Table 2.

Psychosocial mechanisms: subcategories, characteristics, and triggers.

Author(s), year	Subcategories	Associated characteristics	Potential triggers
Baker (2008); Baker et al. (2013, 2014)	Emotion Processing Deficits	Implicit, general emotional arousal (undifferentiated emotions) experienced viscerally (somatization) Fight or flight state	Post–upper respiratory illness or surgery, organic voice disorder, phonotrauma, increased vocal load, life events, stressful situations, COSO
House & Andrews (1988)	COSO	Two requirements: Strong commitment within the communicative scenario; individual required to respond, but they do not to avoid exacerbating the conflict Likely no conscious awareness of the conflict	Stressful experiences
Dietrich et al. (2019); Dietrich & Verdolini Abbott (2012); Roy (2011); Roy & Bless (2000); Roy et al. (2019, 2000a, 2000b); Van Mersbergen et al. (2008)	The Dispositional Bases of Functional Dysphonia and Vocal Nodules, also known as The Trait Theory of Voice Disorders or Trait Theory	Low trait extraversion (introversion) with high trait neuroticism Behavioral inhibition system intensified by nonspecific arousal system (tendency not to perform a behavior is increased; Gray, 1970) Laryngeal muscle activity heightened or disorganized; passive avoidance of stimuli	Environmental signals/cues interpreted as punishment, frustrative nonreward (lack of expected reward in a scenario leads to frustration), novelty, or threat
Daniilidou et al. (2007); Deary & Miller (2011); Deary et al. (2018); Kollbrunner & Seifert (2017); Miller et al. (2014); Misono et al. (2020); O'Hara et al. (2011); Piersiala et al. (2020)	Medically Unexplained Symptoms (MUS) Novel expanded Cognitive Behavioral Therapy model of functional dysphonia (CBT model; Deary et al.)	Predisposing, precipitating, and perpetuating factors have a feedforward/feedback relationship with physical symptoms Presence of other MUS. CBT Model: Predisposing factors: Family history of dysphonia, anxiety, depression, coping style, frequency of vocal use, unhealthy/general perfectionism, high neuroticism, emotional inhibition, responsibility for others, trauma Perpetuating factors: general fatigue, anxiety, depression, avoidance of symptoms	MUS: Stress, loneliness, COSO, chronic somatic concerns CBT Model: Precipitating factors: frequency of vocal use, anxious coping style, viruses/respiratory tract infections, sense of powerlessness, life events
Misono et al. (2019)	Perceived Control	Maladaptive emotional and behavioral reactions due to low present perceived control over voice difficulties	Life events and trauma, heavy vocal demand, stressors, sensations of the voice problem, environmental irritants, reflux
Rammage et al. (1987)	Tensional symptoms (aka functional dysphonia, vocal hyperfunction, or muscular tension dysphonia) Symbolic symptoms Hypochondriacal symptoms Depressive-type symptoms Symbolic, tensional, and hypochondriacal symptoms Combined organic and psychogenic processes	Hyperactive nervous system leads to muscle hypertonicity Laryngeal muscular involvement unconsciously substituted for psychological conflict Anticipation of voice problems Suppression of the urge to cry or verbally display anger Combination of symbolic, tensional, and hypochondriacal symptoms Organic, psychological, and social factors predispose, precipitate, or perpetuate laryngeal symptoms	Disproportionate arousal and anxiety; personality Psychological conflict Physical sensations; personality traits (obsessive-compulsion, dependency, hypochondria). Urge to cry or express anger Symbolic, tensional, and hypochondriacal symptoms Edema, infection, polypoidal change, neoplasia, reflux esophagitis, acid laryngitis, health or voice-related anxiety

Note. MUS = medically unexplained symptom; COSO = conflict over speaking out; CBT = cognitive behavioral therapy.