and RD on the other in psychiatric outpatients in general (Brown, Svrakic, Przybeck, & Cloninger, 1992), and especially in patients with
social phobia (Kim & Hoover, 1996) and alcohol dependence (Meszaros et al., 1996) but also in
non-psychiatric subjects (Krebs, Weyers, & Janke, 1998; Stewart, Ebmeier, & Deary, 2005). Personality dimensions such as NS and RD seemed to covariate only minimally with current mood
and seemed to be independent of mood state and feelings, HA and the subscales of HA seemed to
be inuenced by depression and anxiety (Brown et al., 1992), signicantly higher scores in HA and
signicantly lower scores in PE were found in patients with social phobia compared to healthy
controls (Kim & Hoover, 1996). Therefore, the third aim of the present study was to analyze multivariate dierences between the patients with functional dysphonia and the healthy controls with
respect to personality, mood and anxiety.
In detail, the following three research questions were considered:
(1) Are there signicant univariate dierences between patients with functional dysphonia and
healthy controls with respect to specic anxiety concerning illness and social situations?
(2) Are there signicant univariate dierences between patients with functional dysphonia and
healthy controls with respect to the four dimensions of Cloningers personality model?
(3) Are there signicant multivariate dierences between patients with functional dysphonia and
healthy controls with respect to the four dimensions of Cloningers personality model, mood
and anxiety?

2. Methods
2.1. Subjects
Sixty-one patients with complaints of vocal weakness and discomfort in the throat were consecutively recruited and examined at the Department of Phoniatrics and Logopedics of the University Ear, Nose and Throat Clinic of Vienna. All patients received laryngoscopic and phonic
examinations for exclusion of organic impairment and fullled the DSM-IV (American Psychiatric Association, 1994) criteria of conversion disorder, mainly characterized by one or more symptoms or decits aecting voluntary motor or sensory function without neurological or general

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U. Willinger, H.N. Aschauer / Personality and Individual Dierences 39 (2005) 14411449

medical condition, which are causing clinically signicant distress or impairment in social, occupational, or other important areas of functioning or warrants of medical evaluation and are not
intentionally produced or feigned. Sixty-one controls without voice pathology and without former
ENT, phoniatric, speech or psychiatric treatment were recruited mainly at schools and kindergartens and through a circle of acquaintances of students and were matched for age, sex, and occupation. Both samples consisted of 48 (79%) female and 13 (21%) male patients. Consistent with
the literature (American Psychiatric Association, 1994), sex distribution showed a signicant
majority of female patients (v2 = 20.082; df = 1; p 6 0.0001). The mean age of the patients and
the controls when they entered the study was 36 years (SD = 13 years). About half of the patient
sample and the control sample had a voice-demanding occupation28% were teachers, 7% kindergarten teachers and 12% salespeopleand reported dependence on the voice in their professional life. All of the patients and controls participated voluntarily and without nancial
reward after informed consent was obtained. Selection procedure for the samples of patients
and controls has been described in detail in a previous paper (Willinger et al., 2005).
2.2. Measures
Anamnestic data regarding sociodemographic particulars; information about former treatments, including ENT, phoniatric (e.g. surgery of larynx), speech, and psychiatric treatments; details of onset; and course of functional dysphonia (e.g. duration, remissions) were evaluated
according to a standardized interview.
The Unied Biosocial Personality Model, which is operationalized by the four temperamental dimensions novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and
persistence (PE), was measured by the German version (Aschauer et al., 1994) of the selfadministered Tridimensional Personality Questionnaire (TPQ) (Cloninger, 1987b). NS is dened by being quick-tempered, exploratory, excitable, curious, enthusiastic, exuberant, easily
bored, impulsive, and disorderly. HA is covered by being cautious, careful, tense, fearful, apprehensive, nervous, timid, doubtful, discouraged, passive, insecure, negativistic, or pessimistic even
in situations that do not worry other people. RD is dened by being tender-hearted, warm and
loving, dedicated, sensitive, dependent, and sociable. PE is represented by being industrious,
hard-working, persistent, and stable despite frustration and fatigue. The German version revealed
Cronbachs alpha coecients between 0.57 and 0.65, stability over time (3 months) between 0.62
and 0.79. External validity showed that 68% of patients with schizophrenia and healthy controls
were classied correctly by NS and HA (Aschauer et al., 1994).
Depressive symptoms were measured by the German version (Hautzinger, Bailer, Worall, &
Keller, 1995) of the self-rated Beck Depression Inventory (Beck & Steer, 1987).
Information about the symptoms of unspecic and generalized anxiety (e.g. I feel insecure,
I feel anxious, I feel nervous, I am jittery) was obtained by means of the German version
(Laux, Glanzmann, Schaner, & Spielberger, 1981) of the self-ratable State-Trait-Anxiety Inventory (Spielberger, Gorusch, & Lushene, 1970), which enables anxiety to be quantied both as a
time- and situation-related state (X1) and as a comparatively stable personality trait (X2).
Information about the symptoms of specic anxiety concerning health and social interactions
was assessed by the three dierent scales somatic complaints (FPI-8), health concern (FPI-9),
and extraversion versus introversion (FPI-11) of the self-ratable Freiburg Personality Inven-

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1445

tory (Fahrenberg, Hampel, & Selg, 1994). Somatic complaints ranges from having many somatic complaints and being psychosomatically disturbed to having few somatic complaints and
not being psychosomatically disturbed (e.g. I often have a headache, I sometimes have an
accelerated heart rate, I am often constipated, I often have chest pain or discomfort).
Health concern ranges from being afraid of illness, being conscious about health, and treating oneself with care not to be worried about health, being unconcerned about health, and feeling
robust (e.g. I am informed on the most widespread diseases and their rst signs; If I have a
disease, I would like to consult a second doctor; I consult a doctor regularly, also without serious complaints, only for caution; I avoid eating unwashed fruits).
Extraversion versus introversion ranges from being extraverted, sociable, impulsive, and
enterprising to being introverted, reserved, reective, and serious (e.g. I am able to entertain a
big society, In society or at public events I prefer to be in the background, I am very slow
in contracting a new friendship).
Information about anxiety concerning illness and social situations was obtained by means of
the self-ratable Interaction-Anxiety Questionnaire (Becker, 1997). It consists of six dierent
subscales that are summed up to two higher order factors. The rst factor, illness-anxiety, is
covered by fear of physical injury, fear of illness, and fear of medical treatment (e.g. How
un-/pleasant is it for you . . .: . . . if you are assuming that someone is following you in the darkness, . . . if you are receiving anonymous letters with threats of physical violence, . . . if you
have to go to the hospital for some time, . . . if you are standing in a group of persons and
you notice that one of them has an infectious illness).
The second factor, anxiety of social situations is covered by fear of social scenes, fear of
transgressing social standards, anxiety over self-competence, and fear of social devaluation and
inferiority (e.g. How un-/pleasant is it for you . . .: . . . if your boss is watching you while
you are working, . . . if you should speak in front of many people, . . . if you remember that
you once lied to your best friend, . . . if you should complain about bad treatment in an restaurant, . . . if you realize that other people are laughing about you).
2.3. Statistical analyses
Distribution of sex within the patient sample was analyzed for signicance by the chi-square
test. Univariate group dierences between patients and matched controls were tested for signicance by univariate t-tests for paired samples. Discriminant analysis was used for multivariate
group dierences between patients and controls regarding those variables of the four personality
traits, mood, and anxiety, which were signicantly dierent between patients and controls in the
univariate analyses of the present and a previous study (Willinger et al., 2005). The cut-o level for
statistical signicance was set at p < 0.05, 2-tailed. All statistical analyses were performed by SPSS
for Windows, Version 10.0.

3. Results
Patients with functional dysphonia scored signicantly lower in extraversion versus introversion (t-value = 12.28; df = 56; p 6 0.001) and signicantly higher in fear of illness

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U. Willinger, H.N. Aschauer / Personality and Individual Dierences 39 (2005) 14411449

Table 1
Means, standard deviations and signicance of personality traits, symptoms of anxiety and depression in patients with
functional dysphonia and healthy controls
Variables
a

Novelty seeking (TPQ)

Harm avoidance (TPQ)a
Reward dependence (TPQ)a
Persistence (TPQ)a
Extraversion vs introversion (FPI-R)b
Fear of illness (IAF)a
Fear of social situations (IAF)a
Depressive symptoms (BDI)a,c
State-anxiety (STAI-X1)a,c
Trait-anxiety (STAI-X2)a,c
Somatic complaints (FPI-R)a,c
Health concern (FPI-R)a,c

Patients (n = 61)

Controls (n = 61)

Mean

Mean

SD

Signicance

SD

15.3
15.6
14.0
4.5

5.2
6.2
3.5
2.1

16.7
11.7
13.7
4.2

5.1
5.0
3.6
1.8

n.s.
s.
n.s.
n.s.

7.8
83.6
121.6

2.4
13.1
18.9

11.9
78.3
116.5

0.7
10.6
19.6

s.
s.
n.s.

9.3
38.9
40.7
4.3
5.8

7.4
12.3
11.3
2.9
2.7

4.2
35.1
35.5
2.4
4.8

4.1
9.5
9.6
2.0
2.7

s.
n.s.
s.
s.
s.

s.: signicant (p < 0.05), n.s.: not signicant.

a
Higher values show higher tendencies in variables.
b
Higher values show more extraversion, lower values show more introversion.
c
See Willinger et al. (2005).

(t-value = 2.29; df = 58; p 6 0.026). No signicant dierence was found in fear of social situations (t-value = 1.58; df = 58; p = 0.119). Moreover, the patients showed signicantly higher
scores than healthy controls with respect to harm avoidance (t-value = 3.85; df = 58;
p 6 0.001). No signicant dierences were found in NS (t-value = 1.47; df = 58; p = 0.146),
RD (t-value = 0.4; df = 58; p = 0.69) and PE (t-value = 0.79; df = 58; p = 0.432). Numerical
details of these results and of those previous statistical analyses of the present data (Willinger
et al., 2005) which were used for the following discriminant analysis are given in Table 1.
Multivariate group comparisons between the patients and the controls showed signicant differences between the two groups (canonical correlation = 0.5; Wilks k = 0.8; v2 = 28.6; df = 7;
p 6 0.0001). Seventy-three percentage of the patients and controls were classied correctly by personality, mood, and anxiety. The correlations between the discriminant variables and the standardized canonical discriminant function showed high values with respect to the depressive
symptoms (r = 0.8), to specic anxiety concerning somatic complaints (r = 0.7), and HA
(r = 0.6), modest values with respect to specic anxiety concerning illness (r = 0.4) and health
(r = 0.4), and low values with respect to general anxiety (r = 0.2) and extraversion versus introversion (r = 0.008).

4. Discussion
Personality factors may predispose patients to dysphonia (Nichol et al., 1993). In the current
study we investigated patients with functional dysphonia and their control cohorts by means of
the Unied Biosocial Personality Model, operationalized by the TPQ. Signicant dierences

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1447

were found in one dimension of the TPQ, namely HA. Patients with functional dysphonia tend to
be cautious, careful, tense, fearful, apprehensive, nervous, timid, doubtful, discouraged, passive,
insecure, negativistic, and pessimistic even in situations that do not worry other people. In the
other three temperament dimensionsNS, RD, and PEthere were no signicant dierences. Patients and controls seem to have similar tendencies towards intense excitement to novel stimuli,
exploratory activity, reward, succor, and perseverance despite frustration and fatigue. In the literature there are contradictory results regarding personality in functional dysphonia. House and
Andrews (1987) identied only 2 patients with personality disorder (histrionic) among 71 patients
with functional dysphonia. Personality disorder may be too strong a criterion to look for; it may
be better to look for characteristic personality traits. White, Deary, and Wilson (1997) stated that
patients with functional dysphonia showed a greater degree of mild psychiatric disturbance but no
signicant dierences in personality traits compared to patients with dysphonia associated with
structural laryngeal abnormality and to ENT outpatient controls; patients with functional dysphonia did not show unusual levels of neuroticism, extraversion or hysteroid traits. Otherwise,
according to Scott et al. (1997) psychological and social factors seem to play an important role
in the initiation and perpetuation of functional dysphonia. Bauer (1991) found that functional
dysphonia often appeared as an unspecic reaction to emotional disturbances. Gerritsma
(1991) reported high scores in two scales, neuroticism and neurotic somatization, which measure
the neurotic instability that manifests itself in the expression of psychoneurotic and functional
physical complaints. According to Roy et al. (1997) the patients with functional dysphonia
showed emotional adjustment problems despite successful voice management. These patients considered themselves as people who to a signicantly greater degree than others deny good health
and report a variety of vague somatic symptoms; are pessimistic, dissatised, sad, suspicious,
interpersonally sensitive, diusedly anxious, and confused; adhere rigidly to ideas and attitudes;
and tend to engage in denial, withdraw socially, and be insecure and anxious when in contact with
others.
In the current study we found signicant dierences in anxiety concerning illness. The patients
with functional dysphonia showed signicantly higher scores than healthy controls with respect to
fear of physical injury, fear of illness, and fear of medical treatment. We did not nd any significant dierences in fear of social situations, which encompasses fear of social scenes, fear of transgressing social standards, fear of inadequate self-competence, and fear of social devaluation and
inferiority, but we did nd such a dierence regarding behavior in social situations: the patients
with functional dysphonia considered themselves to be introverted, reserved, reective, and
serious.
According to Nichol et al. (1993) the . . . voice of an individual is a very sensitive indicator of
attitudes, emotions, and role assumptions. It is a major component in social interactions. Therefore it is not surprising that impairments of voice function are not uncommon accompaniments of
psychological conicts.
According to Butcher (1995) functional dysphonia arises mostly in women who tend to assume
an above average number of responsibilities; who are frequently caught up in family and interpersonal relationship diculties; who nd it hard to express their emotions, especially negative feelings; and who have diculties in asserting themselves. Inecient assertiveness may contribute to
feelings of powerlessness and helplessness which might be associated with emotional disturbance
and conditions of anxiety and depression.

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U. Willinger, H.N. Aschauer / Personality and Individual Dierences 39 (2005) 14411449

Multivariate group comparisons between the patients and the controls showed signicant differences between the two groups. Seventy-three percentage of the patients and controls were classied correctly by personality, mood, and anxiety, especially by depressive symptoms, somatic
complaints, and HA. These results emphasized the relationship between personality, mood and
anxiety which were found in several studies about associations between mood disorders and anxiety on the one hand and NS, HA and RD on the other (Brown et al., 1992; Kim & Hoover, 1996;
Krebs et al., 1998; Meszaros et al., 1996; Stewart et al., 2005). However, the multivariate and univariate results indicate that personality, mood and anxiety should be considered not only in the
diagnostic of functional dysphonia but also in the therapeutic interventions.
Summing up: When compared to healthy controls, the patients with functional dysphonia
showed a signicantly higher tendency to respond intensely to aversive stimuli and to avoid punishment, novelty, and non-reward. Moreover, the patients presented signicantly higher scores
than the healthy controls with respect to specic anxiety concerning illness and social situations
by reporting higher fear of physical injury, fear of illness, and fear of medical treatment and by
considering themselves to be introverted, reserved, reective, and serious. These results were
found considering univariate and multivariate analyses and conrm the relationship of psychological factors such as personality traits and anxiety on one hand and conversion disorder in general
and functional dysphonia in particular on the other hand. This important relationship should be
considered in the diagnostic and therapeutic interventions of functional dysphonia.

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