Table 1

A model of predisposing, precipitating and perpetuating risk factors for functional communication, swallowing and cough disorders7 13 14 34 48

Predisposing vulnerabilities
  • Genetic factors.

  • Previous functional symptoms and disorders.

  • Pre-existing medical illness, especially affecting communication, for example, traumatic brain injury.

  • Biological vulnerabilities in nervous system, lower/upper respiratory system, head and neck.

  • Personality traits (neuroticism, low social potency, stress reactivity, emotional inhibition, low self-esteem, perfectionism).

  • Interpersonal difficulties.

  • Suggestibility.

  • Coping styles.

  • Attachment profiles.

  • Mood, anxiety and trauma-related disorders.

  • Adverse life events.

  • Stress.

  • Poor relationships.

  • Symptom modelling (eg, of family members).

Precipitating mechanisms
  • Physical injury; strain/pain; surgery; medical illness.

  • Habituated muscle tension patterns; dysregulated movement patterns; excessive inhibition of movement.

  • Viral infection affecting upper or lower respiratory tract.

  • Inhaled toxic substances.

  • Exposure to noxious odours.

  • Historical or recent choking incident with persisting belief something still caught in the throat.

  • Drug/medication induced side effect.

  • Severe fatigue.

  • Dilemmas with forced choices leading to negative consequences.

  • Ambivalence over expression of negative emotions, conflict over speaking out, sense of entrapment.

  • Anticipation of difficult encounter, illness or pending surgical procedure.

  • Significant adverse life events

  • Interpersonal stress

Perpetuating factors
  • Hypersensitivity to subtle changes in air pressure, temperature, sensation in respiratory and vocal tract.

  • Physiological arousal.

  • Pain.

  • Fear—avoidance.

  • Tendency to ‘all or nothing’ or catastrophic thinking.

  • Perception that voice use or swallowing are dangerous, harmful, effortful.

  • Hypervigilance and excessive self-monitoring.

  • Belief that symptoms are due to damage or suspected or confirmed disease/illness; unusual illness beliefs.

  • Entrenched symptoms have become part of one’s sense of self or personal identity.

  • Litigation or disability compensation issues.

  • Medical uncertainty.

  • Excessive reliance on unreliable sources of information.

  • Stigma.

  • A given factor may cut across a range of components within the biopsychosocial formulation. For example, in some individuals altered threat/emotion processing may be both a predisposing vulnerability and a perpetuating factor.