Original Paper Folia Phoniatr Logop 2015;67:51–56 DOI: 10.1159/000431322
Published online: July 9, 2015
Studying the Psychological Profile of Patients with Laryngopharyngeal Reflux Tamer A. Mesallam a–c Rasha M. Shoeib a, d Mohamed Farahat a, b Fatma-Elzahraa A. Kaddah d Khalid H. Malki a, b a
Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, and Research Chair of Voice, Swallowing, and Communication Disorders, King Saud University, Riyadh, Saudi Arabia; c Otolaryngology Department, College of Medicine, Al-Menoufiya University, Shebin Al-Koum, and d Phoniatrics Unit, Department of Otolaryngology, College of Medicine, Ain Shams University, Cairo, Egypt b
Abstract Background/Aims: Psychological factors have been claimed to play a role in the predisposition for laryngopharyngeal reflux (LPR) symptoms. The aims of this work were to study the relationship between psychological disorders and LPR and to investigate the effect of potential psychological disorders on patients’ self-perception of reflux-related problems. Methods: Forty-two patients with symptoms suggestive of LPR were psychologically evaluated using the Social Readjustment Rating Scale, the Symptom Checklist-90 Revised, the Manifest Anxiety Scale of Taylor, the Minnesota Multiphasic Personality Inventory, and the Zung Self-Rating Depression Scale. Oropharyngeal 24-hour pH monitoring was used to diagnose LPR. LPR-related symptoms were assessed using the reflux symptom index (RSI) and the voice handicap index-10 (VHI-10). Patients were divided into groups based on psychiatric evaluation and pH results. Correlations between psychological profile characteristics and LPR-related parameters were also investigated. Results: No significant difference was found between the positive and negative LPR group for any of the assessed psychological
© 2015 S. Karger AG, Basel 1021–7762/15/0672–0051$39.50/0 E-Mail [email protected] www.karger.com/fpl
disorders. Also, no significant difference was detected between the positive and negative psychological disorder groups regarding RSI, VHI-10, and pH results. Correlations between psychological profile parameters and LPR-related measures were also nonsignificant. Conclusion: It appears that there is no association between psychological disorders and LPR. The psychological background of the LPR patients had no influence on patients’ self-perception of their refluxrelated problems. © 2015 S. Karger AG, Basel
Introduction
Laryngopharyngeal reflux (LPR) is defined as the retrograde flow of the gastric contents up to the aero-digestive tract, which could induce a variety of symptoms [1]. However, great controversy exists concerning the clinical presentations and diagnosis of LPR [2]. Many of the symptoms that are related to LPR are nonspecific, such as change of voice, chronic throat clearing, chronic cough, globus pharyngeus, and dysphagia. At the same time, most of the patients complaining of these symptoms do not show specific abnormalities on laryngeal examination [3]. Previous studies have failed to document an association between symptoms and laryngeal signs of LPR, makTamer A. Mesallam, MD, PhD ENT Department, Communication and Swallowing Disorders Unit (CSDU) King Abdulaziz University Hospital, PO Box 245 Riyadh 11411 (Saudi Arabia) E-Mail tmesallam @ ksu.edu.sa
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 9/3/2015 7:01:40 AM
Key Words Psychological disorders · Laryngopharyngeal reflux · Reflux symptom index
Patients and Methods Patients The study was approved by the Institutional Review Board of the College of Medicine, King Saud University, Riyadh, Saudi Arabia. Informed consent was obtained from all participants in the study. The study included 42 patients (26 females, 16 males) with a mean age of 42.78 ± 12.43 years (range 21–68) who were referred to the reflux or voice clinic with symptoms related to LPR. Adult patients with a history of LPR-related complaints were included in the study, whereas illiterate patients or patients with a history of reflux or psychiatric medications were excluded. Prior to their admission to the clinic, patients were instructed to complete the Arabic versions of the reflux symptom index (RSI) [12] and voice handicap index-10 (VHI-10) [13] questionnaires to document possible LPR-related symptoms. 24-Hour Oropharyngeal pH Monitoring The diagnosis of LPR in the study group was confirmed using a 24-hour oropharyngeal Dx-pH probe system (Restech Corp., San Diego, Calif., USA). The patients were instructed to maintain their normal daily activities as usual during the study and were given a diary to record mealtimes and time in recumbent position. Following the 24 h of recording, an analysis of the data was carried out using a software system provided with the device. Acidic reflux thresholds were set at pH 5.5 in the upright position and pH 5.0 in the supine position; data from mealtimes were excluded from the analysis. The system automatically generates the Ryan score, which is a composite score calculated from the pH thresholds recorded for upright and supine positions. The score incorporates three main parameters including number of reflux episodes, the duration of the longest reflux episode, and the percent-
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Folia Phoniatr Logop 2015;67:51–56 DOI: 10.1159/000431322
age of time below the predetermined pH threshold. Scores greater than 9.41 in the upright position and/or 6.80 in the supine position were considered suggestive of LPR [14, 15]. Psychological Assessment Psychological assessment was performed using (1) the Social Readjustment Rating Scale (SRRS) for estimation of the presence of stressful life events [16]; (2) the Symptom Checklist-90 Revised (SCL-90-R) to measure the 9 major psychiatric symptoms (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism) [17]; (3) the Manifest Anxiety Scale of Taylor [18] to measure the degree of an individual’s anxiety state; (4) the Minnesota Multiphasic Personality Inventory (MMPI) to assess the presence of hypochondriasis and hysteria [19], and (5) the Zung Self-Rating Depression Scale for assessment of the degree of depression [20]. In order to classify patients into positive and negative groups according to psychological disorders, the documented normal cutoff point for each test was used. Cutoff points for the tests are 21 for the MMPI, 16 for the Taylor test, 51 for the Zung test, and 300 for the SRRS. Because we did not apply a specific test to measure somatization, we used the somatization scale of the SCL-90-R questionnaire and categorized patients into the positive group according to the normal cutoff values provided by the Al-Behairy [21] SCL-90-R version. Statistical Analysis Patients were divided into positive and negative LPR groups according to the results of the pH monitoring. Comparisons were made between the positive and negative LPR groups regarding the results of the psychological evaluation. Similarly, patients were also divided into positive and negative groups based on the results of the psychological evaluation test battery. The results of the RSI and of the VHI-10 and Ryan scores were also compared among the positive and negative psychological disorder groups for each of the included psychological tests. Correlations were computed for each of the psychological parameters paired with each of the LPR-related measures, including pH monitoring parameters, RSI, and VHI-10. As a prerequisite for statistical analysis, an assessment was undertaken of the normality of the data distributions by means of the Kolmogorov test. These tests indicated that some of the data were not normally distributed. Thus, nonparametric statistical analyses were applied for group comparisons and correlations. Spearman correlation coefficients were used to test the correlation between variables, and Mann-Whitney tests were used for group comparisons of interest. A p value of
Published online: July 9, 2015
Studying the Psychological Profile of Patients with Laryngopharyngeal Reflux Tamer A. Mesallam a–c Rasha M. Shoeib a, d Mohamed Farahat a, b Fatma-Elzahraa A. Kaddah d Khalid H. Malki a, b a
Department of Otolaryngology, Head and Neck Surgery, College of Medicine, King Saud University, and Research Chair of Voice, Swallowing, and Communication Disorders, King Saud University, Riyadh, Saudi Arabia; c Otolaryngology Department, College of Medicine, Al-Menoufiya University, Shebin Al-Koum, and d Phoniatrics Unit, Department of Otolaryngology, College of Medicine, Ain Shams University, Cairo, Egypt b
Abstract Background/Aims: Psychological factors have been claimed to play a role in the predisposition for laryngopharyngeal reflux (LPR) symptoms. The aims of this work were to study the relationship between psychological disorders and LPR and to investigate the effect of potential psychological disorders on patients’ self-perception of reflux-related problems. Methods: Forty-two patients with symptoms suggestive of LPR were psychologically evaluated using the Social Readjustment Rating Scale, the Symptom Checklist-90 Revised, the Manifest Anxiety Scale of Taylor, the Minnesota Multiphasic Personality Inventory, and the Zung Self-Rating Depression Scale. Oropharyngeal 24-hour pH monitoring was used to diagnose LPR. LPR-related symptoms were assessed using the reflux symptom index (RSI) and the voice handicap index-10 (VHI-10). Patients were divided into groups based on psychiatric evaluation and pH results. Correlations between psychological profile characteristics and LPR-related parameters were also investigated. Results: No significant difference was found between the positive and negative LPR group for any of the assessed psychological
© 2015 S. Karger AG, Basel 1021–7762/15/0672–0051$39.50/0 E-Mail [email protected] www.karger.com/fpl
disorders. Also, no significant difference was detected between the positive and negative psychological disorder groups regarding RSI, VHI-10, and pH results. Correlations between psychological profile parameters and LPR-related measures were also nonsignificant. Conclusion: It appears that there is no association between psychological disorders and LPR. The psychological background of the LPR patients had no influence on patients’ self-perception of their refluxrelated problems. © 2015 S. Karger AG, Basel
Introduction
Laryngopharyngeal reflux (LPR) is defined as the retrograde flow of the gastric contents up to the aero-digestive tract, which could induce a variety of symptoms [1]. However, great controversy exists concerning the clinical presentations and diagnosis of LPR [2]. Many of the symptoms that are related to LPR are nonspecific, such as change of voice, chronic throat clearing, chronic cough, globus pharyngeus, and dysphagia. At the same time, most of the patients complaining of these symptoms do not show specific abnormalities on laryngeal examination [3]. Previous studies have failed to document an association between symptoms and laryngeal signs of LPR, makTamer A. Mesallam, MD, PhD ENT Department, Communication and Swallowing Disorders Unit (CSDU) King Abdulaziz University Hospital, PO Box 245 Riyadh 11411 (Saudi Arabia) E-Mail tmesallam @ ksu.edu.sa
Downloaded by: Univ. of California Santa Barbara 198.143.33.33 - 9/3/2015 7:01:40 AM
Key Words Psychological disorders · Laryngopharyngeal reflux · Reflux symptom index
Patients and Methods Patients The study was approved by the Institutional Review Board of the College of Medicine, King Saud University, Riyadh, Saudi Arabia. Informed consent was obtained from all participants in the study. The study included 42 patients (26 females, 16 males) with a mean age of 42.78 ± 12.43 years (range 21–68) who were referred to the reflux or voice clinic with symptoms related to LPR. Adult patients with a history of LPR-related complaints were included in the study, whereas illiterate patients or patients with a history of reflux or psychiatric medications were excluded. Prior to their admission to the clinic, patients were instructed to complete the Arabic versions of the reflux symptom index (RSI) [12] and voice handicap index-10 (VHI-10) [13] questionnaires to document possible LPR-related symptoms. 24-Hour Oropharyngeal pH Monitoring The diagnosis of LPR in the study group was confirmed using a 24-hour oropharyngeal Dx-pH probe system (Restech Corp., San Diego, Calif., USA). The patients were instructed to maintain their normal daily activities as usual during the study and were given a diary to record mealtimes and time in recumbent position. Following the 24 h of recording, an analysis of the data was carried out using a software system provided with the device. Acidic reflux thresholds were set at pH 5.5 in the upright position and pH 5.0 in the supine position; data from mealtimes were excluded from the analysis. The system automatically generates the Ryan score, which is a composite score calculated from the pH thresholds recorded for upright and supine positions. The score incorporates three main parameters including number of reflux episodes, the duration of the longest reflux episode, and the percent-
52
Folia Phoniatr Logop 2015;67:51–56 DOI: 10.1159/000431322
age of time below the predetermined pH threshold. Scores greater than 9.41 in the upright position and/or 6.80 in the supine position were considered suggestive of LPR [14, 15]. Psychological Assessment Psychological assessment was performed using (1) the Social Readjustment Rating Scale (SRRS) for estimation of the presence of stressful life events [16]; (2) the Symptom Checklist-90 Revised (SCL-90-R) to measure the 9 major psychiatric symptoms (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism) [17]; (3) the Manifest Anxiety Scale of Taylor [18] to measure the degree of an individual’s anxiety state; (4) the Minnesota Multiphasic Personality Inventory (MMPI) to assess the presence of hypochondriasis and hysteria [19], and (5) the Zung Self-Rating Depression Scale for assessment of the degree of depression [20]. In order to classify patients into positive and negative groups according to psychological disorders, the documented normal cutoff point for each test was used. Cutoff points for the tests are 21 for the MMPI, 16 for the Taylor test, 51 for the Zung test, and 300 for the SRRS. Because we did not apply a specific test to measure somatization, we used the somatization scale of the SCL-90-R questionnaire and categorized patients into the positive group according to the normal cutoff values provided by the Al-Behairy [21] SCL-90-R version. Statistical Analysis Patients were divided into positive and negative LPR groups according to the results of the pH monitoring. Comparisons were made between the positive and negative LPR groups regarding the results of the psychological evaluation. Similarly, patients were also divided into positive and negative groups based on the results of the psychological evaluation test battery. The results of the RSI and of the VHI-10 and Ryan scores were also compared among the positive and negative psychological disorder groups for each of the included psychological tests. Correlations were computed for each of the psychological parameters paired with each of the LPR-related measures, including pH monitoring parameters, RSI, and VHI-10. As a prerequisite for statistical analysis, an assessment was undertaken of the normality of the data distributions by means of the Kolmogorov test. These tests indicated that some of the data were not normally distributed. Thus, nonparametric statistical analyses were applied for group comparisons and correlations. Spearman correlation coefficients were used to test the correlation between variables, and Mann-Whitney tests were used for group comparisons of interest. A p value of
