Relationships Among Personality, Daily Speaking Voice Use, and Phonotrauma in Adult Female Singers

Validating the efficacy and value proposition of mental fitness vocal biomarkers in a psychiatric population: prospective cohort study

Background

The utility of vocal biomarkers for mental health assessment has gained increasing attention. This study aims to further this line of research by introducing a novel vocal scoring system designed to provide mental fitness tracking insights to users in real-world settings.

Methods

A prospective cohort study with 104 outpatient psychiatric participants was conducted to validate the "Mental Fitness Vocal Biomarker" (MFVB) score. The MFVB score was derived from eight vocal features, selected based on literature review. Participants' mental health symptom severity was assessed using the M3 Checklist, which serves as a transdiagnostic tool for measuring depression, anxiety, post-traumatic stress disorder, and bipolar symptoms.

Results

The MFVB demonstrated an ability to stratify individuals by their risk of elevated mental health symptom severity. Continuous observation enhanced the MFVB's efficacy, with risk ratios improving from 1.53 (1.09-2.14, p=0.0138) for single 30-second voice samples to 2.00 (1.21-3.30, p=0.0068) for data aggregated over two weeks. A higher risk ratio of 8.50 (2.31-31.25, p=0.0013) was observed in participants who used the MFVB 5-6 times per week, underscoring the utility of frequent and continuous observation. Participant feedback confirmed the user-friendliness of the application and its perceived benefits.

Conclusions

The MFVB is a promising tool for objective mental health tracking in real-world conditions, with potential to be a cost-effective, scalable, and privacy-preserving adjunct to traditional psychiatric assessments. User feedback suggests that vocal biomarkers can offer personalized insights and support clinical therapy and other beneficial activities that are associated with improved mental health risks and outcomes.

Acoustic and Physiologic Correlates of Vocal Effort in Individuals With and Without Primary Muscle Tension Dysphonia

OBJECTIVES

The aims of this study were to determine relationships between vocal effort and (a) acoustic correlates of vocal output and (b) supraglottic compression in individuals with primary muscle tension dysphonia (pMTD) and without voice disorders (controls) in the context of a vocal load challenge.

METHOD

Twenty-six individuals with pMTD and 35 vocally healthy controls participated in a 30-min vocal load challenge. The pre- and postload relationships among self-ratings of vocal effort, various acoustic voice measures, and supraglottic compression (mediolateral and anteroposterior) were tested with multiple regression models and post hoc Pearson's correlations. Acoustic measures included cepstral peak prominence (CPP), low-to-high spectral ratio, difference in intensity between the first two harmonics, fundamental frequency, and sound pressure level (dB SPL).

RESULTS

Regression models for CPP and mediolateral compression were statistically significant. Vocal effort, diagnosis of pMTD, and vocal demand were each significant variables influencing CPP measures. CPP was lower in the pMTD group across stages. There was no statistical change in CPP following the vocal load challenge within either group, but both groups had an increase in vocal effort postload. Vocal effort and diagnosis influenced the mediolateral compression model. Mediolateral compression was higher in the pMTD group across stages and had a negative relationship with vocal effort, but it did not differ after vocal loading.

CONCLUSIONS

CPP and mediolateral supraglottic compression were influenced by vocal effort and diagnosis of pMTD. Increased vocal effort was associated with lower CPP, particularly after vocal load, and decreased mediolateral supraglottic compression in the pMTD group.

Relationships Among Stimulability Testing, Patient Factors, and Voice Therapy Compliance

OBJECTIVE

Voice stimulability testing to determine voice therapy efficacy and prognosis is commonly used during the voice evaluation, but little is known about how patient factors (eg, voice diagnosis, dysphonia severity) can influence stimulability outcomes. The predictability of voice therapy success with different stimulability facilitating techniques (eg, hums, pitch glides) is also unknown. The goals of this study were to identify relationships between patient factors, voice therapy compliance, and stimulability testing.

METHODS

A retrospective chart review was conducted on 50 patients who were seen for their initial voice therapy evaluation at the UT Southwestern Clinical Center for Voice Care. Chart review included documentation of the stimulability tasks that yielded/did not yield voice changes, level of stimulability, voice diagnosis, clinician-rated auditory-perceptual analysis of vocal quality, therapy attendance, and compliance with voice therapy recommendations. Statistical analysis was conducted to determine whether the types of facilitating techniques, voice diagnosis, and dysphonia severity could predict how stimulable patients were and whether any stimulability techniques could predict voice therapy attendance and compliance.

RESULTS

Patients diagnosed with functional voice disorders (eg, muscle tension dysphonia) were 11 times more likely to be stimulable for voice improvements than patients with neurological voice disorders (eg, vocal fold paralysis). Patients with lower dysphonia severity were more likely to be stimulable than patients with high dysphonia severity. Specific facilitating voice tasks did not predict the level of stimulability. Stimulability level was not predictive of therapy attendance or compliance with therapy recommendations.

CONCLUSIONS

Voice diagnosis and severity of dysphonia influenced stimulability levels. However, voice stimulability was not predictive of voice therapy attendance or compliance, and no specific facilitative task predicted the level of stimulability. Future investigations should focus on other means of measuring a patient's motivation for change and on the predictive power of stimulability testing on voice therapy outcomes.

Clinical Psychology and Voice Disorders: A Meta-Analytic Review of Studies Assessing Psychological Characteristics Across Individuals With and Without Voice Disorders

OBJECTIVES

Clinical voice disorders are heterogenous conditions capturing problems with voice production and control. Psychological conceptualizations of voice disorders posit that mood, anxiety, and personality characteristics contribute to the development and maintenance of voice symptoms. This review brings together research comparing these psychological characteristics across groups with and without voice disorders, with the aim of profiling group differences.

METHODS

A systematic search of PubMed, CINAHL, Ovid (PsycInfo, MEDLINE, Embase), and Web of Science databases was conducted, with studies required to assess psychological characteristics between samples with and without voice disorders. Relative study quality and risk of bias were formally evaluated, synthesizing results via meta-analysis (estimating standardized mean difference; SMD) and narrative synthesis.

RESULTS

Thirty-nine studies (N = 4740) were reviewed. Marked psychological differences were observed between case-control groups, including significantly higher self-reported features of depression (SMD = 0.50), state anxiety (SMD = 0.58), trait anxiety (SMD = 0.52), health anxiety (SMD = 0.57), and neuroticism (SMD = 0.47) in voice disorder groups. However, less consistent patterns of difference were observed between voice disorder types, including minimal quantitative differences between functional and organic diagnoses.

CONCLUSIONS

Findings underline and formulate the psychological features associated with experiencing a voice disorder, indicating individuals with voice disorders present with considerable psychological needs that may benefit from clinical psychology input.

Relationship among five-factor personality traits and psychological distress with acoustic analysis

Objectives

The relationship between personality traits and psychological distress with acoustic characteristics was investigated in the present study, regarding the existence of dysphonia, abnormal overall voice quality (AOVQ), and dysphonia type.

Methods

Fifty-five participants with dysphonia and 64 participants without dysphonia completed NEO Five-Factor Inventory and Depression, Anxiety, and Stress Scale-21. Jitter, shimmer, noise-to-harmonic ratio (NHR), cepstral peak prominence (CPP), and cepstral peak prominence-smoothed (CPPS) were calculated in sustained vowel /a/ by Praat. Three expert speech and language pathologists divided participants with dysphonia into mild, moderate, and severe, based on the AOVQ. Pearson and Spearman correlation tests were performed by IBM SPSS Statistics.

Results

The findings were indicative of large correlations between agreeableness with CPP, conscientiousness with shimmer, depression with jitter and shimmer, and anxiety with shimmer in patients with functional dysphonia (p < 0.05). The results showed small to medium significant correlations between agreeableness with jitter and NHR, conscientiousness with CPP in participants without dysphonia, and depression with jitter in the participants with dysphonia (p < 0.05). Lastly, no significant correlation was observed between personality traits and psychological distress with acoustic characteristics in mild, moderate, and severe AOVQ groups (p > 0.05).

Conclusion

In participants with functional dysphonia, personality traits and psychological distress can provide some information about acoustic characteristics and vice versa.

Level of Evidence

3.

Exploring Personality and Perceived Present Control as Factors in Postsurgical Voice Rest: A Case Comparison

OBJECTIVE

This case comparison explored the relation between personality, perceived present control, and postoperative voice rest (as estimated by self-report and objective voice use) following surgery for benign vocal fold lesions.

METHOD

Two participants were included. Both participants were diagnosed with benign vocal fold pathology, underwent phonosurgery, and were assigned to either complete voice rest (CVR) or relative voice rest (RVR) postoperatively. During voice rest (VR), a visual analog scale (VAS) and a dosimeter (the Vocalog2) were used daily to estimate self-perceived and objective voice use, respectively. The participants also completed questionnaires on voice-related demographics, the Voice Handicap Index (VHI), Ten-Item Personality Inventory (TIPI), and Perceived Present Control (PPC). After 7 days of CVR or RVR, participants completed a postoperative questionnaire and a final VAS for overall voice use.

RESULTS

A wide discrepancy was observed in one of two participant's subjective perception of voice use (using the VAS) versus objective dosimetry data wherein she reported significantly more voice use than was observed objectively. Differences in personality and PPC between the participants did not appear to affect their voice use following the VR protocols.

CONCLUSION

The amount of voice use in both VR protocols for these two participants suggests that personality and PPC did not affect their adherence to recommendations of VR. Patients may perceive their voice use differently across time, which might play a role in their adherence to voice rest recommendations: voice use measured as instances versus a unit of time (seconds).

Effects of Cognitive Stress on Voice Acoustics in Individuals With Hyperfunctional Voice Disorders

PURPOSE

Autonomic nervous system dysfunction has been implicated in the development and persistence of hyperfunctional voice disorders (HVDs). The purpose of this study was to determine the effects of cognitive stress, which is known to arouse the autonomic nervous system, on voice acoustics in female speakers with and without HVDs.

METHOD

Adult female speakers-66 with HVDs, 66 without-were recorded while speaking with and without a cognitive stressor. Root-mean-square (RMS) of amplitude, fundamental frequency (f _o), low-to-high spectral energy ratio (L/H ratio), cepstral peak prominence (CPP), and relative f _o (RFF) were measured for each speaker and cognitive stress condition. Mixed-model analyses of variance and post hoc t tests were conducted to determine if cognitive stress affected voice acoustics and whether voice changes were greater for those with HVDs.

RESULTS

All measures differed significantly under cognitive stress for speakers with and without HVDs. RMS and CPP increased whereas f _o, CPP, and RFF decreased under cognitive stress. Changes in these measures were not greater in those with HVDs.

CONCLUSION

Cognitive stress and presumed autonomic arousal affect voice similarly in female speakers with and without HVDs.

Clinical Utility of the Ratio of Sound Pressure Level to Subglottal Pressure in Patients Surgically Treated for Phonotraumatic Vocal Fold Lesions

PURPOSE

This study aimed to determine whether a simplified, and potentially more stable, acoustic-aerodynamic voice outcome ratio (ratio of sound pressure level [SPL] to subglottal pressure) is comparable to a traditional vocal efficiency measure (ratio of acoustic power to the product of average subglottal pressure and average phonatory airflow) in terms of the ability to detect change in vocal function following surgical removal of bilateral phonotraumatic lesions.

METHOD

Pre- and postoperative acoustic and aerodynamic measures were analyzed retrospectively from 75 female patients who underwent surgical removal of bilateral phonotraumatic lesions. A 2 × 2 repeated-measures analysis of variance was conducted for each of three acoustic-aerodynamic voice outcome ratios-traditional vocal efficiency, an SPL-based ratio with both airflow and subglottal pressure, and a simplified SPL-based ratio with subglottal pressure only-to investigate the main effects of treatment stage (pre- and postsurgery), loudness condition (comfortable and loud), and their interaction. Post hoc paired samples t tests were conducted for statistically significant interactions. The within-subject variability of the measures was assessed using the coefficient of variation.

RESULTS

Although exhibiting an expected main effect of loudness (higher values in the loud condition), the traditional vocal efficiency ratio did not exhibit a main effect of treatment. For both SPL-based ratios, there were significant main effects of treatment stage (higher values postoperatively) and loudness condition (lower values in the loud condition). Within-subject, postoperative changes in the two SPL-based ratios moderately correlated with one another. The simplified ratio of SPL to subglottal pressure (without airflow) exhibited the least within-subject variability relative to the other two acoustic-aerodynamic ratios.

CONCLUSIONS

These findings indicate that SPL-based acoustic-aerodynamic voice outcome ratios increase significantly following the surgical removal of phonotraumatic vocal fold lesions. The simplified ratio of SPL to subglottal pressure exhibits the least variability and can be easily obtained without requiring the measurement of airflow.

Self-regulation in children with vocal fold nodules: A multilevel analysis

INTRODUCTION

Vocal fold nodules (VNs) represent the most common cause of voice disorders in children. Phonotrauma related to chronic, repetitive, intense vocal activity is often cited as the proximate cause of VNs. However, diminished self-regulation (SR) may predispose some children toward extreme phonotraumatic voice use, thereby contributing secondarily to their development. This case-control study examined the association between features of SR and VNs in children.

METHOD

Parents of children with VNs (N = 40, Age Mean = 7.5, SD = 2.03 years) and vocally normal, medical controls (VNCs; N = 40, Age Mean = 7.6, SD = 1.54 years) completed the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2; Gioia, Isquith, Guy & Kenworthy, 2015), an inventory that evaluates components of SR in children.

RESULTS

Children with VNs, as compared with the vocally normal control group, were described as (i) impulsive (i.e., scoring significantly worse on the Behavior Regulation Index, BRI; P < 0.001, Cohen's d = 0.86), and (ii) emotionally dysregulated (i.e., scoring significantly worse on the Emotional Regulation Index, ERI; P < 0.001, Cohen's d = 0.81).

CONCLUSIONS

Diminished SR in some children with VNs may contribute to phonotraumatic vocal behaviors and potentially attenuate the effectiveness of voice therapy.