Research Article|Articles in Press

Interoception, Voice Symptom Reporting, and Voice Disorders

  • Julianna Comstock Smeltzer
    School of Behavioral and Brain Sciences, Department of Speech, Language, and Hearing, University of Texas at Dallas, Richardson, Texas
    Search for articles by this author
  • Sy Han Chiou
    Department of Mathematical Sciences, University of Texas at Dallas, Richardson, Texas
    Search for articles by this author
  • Adrianna C. Shembel
    Address correspondence and reprint requests to Adrianna C. Shembel, 1966 Inwood Road, Room A.128, Dallas, TX 75235, 972-883-3063.
    School of Behavioral and Brain Sciences, Department of Speech, Language, and Hearing, University of Texas at Dallas, Richardson, Texas

    Department of Otolaryngology-Head and Neck, Voice Center, University of Texas Southwestern Medical Center, Dallas, Texas
    Search for articles by this author



      Interoception may play a role in how individuals perceive their voice disorder. The first objective of this study was to investigate relationships between interoception and voice disorder class (functional, structural, neurological). The second objective was to determine relationships between interoception and voice-related outcome measures between patients with functional voice and upper airway disorders and typical voice users. The third objective was to determine whether patients with primary muscle tension dysphonia (a type of functional voice disorder) had different levels of interoceptive awareness than typical voice users.

      Study Design

      Prospective cohort study.


      One hundred subjects with voice disorders completed the multidimensional assessment of interoceptive awareness-2 (MAIA-2). Voice diagnosis and singing experience were also acquired from each patient's medical chart. Voice handicap (VHI-10) and Part 1 of the vocal fatigue index (VFI-Part1) scores were obtained from patients diagnosed with functional voice and upper airway disorders. MAIA-2, VHI-10, VFI-Part1, and singing experience were also obtained from 25 typical voice users. Multivariable linear regression models were used to assess the association between response variables and voice disorder class, adjusting for singing experience, gender, and age.


      There were no significant group differences between voice disorder class (functional, structural, neurological) after adjusting for multiple comparisons. Participants with functional voice and upper airway disorders who scored significantly higher on the VHI-10 and VFI-Part1 had lower Attention Regulation sub-scores on the MAIA-2 (P's<0.05). Patients with primary muscle tension dysphonia scored significantly lower on the Emotional Awareness MAIA-2 subscale than typical voice users (P=0.005).


      Patients with functional voice disorders with lower capabilities to attend to body sensations may score higher on voice-related patient-reported outcome measures, like the VHI-10 and VFI-Part1. Patients with primary muscle tension dysphonia may also have lower capabilities in processing their body sensations than typical voice users.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Voice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Calì G
        • Ambrosini E
        • Picconi L
        • et al.
        Investigating the relationship between interoceptive accuracy, interoceptive awareness, and emotional susceptibility.
        Front Psychol. 2015; 6 (Accessed March 8, 2022. Available at:): 1202
        • Forkmann T
        • Scherer A
        • Meessen J
        • et al.
        Making sense of what you sense: disentangling interoceptive awareness, sensibility and accuracy.
        Int J Psychophysiol. 2016; 109: 71-80
        • Ceunen E
        • Van Diest I
        • Vlaeyen J
        Accuracy and awareness of perception: related, yet distinct (commentary on Herbert et al., 2012).
        Biol Psychol. 2013; 92: 426-427
        • Garfinkel SN
        • Critchley HD
        Interoception, emotion and brain: new insights link internal physiology to social behaviour. Commentary on:: “Anterior insular cortex mediates bodily sensibility and social anxiety” by Terasawa et al. (2012).
        Soc Cogn Affect Neurosci. 2013; 8: 231-234
        • Ueno D
        • Matsuoka T
        • Kato Y
        • et al.
        Individual differences in interoceptive accuracy are correlated with salience network connectivity in older adults.
        Front Aging Neurosci. 2020; 12 (Accessed November 8, 2022. Available at:)
        • Schandry R
        Heart beat perception and emotional experience.
        Psychophysiology. 1981; 18: 483-488
        • Garfinkel SN
        • Seth AK
        • Barrett AB
        • et al.
        Knowing your own heart: distinguishing interoceptive accuracy from interoceptive awareness.
        Biol Psychol. 2015; 104: 65-74
        • Mehling WE
        • Acree M
        • Stewart A
        • et al.
        The multidimensional assessment of interoceptive awareness, version 2 (MAIA-2).
        PLoS One. 2018; 13e0208034
        • Vlemincx E
        • Walentynowicz M
        • Zamariola G
        • et al.
        A novel self-report scale of interoception: the three-domain interoceptive sensations questionnaire (THISQ).
        Psychol Health. Published online December 7, 2021; : 1-20
        • Mehling WE
        • Price C
        • Daubenmier JJ
        • et al.
        The multidimensional assessment of interoceptive awareness (MAIA).
        PLoS One. 2012; 7: e48230
        • Atanasova K
        • Lotter T
        • Reindl W
        • et al.
        Multidimensional assessment of interoceptive abilities, emotion processing and the role of early life stress in inflammatory bowel diseases.
        Front Psychiatry. 2021; 12680878
        • Borg C
        • Chouchou F
        • Dayot-Gorlero J
        • et al.
        Pain and emotion as predictive factors of interoception in fibromyalgia.
        J Pain Res. 2018; 11: 823-835
        • Flasinski T
        • Dierolf AM
        • Rost S
        • et al.
        Altered interoceptive awareness in high habitual symptom reporters and patients with somatoform disorders.
        Front Psychol. 2020; 11 (Accessed March 8, 2022. Available at:): 1859
        • Park YL
        • Hunter J
        • Sheldon BL
        • et al.
        Pain and interoceptive awareness outcomes of chronic pain patients with spinal cord stimulation.
        Neuromodulation. 2021; 24: 1357-1362
        • Crow KM
        • van Mersbergen M
        • Payne AE
        Vocal congruence: the voice and the self measured by interoceptive awareness.
        J Voice. 2021; 35: 324.e15-324.e28
        • Schirmer-Mokwa KL
        • Fard PR
        • Zamorano AM
        • et al.
        Evidence for enhanced interoceptive accuracy in professional musicians.
        Front Behav Neurosci. 2015; 9 (Accessed November 3, 2022. Available at:): 349
        • Misono S
        • Dietrich M
        • Piccirillo JF
        The puzzle of medically unexplained symptoms—a holistic view of the patient with laryngeal symptoms.
        JAMA Otolaryngol Head Neck Surg. 2020; 146: 550-551
        • Piersiala K
        • Akst LM
        • Hillel AT
        • et al.
        Chronic pain syndromes and their laryngeal manifestations.
        JAMA Otolaryngol Head Neck Surg. 2020; 146 (Published online April 30): 543-549
        • D'Alessandro G
        • Cerritelli F
        • Cortelli P
        Sensitization and interoception as key neurological concepts in osteopathy and other manual medicines.
        Front Neurosci. 2016; 10 (Accessed February 1, 2023. Available at:): 100
        • Shembel AC
        • Lee J
        • Sacher JR
        • et al.
        Characterization of primary muscle tension dysphonia using acoustic and aerodynamic voice metrics.
        J Voice. Published online July 17, 2021;
        • Gillespie AI
        • Gartner-Schmidt J
        Immediate effect of stimulability assessment on acoustic, aerodynamic, and patient-perceptual measures of voice.
        J Voice. 2016; 30: 507-5e9
        • Verdolini K
        • Rosen CA
        • Branski RC
        Classification Manual for Voice Disorders-I.
        Psychology Press, 2005 (Accessed November 17, 2013. Available at:)
        • Nanjundeswaran C
        • Jacobson BH
        • Gartner-Schmidt J
        • et al.
        Vocal fatigue index (VFI): development and validation.
        J Voice. 2015; 29: 433-440
        • Nanjundeswaran C
        • Shembel AC
        Laying the groundwork to study the heterogeneous nature of vocal fatigue.
        J Voice. 2022; (Published online August 6)
        • Shembel AC
        • Nanjundeswaran C
        Potential biophysiological mechanisms underlying vocal demands and vocal fatigue.
        J Voice. 2022; (Published online August 23)
      1. R Core Team. A language and enviroment for statistical computing. 2022. Available at:

        • Holm S
        A simple sequentially rejective multiple test procedure.
        Scand J Stat. 1979; 6: 65-70
        • Drane DL
        • Fani N
        • Hallett M
        • et al.
        A framework for understanding the pathophysiology of functional neurological disorder.
        CNS Spectr. 2020; 4: 1-7
        • McDowell S
        • Morrison R
        • Mau T
        • et al.
        Clinical characteristics and effects of vocal demands in occupational voice users with and without primary muscle tension dysphonia.
        J Voice. 2022; (Published online In Proof)
        • Vertigan AE
        • Gibson PG
        • Theodoros DG
        • et al.
        The role of sensory dysfunction in the development of voice disorders, chronic cough and paradoxical vocal fold movement.
        Int J Speech Lang Pathol. 2008; 10: 231-244
        • Vertigan AE
        • Bone SL
        • Gibson PG
        Laryngeal sensory dysfunction in laryngeal hypersensitivity syndrome.
        Respirology. 2013; 18: 948-956
        • Morrison M
        • Rammage L
        The irritable larynx syndrome as a central sensitivity syndrome.
        Can J Speech Lang Pathol Audiol. 2010; 34: 282-289
        • van MM
        • Patrick C
        • Glaze L
        Functional dysphonia during mental imagery: testing the trait theory of voice disorders.
        J Speech Lang Hear Res. 2008; 51: 1405-1423
        • Cohen J
        Statistical Power Analysis for the Behavioral Sciences.
        2nd ed. Routledge, 2013