Elsevier

Journal of Fluency Disorders

Volume 59, March 2019, Pages 21-32
Journal of Fluency Disorders

Exposure therapy for social anxiety disorder in people who stutter: An exploratory multiple baseline design

https://doi.org/10.1016/j.jfludis.2018.12.001Get rights and content

Highlights

  • An exposure therapy protocol was developed specifically for people who stutter and have social anxiety disorder.

  • Efficacy of intervention was evaluated utilizing a multiple baseline design.

  • Social anxiety reduced.

  • Affective, behavioral, and cognitive experiences of stuttering improved.

  • There was no consistent change in stuttering frequency.

Abstract

Background & objectives: Social anxiety disorder (SAD) is a debilitating condition, and approximately half of adults who stutter have SAD. Cognitive-behavioral therapy (CBT) has shown promise in decreasing social anxiety symptoms among adults who stutter, but exposure, arguably the essential component for successful CBT for SAD, has been understudied and underemphasized. Aims of this study were to develop an exposure therapy protocol designed specifically for people who stutter and have SAD and evaluate its potential efficacy in reducing social anxiety and stuttering severity using a multiple baseline design.

Methods: Six participants received ten sessions of exposure therapy. Participants reported daily social anxiety, and social distress and stuttering severity were evaluated at major assessment points.

Results: There were substantial reductions in social anxiety and considerable improvements in affective, behavioral, and cognitive experiences of stuttering. No consistent change was observed for stuttering frequency. Gains were mostly maintained after six-months.

Conclusions: Results suggest that the novel exposure approach may decrease social distress, but not necessarily influence speech fluency. These findings underscore the importance of the assessment and treatment of SAD among adults who stutter and suggest that the integration of care between clinical psychologists and speech-language pathologists may prove beneficial for this population.

Introduction

Stuttering is a communication disorder characterized by involuntary interruptions in the forward flow of speech (Bloodstein & Bernstein Ratner, 2008). Most fluency experts agree that stuttering consists of sound, syllable, or monosyllabic word repetitions; oral or silent sound prolongations; and broken words. Lifetime incidence of stuttering is approximately 5%, while at any given point in time, about 1% of the population stutters (Bloodstein & Bernstein Ratner, 2008; Yairi, 2016). While the majority of children who stutter recover naturally, an estimated 15–20% will chronically stutter (Craig, 2000; Yairi & Ambrose, 2005). Stuttering is associated with numerous negative outcomes. Children as young as three who stutter are more likely to demonstrate impaired behavioral, emotional, and social development compared to peers (McAllister, 2016), and adults who stutter are at increased risk for developing social and psychological problems (Craig, 2003; Tran, Blumgart, & Craig, 2011). In general, stuttering negatively impacts quality of life across a variety of domains, including vitality, pain, cognition, daily activities, and social and emotional functioning (Craig, Blumgart, & Tran, 2009; Koedoot, Bouwmans, Franken, & Stolk, 2011).

Although stuttering has a neurological basis, anxiety remains one of its most common concomitants (Menzies, Onslow, & Packman, 1999; Smits-Bandstra & De Nil, 2007). Preschool children who stutter have been found to be neither shyer nor more socially anxious than peers who do not stutter; yet, speech-related social anxiety develops in many cases of stuttering before adulthood (Alm, 2014). The majority of adults who stutter have moderately elevated trait anxiety and substantially elevated social anxiety (Blood & Blood, 2016; Blumgart, Tran, & Craig, 2010; Craig, Hancock, Tran, & Craig, 2003; Craig & Tran, 2014; Kraaimaat, Vanryckeghem, & Van Dam-Baggen, 2002), and there is a growing body of evidence supporting the significant prevalence of social anxiety disorder among adults who stutter (Blumgart et al., 2010; Iverach & Rapee, 2014), especially among those seeking speech therapy (Iverach, O’Brian et al., 2009).

Social anxiety disorder (SAD)1 is characterized by fear of social judgment. It is a serious, debilitating condition resulting in substantial impairment and reduced quality of life (Buckner et al., 2008; Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992; Stein & Kean, 2000). Individuals with SAD fear and/or avoid various social situations. Possibly due to negative stereotypes and listener reactions (Klompas & Ross, 2004; Snyder, 2001), people who stutter (PWS) may fear and/or avoid situations in which they have to speak (Lowe et al., 2017; Plexico, Manning, & Levitt, 2009; Vanryckeghem & Brutten, 2011, 2012; Vanryckeghem, Matthews, & Xu, 2017). Common avoidant behaviors include avoidance or substitution of difficult words (Plexico et al., 2009; Vanryckeghem, Brutten, Uddin, & Van Borsel, 2004). Indeed, the definition of stuttering – in addition to repetitions of sounds, syllables, and monosyllabic words, prolongations, and blocking of sounds – often includes the substitution and avoidance of words (Bloodstein & Bernstein Ratner, 2008).

Various studies have assessed the prevalence of social anxiety disorder among adults who stutter. Within a treatment seeking population, Iverach, O’Brian et al. (2009) found the 12-month prevalence rate to be 21.7%; Stein, Baird, and Walker, (1996) reported a point prevalence rate of 44%; and Menzies et al. (2008) noted a point prevalence rate of 60%. Another study concluded that at least 40% of adults who stutter meet criteria for social anxiety disorder (Blumgart et al., 2010). Yet another study found that approximately 50% of adults who stutter fell in the range of a group of highly socially anxious psychiatric patients (Kraaimaat et al., 2002). The comorbid presence of stuttering and significant anxiety may increase the likelihood that individuals who stutter will seek treatment for their stuttering (Iverach, O’Brian et al., 2009). It has been suggested that comprehensive treatment for stuttering should address anxiety specifically (Blumgart, Tran, & Craig, 2014; Craig, 1990; Iverach, Rapee, Wong, & Lowe, 2017), as targeted psychological assessment and intervention may improve overall stuttering treatment (Iverach, Jones et al., 2009).

Current treatment for stuttering typically uses fluency shaping, stuttering modification, or (typically) an integration of both approaches. While these methods are effective in reducing stuttering severity (Andrews, Guitar, & Howie, 1980; Blomgren, Roy, Callister, & Merrill, 2005), fluency shaping largely ignores any role of anxiety; and stuttering modification often does not explicitly address the widespread social anxiety among PWS. Another approach is avoidance-reduction therapy (Sheehan, 1953, Sheehan, 1975), in which PWS are encouraged to approach situations they had been avoiding. This approach emphasizes communication ability over fluency and is actually quite similar to typical psychological interventions for SAD.

Cognitive-behavioral therapy (CBT) has the greatest empirical support for SAD (Acarturk, Cuijpers, Van Straten, & De Graaf, 2009; Heimberg, 2002; Rodebaugh, Holaway, & Heimberg, 2004). CBT can be considered a general term that incorporates a number of various techniques in varying combinations, such as exposure, applied relaxation, social skills trainings, and cognitive restructuring. However, exposure appears to be the essential component for successful treatment of SAD (Feske & Chambless, 1995; Gould, Buckminster, Pollack, & Otto, 1997; Rodebaugh et al., 2004). Exposure is a behaviorally-oriented technique in which individuals confront feared situations in a controlled manner. In SAD, feared situations are social encounters in which individuals are exposed to potential negative evaluation.

Several studies endorse the use of CBT for adults who stutter to improve their psychological functioning (see Gupta, 2016; Gupta, Yashodharakumar, & Vasudha, 2016; Helgadóttir, Menzies, Onslow, Packman, & O’Brian, 2014; Menzies, O’Brian, Lowe, Packman, & Onslow, 2016, 2008; Reddy, Sharma, & Shivashankar, 2010). However, the interventions described in these studies emphasize the cognitive model of social anxiety (i.e., maladaptive thoughts about the self and the social world) and are multi-component. Thus, they have neither emphasized nor isolated the effectiveness of exposure. Several of these studies reported positive outcomes in both psychological functioning and speech fluency (Gupta, 2016; Gupta et al., 2016; Reddy et al., 2010). However, they incorporated traditional speech-therapy techniques in their interventions. Thus, the potential effectiveness of CBT in also improving speech fluency could not be determined. A proof-of-concept conference paper presentation reported psychological and fluency gains using only exposure, specifically virtual-reality-assisted exposure therapy (Walkom, 2016). However, study outcomes were not rigorously assessed and detailed outcome data were not provided.

In summary, no previous studies have rigorously investigated the isolated effectiveness of exposure for PWS and have SAD. Therefore, the primary aim of this study was to develop and evaluate an exposure therapy protocol designed specifically for PWS and have SAD, using a multiple baseline design. It was hypothesized that social anxiety would remain stable during the baseline phase, reduce slightly during the psychological placebo phase, decrease gradually and substantially during the exposure therapy phase, and remain low at post and follow-up assessments. Social anxiety and stuttering severity were further evaluated at major assessment points and were expected to improve only after exposure therapy. No studies have reported fluency gains from a strictly psychological intervention, except for one small-scale exposure-based study. Thus, a secondary aim of the study was to assess whether the anticipated reduction in social anxiety following the exposure therapy was accompanied by improvements in speech fluency.

Section snippets

Participants

Participants were six individuals recruited from Central Florida. Inclusion criteria were: (a) at least 17 years of age; (b) English language proficiency; (c) met criteria for SAD, as defined by DSM-5 (confirmed via administration of Anxiety and Related Disorders Interview Schedule for DSM-5 [ADIS-5] - Adult Version); (d) if met criteria for another DSM-5 defined clinical disorder, SAD was determined to be primary (excluding childhood onset-fluency disorder [stuttering]); (e) onset of

Anxiety

Fig. 2 displays the data for all six participants (P1 - P6). BL data points represent the first seven days that participants began recording daily social anxiety. Data points in subsequent phases represent the average daily rating from one session to the next. The first PMR data point represents the participant’s social anxiety rating from that day, and the second PMR data point represents an average from the day after the first PMR session up to and including the second PMR session. Similarly,

Discussion

This study presents a novel exposure therapy protocol designed specifically for PWS and have SAD and provides initial support for its potential effectiveness in reducing social distress for this population. The results of this investigation indicate that approximately 83% (5 out of 6) of the participants demonstrated a gradual and substantial reduction in social anxiety throughout EXP, and treatment gains were maintained at follow-up. These data suggest that the decrease in social anxiety is

Declaration of interest

There is no conflict to report.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Deborah Beidel, PhD, ABPP receives a small royalty from sales of the Social Phobia and Anxiety Inventory (SPAI).

Acknowledgements

The authors like to thank the study participants; Sandra M. Neer, PhD for her contributions related to the design of the project and for providing valuable feedback on drafts of the manuscript; and the research assistants, Meagan Seago, Alexis Hampilos, and Kelti Keister, for their assistance in data collection and management.

Jennifer A. Scheurich, M.S. is an advanced graduate student in the clinical psychology Ph.D. program at the University of Central Florida. Her research interests include anxiety disorders and treating behavioral and emotional concomitants of medical conditions.

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    Jennifer A. Scheurich, M.S. is an advanced graduate student in the clinical psychology Ph.D. program at the University of Central Florida. Her research interests include anxiety disorders and treating behavioral and emotional concomitants of medical conditions.

    Deborah C. Beidel, Ph.D., ABPP is Trustee Chair and Pegasus Professor of Psychology and Medical Education and Director of UCF RESTORES at the University of Central Florida. She is the author of over 275 scientific publications including journal articles, book chapters and books on the treatment of anxiety disorders and post-traumatic stress disorder. Her work focuses on developing effective treatments for anxiety disorders and PTSD and utilizing technology to enhance effective treatments for clinical practice. She is the principal investigator of a Department of Defense funded multi-site, randomized controlled trial for the treatment of PTSD in active duty military personnel.

    Martine Vanryckeghem, Ph.D., CCC-SLP received her Ph.D. from Southern Illinois University after having worked as a speech-language pathologist in Belgium. Dr. Vanryckeghem is professor at the University of Central Florida, ASHA fellow, and Board Certified Fluency Specialist. She has published widely in peer-reviewed journals and has given workshops, internationally, with respect to the assessment and treatment of individuals who stutter. For her international endeavors, Prof. Vanryckeghem received ASHA’s Certificate of Recognition for Outstanding Contribution in International Achievement. From 1990 until 2000, she was managing editor of the Journal of Fluency Disorders. Dr. Vanryckeghem serves on the Scientific Board of different internationally-based organizations.

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