Professor Ashley Craig and Dr Yvonne Tran,
Department of Health Sciences, University of Technology, Sydney
Theories that have attempted to explain the causes of stuttering have often echoed the prevailing beliefs of the time. For example, in the mid 20th century there was a trend to believe that many diseases were psychosomatic in origin, that is, they were caused by psychological factors such as anxiety. Coronary heart disease was a case in hand as many believed it to be caused by Type A personality. A person with a Type A personality by definition had high levels of anxiety and hostility. However, evidence for a primary causal role of anxiety in heart disease is lacking and therefore these theories have been largely discarded. It is interesting though, that latest research indicates that anxiety is a risk factor for heart disease. People with high levels of anxiety have higher risks of experiencing heart attack.
In a similar way, the prevailing view in the 20th century assumed that stuttering was caused by psychological factors such as anxiety, in contrast to a physiological cause. Even though it was believed that anxiety caused stuttering, there is no evidence supporting this whatsoever (Craig, 2000). For instance, stuttering is a childhood disorder, and therefore, one would assume that if stuttering is caused by abnormal anxiety levels, then one should expect to see raised anxiety levels in children. We have not found that children who stutter are more chronically anxious about life than children who do not stutter (Craig, 2000).
The relationship between anxiety and stuttering
This debate on the relationship between stuttering and anxiety has been continuing for many years. Because of this, it is important to clarify the relationship between anxiety and stuttering. First, it is important to say that people who stutter (PWS) are not any different to those who do not stutter in terms of their personality or mood (Craig, 2000). We have looked long and hard, but we now believe that stuttering does not result from a special type of personality, nor is it caused by being depressed. Nonetheless, evidence does suggest that PWS have higher levels of social anxiety (Craig, 2000), in which the anxiety is more likely a consequence rather than a cause of stuttering. After all, speaking to others is an important social skill and experiencing an involuntary disruption to this skill will more than likely result in increased fears. Given the consequent social difficulties PWS can experience, we believe it is reasonable and rational to feel worried when, for instance, a PWS is faced with the prospect of feeling embarrassed and frustrated when attempting to get their opinion across in a group of fast speaking strangers (Craig, et al., 2003a). Research has found that many PWS are socially anxious people. As suggested above, this is not surprising given the circumstances and symptoms they experience. The raised anxiety could be considered a reasonable reaction to difficulties faced when dealing with the physical symptoms (eg blocking, repetitions of sounds, and so on.) and negative consequences of stuttering (awkwardness, disappointment, avoidance of speaking, negative social reactions etc.). The following evidence which has been discussed in some detail in Craig et al., (2003a), reinforces and supports the view that social anxiety is a consequence of stuttering.
- PWS feel more helpless and out of control about their life due to their stuttering.
- Children with speech disabilities have an increased risk of developing an anxiety disorder in their early adulthood. Teenagers who stutter have been shown to have higher levels of communication fears and worries than teenagers who do not stutter.
- Speaking in complex social interactions requiring increased speech demands results in higher risks of stuttering. This suggests that the more complex and difficult a conversation becomes, the higher the anxiety levels experienced, which in turn raises the risks of stuttering. We should not be surprised that stuttering is more likely to be associated with raised fears.
- Survey research has found that the majority of PWS believe their anxiety plays an important part in their stuttering and most clinicians who treat stuttering also believe anxiety to be an important component of the problem.
- A strong relationship exists between high levels of anxiety and high risks of relapse in those people successfully treated for stuttering. PWS who had relapsed following treatment have been shown to be three times more likely to experience high anxiety levels than those who have not experienced a relapse.
- Prior to receiving treatment, PWS generally have high levels of anxiety. After receiving successful treatment (in terms of substantially reducing stuttering), PWS are generally much less anxious.
Presumably, the above evidence suggests that chronic levels of socially related anxiety develop as a consequence of living with stuttering. The evidence also suggests that as a PWS grows older and is not treated, the sustained negative influence of stuttering can cause distress that, we argue, results in chronically raised anxiety levels. It is important to say though, that not every consequence of stuttering is negative. Many PWS have been able to adapt to their dysfluency in a very positive manner. Furthermore, almost 60% of PWS in the community have not ever sought treatment (Craig et al., 2002). When questioned, many of these people will say they were not severe enough to warrant seeking help.
One aspect of the relationship between anxiety and stuttering that has not yet been carefully studied is whether social anxiety is high in the average person who stutters in the community who has never sought treatment compared to those PWS who have sought out treatment. The problem is that research has almost always studied PWS who have been referred for treatment, and this we believe is a biased sample. It makes sense that those who stutter more severely would have higher levels of anxiety and therefore would seek out treatment more readily.
Are all people who stutter socially anxious?
This is a difficult question. To answer it convincingly, one would need to interview many thousands of people in order to find a large enough sized group of PWS to study. Remember the number of PWS who stutter in the community is not large. Our research (Craig et al., 2002) shows that it ranges from 1.4% in children (2% in boys, 0.8% in girls), down to 0.5% in adolescents (0.8% in boys, 0.2% in girls) to about 0.8% in adults (1.2% in males and 0.5% in females). Therefore, to answer the above question we interviewed over 12,000 people in 4,689 households in NSW: Households were selected randomly and were distributed across all of regional NSW so as to ensure the sample was representative of all people in NSW: From this large group we found 87 people who definitely stuttered. We measured their anxiety levels as well as their severity of stuttering. We also asked them whether they had ever sought or received treatment for their stuttering.
The results were interesting. As mentioned above, the majority (around 60%) had never sought treatment for reasons such as "I am not severe enough" and "I did not realise I stuttered". Surprisingly, the total stuttering sample was shown to have higher chronic anxiety levels than people who do not stutter. This suggests that PWS are at risk of developing higher levels of anxiety than expected, regardless of their severity of stuttering or whether they have had treatment or not. It is important to note that those who had received therapy at some time in their life were more anxious than those who had never sought treatment. Clearly, people who seek treatment are likely to be more anxious, simply because they are more severe. The group who had sought therapy were almost twice as severe in their stuttering (stuttering on almost 1 in 10 syllables) than those who had never received treatment (stuttering on almost 1 in 20 syllables), so it seems reasonable to conclude that more severe stuttering is associated with greater levels of social and psychological distress leading to higher levels of social anxiety. As a result, their worries and concerns lead them to seek professional help for their stuttering.
We also found that chronic anxiety levels increased with age, at least up to mid-adulthood. While children do not show abnormal levels of anxiety, anxiety did begin to increase into adolescence and continues to increase into adulthood. As one grows older increased social demands and skills are required to function in society. For a person who cannot always be fluent, this increased social and personal responsibility will take its toll and result in increased stress. If this stress is not dealt with appropriately, then negative outcomes may result, such as raised trait anxiety levels that can then result in negative personal and social stereotypes (Craig et al., 2003b), limited vocation prospects and social avoidance. Another quite important finding was the difference between male and female anxiety levels. We found that female PWS had consistently higher anxiety scores than male PWS, right across the lifespan. This information is crucial for improving the management and treatment of stuttering.
Implications for seeking help for stuttering
The above results are compelling in the sense that they argue strongly for inclusion of techniques for managing anxiety into stuttering treatment protocols. Clinicians who treat stuttering should be aware that people presenting for help with managing their stuttering are likely to have chronically raised levels of social anxiety. People who stutter should also be aware of the risks of not managing their own anxiety levels and they should therefore seek out appropriate help that offers assistance in managing their fears and worries. This is especially true for those PWS who are maturing through their teenage years and also for adults who stutter, and is especially true for females who stutter. It is important though, that the treatment received target the correct behaviour. It is clear that effective treatment that reduces stuttering symptoms will also to some degree result in a reduction of fear and anxieties as a result of the decreased stuttering. However, given the raised levels of anxiety in people who stutter, it may be wise to seek additional treatment that is designed to manage anxiety. Very effective programs have been designed and developed by the first author to achieve this goal of developing self-control over anxiety (Craig, 1998).
- learning how to control physical anxiety and tension associated with speech fears (towards relaxed speech)
- learning how to control anxious thoughts and feelings associated with stuttering (changing the way you think and talk)
- learning how to control anxiety through strengthening social skills and assertiveness (becoming a socially skilled speaker).
In conclusion, it is becoming clearer that a fluency disorder like stuttering, if it persists past the teenage years, is associated with higher levels of social anxiety. This is especially the case if their stuttering is severe enough to warrant therapy. It is also especially true for women. It is important that we should not be surprised that stuttering can cause distress serious enough to create social fears and anxieties. People who stutter should also be more willing to seek additional help that can offer professional guidance in helping them to control their anxiety. The future is in their hands.
To purchase the manual contact Ashley Craig, email: Ashley.Craig@uts.edu.au
This is a fuller version of an article appearing in the Summer 2005 edition of Speaking Out