Rapid/shallow breathing, a ‘racing’ heart, light headedness, weakness in the legs, nausea, sweaty palms and fearful expression are physical symptoms created by the Sympathetic Nervous System (6). These symptoms occur when the body feels a need to fight or to run away. And this is called ‘the fight or flight response.’ Many of us experience these unpleasant symptoms during times of stress and fear.

Butterflies in the stomach and other symptoms of fear are the result of signals coming down the spinal cord from the Limbic System deep inside our brains (7). One of the brain structures within the Limbic System is called the amygdala. The amygdala “has long been associated with emotion, especially fear…nerve fibers from the amygdala project into the upper brain regions that control the release of stress hormones…when a person perceives a threat, alarms go off in the brain, causing arousal, hypervigilance…the fight or flight response.” (8)

The brain learns and remembers fear. “…research suggests that it takes only one terrifying experience for a lifelong emotional memory to be put into place that is extremely difficult to erase, because the ‘thinking’ part of the brain is ‘out of the loop’ when the fear-related memory is formed…many fearful situations are experienced, learned, and unconsciously committed to emotional memory without people being aware of the initial fear trigger…not being able to pinpointing the cause of their fear leads to a feeling of being weak and helpless.” (9)

Betty Horwitz, in her book Communication Apprehension, further describes several sources of fear. Innate fear are intrinsic reactions that cause an animal to withdraw, attack, become immobile or call for help. As an example she sites a fear of staring eyes and writes that disapproving looks can trigger innate fear. Conditioned fear is learned after repeated experiences in a specific circumstance, such as interactions with a critical authority figure. Unfamiliar event fear is somewhat self-explanatory. Freezing and avoidance are common fear reactions to unfamiliar situations. Fear of the unfamiliar transforms into anxiety with increasing age and social phobias can appear in adolescence.

What relevance does this all have to stuttering? Speech therapy for children includes activities intended to prevent and/or reduce communication apprehension – fear of speaking. Speech therapy for teens and adults includes activities intended to reduce communication anxiety already established by years of painful experience and avoidance behavior.

Recent research related to stuttering refers to two types of anxiety: “Trait anxiety refers to a person’s inherent level of anxiety and state anxiety, referring to a condition or situation-specific anxiety.” (2)

In any given situation, a person’s perception of danger and his ability to cope affects anxiety. One theory proposes four different types of situation anxiety: social evaluation, physical danger, ambiguity, and daily routines. A person may respond differently to each of these four kinds of situations. A person with a high level of trait anxiety may become exceedingly anxious in a situation of social evaluation, but feel quite capable of coping with a dangerous situation. This person would experience a higher level of situation anxiety in, let’s say, public speaking, than in conflict.

“The association between stuttering and anxiety has been robustly debated over the years…” (1) Some researchers have viewed anxiety as “the main cause of the disorder…as a mediating variable…as a by-product of stuttering…as a general stress trait…as a state condition related to communication in general and to speech communication in particular.” (3) Research into anxiety in persons who stutter has been done using self-report questionnaires. The Inventory of Interpersonal Situations, one such questionnaire, appeared in the appendix of one such study. (4)

Results suggest that many adults who stutter do have higher levels of trait anxiety than fluent speakers. Is this characteristic of some persons who stutter since childhood? I don’t think anyone knows the answer to that. However, trait anxiety can increase over time for the person who stutters. When I meet with a child who stutters who appears to have substantial trait anxiety, I immediately include conversation to address this issue in an attempt at prevention.

State anxiety is greater during social communication, which seems like a no-brainer. But, it was interesting to read one reason why: “Anxiety has an effect on human performance, which is expressed in qualitative changes in performance and strong muscle activation…Nonautomatic actions that need attention can be harmed by anxiety…In the process of producing speech there are automatic factors, such as the semantic selection, the syntax, and phonology. However, the phonetic stage that plans the articulation and the motor control are not automatic and require attention…All of these factors can explain the relationship between anxiety and stuttering severity…” (5)

Therefore, it makes sense to include treatment for anxiety as part of a total therapy program, even if that means referral to a specialist in anxiety disorders.

I would like to close with a more philosophical perspective. I am in chapter 2 of a book (10) that quotes Martin Luther King in his 1963 book The Strength to Love, “In these days of catastrophic change and calamitous uncertainty, is there anyone who does not experience the depression and bewilderment of crippling fear…?” King describes courage as “the strength of mind capable of conquering whatever threatens attainment of the highest good.” Fear has an insidious way of paralyzing us and we doubtless have justifications for this to be so. Persons who stutter have good reason to be fearful and clinicians perhaps need to reach beyond the physiological into the philosophical in order to be helpful.

Courage may need to be the topic of a new blog entry.

(1) Craig, A. et al (2003) Anxiety Levels in People Who Stutter: A Randomized Population Study, Journal of Speech, Language and Hearing Research, Vol. 46, p. 1197.
(2) Ezrati-Vinacour, R. & Levin, I. (2004) The relationship between anxiety and stuttering: a multidimensional approach. Journal of Fluency Disorders, 29, p.136.
(3) Ibid
(4) Kraaimaat, F.W., et al (2002) Stuttering and social anxiety, Journal of Fluency Disorders, Vol 27, pp 319-331.
(5) Ezrati-Vinacour, p.144
(6) http://faculty.washington.edu/chudler/auto.html
(7) http://health.howstuffworks.com/human-nature/emotions/other/laughter4.htm
(8) Betty Horwitz (2002) Communication Apprehension: Origins and Management, Albany, NY: Singular/Thompson Learning, p. 29-30
(9) Ibid. p. 31
(10) Rev. Scotty McLennan (2009) Jesus was a Liberal: Reclaiming Christianity for All, NY, NY: Palgrave MacMillan, p. 40.

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