gms | German Medical Science

Communicating is one of the most important existential acts of man. Vocal communication plays a major role in human interaction, with the voice as the instrument par excellence. Therefore, voice disorders may cause a significant communication handicap, especially in voice professionals. The voice is the result of individual possibilities in interaction with the environment with its specific demands and possibilities. Oral communication can be considered as the dynamic and adapted interaction between man and environment. This is the subject of voice ergonomics, that is gaining increasing importance in voice care.

The WHO states that health is a multidimensional concept incorporating physical, mental and social states of being. Health problems should be approached in a multidisciplinary way. Only multidisciplinary, however, is not sufficient. The various disciplines have to work together, resulting into an interdisciplinary approach. This can be organised in a voice team. Objective disease phenomena, that are the subject of biomedical practise, often are not a good measure of the subjective perception of the disease by the patient. Therefore, effects of voice dysfunction on quality of life cannot be assessed with objective voice measurements. Schutte states that dysphonia is only a disorder if it yields problems in social functioning.

In 1882 Nothnagel said in his inaugural lecture: “I repeat once again, medicine is about treating sick people and not diseases” [1]. This is attuned to the holistic notions of Hippocrates, with a gap of many centuries. H. Cairns (1896–1952) stated: “A good clinician always studies a patients personality as well as his/her disease.”

Because psychosocial factors can directly influence both physiologic function and health outcomes, a broader approach of the sick patient is necessary. Engel formulated a broader approach in the biopsychosocial model [2]. The biopsychosocial model pays attention to the most important personality features of the patient, their influence on the disease and “being patient”, and the social context of the patient, his relation tot his practitioners and the health system in general. The complaint is considered to be part of the whole system, in which the patient is situated. Also Schwartz opposes the single-cause biomedical approach to behavioural medicine, in which more dynamic, relatively continuous, multicategory, multicause approaches to viewing health and disease are involved [3]. Voice loading, physical, environmental and psycho emotional factors, as well as personality may have an impact on vocal health. In this perspective, the application of the biopsychosocial model seems to be appropriate in voice care.

In the above mentioned context, the author prefers to use the term “voice complaint” or “voice problem” instead of “voice disease” or “voice disorder” in clinical practise. In the term “complaint/problem” the appraisal of vocal dysfunction by the patient is taken into account. The course of complaints depends on predisposing factors, provoking factors and maintaining factors. Predisposing factors consist of existing pathophysiological conditions (inborn or acquired vulnerability), structural organic conditions, and psychological and psychophysiological conditions (e.g. chronic stress, personality, premorbid psychopathology and high (muscular) tension levels). These factors facilitate the occurrence of a complaint. Provoking factors like an acute stressful or adjustment-requiring event or an acute organic stimulus (infection, pain, injury, etc.) are the cause the complaint. Besides the predisposing and provoking factors, attention must be paid to maintaining factors. Why does the complaint persist, despite care? Permanent injury or pathophysiological processes, high levels of stress, inadequate coping, behavioural factors (adjustment of lifestyle, therapy dedication), emotional factors (a.o. reactive anxiety, depression or somatisation), cognitive factors (false illness-cognitions, catastrophying), social factors (juridical procedures, profit from illness), and persistent predisposing and provoking factors can impede cure. Furthermore, adverse life experiences (life events, chronic stressors), psychological dispositions (traits) (protective or increasing vulnerability to stress), social environment (social support or social isolation) can maintain the complaints.

The predisposing factors, provoking factors and maintaining factors doe not act alone, but are in continuous (circular) interaction. De Jong et al. described the interaction of these factors in the application of a psychological cascade in persistent voice problems in teachers [4]. A parallel was drawn to a psychological cascade model which was designed by Anderson in patients with chronic back pain. If treatment is successful, the subject runs through the cascade (once or more times) passing three subsequent phases: thread (1), pit (2) and renewal (3), what may lead to recovery. Maintaining factors and coping strategies were assessed in 76 teachers with persisting voice problems. Physical, functional, psychological and socioeconomic factors were addressed. The majority of the subjects were found to be deadlocked in phase 1 of the cascade model, for which the combination of externalization and unawareness of the situation showed to be the main risk factor. Subjective rating of the voice problem was assessed by the Voice Handicap Index (VHI) and a visual analogue scale (VAS). The subjects in phase 1 of the cascade model showed significantly higher VHI and VAS scores compared with the other subjects. For a high VHI score, the combination of socioeconomic factors and being in phase 1 was the most important risk factor. Socioeconomic factors were found to be the most important risk factors for a high VAS score. The authors introduced the term “chronicity”, which means that the problems are maintained, the subject finds himself in a deadlocked situation, and is sliding down into a chronic disease. “Chronicity” is essentially different from “chronic”, which refers only to the duration of the disease. Maintaining factors and (inadequate) coping factors, which consist of emotional/psychological, physical and socioeconomic aspects, were considered as indicators for chronicity.

Predisposing factors, provoking factors and maintaining factors have to be included in the care of voice problems as pointed out by Van Opstal [5], [6]. She presented a learning strategy for eustress-euvoicing, which prevails over distress-disvoicing. Citating Van Opstal: The strategy is based on the understanding of the mechanisms of stress-voicing, conceived as a dynamic circular process of interacting entities, i.e. stressors/signals-arousal/activation-emotion-coping-effects (SAECE), which is the rationale for a multidisciplinary approach in coaching professional voice users. A systematic, holistic and integrative process of self-control (SHIPS) is directed by functional analysis and consists of awareness and change. Emotion, a mixture of appraisal, affect and movement, is the pivot in SHIPS. SHIPS with the subject aims at the competence of voicing (V) in an optimal (O) way of coping (C). This means vocal communication is effective (E) to meet a balance in physical, interpersonal and existential wellness when responding to demands and challenges in the individual subject’s field of communication (VOCE). The process of awareness intends to understand the course of multiple interactions in SAECE that condition eustressors and distressors related to (non)-integrated coping. The process of change intends to influence the course of multiple interactions in SAECE. SHIPS (de)conditions distressors and eutressors related to (non)-integrated coping. The subject and coach are conscious and active participants in the process of awareness that is dynamic and evolving, and aims at the preparedness to change non-desirable habits and skill modes into VOCE. Furthermore, they are conscious and active participants in the process of change that aims at (un)learning of attitudes and skills for coping by VOCE.

The author pleads for a holistic biopsychosocial approach of diagnosis, therapy and prevention of voice problems (with a wink to Hippocrates).