Let’s talk about the throat and its ability to respond to childhood trauma!
This is the extra long-form version of the episode – a brand new thing I’m doing – that includes Results and study Limitations with extended commentary on both.
Maybe we do this forever, maybe not. But you want to talk research? Ohhhh, we’ll fucking talk research.
And we’ll do so, today, as we explore the paper I told you to hold out for:
Investigating Past Trauma in Laryngoresponders Versus Non- Laryngoresponders: Piloting New Methods in an Exploratory Study
*Diana Rose Becker, †Brett Welch, ‡Elisa Monti, §Harmony Sullivan, and †Leah B. Helou, *
Journal of Voice
2022
Let’s begin with the introduction.
We know by now, hopefully, if you’ve been here for more than a few minutes, that the body responds to stress in undiagnosable and debilitating ways. What we might not know is stress counts as anything that offsets balance mentally, physically, and emotionally – and the three are related. A single dose of stress can be significant, but regularly or chronically repeated stress RESPONSES establish a basis for lasting diseases, dysfunctions, and pathologies. We make a point to say stress RESPONSES, because the original stress doesn’t have to be present – the brain or body may continue to react as though it is. Common provokers are early childhood traumas, depression, and anxiety; common outcomes include digestive disorders like IBS.
Numerous bodily regions are affected by stress.1 A stressor, defined as anything that threatens “homeostasis” (Greek for “steady state”) or equilibrium,2 can initiate psychological, physiological, and emotional changes. This “mind-body link” undergirds many of the historical and current clinical and theoretical frameworks used to understand so-called functional disorders and medically unexplained symptom complexes.3,4 It is thought that when acute stress responses are repeated over time (sometimes regardless of whether the initiating stressor remains present) a stage is set for the pathogenesis and maintenance of chronic impairments. For instance, people are more susceptible to developing a functional gastrointestinal disorder such as irritable bowel syndrome if they also have experienced depression, anxiety, and early adverse life events.5
Overall, the link between childhood maltreatment and somatization later in life is well-established. 6-9 It remains unclear, though, why a functional disorder manifests in one bodily region versus another.
We know that stress, trauma, abuse, and mistreatment lead to somatic impairments – potentially with significant delay. What we don’t know is why some biological systems are affected instead of others, and why this is seen variably between individuals.
One area of trauma-inspired disfunction is thought to be the throat; specifically, the larynx, which takes care of speaking and swallowing. Muscle tension dysphonia (as we’ve heard before) is anecdotally connected to stress load and has the outcome of losing the ability to speak. It’s characterized by excessive, abnormal tension in the muscles around the larynx (voice box). It causes the vocal cords to overexert and work inefficiently, resulting in a strained, hoarse, or weak voice, vocal fatigue, and throat pain or tightness.
A specific bodily region of interest is the larynx, and by extension, its functions such as voice and swallowing, all of which are also vulnerable to effects of acute stress.10-14 One voice disorder commonly linked to stress is that of primary muscle tension dysphonia15, which comprises a substantial proportion of clinical caseloads in specialty voice centers.16,17
Though the link between imbalance and voice loss (or any other functional disorder) isn’t currently understood, there’s some common wisdom that somatic ailments are somehow symbolic or “awfully coincidental” presentations of prior experience. For instance, not being able to stand up for oneself could manifest in back issues, or, in this case, not being able to speak for self-protection during a stressful event could lead to later voice impairment. Psychosomatic illness could be metaphorical or directly representative of traumatic events.
A historical school of thought is that the functional voice disorder will manifest in a manner that has a symbolic significance or functional purpose, sometimes referred to as the “conflict over speaking out.”
Another theory is that the most at-risk part of the body will accept the dysfunction caused by the stress. If the voice or throat is already compromised, it could acquire the burden of the trauma.
18-20 An alternative theory is that of the “vulnerable pathways hypothesis,” where manifestation of discomfort or dysfunction occurs at a “site of least resistance” (ie, a bodily region that is already weakened or vulnerable in some way).20
And lastly, there is the possibility that particular personality plus situational factors simply causes some people to experience voice and throat responses while others do not.
A more well-developed theory implicating stress in the pathogenesis and maintenance of MTD is the Trait Theory of Voice Disorders, which holds that unique features of a person (eg, personality traits) in combination with certain situations (in particular, those that are deemed negatively stressful to the person) will trigger maladaptive laryngeal responses.21-23
In light of these unknowns and observations, researchers began referring to those affected as “larynoresponders” – individuals who, for unknown reasons, experience distress alongside changes in the throat, causing voice or sensational disorders. Some folks report pain or vocal alterations during or after upset; others do not. What is the difference between the two?
Aronson proposed the term laryngoresponder to refer to someone who is predisposed, whether by physical or psychological makeup, to express emotional distress through changes of the function or sensation of the larynx or voice (p 484) and eventually develop a voice disorder.13 For example, some individuals might report that they experience throat pain or vocal changes during periods of acute stress. By definition, these people might be considered self reported laryngoresponders.
The diverse nature of the stress experience is probably part of this discrepancy. Stress, itself, isn’t a determinedly negative thing, though it is marked by tension and it comes with change. Some stressful events are positive, like new jobs, marriage, having children. Others are traumatic – meaning they cause a degree of pain, suffering, and functional compromise. Major life events, social changes, disasters and accidents are some examples of long-lasting stressors that alter thought, emotional, and living patterns. Even after the events conclude, the imbalance they caused can live in the body, like long-term echoes. This is confusing to medical science due to the individual nature of physical disorders. In terms of laryngoresponders, the connection between past trauma and vocal defect seems clear for some, but it hasn’t been well investigated or documented.
It is important to note that while stress is often portrayed as a negative experience, stress and stressors are not uniformly negative, harmful, or traumatic. In contrast, traumatic experiences are always stressful, involve some level of harm to the person experiencing them, and typically compromise the individual’s functional capacity to some degree.28 Traumatic events such as family and social violence, disasters, and accidents can create a threat that may temporarily or permanently alter their capacity to cope, or alter the physiological stress response of the individual.32,33 These changes often present as abnormal, patterned psychophysiological reactivity not just in the face of trauma reminders or “triggers,” but even when the person is exposed to patently neutral stressors.34 Given this backdrop, it is feasible that the manner in which one’s body responds to stress in the present day might be reflective—at least to some degree—of their past traumatic experiences. Relatively little is known about the relationship between a person’s voice or vocal subsystems and their past experiences of trauma, though the relationship seems indisputable for some individuals, at least.29-31
For these authors, this throaty response is the focus. By identifying those affected in the population, they say, somatic disorders could be more efficiently studied. Rather than sending those afflicted to voice pathologists, they might visit psychotherapists. And rather than studying myriad somatic ailments in general populations hoping for clear connections between dissimilar biological systems, throat responders might be separated from, say, those who are gut or headache impaired by stress.
For our line of research interested in the pathogenesis and maintenance of functional voice disorders, the proactive identification of participants with elevated laryngeal and/or voice-specific symptoms are of particular interest. The ability to identify laryngoresponders would facilitate well-designed and more appropriately-populated research studies, with the rationale being that it might be ineffective and inefficient to spend resources studying voice-stress psychophysiology in a cohort comprised of mostly “gut responders” and “headache responders.”
This framing motivates the exploratory methods in the present study, as we sought to probe linkages between selfreported childhood experiences of trauma and the nature of physical stress response patterns that rise to individuals’ awareness in the present day. This exploratory study1 sought to (1) pilot methods for identifying self-reported laryngoresponders, (2) generate preliminary data regarding self-identified laryngoresponders and the extent to which they might differ from nonlaryngoresponders in experiences of past trauma, and (3) obtain information regarding the communicative context of their trauma experiences.
These points are the motivations behind this study, where childhood trauma and neglect were compared against biological stress responses of the present. The purpose was to improve identification of throat responders, understand differences in the traumatic histories between laryngoresponders vs nonlaryngoresponders, and better understand how communication of prior trauma may be implicated in vocal dysfunction. In other words, if disclosure and support weren’t available, could this contribute to later vocal box impairment?
And how did they begin to address these questions?
METHODS
Here’s the thing. The authors didn’t have tools to do this investigation. So, they made some.
Instrument design
In the absence of any validated or standardized tools which could assist with identifying laryngoresponders or providing insight into the communicative context of the participants’ past trauma experiences, we developed two original instruments with these aims: (1) a tool used to identify laryngoresponders, and (2) a set of questions that would provide insight about the communicative context in which individuals’ most notable past trauma occurred.
These two forms are described below.
First, the Physical Report Form (PRF). This was a “show me where trauma has touched you” tool using a genderless mannequin split into six planes where participants marked the areas most affected by pain. They were given paper copies of the diagram and used colored pencils for expression of these responses.
Physical Report Form (PRF). The PRF was designed to enable participants to identify the body systems in which they tend to have “a pattern or history of vulnerability” in the face of “stress or other heightened emotion,”2 and the manner in which those responses occur. The PRF is closely modeled on figurines commonly used by physicians and researchers to elicit patient report of the location and severity of bodily pain.36 A front- and a back-view of a genderneutral mannequin was visually divided into six horizontal planes. Simple anatomic reference words (eg, neck, shoulders; upper back; face, head) were printed in each subdivision of the body. Although the primary area of interest was the laryngeal area and its behavioral functions, the PRF did not emphasize any bodily region over any others, to avoid biasing participant responses. Participants were given a hard copy form; they completed it using colored pencils to allow for unbiased expression and the possibility of user-guided differentiation of responses throughout the body.
Secondly, the Ideal Internal and External Communication Question tool was developed to qualify the “ideal” communication circumstances post-trauma. In other words, did the individual receive compassion and support? Were they able to disclose safely? Previous tools we’ve heard about (the Childhood Trauma Questionnaire, for instance) do not include questions about this post-traumatic experience, which the authors note, may explain differences in long-term stress responses. Since they are examining the effects of trauma on the throat, unwelcome, stressful, or punitive communication about childhood trauma is of utmost concern. Thus, they developed this unique questionnaire (the Ideal Internal and External Communication Questionnaire) known as the IECQ for short.
Ideal” Internal and External Communication Questions (IECQ). The IECQ was designed to operationalize and outline the qualities of an “ideal” communication scenario surrounding a traumatic experience.2 A notable feature of most validated and commonly used trauma questionnaires (e.g., Childhood Trauma Questionnaire,37 Trauma History Questionnaire,38 Traumatic Life Events Questionnaire)39 is that they do not tend to query respondents about the communicative context in which their trauma occurred. That is, most trauma instruments do not probe whether, how, when, with whom, or to what extent the individual was able to communicate about their experience of trauma. Yet the communicative context in which trauma occurred seems relevant to understanding trauma in general, as well as for the effort of parsing who might develop one functional disorder versus another. Perhaps the experience of a stressful and potentially traumatic event is less predictive of certain outcomes than the communicative context in which it occurred. For example, being prevented from speaking out, receiving punishment for speaking out, or being pre-verbal during the traumatic experiences may influence one’s experience of trauma. Conversely, having a trusted person to confide in about the abuse could also impact one’s ability to navigate the trauma. Most existing trauma scales solicit little if any information about the communicative milieu in which past trauma occurred. To fully understand these complex topics, we see value in collecting information about the communicative circumstances with regard to one’s traumatic experiences.
The IECQ specifically examines how individuals communicated with themselves post-trauma. If they addressed their experience compassionately and emotionally to themselves. And it also explores communicating outwardly about the events – how were their words received? These questions were answered via a simple scale, where participants marked how ideal each experience was along a 100mm line. For later data analysis, this scale was broken into categories of low, medium, and high idealness.
The IECQ presented two different types of ideal communication scenarios to participants, summarized as follows. Internal Communication describes communication with oneself and their own acknowledgement of their feelings or emotions, whereas External Communication refers to their communication with others about their traumatic experiences. Each scenario was presented to participants with verbal explanations and confirmation of their understanding. Participants then used a 100 mm visual analog scale to respond to each of the two questions, for each of the two types of communication. To render the “ideal” internal and external communication data as categorical variables, the continuous data (originally from 0-100 for each variable) were binned into “low,” “medium,” and “high” categories.
Participants
Participants were cisgender women from 19 to 65 years old who responded to flyers in the Pittsburgh area. This demographic reflects the population most likely to have voice disorders, per vocal pathology clinics. A number of health conditions ruled out some participants for the study – anything easily diagnosable like asthma, respiratory disorder, pregnancy that could affect the throat was reason for exclusion from the study to maintain the focus on unclear somatic disorders.
recruitment was conducted via public-facing flyers posted throughout the Pittsburgh metropolitan region. Healthy self-identified cisgender women between the ages of 19 to 65 years were eligible. People assigned female at birth were recruited to investigate the demographic that is reportedly most likely to comprise traditional voice-disordered caseload in voice-specialized clinics.40 Exclusionary criteria by self-report were as follows: assigned male at birth; difficulty hearing or understanding conversational speech without aids; difficulty reading written words aloud; difficulty using the computer sufficiently enough to complete tasks; pregnancy; current lower or upper respiratory illness or seasonal allergies with respiratory manifestation; current Voice Handicap Index-10 (VHI-10) score greater than 11;41 history of: voice disorders; difficulty breathing or known respiratory disorders; autonomic dysfunction or dysautonomia; asthma. Participants received $10 per experimental hour upon completion of the study.
Setting and procedures
This research was conducted in a University laboratory space where they completed questionnaires and were given the option to opt-out of the study when the trauma-related probes began.
In addition to the tools already discussed, they answered the Childhood Trauma Questionnaire Short Form, which was further used to create a score of Adverse Childhood Experiences. They also responded to the Trauma History Questionnaire and Dissociative Experiences Scale.
This experiment took place in a dedicated laboratory space within the University of Pittsburgh’s School of Health and Rehabilitation Sciences. It was part of a larger experimental paradigm that included multiple brief collections of speech samples and completion of other questionnaires not discussed here. Participants were also fitted with various physiological equipment items (eg, electrodes, headset microphone, respiratory band) in each of the six bodily regions of the PRF except for the pelvic region.
In Phase I of the study, all participants completed the PRF and two questionnaires not discussed here (the Multidimensional Personality Questionnaire − Brief Form,42 and the State and Trait Anxiety Index).43
Researchers designed the recruitment and initial consent process of this study to minimize self-selection bias, foregoing consent to the trauma related portions of the study until after completing the first phase of the study. At that point, researchers presented each participant with the option of (1) continuing their participation by progressing to Phase II of the study, which involved the completion of additional questionnaires specifically aimed at measuring the presence and severity of trauma in their childhood experiences, or (2) ending their participation in the study. Participants were clearly encouraged to make the choice that was best for them, with all efforts made to avoid any sense of coercion to participate. All participants agreed to continue their participation into Phase II.
In Phase II, participants completed the following three self-reported measures of trauma via web-based administration (Qualtrics, Seattle, WA). The Childhood Trauma Questionnaire − Short Form (CTQ-SF)37 is a 28-item selfreported questionnaire which measures any experiences of abuse and neglect prior to the age of 18. Childhood trauma is the psychological result of an external setback or series of setbacks that render the child temporarily helpless and breaks ordinary coping mechanisms.44 This includes the presence of verbal assaults on a child’s sense of worth, bodily assaults, sexual contact, and failure to provide basic psychological/emotional needs.45 In addition to providing a “total” score of the amount of trauma exposure, the CTQSF provides subscales regarding emotional abuse and neglect, physical abuse and neglect, and sexual abuse, and a minimization-denial subscale which assesses the individual’s propensity for denying their traumatic experiences. Whereas physical neglect is defined as the caretaker’s inability to provide for a child’s basic physical needs (eg, food, healthcare), emotional neglect refers to their inability to provide for basic psychological and emotional needs.45 Additionally, by computing and summing validated cutoffs of abuse and neglect categories in the CTQ, a total score was obtained of how many categories of abuse and neglect one endured; this practice is similar to the common practice of creating a summative score of one’s Adverse Childhood Experiences (ACEs).46 For simplicity, this will be referred to as the CTQACE score.
The Trauma History Questionnaire (THQ)38 is a reliable measure of the amount and types of trauma an individual has experienced throughout their life. The Dissociative Experiences Scale (DES)47 measures various types of dissociation, a psychiatric construct related to how one separates from normal mental processes. The DES captures dissociative experiences such as daydreaming, as well as abnormal and potentially problematic experiences such as depersonalization (when one’s thoughts or feelings seem detached from reality or from their own identity or experience). Higher scores on the DES indicate a higher degree of dissociation. Finally, participants responded to the IECQ, described above.
This is where we talk about results for the super nerds. And they’re fascinating – really go beyond the intention of the study and give you some extra things to think about, if you’re into that sort of thing.
For instance, let me share, as a self-validated asshole, this line, with everyone:
The following regions had more participant responses than the vulnerable system of interest (ie, the larynx): abdomen and digestive system (83%), back neck (72%), shoulder (69%), chest and respiratory (69%), and the head (59%).
4/5 participants reported what? Abdominal responses to trauma. Trauma affects and weakens the guts. Contributing, perhaps, to vocalization and walking gait issues that we’ve been speaking about.
Nerds, stay tuned and here we go, bravely, into the findings details!
(for the full results, check that SUPANERD version of the lesson!)
DISCUSSION
From this and other studies, as we’ve briefly covered here, the throat with its vocal capabilities might be vulnerable to stress load and/or associated trauma for some. These authors intended to find out why some traumas might have this effect, and why some individuals might have this particular biological response.
the larynx—and relatedly, its acoustic vocal product and other functions such as swallowing and breathing— might constitute a “vulnerable body system” in some individuals. Thus, this pilot study focused primarily on the concept of the vulnerable body pathway by (1) developing a means of identifying LR, and (2) exploring what might distinguish LR from NLR.
The most reported stress responses in the present sample included stomach aches, heart palpitations, and headaches, all of which are generally appreciated as “classic” stress responses. Descriptive data collected via the custom-made PRF identified that 21% of participants without current voice complaints acknowledge their larynx as a body region that predictably and/or habitually responds during times of stress.
While it’s more common for other areas to be afflicted by stress and phantom stress responses, including the abdomen, chest, neck, back, shoulders, heart, lungs, and head – reactions that we commonly accept as signals of anxiety or strain – about one in five participants of this study identified that the larynx, not the back of the neck, could be afflicted by stress in a consistent manner (not a one-off or uncommon experience that might only be coincidentally correlated with a stress event).
Those LRs self-reported nearly three-quarters more experienced and severe trauma than NLRs, and they experienced both more ACEs and more traumatic events in every category. This validates the idea that long-past personal history might cause disorder of the throat and voice.
In tentative descriptive terms, LR differed from NLR on 75% of all trauma measures used in this study, scoring worse in both trauma exposure and severity. These data lend provisionary support to the notion that a relationship exists between personal history and the larynx (and by proxy, the voice), and that the laryngeal region might be uniquely vulnerable during stress for some individuals.
Most significantly, though, emotional neglect was most commonly indicated by LRs (83% compared to 43% of NLRs). We can never make definitive statements from one single study, and it is possible that emotional neglect could cause personal characteristics such as shyness that explain the vocal difficulties. And yet, it is also possible that with future research the connection between trauma, inability to successfully discuss the trauma, and later physiological disorder of the vocal region could be confirmed.
Specifically, self-report of emotional neglect as measured by the CTQ-SF was the most unifying trauma variable for LR in this pilot study. Of course, no causal relationships can be inferred from this work, and any relationships that do exist might very well be mediated by temperamental or personality characteristics (eg, assertiveness, shyness). Thus, our strongest conclusion is that these research questions seem to warrant more rigorous pursuit in subsequent studies. However, if this finding is recapitulated in future studies containing larger samples of LR, it might corroborate a psychoclinical perspective that if a person feels they are unimportant, or their needs remain unmet or ignored, their ability to effectively express their feelings and their needs might be compromised.54
Broadly, these data suggest that childhood experiences of emotional neglect might negatively impact one’s ability to communicate with total ease and/or effectiveness. We also probed the relationship between emotional neglect and one’s “ideal” communication experience, again in a very exploratory manner. Participants who had experienced emotional neglect (45% of all participants) reported having less “ideal” internal and external communication surrounding traumatic events.
Based on the lackluster scores in ideal communication after a trauma, it appears that ENs fail to show up for themselves (51% ideal communication) and others fail to show up for them (a similar 45/100 for ideal communication). Whereas NENs experienced far more supportive communication (roughly 75% for both self- and other-communication experiences). The authors’ findings implicate childhood emotional neglect as a causative factor that could decrease easeful or effective communication down the road and further validate the results as being cohesive with clinical observations.
They say:
For example, it is not uncommon for a patient who presents with a functional voice disorder to disclose that they are sometimes known to limit their verbal communication at a general level, to hold in their verbal acknowledgement of emotional state, or to engage in ostensibly inhibitory behaviors such as breath-holding and laryngeal muscular hyperfunction.
While the present study did not address the cohort’s physiological responses to stress, the data are at least theoretically compatible with a behaviorally inhibitory framework.
Although this study didn’t include measures of physiological responses in real time, but rather relied on self-reports about previous experiences, the research suggests that post-traumatic behavioral patterns could be established during early childhood neglect and other ACEs which carry through into adulthood, including learning to somatically inhibit communication attempts.
And with that, let’s hit the:
CONCLUSION
Preliminary findings from this study suggest that the oftcited voice-trauma link warrants future investigations with further refined tools. In particular, experiences of emotional abuse and neglect in LR seem worthy of further exploration.
From this research it seems not only logical and anecdotal, but perhaps also statistically validated; trauma affects the ability to communicate. The isolative environment and difficulty explaining distressing emotional events that are common in the traumatic aftermath – or, even worse, dismissal and punishment for disclosure - could teach the body not to allow communication to take place.
One doesn’t have to try hard to imagine that emotional neglect corresponds with an environment of difficult or lacking communication. Something that could be further evidenced by the LRs reported dissatisfaction in how they communicated with themselves after a trauma; we learn how to talk to ourselves based on how others speak to us. This result suggests that in the childhood home, the individual has already been conditioned to avoid self-disclosure, self-comfort, and self-compassion at the time that adverse events take place. They cannot turn to themselves for support, and the same result is obtained if attempting to discuss the happenings with others. This further concretizes the learned behavior of not speaking ideally to themselves. In general, when it comes to care, if we don’t receive it outwardly, we fail to give it to ourselves inwardly, and both experiences support each other to create a sense of correctness. In this way we believe that it’s our lot in life or unique role to be silent, destitute, unexpressed and unheard. Even within ourselves.
This behavioral pattern may stretch all the way into the physical realm; physiologically disabling or diminishing vocal capacity at the point of the larynx.
One might suggest the antidote is to begin ideal self-communication, to break the cycle of silence psychologically and physiologically.
And with that…
Get out of here! I’ll talk to you next week!
Or continue on to the Limitations and future directions of the study in the supergeek version of the episode.
What we can say today is?
There appears to be a connection between childhood emotional neglect, learned self-suppression in private and interpersonal situations, and potentially physiological disordering that makes expression unlikely, painful, or impossible.
And these are findings ripe for self-reflection, self-compassion, and self-healing.
Speak to yourself the way you want to be spoken to by others, and see how the larynx responds to the opposite of stress. Comfort, care, and relief.
Thank you for being here.
Please don’t stop expressing yourself or stop yourself from expressing to yourself.
Do mind all the various systems that could be impacted by stress or artifactual stress responses from the past.
And I’ll talk to you, larynx permitting, real soon.