Research has been supportive of HoNOS, although some questions have been asked about whether it provides adequate coverage of the range and complexity of mental illness problems, and whether the fact that often only 3 of the 12 scales vary over time gives enough subtlety to accurately measure outcomes of treatment. Criticism
Since the 1980s, Paula Caplan has been concerned about the subjectivity of psychiatric diagnosis, and people being arbitrarily "slapped with a psychiatric label." Caplan says because psychiatric diagnosis is unregulated, doctors are not required to spend much time interviewing patients or to seek a second opinion. The Diagnostic and Statistical Manual of Mental Disorders can lead a psychiatrist to focus on narrow checklists of symptoms, with little consideration of what is actually causing the persons problems. So, according to Caplan, getting a psychiatric diagnosis and label often stands in the way of recovery.In 2013, psychiatrist Allen Frances wrote a paper entitled "The New Crisis of Confidence in Psychiatric Diagnosis", which said that "psychiatric diagnosis... still relies exclusively on fallible subjective judgments rather than objective biological tests." Frances was also concerned about "unpredictable overdiagnosis." For many years, marginalized psychiatrists (such as Peter Breggin, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality." More recently these concerns have come from insiders who have worked for and promoted the American Psychiatric Association (e.g., Robert Spitzer, Allen Frances).
Symptoms affecting quality of voice tend to worsen after speaking for long periods of time, or when speaking with increased volume. Many individuals who use their voice professionally find even a slight presence of symptoms to be problematic. However, some voice professionals are not impacted by the presence of vocal cysts. Vocal Dynamics
Vocal fold cysts cause the properties of the vocal folds to change. When a cyst is present on a vocal fold, the cover of the vocal fold becomes more stiff and increases in mass. The increased mass and stiffness tends to result in hyperkinetic muscular movement during phonation. Hyperkinetic movement is characterized by increased rigidity in the affected vocal fold(s). This hyperkinetic movement results in the voice being perceived as hoarse. (see Signs and Symptoms) Specifically, the presence of a vocal fold cyst leads to an asynchronous mucosal wave of the vocal folds during phonation. Causes
There are several possible causes of vocal fold cysts: 

They can be congenital. They can result from the blockage of a mucous glands excretory duct. In this case, they are sometimes referred to as retention cysts. They can be the result of phonotrauma. Phonotrauma refers to behaviours that can lead to vocal fold injuries, such as vocal overuse (i.e. too much speaking), vocal misuse (i.e. speaking in an unnaturally high or low pitch), or vocal abuse (i.e. yelling or whispering for prolonged periods). Vocal folds vibrate during phonation resulting in repeated collisions of the right and left vocal folds.