Given the complex intertwined relationships between speech fluency and anxiety, it is not surprising that there will be adults who stutter who have Social Anxiety Disorder related to speech fears.
It is noteworthy that some adults who stutter have a Generalized Social Anxiety Disorder, meaning they have significant social and performance difficulties, and these difficulties may extend beyond speech. (Blumgart, 2010). The presence of Social Anxiety Disorder, or other mental health diagnoses, has been shown to predict relapse from speech restructuring treatment (Iverach, 2009). However, of the many psychiatric diagnoses potentially co-existing with stuttering, Social Anxiety Disorder has unique significance to speech pathologists for two reasons. Firstly it is by far the most common stuttering-associated disorder (Iverach, 2009), and secondly it logically impacts on the ability to speak well and comfortably.
Therefore, given the direct impact that Social Anxiety Disorder has on speech as well as the recommendation by numerous governing bodies internationally (Rose et al., 2015) that health providers routinely screen for mental health problems that have potential to impact the patient as well as therapeutic progress, we strongly recommend that adults who stutter should be routinely screened for Social Anxiety Disorder. This can be achieved using any one of the many freely-available and validated assessments (see Appendix A for sample instruments). If such screening identifies potential Social Anxiety Disorder, the Speech Language Pathologist must be aware of the negative effects of safety behaviour formation (see Appendix B) and ensure that the full plan for treatment addresses the complete range of the patient/client's functional impairment. As appropriate, this could include referral to specialists in allied disciplines such as clinical psychology and psychiatry.
Blumgart, E., Tran, Y., & Craig, A. (2010). Social anxiety disorder in adults who stutter. Depression and Anxiety, 27, 687–692.
Connor K. M., Davidson J. R., Churchill L. E., Sherwood A., Weisler R.H. (2000). Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale. The British Journal of Psychiatry176: 379-386.
Cream A., Onslow M., Packman A., Llewellyn G. (2003). Protection from harm: the experience of adults after therapy with prolonged-speech. Int. J.Lang.Comm.Dis., 38, 379-395.
Finn P., Howard R., Kubalab R. (2005) Unassisted recovery from stuttering: Self-perceptions of current speech behavior, attitudes, and feelings. Journal of Fluency Disorders 30, 281–305.
Fresco, D. M., Coles, M E., Heimberg, R.C., Liebowitz, M.R., Hami S., Stein , M. R., Goetz, D. (2001). The Liebowitz Social Anxiety Scale: a comparison of the psychometeric properties of self-report and clinician administered formats. Psychological Medicine, 31, (6) 1025 –1035.
Helgadottir F.D., Menzies R. G., Onslow M., Packman A., O’Brian S., (2014) Safety Behaviors and Speech Treatment for Adults Who Stutter. Journal of Speech, Language, and Hearing Research, Vol. 57, 1308-1313.
Holaway R.M., and Heimberg R.G. (2004) In Bandelow, B. & Stein, D..J. (eds) Social Anxiety Disorder. N.Y. Marcel Dekker, Inc.
Iverach, L., Jones, M., O’Brian, S., Block, S., Lincoln, M., Harrison, E., et al. (2009). The relationship between mental health disorders and treatment outcomes among adults who stutter. Journal of Fluency Disorders, 34, 29–43.
Kraaimaat, F.W., Vanryckeghem, M. & Van Dam-Baggen, R. (2002). Stuttering and social anxiety. Journal of Fluency Disorders, 27, 319-331.
Lovibond,P.F., Mitchell,C.J., Minard,E., Brady,A., Menzies,R.G. (2009). Safety behaviours preserve threat beliefs: Protection from extinction of human fear conditioning by avoidance response. Behaviour Research and Therapy, 47, 716-720.
Menzies, R., Onslow, M., & Packman, A. (1999). Anxiety and stuttering: Exploring a complex relationship. American Journal of Speech-Language Pathology, 8, 3–10.
Menzies, R., O’Brian, S., Onslow, M., Packman, A., St Clare, T., & Block, S. (2008). An experimental clinical trial of a cognitive behavior therapy package for chronic stuttering. Journal of Speech, Language and Hearing Research, 51, 1451–1464.
Perkins,W. H. (1990). What is stuttering? Journal of Speech and Hearing Disorders, 55, 370-382
Plexico L., Manning W., DiLollo A.(2005) A phenomenological understanding of successful stuttering management. Journal of Fluency Disorders 30, 1–22
Ranta K.,Kaltiala-Heino R., Rantanen P.,Tuomisto M. T., Marttunen M. (2007). Screening social phobia in adolescents from general population: The validity of the Social Phobia Inventory (SPIN) against a clinical interview. European Psychiatry 22, 247 -251
Rose, G. L., Ferraro, T. A., Skelly, J. M., Badger, G. J., MacLean, C. D., Fazzino, T. L., & Helzer, J. E. (2015). Feasibility of automated pre-screening for lifestyle and behavioral health risk factors in primary care. BMC Family Practice, 161-9. doi:10.1186/s12875-015-0368-9
Schneirer,F.R., Wexler,K.B., Liebowitz, M.R. (1997) Social Phobia and Stuttering, American Journal of Psychiatry, 154(1),131
Stein, M., Baird, A., & Walker, J. (1996). Social phobia in adults with stuttering. American Journal of Psychiatry, 153, 278–280.
Yairi, E., Ambrose N. (2013). Epidemiology of stuttering: 21st century advances. Journal of Fluency Disorders. 38, 6687
Appendix A: Freely available Screens which have been validated against clinical diagnosis of Social Anxiety Disorder (SAD)
SCREENS FOR ADULTS
Mini-SPIN (A 3 question survey able to produce 90% accuracy in diagnosing the presence or absence of Generalized Social Anxiety Disorder)
Please score these three items about avoidance and fear of embarrassment that you rate based on the past week.
The items are scored using the following rating: 0 = not at all, 1 = a little bit, 2 = somewhat, 3 = very much, 4 = extremely.
- Fear of embarrassment causes me to avoid doing things or speaking to people.
- I avoid activities in which I am the centre of attention.
- Being embarrassed or looking stupid are among my worst fears.
TOTAL SCORE …………
(A score of 6 indicates the likely presence of Generalised Social Anxiety Disorder)
Other Widely Used Screens for Social Anxiety Disorder (Information on each of these screens can be sourced from ……https://en.wikipedia.org/wiki/Social_anxiety_disorder#Diagnosis)
Liebowitz Social Anxiety Scale. (LSAS)
Social Phobia Inventory (SPIN)
Social Phobia and Anxiety Inventory (SPAI)
SCREENS FOR CHILDREN
Google links are available to the following……
Spence Children’s Anxiety Scale (SCAS)
Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R)
Safety behaviours (also known as Safety-seeking behaviours) are a common complication to treatment of anxiety disorders such as Social Anxiety Disorder. This occurs because, even though a behaviour may be of short term benefit, in the long term the client comes to attribute ability to cope socially with the use of the behaviour rather than by re-evaluation of the apparent social threat. The use of safety behaviours comes to be regarded by the client as necessary for perceived social competence and/or reduction of anticipated distress. This has the counter-productive effect of maintaining the anxiety.
Examples of safety behaviours used in cases of Social Anxiety Disorder are..
- Sitting in the back of the room;
- Wearing clothes that don’t show sweating or blushing;
- Carrying water in case of dry-mouth;
- Making sure people are friendly;
- Avoiding eye contact
Clients accustomed to using these behaviours become extremely anxious when either they are encouraged or, through circumstance, forced to give them up.
It is helpful for Speech Language Pathologists (SLPs) and clients to be aware that the goals of dysfluency reduction can be at odds with the long term goals of social anxiety reduction. That is in the quest to promote fluency SLPs must take care not to encourage safety behaviour formation. The results of a survey conducted by Helgadottir et al (2014) showed
“many SLPs working with those who stutter may be using safety behaviours as a means of managing social anxiety, and this could be having the effect of sustaining social anxiety…… For example, only 6% of SLPs surveyed claimed never to recommend the use of safe or easy speaking partners, 81% had recommended the use of safe speaking partners in socially threatening situations, and 92% had recommended rehearsing the opening line of telephone calls prior to making them. In addition, 57% of SLPs had recommended that clients avoid difficult words, while 52% had recommended avoidance of difficult syllables when anxious. It was surprising that 51% of SLPs surveyed had even recommended avoiding unnecessary talking as a means of controlling anxiety.” JSHR p1311.
Of course the use of these strategies may be appropriate when they are used as part of a well-monitored desensitization programme.
Finally it is likely that, without a continued focus on social anxiety reduction, a speech restructuring technique itself may come to be used by the client as a safety behaviour. The IFA advises both therapists and clients to be aware of this possibility.