Anxiety, Depression, and Posttraumatic Stress Disorder in Patients With Induced Laryngeal Obstruction

Key Points

Question

What is the prevalence of anxiety, depression, posttraumatic stress disorder (PTSD), and physical somatic symptoms in adult and pediatric patients with induced laryngeal obstruction (ILO)?

Findings

This study including 83 adult and 81 pediatric participants found that symptoms associated with anxiety, depression, PTSD, and somatic physical complaints were highly prevalent in adult and pediatric patients with ILO. Rates of formal anxiety, depression, and PTSD diagnoses were also elevated above normative levels.

Meaning

Patients with ILO may require treatment for both dyspnea and behavioral health.

This cross-sectional study examines the prevalence of anxiety, depression, posttraumatic stress disorder, and physical somatic symptoms in adult and pediatric patients with induced laryngeal obstruction.

Abstract

Importance

Patients with induced laryngeal obstruction (ILO) present with a variety of behavioral health profiles. Identifying these profiles is crucial in that behavioral health conditions may affect treatment duration and outcomes.

Objective

To characterize the prevalence of anxiety, depression, posttraumatic stress disorder (PTSD), and physical somatic symptoms in adult and pediatric patients with ILO and determine the factors associated with anxiety, depression, PTSD, and physical somatic symptoms in patients with ILO?

Design, Setting, and Participants

This cross-sectional study included a nonprobability sample of 83 adult and 81 pediatric patients diagnosed with ILO at outpatient adult and pediatric otolaryngology clinics between 2021 and 2023. Exclusion criteria included a comorbid respiratory diagnosis other than asthma, head or neck cancer, or neurological impairments. Recruitment took place between September 2021 and March 2023. The analyses were run in January 2024.

Main Outcome Measures

Patients were prospectively screened for anxiety, depression, PTSD, and somatic physical symptoms. In addition, any past behavioral health diagnoses were extracted from the medical record. Comorbidities, ILO symptoms triggers, and onset details were gathered from ILO evaluations. Adult patients completed the Screen for Adult Anxiety Related Disorders (SCAARED), depression (Patient Health Questionnaire [PHQ]-9), and somatic physical symptoms portions of the Patient Health Questionnaires (PHQ-15), and the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5). Pediatric patients completed the Screen for Child Anxiety Related Disorders (SCARED), depression (PHQ-9A) and somatic physical symptoms portions of the Patient Health Questionnaires for Adolescents (PHQ-15A), and the UCLA PTSD Reaction Index brief screeners.

Results

Eighty-three adult patients participated in this study (mean [SD] age, 45.8 [14.3] years; 64 female, 19 male). Eighty-one pediatric patients participated (mean [SD] age, 13.83 [2.55] years; 67 female, 14 male). Adult and pediatric patients with ILO screened positive for elevated rates of anxiety (53 adults [63%]; 49 children [60%]), depression (27 adults [32%]; 25 children [30%]), and PTSD (29 adults [34%]; 13 children [16%]). Most of the patients with anxiety and depression symptoms were formally diagnosed prior to ILO evaluation, with rates of previously diagnosed anxiety, depression, and PTSD also above published norms. Adults were twice as likely as children to present with PTSD (odds ratio, 2.1; 95% CI, 0.05-4.48). Elevated rates of physical somatic symptoms were also evident, with 38 adults (45%) and 32 children (39%) scoring in the moderate to severe range.

Conclusions and Relevance

This study found high rates of adult and pediatric patients with ILO screened positive for anxiety, depression, and PTSD symptoms. Future work should investigate how behavioral health and ILO treatments can best be coordinated to maximize treatment outcomes.

Introduction

Induced laryngeal obstruction (ILO) involves adduction of laryngeal or supralaryngeal tissues on inhalation.^1,2 The resulting dyspnea can be frightening, debilitating, and costly, limiting quality of life for those affected.^3,4,5 Symptom triggers vary and include irritants, environmental factors, and physical exertion.^1,6 When symptoms are induced by physical exertion, proper nomenclature is exercise-induced laryngeal obstruction (EILO).^7,8 Symptoms include inhalation/exhalation difficulty, chest/throat tightness, dizziness, and lightheadedness.⁹ Numerous terms have been used to describe ILO, including paradoxical vocal fold motion and vocal cord dysfunction.¹⁰ The prevalence of ILO is unknown; however, the condition is relatively common, occurring in as many as 7.5% of young healthy adults¹¹ and as many as 5% of pulmonology rehabilitation patients.^12,13 In addition, as many as 8% of adolescents experience ILO,^13,14 and pediatric patients account for approximately 30% of cases.¹⁵

Research indicates that there is an association between ILO and behavioral health.^16,17,18 For example, 45 adult patients with ILO produced elevated scores on the hypochondriasis and hysteria sections of the Minnesota Multiphasic Personality Inventory,¹⁹ suggesting that patients with ILO experience elevated health-related distress and/or anxiety related to physical symptoms.²⁰ Another study sampling 27 patients with ILO reported that 48% presented with anxiety and 11% with depression symptoms.²¹ Studies examining posttraumatic stress disorder (PTSD) in patients with ILO are less common; however, 43.8% of 16 patients with ILO screened positive for PTSD.²² An additional retrospective study reported a history of abuse in 38% of patients with ILO,²³ suggesting that trauma could also be a consideration for this population.

In children and adolescents, retrospective studies have reported that from 16% to 33% of patients with ILO reported a past diagnosis of anxiety.^24,25,26 In addition, as many as 10% of athletes with EILO experienced depression.²⁵ For example, when The Child and Adolescent Psychiatric Assessment was administered to 12 adolescents with ILO,¹⁶ 7 of 12 patients presented with some form of anxiety, and 4 presented with depression.

Although evidence suggests that anxiety symptoms are common in patients with ILO,²⁷ there are several factors that limit estimates of prevalence.^{16,17,19,24,26} Research has often involved relatively few participants and/or has relied on retrospective patient records.^24,25,26 Such studies may not accurately estimate the prevalence of behavioral health conditions, particularly when patients have not seen the appropriate professionals. In addition, national anxiety and depression rates in the US have increased in recent years, particularly in adolescents and young adults.^28,29,30 Most prospective studies are more than a decade old, and few have examined anxiety subtypes^16,17,19 or PTSD in this population.²²

The current study examined the prevalence of anxiety, depression, PTSD, and physical somatic symptoms in adult and pediatric patients with ILO. Based on past study, it was hypothesized that the prevalence of anxiety, PTSD, and somatic physical symptoms would be elevated in adults, and anxiety and somatic physical symptoms would be elevated in children. Factors associated with anxiety, depression, PTSD, and physical somatic symptoms in patients with ILO were also examined.

Methods

All study procedures were approved by the relevant institutional review board (#2021-1294), and patients gave informed consent prior to participation. A cross-sectional design was used. Patients seen for ILO evaluations in the outpatient voice and swallow clinics of a large tertiary hospital and pediatric hospital were prospectively screened for anxiety, depression, PTSD, and somatic physical symptoms. In addition, any previous behavioral health diagnoses were extracted from the medical record. Table 1 presents descriptions of these conditions.³¹ Patients completed behavioral health screeners following ILO diagnosis and prior to treatment initiation. Recruitment took place between September 2021 and March 2023. Patient symptoms, triggers, comorbidities, and onset details were collected from ILO evaluations.

Table 1. Descriptions of Behavioral Health Diagnoses.

Diagnosis	Description
Anxiety	Anxiety disorders are a group of psychiatric disorders characterized by significant levels of fear and anxiety that affect an individual’s ability to function in daily life. Anxiety disorders are differentiated by the content of the worry that is impairing an individual’s life. For example, generalized anxiety disorder entails frequent, distressing, difficult to control, worry about a variety of areas in an individual’s life. Other anxiety disorders consist of more specific areas of fear including anxiety about social situations/perception by others, separation from caregivers or loved ones, anxiety related to school attendance, panic attacks, and others. Although different anxiety disorders have unique diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), clinically, they can present with some common symptoms. A few symptoms frequently seen in anxiety disorders include frequent worry, avoidance of anxiety provoking situations, difficulty concentrating due to worry, or difficulty initiating and/or maintaining sleep. Clinicians frequently encounter individuals in which physical symptoms accompany anxiety disorders—particularly headaches and gastrointestinal upset (eg, stomachache, nausea, vomiting, diarrhea). Anxiety diagnoses vary by age and demographic. Many anxiety disorders develop in childhood and may persist into adulthood and tend to be more prevalent in women compared with men. Content of worry may vary with age and developmental maturity.
Depression	Major depressive disorder is characterized by persistent low mood or loss of interest in previously enjoyed activities (anhedonia). Individuals may also experience changes in energy, sleep, movement, or appetite, as well as feelings of guilt, worthlessness/hopelessness, difficulty concentrating, frequent crying, and/or suicidal or self-harm ideation. DSM-5-TR criteria are the same for adult and pediatric populations; however, it is noted that children/adolescents may exhibit increased irritability in place of depressed mood. Clinically, symptoms may lead children/adolescents to have increased social isolation, somatic complaints, school performance decline, behavioral outbursts (in younger children), and decreased participation in hygiene. Depression does not affect all age groups/genders equally and is more common in postpubertal individuals and female patients.
Posttraumatic stress disorder (PTSD)	PTSD is a psychiatric condition that may arise after an individual experiences or witnesses a traumatic event. Although the term trauma is colloquially used to describe a variety of experiences, the DSM-5-TR defines a traumatic experience as a situation in which there is a perceived threat of death, severe injury, or sexual violence. Those who have PTSD may have experienced such an event, witness an event, or learn of the event occurring to a loved one. Although many people may experience such an event in their lifetime, not all such events culminate in PTSD. PTSD symptoms are characterized by symptoms of intrusion, avoidance, changes in mood, and hyperarousal. Intrusion symptoms may include flashbacks, nightmares, or intrusive memories. Avoidance symptoms entail avoidance of things that remind an individual of the traumatic event (eg, memories, places, people). Mood symptoms can lead to difficulty experiencing positive emotions, feelings of guilt/shame, negative self-perception, and decreased interest in previously enjoyed activities. Arousal symptoms may include hypervigilance, increased startle, periods of anger or rage, and poor concentration. These symptoms must persist for more than 1 mo after the traumatic event.
Somatic physical symptoms	Somatic symptoms are physical symptoms experienced by an individual. The DSM-5-TR contains a category of disorders referred to as somatic symptoms and related disorders. These disorders are characterized by physical symptoms and/or anxiety about symptoms that cause significant emotional distress. These symptoms may be related to a known underlying medical etiology but often do not have a clear underlying medical cause. Although some individuals may meet criteria for a somatic symptoms and related disorder, other psychiatric diagnoses such as anxiety and depression may be accompanied by the presence of physical/somatic symptoms. Individuals with high levels of somatic symptoms may experience significant functional impairment and often lead to high utilization of health care services.

Patients

Children with ILO were younger than 18 years and adults were aged between 18 and 80 years. All read and spoke fluent English. Patients were excluded if they had a comorbid respiratory diagnosis other than asthma, head or neck cancer, or any neurological condition preventing screener completion (ie, dementia, brain injury).

ILO Diagnosis

For all patients, ILO was diagnosed by a laryngologist (or pediatric otolaryngologist for children) and speech language pathologist (SLP) following laryngoscopy. Laryngoscopy followed exercise in cases where symptoms were induced by physical exertion. Patients either presented with laryngeal or supralaryngeal adduction upon inhalation (complete or partial) during the examination, or met the following criteria: (1) their symptoms and medical history were consistent with ILO (eg, symptoms were episodic, connected to specific triggers, did not resolve with inhaler use), (2) other respiratory pathologies were excluded through medical testing (eg, chest radiograph, bronchoprovocation testing), and (3) the diagnosing physician judged ILO to be the etiology of dyspnea.^32,33 Patients for whom ILO diagnosis was in question were excluded. Auditopry-perceptual assessment of voice quality was performed by the evaluating SLP using the Grade Roughness Breathiness Asthenia and Strain (GRBAS) scale.³⁴ Patients with a GRBAS score of 1 or higher were considered as having dysphonia.

Previous Behavioral Health Diagnoses

Any previous anxiety, depression, or PTSD diagnoses were extracted from the medical record. Anxiety and depression subtypes were considered collectively. Diagnoses were made by psychiatry prior to the date of ILO evaluation and were considered as a binary variable (present or not). Somatic physical symptoms were not extracted from the electronic medical record because these may be associated with a variety of diagnostic codes and conditions.

Screeners

Adult and pediatric screeners, cutoff scores, and psychometrics (sensitivity and specificity) are described in detail in Table 2.^{35,36,37,38,39,40,41} Adult patients completed the Screen for Adult Anxiety Related Disorders (SCAARED),⁴⁰ depression (Patient Health Questionnaire [PHQ]-9),⁴² and somatic physical symptoms portions of the Patient Health Questionnaires (PHQ-15),⁴³ and PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) with Criterion A (PCL-5).⁴⁴ Pediatric patients completed the Screen for Child Anxiety Related Disorders (SCARED),⁴⁵ depression (PHQ-9A) and somatic physical symptoms portions of the Patient Health Questionnaires for Adolescents (PHQ-15A),⁴⁶ and UCLA PTSD Reaction Index brief screeners.³⁷ The SCARED was also completed by parents who answered the questions about their child. Screeners were chosen because they are commonly used in behavioral health practices, their psychometric properties are reported in the literature, they demonstrate predictive value for diagnoses, and comparable forms exist for both adult and pediatric populations.^{35,36,37,38,39,40,41,47}

Table 2. Descriptions and Cutoff Scores for Behavioral Health Screeners.

Diagnosis	Screener	Description	Psychometricsa
Adults
Depression	PHQ-9	This 9-question scale screens for frequency of depression symptoms on a 4-point Likert scale. Higher scores indicate more severe depression symptoms. Scores >5 indicate mild, >10 moderate, >15 moderate to severe, and >20 severe depression symptoms. Major depressive disorder is suggested by an overall score >10, and a minimum of 5 items are marked as occurring on “more than half of days.”	Sensitivity, 0.88; specificity, 0.88
Anxiety	SCAARED	This validated 44-item scale is used to assess for the presence of an anxiety disorders in adults. Symptoms are rated on a 3-point Likert scale depending on how often they occur. A score >23 suggests the presence of an anxiety disorder. In addition, questions can be separated into subsections to screen for anxiety subtypes. Each subsection has a cutoff score that may indicate the presence of panic disorder (>5), GAD, (>12), separation anxiety disorder (>3), and social phobia disorder (>7).	Sensitivity, 0.76; specificity, 0.77
PTSD	PTSD PCL-5	The PCL-5 consists of 20 items that are rated on a 5-point Likert scale to assess for the frequency of PTSD symptoms. Scores >31 to 33 are suggestive of PTSD. For the current study a cutoff score of 33 was used to conservatively estimate PTSD prevalence. Criterion A asks individuals to identify their traumatic event, how long ago it occurred, the manner in which it was experienced, and if it involved death.	Sensitivity, 0.66; specificity, 0.97
Physical somatic symptoms	PHQ-15	This 15-question scale screens for frequency of somatic physical symptoms on a 3-point Likert scale. Scores >5 indicate mild, scores >10 moderate, and scores >15 indicate severe levels of somatic symptoms.	Sensitivity, 0.78; specificity, 0.71
Children
Depression	PHQ-9A	The PHQ-9A is a version of the PHQ-9 adapted for children and teens aged between 11 and 17 years. Nine questions regarding depression symptoms are rated on a 4-point Likert scale based on how often they occur. Higher scores indicate more severe depression symptoms. Scores >5 indicate mild, >10 moderate, >15 moderate to severe, and >20 severe depression symptoms. Major depressive disorder is suggested by an overall score >10, and a minimum of 5 items being marked as occurring on “more than half of days.”	Sensitivity, 0.73; specificity, 0.94
Anxiety	SCARED	This validated 41-item scale is used to assess for the presence of an anxiety disorders in children. This tool contains both child and parent forms—both completed on behalf of the child. Symptoms are rated for a 3-point Likert scale depending on how often they occur for the child. A score >25 suggests the presence of an anxiety disorder. In addition, questions can be separated into subsections to screen for anxiety subtypes. Each subsection has a cutoff score that may indicate the presence of panic disorder (>7), GAD (>9), separation anxiety disorder (>5), social phobia disorder (>8), and significant school avoidance symptoms (>3).	Sensitivity, 0.81; specificity, 0.52
PTSD	UCLA brief screen for child/adolescent trauma and PTSD	This tool asks children to identify if any traumatic events have occurred in their recent and extended past. Patients then complete an 11-item scale determining how frequently they experience various symptoms of PTSD. Items are rated on a 5-point Likert scale. Scores from <10 indicate minimal symptoms, >11 mild symptoms, and scores >21 indicate that a child may have PTSD and should be referred for further evaluation.	Sensitivity,1.00; specificity, 0.86
Physical somatic symptoms	PHQ-15A	This 13-question scale screens for frequency of somatic physical symptoms on a 3-point Likert scale. Items are identical to the PHQ-15 with the questions regarding menstruation or sexual intercourse eliminated. Scores >5 indicate mild, scores >10 moderate and scores >15 indicate severe levels of somatic symptoms.	Sensitivity,b NA; specificity,b NA

Abbreviations: GAD, generalized anxiety disorder; NA, not applicable; PCL-5, Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition); PHQ, Patient Health Questionnaire; PTSD, posttraumatic stress disorder; SCAARED, Screen for Adult Anxiety Related Disorders; SCARED, Screen for Child Anxiety Related Disorders; UCLA, University of California, Los Angeles.

^a All psychometrics reported from previous literature.

^b Psychometrics on a comparable adolescent population not reported.

Statistical Analysis

Descriptive statistics were used to examine prevalence of anxiety, depression, PTSD, and physical somatic symptoms. Multivariable linear regression was used to estimate screener scores and univariate analyses determined which factors should be included in the regression model (P < .05). Factors considered for the model included age, sex (male/female), time from onset to diagnosis, trigger type (ILO, EILO, EILO with irritant triggers), athlete status (yes/no), overall GRBAS score, medical comorbidities (asthma, reflux, allergies; yes/no), and previous anxiety, depression, or PTSD diagnoses (yes/no, previous PTSD diagnosis was not analyzed for children owing to small sample size). Tukey’s HSD tests with Cohen d estimates of effect size were calculated for post hoc comparisons. Pearson correlations were used to measure the relationship between parent and child SCARED scores, as well as depression and anxiety screeners—as these conditions are known to be associated.⁴⁸ Alpha was set at .05 for determining statistical significance. SPSS statistical software (version 29; IBM) was used for all statistical analyses. The analyses were run in January 2024.

Results

Eighty-three adult patients participated in this study (mean [SD] age, 45.8 [14.3] years; 64 female [77%], 19 males [23%] [1 cis-male participant identified as gender-fluid]; 4 were Asian [5%] and 79 were White [95%]). Table 3 presents the distribution of ILO subtype, patient demographics, symptoms, voice assessments for the overall study population, and for patients with previous anxiety and depression diagnoses. Mean (SD) time from onset of symptoms to diagnosis was 25.9 (11) months. Overall, 12 patients (14%) self-identified as athletes. Two adult patients became emotionally distressed at the thought of recalling specific events during the PTSD screening and discontinued the study. Because scored portions of screeners were completed, data from these patients were included in analyses.

Table 3. Patient Demographics and Prevalence of Symptoms and Comorbidities.

Characteristic	No. (%)
	All patients		Patients with anxiety		Patients with depression
	Adults (n = 83)	Children (n = 81)	Adults (n = 42)	Children (n = 51)	Adults (n = 34)	Children (n = 21)
Demographics
Age, mean (SD), y	45.8 (14.3)	13.8 (2.5)	47.1 (14.0)	14.2 (2.4)	47.0 (16.4)	14.4 (2.8)
Sex
Female	64	67	31	42	25	17
Male	19	14	11	9	9	4
Time since onset, mean (SD), mo	25.9 (11.0)	19.6 (15.9)	23.7 (21.0)	19.1 (15.2)	21.7 (21.4)	18.6 (12.1)
Triggers
EILO plus irritant triggers	50 (60)	50 (61)	28 (66)	31 (60)	22 (64)	12 (57)
ILO	25 (30)	10 (12)	8 (19)	6 (11)	10 (29)	3 (14)
EILO	8 (9)	21 (25)	6 (14)	14 (27)	2 (5)	6 (28)
Symptoms
Inhalation difficulty	83 (100)	81 (100)	42 (100)	51 (100)	34 (100)	21 (100)
Exhalation difficulty	30 (36)	24 (29)	15 (35)	16 (31)	12 (37)	7 (33)
Throat and chest tightness	71 (85)	72 (92)	35 (83)	45 (90)	30 (88)	19 (90)
Stridor	39 (46)	27 (33)	21 (50)	17 (33)	15 (45)	8 (38)
Voice assessments
GRBAS (normal)	34 (40)	71 (87)	15 (35)	46 (90)	11 (32)	21 (100)
GRBAS (mild)	27 (32)	10 (12)	15 (35)	5 (9)	12 (35)	0
GRBAS (moderate)	22 (26)	0	12 (28)	0	11 (32)	0
Voice Handicap Index, mean (SD)	22.4 (24.4)	NA	17.1 (18.8)	NA	16.2 (18.5)	NA
Glottal Function Index, mean (SD)	NA	2.1 (1.06)	NA	1.18 (2.0)	NA	1.4 (2.3)
Comorbidities
Asthma	26 (31)	21 (25)	15 (35)	17 (33)	11 (32)	8 (38)
Reflux (self-reported)	26 (31)	28 (34)	12 (28)	16 (31)	12 (35)	7 (33)
Allergies (self-reported)	45 (54)	41 (50)	21 (50)	25 (49)	15 (45)	12 (57)

Abbreviations: EILO, exercise-induced laryngeal obstruction; GRBAS, Grade Roughness Breathiness Asthenia and Strain scale; ILO, induced laryngeal obstruction; NA, not applicable.

Eighty-one pediatric patients participated in this study (mean [SD] age,13.83 [2.55] years; 67 female [83%], 14 male [17%]; 2 were Asian [2%], 3 Black [4%], and 76 White [94%]). Three participants assigned female at birth identified as gender-fluid or transmale. The mean (SD) time from onset of symptoms to ILO diagnosis was 19.6 (15.9) months. Distribution of ILO subtype, patient demographics, symptoms, and voice assessments are presented in Table 3. Sixty-six pediatric patients (81%) self-identified as athletes based on participation in formal athletic events.

Compared with pediatric patients, adults were 2.4 times more likely to present with irritant induced ILO (odds ratio [OR], 2.43; 95% CI, 1.10-5.30) and 63% less likely to present exclusively with EILO (OR, 0.37; 95% CI, 0.15-0.88). In addition, adults were 3.2 times more likely to present with concomitant dysphonia than children (OR, 3.22; 95% CI, 1.40-6.90).

Anxiety

For adults, 42 (50%) presented with previous anxiety diagnosis. The mean (SD) SCAARED score was 29.48 (16.5). Overall, 53 patients (63%) presented with SCAARED scores suggestive of anxiety (eFigure in Supplement 1). The mean (SD) prevalence of anxiety subtypes was as follows: 53 screened positive for panic disorders (63%; 8.9 [6.1]), 36 for GAD (43%; 11.6 [6.7]), 40 for separation anxiety (48%; 3.1 [2.9]), and 37 for social phobia (44%; 5.8 [3.8]). A history of anxiety was significantly associated with SCAARED scores (Table 4) because these patients presented with considerably higher mean (SD) scores than those without anxiety (anxiety, 32.9 [16.2]; no anxiety, 25.9 [16.1]; Cohen d = 0.43; 95% CI, 0.001-0.87; Table 4).

Table 4. Predictors of Behavioral Health Diagnoses.

Factors	Adult			Pediatric
	β (SE)	95% CI	t	Factors	β (SE)	95% CI	t
Anxiety screener scores
Time to diagnosis	−0.06 (0.08)	−0.23 to 0.12	−0.64	Time to diagnosis	−0.01 (.07)	−0.15 to 0.14	−0.1
Anxiety	9.05 (4.6)	−0.11 to 18.2	1.9	Anxiety	16.3 (2.6)	11.0 to 21.6	6.1
Depression	−3.7 (4.7)	−13.1 to 5.6	−0.78	Depression	9.6 (2.9)	3.8 to 15.4	3.3
NA	NA	NA	NA	Athlete status	−5.6 (3.1)	−11.9 to 0.60	−1.7
Depression screener scores
Time to diagnosis	0.01 (0.03)	−0.05 to 0.07	0.31	Time to diagnosis	−6.9 (3.5)	−13.9 to 0.08	−1.9
Anxiety	1.25 (1.6)	−2.1 to 4.6	0.74	Anxiety	17.1 (2.6)	11.9 to 22.3	6.5
Depression	−0.02 (1.7)	−3.5 to 3.4	−0.01	Depression	7.8 (2.9)	1.9 to 13.7	2.6
PTSD	3.65 (1.9)	−.27 to 7.5	1.80	GRBAS	0.05 (0.07)	−0.08 to 0.19	0.7
PTSD screener scores
Trigger type	−0.21 (.74)	−1.6 to 1.2	−0.28	Trigger type	−1.5 (1.2)	−4.1 to 1.0	−1.2
Anxiety	−0.01 (.98)	−1.9 to 1.9	−0.01	Anxiety	5.6 (2.5)	0.45 to 10.7	2.1
PTSD	0.27 (1.4)	−2.6 to 3.1	0.18	Depression	5.8 (2.8)	0.11 to 11.4	2.0
Somatic physical symptom screener scores
Age	−0.02 (0.03)	−0.08 to 0.05	0.56	Time to diagnosis	0.02 (0.02)	−0.15 to 0.14	0.8
Time to diagnosis	−0.01 (0.03)	−0.05 to 0.03	−0.37	Anxiety	2.5 (0.87)	−0.24 to 10.1	2.9
Anxiety	0.01 (0.98)	−1.9 to 1.9	0.01	Depression	7.1 (0.95)	0.85 to 12.2	7.4
NA	NA	NA	NA	Athlete status	−3.3 (1.00)	−11.3 to 0.96	−3.2

Abbreviations: GRBAS, Grade Roughness Breathiness Asthenia and Strain scale; NA, not applicable; PTSD, posttraumatic stress disorder.

For pediatric patients, 35 (43%) presented with previous anxiety diagnoses. Mean (SD) SCARED score was 29.6 (14.7). Overall, 49 patients (60%) presented with SCARED scores suggestive of anxiety (eFigure in Supplement 1). The prevalence of anxiety subtypes was as follows: 45 screened positive for panic disorders (55%; mean [SD], 7.8 [5.4]), 41 for GAD (50%; mean [SD], 8.8 [4.9]), 23 for separation anxiety (28%; mean [SD], 3.5 [3.4]), 36 for social phobia (44%; mean [SD], 7.2 [3.9]), and 33 for school avoidance (40%; mean [SD], 2.2 [1.9]). A history of anxiety was significantly associated with SCARED scores (Table 4). Patients with a previous anxiety diagnosis presented with significantly higher mean (SD) scores than those without this diagnosis (anxiety, 37.3 [12.1]; no anxiety, 16.5 [8.0]; Cohen d = 1.65; 95% CI, 1.1-2.1). A history of depression was also associated with SCARED scores (Table 4), as those with depression scored significantly higher than those without this diagnosis (mean [SD] depression, 42.6 [14.2]; no depression, 25.1 [12.1]; Cohen d = 1.3; 95% CI, 0.8-1.9).

The mean (SD) parent SCARED score was 22.4 (15.09). Child and parent total scores were significantly correlated with an r value of 0.52 (95% CI, 0.34-0.66). Pediatric scores were higher than parent scores across all domains, indicating that children self-reported more anxiety symptoms than did their parents on their behalf. Correlations between parent and pediatric scores were as follows: 0.38 for panic disorders (95% CI, 0.18-0.55; parent mean [SD], 5.2 [5.1]), 0.49 for general anxiety disorder (95% CI, 0.30-0.64; mean [SD], 7.1 [4.2]), 0.36 for separation anxiety (95% CI, 0.15-0.53; mean [SD], 2.2 [2.9]), 0.62 for social phobia (95% CI, 0.47-0.74; mean [SD] 5.9 [4.6]), and 0.45 for school avoidance (95% CI, 0.26-0.61; mean [SD], 1.8 [1.9]).

Depression

For adults, 34 (41%) presented with a previous diagnosis of depression. Mean (SD) PHQ-9 score was 6.78 (6.02). Overall, 27 patients (32%) presented with PHQ-9 scores suggestive of major depressive disorder (eFigure in Supplement 1). The distribution of depression scores was as follows: 44 patients (53%) presented without symptoms, 12 (14%) with mild symptoms, 15 (18%) with moderate symptoms, 8 (9%) with moderate to severe symptoms, and 4 (4.8%) with severe symptoms. No significant factors associated with PHQ-9 scores were observed (Table 4); however, PHQ-9 scores were strongly correlated with SCAARED scores (r = 0.55; 95% CI, 0.47-0.74) (Figure).

Figure. Distribution of Anxiety and Depression Screeners Across Adults and Children With Induced Laryngeal Obstruction (ILO).

Distribution of Patient Health Questionnaire-9 (PHQ-9; PHQ9-A for children) scores by Screen for Adult Anxiety Related Disorders (SCAARED; SCARED for children) scores.

For children, 21 participants (25%) presented with a previous depression diagnosis. The mean (SD) PHQ9-A score was 6.78 (6.02). Overall, 25 patients (30%) presented with scores suggestive of major depressive disorder (eFigure in Supplement 1). The distribution of depression scores was as follows: 35 patients (43%) presented without symptoms, 21 (25%) with mild symptoms, 15 (18%) with moderate symptoms, 5 (6%) with moderate-to-severe symptoms, and 5 (6%) with severe symptoms. A history of depression was associated with PHQ9-A scores (Table 4), as patients with a previous depression diagnosis presented with significantly higher mean (SD) scores than those without this diagnosis (depression, 15.1 [3.8]; no depression, 4.1 [3.3]; Cohen d = 3.2; 95% CI, 2.5-3.9). A history of anxiety was also associated with PHQ9-A scores (Table 4), as those diagnosed with anxiety had mean (SD) scores higher than those without anxiety (anxiety, 9.9 [5.4]; no anxiety, 2.1 [2.4]; Cohen d = 1.72; 95% CI, 1.1-2.2). PHQ9-A scores were strongly correlated with SCARED scores (r = 0.59; 95% CI, 0.57-0.79).

Posttraumatic Stress Disorder

Eleven adults (13.3%) presented with previous PTSD diagnoses. Mean (SD) PCL-5 score was 21.7 (18.4). Twenty-nine adults (34%) with ILO presented with a score suggestive of PTSD on the PCL-5 (eFigure in Supplement 1). Criterion A items are presented in Table 4. No factors associated with PCL-5 scores were identified (Table 4).

For pediatric patients, 4 presented with a previous PTSD diagnosis (4.9%). Mean (SD) University of California, Los Angeles (UCLA) Brief Screen score was 9.27 (10.9). Thirteen patients (16%) with ILO presented with a score suggestive of PTSD. Criterion A events are presented in Table 4. A history of depression was also associated with scores (Table 4), as patients with a previous depression diagnosis presented with significantly higher mean (SD) scores than those without this diagnosis (depression, 15.1 [13.6]; no depression, 7.0 [8.8]; Cohen d = 0.85; 95% CI, 0.33-1.30). A history of anxiety also predicted scores (Table 4), as those diagnosed with anxiety had mean (SD) scores significantly higher than those without anxiety (anxiety, 12.2 [12.1]; no anxiety, 4.1 [5.9]; Cohen d = 0.79; 95% CI, 0.32-1.20).

Somatic Physical Symptoms

For adults, mean PHQ-15 score was 8.83 (4.36). The mean (SD) distribution of physical somatic symptom scores was as follows: 11 patients (13%) scored in normal range, 34 (41%) in mild range, 20 (24%) in moderate range, and 18 (21%) in severe range on the PHQ-15. No significant associations with PHQ-15 scores were observed (Table 4).

For children, the mean (SD) PHQ-15A score was 8.28 (5.22). Distribution of physical somatic symptom scores was as follows: 22 patients (27%) scored in the normal range, 27 (33%) mild, 21 (25%) moderate, and 11 (13%) in the severe range. A history of depression was associated with PHQ-15A scores (Table 4), as patients with a previous depression diagnosis presented with significantly higher mean (SD) scores than those without this diagnosis (depression, 14.3 [4.0]; no depression, 6.1 [3.7]; Cohen d = 2.1; 95% CI, 1.5-2.7). A history of anxiety was also associated with PHQ-15A scores (Table 4), as those diagnosed with anxiety had significantly higher mean (SD) scores than those without anxiety (anxiety, 10.4 [5.1]; no anxiety, 4.6 [3.0]; Cohen d = 1.3; 95% CI, 0.84-1.80). Finally, athlete status was also associated with PHQ-15A scores as athletes presented with lower mean (SD) scores than nonathletes (athletes, 7.6 [4.8]; no anxiety, 11.1 [5.8]; Cohen d = 0.69; 95% CI, 0.12-1.20).

When comparing adults and children, adults were twice as likely to present with PTSD (OR, 2.1; 95% CI, 1.05-4.48). No other significant differences between adults and children were observed. Although there was increased prevalence of separation anxiety in adults, levels did not reach statistical significance (OR, 1.6; 95% CI, 0.93-3.10).

Discussion

ILO and the resulting dyspnea can be frightening and debilitating for patients.⁴⁹ Preliminary study suggests that ILO is also associated with various behavioral health conditions; however, the nature and scope of these challenges have not been well understood. Considering the critical effect that behavioral health conditions have on treatment duration and outcomes,^22,24,50 further study of the mental health profiles of patients with ILO is warranted. The current study examined the prevalence of anxiety, depression, PTSD, and physical somatic symptoms in adult and pediatric patients with ILO. It was hypothesized that the prevalence of anxiety, PTSD, and somatic physical symptoms would be elevated in adults, and that anxiety and somatic physical symptoms would be elevated in children. These hypotheses were confirmed as the prevalence of anxiety, depression, and PTSD symptoms were elevated in both adults and children compared with normative data from the general population. In addition, high levels of physical somatic symptoms were observed. As might be expected, an association between depression and anxiety was evident.

The elevated prevalence of anxiety in both the adult and pediatric patients in this study supports past research associating these conditions.^16,19 Sixty percent of pediatric patients and 63% of adult patients screened had positive results for anxiety, and 50% of adults and 43% of children presented with prior anxiety diagnoses. These proportions are significantly higher than the 7%⁵¹ and 19%^52,53 levels evident for the general pediatric and adult populations, respectively. No single anxiety subtype accounted for symptoms in all patients. Most children screened had positive results for panic disorders and GAD. Rates of social and school avoidance were also high, but separation anxiety was the least prevalent. The primary association of SCARED scores was with a previous anxiety diagnosis—suggesting that many adults and children remained symptomatic for the condition at the time of ILO diagnosis. In children, a history of depression was also associated with higher scores on the SCARED, further supporting the notion that pediatric patients, in particular, were undertreated for behavioral health.

The high rates of anxiety reflected high rates of depression as well. The prevalence of depression symptoms was 32% in adults and 30% in children, with 41% of adults and 25% of children presenting with a previous diagnosis. Again, these numbers were considerably higher than the 8.6%⁵⁴ reported in adults or the 11% reported for adolescents in the general population.⁵¹ Findings were theoretically congruent with psychology research indicating that depression and anxiety are highly associated.⁴⁸ In fact, as many as 85% of patients with depression also present with anxiety, and 90% of those with anxiety may also have depression.⁵⁵ As such, it is not surprising that depression and anxiety screeners were positively correlated, and that the conditions often co-occurred.

In children, depression screeners were elevated in patients with previous depression and/or anxiety diagnoses. This was not the case, however, in adults. It is possible that adults’ depression symptoms were better managed, whereas problems persisted in pediatric patients because access to pediatric psychiatry is limited nationwide,^56,57 or because children had less time to establish behavioral health plans of care prior to ILO onset. Regardless, elevated screener scores suggest that depression symptoms may have been undertreated in these patients.

Sixteen percent of children and 34% of adults screened had positive results for PTSD. Thirteen percent of adults and almost 5% of children had been previously diagnosed with the condition. These rates were elevated compared with the 3.9% observed in the general adolescent population^52,53 and 3.6% to 4.7% observed in adults.^52,58 These findings suggest that ILO may well be associated with trauma symptoms—particularly in adults. In fact because PTSD symptoms can present similarly to both anxiety and depression, it is possible that trauma partially underlies the elevated rates of these other symptoms. Importantly, no patient reported dyspnea as the source of PTSD symptoms, suggesting that PTSD was not simply a result of ILO itself. In both adult and pediatric patients, there were Criterion A events involving near death or loss of a family member that had occurred during the COVID-19 pandemic. The relatively recent nature of these events may partially explain the larger discrepancy between screeners and past PTSD diagnoses.

Both adults and children with ILO averaged approximately 8 on the PHQ-15. Considering that for adults, a mean score of 4.6 for men and 6.3 for women is typical,⁵⁹ the number of physical symptoms reported in the current study was markedly elevated. This finding supports a previous study suggesting elevated hypochondriasis and hysteria scores in patients with ILO.¹⁹ This may also explain why patients with ILO used health care more frequently than controls with asthma.⁶⁰ In addition, research may clarify the relationship between various types of physical pain and ILO.

Adult and pediatric populations presented with slightly different manifestations of ILO. Adults were significantly more likely to present with ILO and more likely to experience comorbid dysphonia. With regard to behavioral health, adults were twice as likely to experience PTSD. A previous study indicated that adolescents with strict ILO may be more likely to experience behavioral health comorbidities⁶¹; however, ILO type was not associated with behavioral health diagnoses in the current study. The higher prevalence of PTSD in adult patients may reflect the fact that PTSD is difficult to diagnose in pediatric populations.⁶²

Limitations

The current investigation provides compelling evidence regarding the behavioral health profile of patients with ILO. It should be remembered, however, that the psychological screenings conducted for this study were not, in isolation, sufficient for diagnosis. Many patients had been previously diagnosed by psychiatrists, but others presented with symptoms that had not been formally assessed. Definitively diagnosing anxiety disorders, depression, and PTSD requires interviewing with a licensed psychiatrist, and further study is clearly warranted. Because it was beyond the scope of the current study to examine the influence of ILO or behavioral health treatment on behavioral health conditions or ILO symptoms, future research should examine possible associations. Although therapy with an SLP is often effective in resolving ILO,^63,64 this treatment alone should not be expected to resolve behavioral health problems. Rather, the current findings underscore the critical importance of collaboration among professionals, integration of behavioral health services into other specialty practices, and coordination of psychiatric, psychological, and SLP services.⁶⁵

Conclusions

Adult and pediatric patients with ILO not only presented with elevated rates of previously diagnosed anxiety, depression, and PTSD, but also had positive screen results for elevated levels of anxiety, depression, and PTSD symptoms at the time of ILO diagnosis. Elevated anxiety scores were high across all subtypes; however, panic disorders and GAD were particularly high. Children with a history of anxiety and depression presented with particularly high scores on behavioral health screeners, suggesting that behavioral health symptoms remained problematic at the time of ILO diagnosis. In addition, elevated rates of physical somatic symptoms were also evident. Future research may investigate causal relationships between behavioral health conditions and ILO and describe ways to coordinate ILO treatments most effectively.

Supplement 1.

eFigure. Counts for Positive and Negative Anxiety, Depression, and PTSD Screeners for Adults and Children with ILO

eTable. Events Associated With PTSD Onset

Supplement 2.

Data Sharing Statement