CPCP: Vocal Cord Paralysis and Anxiety, by Medical Students

Hodad Naderi M4

Hodad Naderi M4

Jeffrey Coble M4

Jeffrey Coble M4

Here’s a very interesting Clinical Problems in Consultation Psychiatry (CPCP) presentation on the association between vocal cord paralysis and anxiety, about which consulting psychiatrists occasionally are called. The two senior medical students rotating on the service presented and did a very fine job. Jeffrey Coble is interested in doing a residency in anesthesia. Hodad Naderi is planning to pursue residency in general surgery. And they were really happy to be getting their psychiatric experience on the consult service.

The question I always ask myself is, when the consultee tells me that the anxiety is causing hypoxia, is there any hard evidence that panic attacks lead to oxygen desaturations in the 60%-70% level? I’m skeptical about it.

The medical students found the literature more than a bit thin on the question but a couple of points can be made.

  • There is definitely an association between vocal cord motion abnormalities and depression and anxiety but the jury is still out about cause and effect relationships.
  • There was not objective evidence that panic attacks cause hypoxia.

On the other hand, based on another hypotheses that a consultee had on an related problem, it may be possible for selective serotonin reuptake inhibitors (SSRIs) to worsen hypercapnia in some patients with severe pulmonary disease in which C02 retention is problematic. It turns out that the literature about this is dominated by animal studies and experimental procedures with medulla isolates.

And this led me to search the Psychosomatics Journal, to which I have access because I’m a member of the Academy of Psychosomatic Medicine. This was written by a colleague and a former resident and the title, “Improvement of paradoxical vocal cord dysfunction with integrated psychiatric care,” foreshadows the emphasis on integrated care. According to them, the prevalence of psychiatric comorbidity in Paroxysmal Vocal Cord Dysfunction (PVCD) could be as high as 75%. However, they are also careful to point out that “…patients with confirmed PVCD have not been able to voluntarily reproduce the symptoms…” of PVCD exacerbations, casting doubt on the tendency to think of it as a purely psychogenic disorder.

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Richerson, G. B. (2004). “Serotonergic neurons as carbon dioxide sensors that maintain pH homeostasis.” Nat Rev Neurosci 5(6): 449-461. Serotonergic neurons in the medulla have recently been shown to be sensors of carbon dioxide and pH. There is compelling evidence that the co-release of serotonin, substance P and thyrotropinreleasing hormone from these neurons stimulates the neural network that controls breathing at numerous sites using many different mechanisms. Serotonergic neurons in the midbrain are also chemosensitive, and might mediate non-respiratory responses to increased carbon dioxide, such as arousal. This role in control of pH homeostasis could provide a neurobiological explanation for the link between changes in the serotonin system and sudden infant death syndrome (SIDS).

Dietrich, M., et al. (2008). “The frequency of perceived stress, anxiety, and depression in patients with common pathologies affecting voice.” J Voice 22(4): 472-488.
The study’s objectives were to investigate (1) the frequency of perceived stress, anxiety, and depression for patients with common voice disorders, (2) the distribution of these variables by diagnosis, and (3) the distribution of the variables by gender. Retrospective data were derived from self-report questionnaires assessing recent stress (Perceived Stress Scale-10), anxiety, and depression (Hospital Anxiety and Depression Scale) in a cohort of new patients presenting to a voice clinic. Data are presented on 160 patients with muscle tension dysphonia (MTD), benign vocal fold lesions, paradoxical vocal fold movement disorder (PVFMD), or glottal insufficiency. Pooled data indicated that average stress, anxiety, and depression scores were similar to those found for the healthy population. However, 25.0%, 36.9%, and 31.2% of patients showed elevated stress, anxiety, and depression scores, respectively, compared to norms. Patients with PVFMD had the most frequent occurrence-and patients with glottal insufficiency had the least frequent occurrence of elevated stress, anxiety, and depression. Stress and depression were more common with MTD than with lesions, whereas reverse results were obtained for anxiety. More females than males had elevated stress, anxiety, and depression scores. The data are consistent with suggestions that stress, anxiety, and depression may be common among some patients with PVFMD, MTD, and vocal fold lesions and more common for women than men. However, individual variability in the data set was large. Further studies should evaluate the specific role of these conditions for selected categories of voice disorders in susceptible individuals.

Misono, S., et al. (2014). “Psychosocial distress in patients presenting with voice concerns.” J Voice 28(6): 753-761.
OBJECTIVES: To assess the prevalence of psychosocial distress (depression, anxiety, somatization, and perceived stress) in a consecutive sample of patients presenting with voice concerns and to qualitatively analyze patient comments on challenges associated with voice problems. STUDY DESIGN: Cross-sectional study. METHODS: New patients presenting to a multidisciplinary voice clinic with voice concerns were invited to participate. Respondents (n = 197) completed the Brief Symptom Inventory 18-item scale, the 4-item Perceived Stress Scale, and the Voice Handicap Index 10-item scale. Qualitative analysis was performed of responses to an open-ended question about challenges associated with a voice problem. RESULTS: Approximately one-third (32%) of the patients met the strict case criteria for depression, anxiety, and/or somatic concerns based on the Brief Symptom Inventory 18-item scale. Most patients had no prior diagnosis of depression or anxiety, and the degree of distress was not predicted by the type of voice-related diagnosis. Perceived stress was higher among female patients (P = 0.02). As expected, scores on the Voice Handicap Index 10-item scale were indicative of concurrent voice-related handicap (mean, 19.5; standard deviation, 9.4). In qualitative analysis of responses regarding challenges associated with a voice problem, 19 themes were identified (eg, threat to occupational functioning). CONCLUSIONS: These findings identify a high prevalence of multiple types of distress among patients with voice disorders, presenting an opportunity to provide more comprehensive care to this patient population.

Thurston, N. L. and J. G. Fiedorowicz (2009). “Improvement of paradoxical vocal cord dysfunction with integrated psychiatric care.” Psychosomatics 50(3): 282-284.
BACKGROUND: Paradoxical vocal cord dysfunction is associated with a high rate of psychiatric comorbidities, including mood, anxiety, somatoform, and personality disorders, and psychosocial distress. OBJECTIVE: The authors draw attention to this disorder because delayed diagnosis and misdiagnosis are common and can contribute to excessive morbidity. METHOD: The authors present a case of paradoxical vocal cord dysfunction. RESULTS: The condition improved dramatically with integrated psychopharmacologic and psychotherapeutic intervention. CONCLUSION: Integrated medication management and psychotherapy by a single psychiatrist-provider with relevant medical understanding can achieve a better alliance between patient and physician and, thus, improved outcomes.

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