Comparison of adults who stutter with and without social anxiety disorder
Introduction
Stuttering is a common speech disorder marked by involuntary interruptions to speech. These interruptions can have a profound impact on communication and social participation throughout life. A growing body of research has confirmed that stuttering has a genetic basis (Domingues et al., 2014), with deficits in neural processing identified as a possible causal factor (Etchell, Johnson, & Sowman, 2014). The lifetime incidence of stuttering is approximately 4–5%, with a 1% point prevalence (Bloodstein & Bernstein Ratner, 2008). Stuttering typically starts in the preschool years when children are learning to put words into sentences (Yairi, Ambrose, & Cox, 1996). Recent evidence has shown that 8.5% of children are affected by stuttering at age 3 years, with a cumulative incidence of 11% at age 4 years, and only 6.3% natural recovery during the first year after onset (Reilly et al., 2013). When natural recovery does not occur, stuttering is often associated with an accumulation of social, psychological, educational, and occupational disadvantages across the lifespan.
Social anxiety disorder is a prevalent anxiety disorder with a chronic and debilitating trajectory (Ruscio et al., 2008; Slade et al., 2009; Stein & Kean, 2000). A defining feature of the disorder is an excessive, intense, and unreasonable fear of social-evaluative situations where negative evaluation is possible (American Psychiatric Association, 2013). This anxiety can occur across a broad range of situations, such as socializing at parties, meeting new people, public speaking, giving presentations, and speaking to authority figures at work (Ballenger et al., 1998). Social anxiety disorder typically develops in childhood or adolescence when social and peer relationships are growing in importance. It has an average age of onset between 14 and 16 years (Kessler et al., 2005; Ollendick & Hirshfeld-Becker, 2002), and lifetime prevalence in the general community is estimated at 8–13% (Kessler et al., 2005; Ruscio et al., 2008; Somers, Goldner, Waraich, & Hsu, 2006).
Socially anxious individuals tend to avoid or perform poorly in social, educational, and occupational situations. This avoidance can severely hamper social development, overall functioning, and quality of life (Stein & Kean, 2000). Social anxiety disorder is more prevalent among females and is frequently associated with lower educational attainment, increased unemployment, financial dependency, lower socioeconomic status, less likelihood of being involved in a personal relationship, reduced quality of life, greater utilization of health services, psychological distress, and the comorbid presence of other mental disorders such as depression and substance use (Australian Bureau of Statistics, 2008; Katzelnick et al., 2001; Lipsitz & Schneier, 2000; Schneier et al., 1994; Slade et al., 2009; Stein & Kean, 2000; Wittchen & Fehm, 2003). This comorbidity tends to compound symptom severity, life interference, and functional impairment (Ballenger et al., 1998). Without treatment, social anxiety disorder is associated with a chronic and debilitating life trajectory. It also leads to significant social and economic burden relating to the ongoing costs associated with treatment, health care, disability, and social welfare (Wittchen & Fehm, 2003).
A growing body of evidence has established that stuttering is frequently associated with social anxiety. Across these studies, a significant proportion of adults who stutter have been found to meet criteria for social anxiety disorder (Blumgart, Tran, & Craig, 2010; Iverach, O’Brian, et al., 2009; Menzies et al., 2008; Stein, Baird, & Walker, 1996). In the only study to evaluate the prevalence of anxiety disorders among adults who stutter and non-stuttering controls using a structured diagnostic interview, 22% of adults seeking treatment for stuttering met criteria for social anxiety disorder compared to only 1.2% of non-stuttering controls from the general community (Iverach, O’Brian, et al., 2009). Whilst it was initially thought that these findings might only apply to adults who stutter, recent evidence suggests that social anxiety disorder may also be prevalent among school-age children who stutter (Iverach, Jones et al., 2016). In particular, 24% of school-age children (7–12 years) seeking treatment for stuttering met criteria for social anxiety disorder, compared to only 4% of non-stuttering control children (Iverach, Jones et al., 2016). This suggests that social anxiety disorder in stuttering may develop earlier than previously thought. Having said this, it should be noted that other studies have failed to find heightened anxiety scores in school age children who stutter (Messenger, Packman, Onslow, Menzies, & O’Brian, 2015; Smith et al., 2017).
Several etiological risk factors associated with the development of social anxiety are relevant to stuttering. Foremost among these, the negative social conditioning experienced by children, adolescents, and adults who stutter across the lifespan is considered to be a prominent risk factor for social anxiety disorder (Iverach & Rapee, 2014; Iverach, Rapee, Wong, & Lowe, 2017). Research has confirmed that these negative experiences commence early, with evidence of bullying, teasing, exclusion, and negative peer reactions among preschool children who stutter (Langevin, Packman, & Onslow, 2009; Packman, Onslow, & Attanasio, 2003). As children move through the school years and adolescence, these negative experiences are often exacerbated by the increased importance of peer relationships. For instance, children and adolescents who stutter frequently experience peer victimization, isolation and rejection, and may be rated as less popular and less likely to have leadership potential than their non-stuttering classmates (Blood et al., 2011; Davis, Howell, & Cooke, 2002; Hearne, Packman, Onslow, & Quine, 2008). Children who stutter are also significantly more likely to repeat a grade at school than non-stuttering children (Boyle, Decoufle, & Yeargin-Allsopp, 1994), with those educational problems not explained by lower intelligence (Bloodstein & Bernstein Ratner, 2008). As a result of those experiences, stuttering is associated with several risk factors for the development of social anxiety, including low self-esteem, reduced school performance, fear of negative evaluation, and social embarrassment (Hudson & Rapee, 2009).
Not surprisingly, retrospective reports from adults who stutter indicate that stuttering had an extremely damaging impact on school life, with negative long-term implications for emotional and social functioning (Blood & Blood, 2016; Daniels, Gabel, & Hughes, 2012; Hayhow, Cray, & Enderby, 2002; Hugh-Jones & Smith, 1999). These adverse outcomes continue into adulthood, with many adults who stutter experiencing negative listener reactions, stereotypes and stigma, relationship difficulties, and long-term educational and occupational disadvantages (Boyle, 2013; Healey, 2010; Klein & Hood, 2004; Van Borsel, Brepoels, & De Coene, 2011). For instance, people who stutter may be viewed as less attractive and with lower opportunities for romantic relationships (Van Borsel et al., 2011). They also report reduced chances of employment and promotion, interference with job performance, and increased likelihood of turning down a job or promotion (Klein & Hood, 2004). Employers have also reported that adults who stutter are less employable and promotable than their non-stuttering peers (Hurst & Cooper, 1983). The occupational stereotyping and role entrapment experienced by adults who stutter (Logan & O’Connor, 2012) have implications for long-term quality of life and socioeconomic status. For instance, a birth cohort study has confirmed lower socioeconomic status for those who stutter when compared to non-stuttering peers (McAllister, Collier, & Shepstone, 2012). Numerous studies have also documented poor quality of life and emotional, social, and psychological dysfunction among adults who stutter (Craig, Blumgart, & Tran, 2009).
Both stuttering and social anxiety disorder are prevalent and chronic conditions with debilitating life trajectories. Social anxiety disorder, in particular, is typically associated with demographic characteristics such as increased unemployment, lower socioeconomic status, financial dependency, and being single and/or female (Australian Bureau of Statistics, 2008; Katzelnick et al., 2001; Lipsitz & Schneier, 2000; Schneier et al., 1994; Slade et al., 2009; Stein & Kean, 2000; Wittchen & Fehm, 2003). It is also associated with increased psychological distress, emotional and social problems, life stress, and the comorbid presence of other mental disorders such as depression (Australian Bureau of Statistics, 2008; Katzelnick et al., 2001; Lipsitz & Schneier, 2000; Schneier et al., 1994; Slade et al., 2009; Stein & Kean, 2000; Wittchen & Fehm, 2003). These burdens may be multiplied for adults who stutter, and may impact overall functioning.
Therefore, the purpose of the present study is to evaluate overall functioning for adults who stutter with and without a diagnosis of social anxiety disorder. Specifically, the present study will compare demographic, speech, and psychological variables for a clinical sample of adults seeking speech treatment for stuttering and/or cognitive behavior therapy (CBT) for anxiety in stuttering with and without a diagnosis of social anxiety disorder. Based on the literature reviewed documenting the psychosocial difficulties associated with stuttering and social anxiety disorder, it was hypothesized that adults who stutter with social anxiety disorder, compared to those who stutter without social anxiety disorder, will demonstrate greater speech and psychological difficulties, including significantly greater: (1) avoidance of speaking situations, (2) negative overall impact of stuttering, (3) social, emotional, and behavioral difficulties, (4) depressive symptomatology, (5) life stress, and (6) unhelpful thoughts and beliefs about stuttering. In addition, this study will also explore whether the presence of social anxiety disorder is associated with: (1) more negative speech outcomes, including speech dissatisfaction, self-rated stuttering severity, and clinician-rated stuttering severity; and (2) more negative demographic characteristics, including age, gender, relationships status, employment, and household income. No predictions for these latter speech and demographic variables were determined a priori, given the current lack of evidence regarding the impact of social anxiety disorder on speech and demographic variables for adults who stutter. Findings from this study will contribute new knowledge about whether additional psychosocial support is required for adults who stutter with social anxiety disorder in order to improve overall life functioning.
Section snippets
Participants
Adults who stuttered were drawn from treatment waiting lists across seven university-affiliated stuttering treatment clinics across Australia and New Zealand (Australian Stuttering Research Centre, The University of Sydney; School of Human Communication Sciences, La Trobe University, Melbourne; Discipline of Speech Pathology, The University of Sydney; Department of Linguistics, Macquarie University, Sydney; School of Humanities and Social Science, University of Newcastle; Royal Prince Alfred
Results
Of the 275 participants included in the present study, nearly one-third met criteria for a diagnosis of social anxiety disorder (n = 82, 29.8%), and the remaining 193 participants did not meet criteria (70.2%). This rate of social anxiety disorder corresponds with rates reported in previous studies of adults seeking treatment for stuttering (Blumgart et al., 2010; Iverach, O’Brian, et al., 2009; Iverach et al., 2011; Stein et al., 1996). Demographic, speech, and psychological variables were
Discussion
The purpose of the present study was to evaluate overall functioning for a clinical sample of adults who stuttered with and without social anxiety disorder. Both stuttering and social anxiety disorder are prevalent conditions that have a chronic and disabling impact across the life span. Independently, each disorder negatively impacts quality of life, social participation, educational and occupational achievement, and socioeconomic status. The co-occurrence of both disorders has the potential
Acknowledgements
This research was supported by funding from the National Health and Medical Research Council of Australia (NHMRC), Program Grant #633007 awarded to the Australian Stuttering Research Centre at the University of Sydney, Australia.
Dr Lisa Iverach is a Senior Research Fellow at the Australian Stuttering Research Centre, The University of Sydney, and an Honorary Associate with the Department of Psychology, Macquarie University. She was previously funded by an Early Career Fellowship from the National Health and Medical Research Council, based at the Centre for Emotional Health, Macquarie University. Her research interests include the relationship between stuttering and anxiety, and the mental health of people who stutter.
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Dr Lisa Iverach is a Senior Research Fellow at the Australian Stuttering Research Centre, The University of Sydney, and an Honorary Associate with the Department of Psychology, Macquarie University. She was previously funded by an Early Career Fellowship from the National Health and Medical Research Council, based at the Centre for Emotional Health, Macquarie University. Her research interests include the relationship between stuttering and anxiety, and the mental health of people who stutter.
Dr Mark Jones is a Senior Lecturer in Biostatistics at the School of Public Health, University of Queensland. He obtained his PhD at the Australian Stuttering Research Centre, University of Sydney, and has a strong research interest in stuttering.
Dr Robyn Lowe is a researcher at the Australian Stuttering Research Centre. Her research interests include exploring the psychological aspects associated with stuttering and how this impacts the long-term maintenance of speech treatment benefits. Robyn is involved in the development and evaluation of online speech and anxiety treatment programs for stuttering.
Dr Sue O’Brian is a Senior Researcher at the Australian Stuttering Research Centre. She has extensive experience in the field of stuttering treatment and research. Her current interests include the effectiveness of early stuttering intervention in community settings, development of treatments for adults who stutter and stuttering measurement.
Associate Professor Ross Menzies is a clinical psychologist with an interest in the origins and management of anxiety. He has developed cognitive behaviour therapy packages for the treatment of obsessive compulsive disorders and published theories of the origins of phobias. He is currently the director of the Anxiety Clinic at The University of Sydney.
Associate Professor Ann Packman is a Principal Research Fellow at the Australian Stuttering Research Centre. She has worked for more than 30 years in the area of stuttering as a clinician, teacher and researcher. One of her current interests is theories of the cause of stuttering.
Professor Mark Onslow is the foundation Director of the Australian Stuttering Research Centre at The University of Sydney. His research interests are epidemiology of early stuttering, mental health and stuttering, measurement of stuttering, and clinical trials for the disorder.