Study of the Influence of Psychological Factors in the Etiology of Vocal Nodules in Women *M. El Uali Abeida, †R. Fern andez Liesa, ‡H. Vall  es Varela, †J. Garc  ıa Campayo, †P. Rueda Gormedino, and †A. Ortiz Garc  ıa, *Soria, yzZaragoza, Spain Summary: Objective. The role placed by certain psychological factors such as stress and personality on the devel- opment of vocal nodules has not yet been established. The aim of this case-control type study is to analyze the relation- ship between these psychological factors and the presence of vocal nodules while also considering the professional and social aspects of the subjects suffering from this pathology. Methods. The case group is made up of 50 patients diagnosed with vocal nodules and with at least 6 months of evo- lution. The control group is made up of 50 patients diagnosed with nasal respiratory insufficiency. All the patients were examined by laryngeal stroboscopy. For the personality study, the perceived stress, and the voice use, the Minnesota Multiphasic Personality Inventory-2, Levenstein Perceived Stress Questionnaire, and Goldman Voice Use Survey were used, respectively. Results. The subjects with vocal nodules presented a mean perceived stress score of 0.41 ± 0.09, which was higher than that of the control group (0.35 ± 0.06), the differences observed being statistically significant (P < 0.001). In the personality study (MMPI-2), the only scale that was associated with the presence of the vocal nodules was that of psy- chomotor acceleration. The mean score obtained for the scale was 51.64 ± 8.25 in the vocal nodule group and 45.02 ± 0.06 in the control group (P < 0.001). In the analysis of voice use, the subjects with vocal nodules scored 9.31 ± 1.36, which was significantly higher than the score of the control group (8.07 ± 1.24; P < 0.001). In addition, other variables were associated with the presence of vocal nodules, such as being young and working in professions considered to be of vocal risk. Conclusions. Perceived stress and personality features of hyperactivity and impulsivity are independent factors re- lated to vocal nodules. Key Words: Vocal nodules–Personality–Perceived stress. INTRODUCTION Vocal nodules are small lesions situated in the union of the middle third with the anterior third of the vocal folds, classi- cally related to vocal trauma. They are lesions in the superfi- cial layer of the lamina propria caused by an intense vibration that alters the tissue, with an excessive deposit of collagen IV and fibronectin. 1,2 The prevalence of vocal nodules in the general population may be between 0.5 and 1.3 of the visits to the otolaryngologist and represents between 15% and 35% of all benign laryngeal pathology. 3–5 In adults, they are much more frequent in women (94.5%) than in men. 2,6 The group of the population where these disorders cause most impact is that which uses the voice professionally. In a study of 527 teachers, Preciado et al 7 found a prevalence of vocal disorders of 57%, where 20% were or- ganic lesions, the majority vocal nodules (13.8%). The role played by certain psychological factors, such as stress and personality, in the development of vocal nodules is still unclear, and the physiopathological mechanism and the direction of this association are not yet well known. 8–13 With re- gard to stress, Aronson 14 suggested that although vocal nodules appear as the only result of vocal abuse, the subjects who suffer these disorders often report concomitant emotional stress. Other authors, such as Morrison and Rammage (1993), 11 established that in some individuals, the misuse of the laryngeal muscles could be a direct result of psychological stressors triggering the vocal fold trauma and the development of secondary organic pathology such as nodules. In the area of personality, various authors have indicated that the subjects were talkative, socially aggressive, extrovert, and hostile, characteristics that lead to ag- gressive vocal behavior. 15–17 No studies have been published that analyze the conjoint involvement of these factors, which is what this article sets out to do. METHODS Subjects Fifty patients were systematically selected over 1 year who had been diagnosed with vocal nodules and seen as outpatients in our center. The group was made up of women aged 18 years or older with vocal nodules and with a clinical evolution of at least 6 months. Excluded from the study were men (because of the low frequency of vocal nodules in adult men) and patients with antecedents of another laryngeal pathology, psychopathol- ogy, and/or laryngopharyngeal reflux. The subjects who made up the control group were 50 women aged 18 years or older, diagnosed with septal deviation and selected at random. Excluded from this group were people with antecedents of another laryngeal pathology, psychopathol- ogy, and/or laryngopharyngeal reflux. Procedures A clinical interview was conducted with each participant, and the participants’ informed consent was requested for inclusion. Accepted for publication August 18, 2011. From the *General Hospital of Soria, Soria, Spain; yMiguel Servet Hospital, Zaragoza, Spain; and the zLozano Blesa Hospital, Zaragoza, Spain. Address correspondence and reprint requests to M. El Uali Abeida, Calle Eloy Mart  ınez, 19, 3  A, Zaragoza 50017, Spain. E-mail: mahfud_es@yahoo.com Journal of Voice, Vol. 27, No. 1, pp. 129.e15-129.e20 0892-1997/$36.00 Ó 2013 The Voice Foundation doi:10.1016/j.jvoice.2011.08.012