Prevalence of anxiety disorders among adults seeking speech therapy for

stuttering
Lisa Iverach
a
, Sue OBrian
a
, Mark Jones
b
, Susan Block
c
, Michelle Lincoln
a
, Elisabeth Harrison
d
,
Sally Hewat
e
, Ross G. Menzies
a,
*, Ann Packman
a
, Mark Onslow
a
a
Australian Stuttering Research Centre, The University of Sydney, Australia
b
School of Population Health, The University of Queensland, Australia
c
School of Human Communication Sciences, La Trobe University, Australia
d
Department of Linguistics, Macquarie University, Australia
e
School of Humanities and Social Science, The University of Newcastle, Australia
The capacity to use speech to communicate is fundamental to
interpersonal relationships, occupational success, andquality of life.
Stutteringisauniversal speechdisorder whichaffects thecapacityto
communicate effectively. The incidence of stuttering is estimated at
approximately 45%, with a 1% prevalence rate (Bloodstein &
Bernstein Ratner, 2008), and there is a male to female ratio of 4:1 for
the disorder in adulthood. The cause of the condition is unknown,
although there is clearly a genetic contribution to emergence of
stuttering (Bloodstein & Bernstein Ratner, 2008). Onset typically
occurs betweenthe ages of twoandveyears (Yairi, Ambrose, &Cox,
1996), and whilst the majority of children who begin to stutter will
recover naturally, stuttering will become an intractable, long-term
problemfor a small proportion of adults (Onslow, 2004). Behavioral
speech therapy for chronic stuttering typically involves speech
restructuring to reduce or eliminate stuttering by changing aspects
of speech production. However, relapse after such treatment is
common (Block, Onslow, Packman, & Dacakis, 2006).
Stuttering is frequently associated with negative consequences
across the lifespan. In particular, children who stutter are often
teased and bullied (Blood & Blood, 2007), and children as young as
four years of age may experience negative peer reactions
(Langevin, Packman, & Onslow, 2009). These problems multiply
in adolescence, negatively impacting self-esteem, anxiety levels,
social relationships and academic performance (Blood & Blood,
2004). Children, adolescents, and adults who stutter frequently
experience negative stereotypes and listener reactions (Snyder,
2001), and many develop negative attitudes towards speaking and
experience avoidance, struggle, or anxiety in speech situations
(Peters & Starkweather, 1989). These experiences may lead to
feelings of helplessness, shame, embarrassment, and expectancy of
social harm, and may diminish occupational and educational
success, and quality of life (Yaruss, 2001). Consequently, adults
who stutter may be at increased risk of developing psychological,
emotional, and behavioral problems (Craig, 2003).
Anxiety, in particular, has been highlighted as one of the most
common psychological concomitants of stuttering (Menzies,
Onslow, & Packman, 1999), and there is a growing body of
evidence which suggests the presence of social anxiety or social
phobia in people who stutter (Schneier, Wexler, &Liebowitz, 1997;
Stein, Baird, & Walker, 1996). Social phobia is one of the most
Journal of Anxiety Disorders 23 (2009) 928934
A R T I C L E I N F O
Article history:
Received 9 September 2008
Received in revised form 1 June 2009
Accepted 5 June 2009
Keywords:
Anxiety disorders
Social phobia
Diagnosis
Stuttering
A B S T R A C T
The present study explored the prevalence of anxiety disorders among adults seeking speech
therapy for stuttering. Employing a matched casecontrol design, participants included 92 adults
seeking treatment for stuttering, and 920 age- and gender-matched controls from the Australian
National Survey of Mental Health and Well-being. A conditional logistic regression model was used to
estimate odds ratios for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
and International Classication of Diseases (ICD-10) anxiety disorders. Compared with matched
controls, the stuttering group had six- to seven-fold increased odds of meeting a 12-month diagnosis
of any DSM-IV or ICD-10 anxiety disorder. In terms of 12-month prevalence, they also had 16- to 34-
fold increased odds of meeting criteria for DSM-IV or ICD-10 social phobia, four-fold increased odds
of meeting criteria for DSM-IV generalized anxiety disorder, and six-fold increased odds of meeting
criteria for ICD-10 panic disorder. Overall, stuttering appears to be associated with a dramatically
heightened risk of a range of anxiety disorders.
2009 Published by Elsevier Ltd.
* Corresponding author at: Australian Stuttering Research Centre, Faculty of
Health Sciences, The University of Sydney, Lidcombe, NSW, Australia.
Tel.: +61 2 9351 9061; fax: +61 2 9351 9054.
E-mail address: r.menzies@usyd.edu.au (R.G. Menzies).
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
0887-6185/$ see front matter 2009 Published by Elsevier Ltd.
doi:10.1016/j.janxdis.2009.06.003
commonly experienced anxiety disorders (Moutier & Stein, 1999).
It is characterized by signicant, enduring, and excessive fear of
humiliation, embarrassment, or negative evaluation in social or
performance-based situations, often resulting in extreme distress
(American Psychiatric Association, 2000). In most cases, social
phobia develops in childhood or adolescence, and its develop-
mental course is often associated with age-related increases in fear
and avoidance of social interaction, peer group rejection and
victimisation, traumatic or negative life events, and behavioral
inhibition. Hence, the negative childhood experiences associated
with stuttering may act as precursors to the development of social
anxiety in adults who stutter (Blood & Blood, 2007).
Unlike the International Classication of Diseases (ICD-10)
(World Health Organisation, 1993), the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV) (American
Psychiatric Association, 2000), currently excludes the diagnosis of
social phobia in individuals whose anxiety relates only to the fear
of stuttering (Moutier & Stein, 1999). Stein et al. (1996) evaluated
social phobia in adults seeking treatment for stuttering, and
modied the DSM-IV criteria to allowa diagnosis of social phobia in
cases where phobic symptoms were in excess of the real demands
associated with the stutter. According to these authors, 44%of their
sample warranted a diagnosis of social phobia. These ndings were
subsequently supported by Schneier et al. (1997), who found that
more than half their sample of adults who stuttered demonstrated
social anxiety scores similar to those of social phobia patients from
an anxiety disorder clinic.
If a large proportion of adults who stutter experience signicant
social anxiety, this would suggest the need for the routine
involvement of psychiatrists and clinical psychologists in the
assessment and treatment of this population. To date, there are no
placebo controlled trials of serotonergic agents in adults who
stutter. Although there have been a number of studies investigat-
ing the use of cognitive behavioral therapy (CBT) to treat anxiety in
adults who stutter (Neilson, 1999; Stein et al., 1996), there has only
been one randomized controlled trial of such treatment (Menzies
et al., 2008). In this trial, Menzies et al. (2008) found that the
addition of a CBT treatment package for social anxiety in adults
who stutter was associated with signicant improvements in
global functioning and signicant reductions in anxiety and
avoidance, even though rates of uency were no better than that
achieved by speech pathology treatment alone. Of note, at 12-
month follow-up no participant who had received CBT was given a
diagnosis of social phobia in blinded psychiatric interviews. In
comparison, 50% of the participants who had received speech
therapy alone were diagnosed with social phobia at the same
assessment point. Menzies et al. (2008) suggest that involvement
of psychiatric services in the treatment of adults who stutter is
urgently needed and that such services may signicantly enhance
long-term outcomes for these patients.
To our knowledge, no previous studies have comprehensively
assessed presence of anxiety disorders in a large sample of adults
who stutter according to the diagnostic criteria employed by the
DSM-IV and the ICD-10. Hence, the present study sought to
investigate the relationship between anxiety and stuttering in a
large sample of adults who stutter, with the following aims: (1)
determine the rate of social phobia, and other anxiety disorders,
among adults seeking speech therapy for stuttering using the
Composite International Diagnostic Interview (CIDI-Auto-2.1)
(World Health Organization, 1997); (2) compare the rate of anxiety
disorders in this sample with age- and gender-matched controls
from the Australian National Survey of Mental Health and Well-being
(ANSMHWB) of 10,641 Australian household residents (Andrews,
Henderson, & Hall, 2001); (3) assess anxiety via a number of self-
report measures including the State-Trait Anxiety Inventory Trait
(STAI-T) (Spielberger, 1983) and the Endler Multidimensional
Anxiety Scales Trait (EMAS-T) (Endler, Edwards, & Vitelli,
1991); and (4) evaluate the extent of fear of negative evaluation
among those who stutter. Given previous research ndings, it was
hypothesized that adults seeking speech therapy for stuttering
would(1) exhibit asignicantlyhigher rateof anxietydisorders than
the Australian general community and (2) demonstrate heightened
levels of self-reported anxiety and fear of negative evaluation when
compared with normative data.
1. Method
1.1. Participants
1.1.1. Adults seeking speech therapy for stuttering
Adults who stutter were drawn from treatment waiting lists
across seven university-afliated stuttering treatment clinics in
four cities across Australia and NewZealand (Australian Stuttering
Research Centre, The University of Sydney; School of Human
Communication Sciences, La Trobe University, Melbourne; Dis-
cipline of Speech Pathology, The University of Sydney; Department
of Linguistics, Macquarie University, Sydney; School of Humanities
and Social Science, University of Newcastle, Australia; Royal Prince
Alfred Hospital, Sydney; Stuttering Treatment and Research Trust,
Auckland, New Zealand).
Eligibility criteria for inclusion in the study included: (1) age 18
years and above, (2) developmental stuttering present before 12
years of age, (3) seeking speech therapy for stuttering, (4) no
previous speech therapy in the six months prior to commencement
in the present study, and (5) presence of stuttering conrmed by
participant and speech pathologist during assessment. Speech
therapy at all sites included behavioral and speech restructuring
techniques designed to control stuttering. The study was approved
by the University of Sydney Human Research Ethics Committee
and the Human Research Ethics Committees overseeing each site.
Written informed consent was obtained from all participants.
1.1.2. Age- and gender-matched controls
Controls were selected from the 1997 ANSMHWB (Australian
Bureau of Statistics, 2000). The ANSMHWB was conducted by the
Australian Bureau of Statistics (ABS) to comprehensively assess the
prevalence of mental health disorders in Australia. Overall, 10,641
Australian household residents, aged 18 years and above, partici-
pated in the survey. The sample was weighted to match the
distributionof age andgender inthe Australiancensus, andincluded
residents living in private dwellings across Australia, excluding
remote and special dwellings such as hospitals and institutions.
Interviewers administered a computerized psychiatric interview
(CIDI-Auto-2.1) to all respondents using a laptop computer.
1.2. Measures
Adults seeking treatment for stuttering completed the follow-
ing measures during their initial assessment for treatment.
1.2.1. Computerized version of the CIDI-Auto-2.1 (World Health
Organization, 1997)
The CIDI-Auto-2.1 is a standardized computer interview
designed to comprehensively assess and diagnose mental health
disorders according to the diagnostic criteria employed by the
DSM-IV and the ICD-10. The interview is self-administered by the
respondent via a laptop computer. It takes approximately 70 min
to complete, and does not necessitate the use of medical records or
outside informants. The CIDI-Auto-2.1 has demonstrated adequate
reliability and validity for research purposes (World Health
Organization, 1997). As the interview is computer-scored and all
diagnoses are programmed, the interview requires no clinical
L. Iverach et al. / Journal of Anxiety Disorders 23 (2009) 928934 929
judgment which eliminates interviewer bias (Andrews and Peters,
1998; Wittchen, 1994). The CIDI-Auto-2.1 has demonstrated
adequate reliability and validity for research purposes (Andrews
& Peters, 1998; World Health Organization, 1997), and evidence
also suggests that the CIDI returns comparable prevalence rates
for the anxiety disorders to those obtained through psychiatric
interviews with clinicians (Lampe, Slade, Issakidis, & Andrews,
2003).
1.2.2. STAI-T (Spielberger, 1983)
The STAI-T is a 20-item self-report measure of trait anxiety.
Items are rated on a scale ranging from 1 (almost never) to 4
(almost always), with total scores range from 20 to 80. Extensive
data support the psychometric properties and utility of the STAI-T
as a unidimensional measure of trait anxiety (Shamir-Essakow,
Ungerer, & Rapee, 2005; Willoughby & Edens, 1996).
1.2.3. EMAS-T (Endler, Edwards et al., 1991)
The Social Evaluation (EMAS-T-SE) Scale and the New/Strange
Situations (EMAS-T-AM) Scale of the EMAS-T were administered to
participants. Both scales consist of 15 statements which are rated
on a 5-point scale ranging from 1 (not at all) to 5 (very much),
with total scores for each scale ranging from 15 to 75. The EMAS-T
has demonstrated satisfactory reliability and validity as a multi-
dimensional measure of anxiety (Endler, Edwards, Vitelli, &Parker,
1989; Endler, Parker, Bagby, & Cox, 1991).
1.2.4. The Fear of Negative Evaluation Scale (FNE) (Watson & Friend,
1969)
The FNE consists of 30 items which assess fear of negative
evaluation. Seventeen true and 13 false responses are summed
to create a total score out of 30. The FNE has been utilized
extensively in research regarding social anxiety and social phobia
(Stopa & Clark, 2001), and has demonstrated excellent psycho-
metric properties (Durm & Glaze, 2001; Garcia-Lopez, Olivares,
Hidalgo, Beidel, & Turner, 2001).
1.2.5. Anxiety Problems DSM-Oriented Scale of the ASEBA Adult Self-
Report (ASR) (Achenbach & Rescorla, 2003)
The ASR assesses adaptive functioning in adults aged 1859
years of age, and includes 123 items regarding behavioral,
emotional, and social problems. Scores are used to generate 6
DSM-IV-Oriented Scales including the Anxiety Problems Scale. The
ASR is widely used, and has strong research foundations and
psychometric properties (Achenbach & Rescorla, 2003).
1.3. Data analysis
Rate of anxiety disorders in the stuttering group was compared
with rate reported in the ANSMHWB (Andrews et al., 2001;
Australian Bureau of Statistics, 2000). Approval was obtained from
the ABS to access data from the ANSMHWB in the form of a
Condentialized Unit Record File (CURF) (Australian Bureau of
Statistics, 2000). Under the Census and Statistics Act 1905, these
data are released as unit records which protect the condentiality
of individuals involved in the survey. Approved CURF users are able
to tabulate and statistically analyze data for their own specic
purposes. Analysis was performed using SAS version 8.2 for
Windows (SAS Institute, Cary, NC) and Stata version 10.0 for
Windows (StataCorp LP, College Station, TX). A conditional logistic
regression model was used to estimate odds ratios, 95% condence
intervals and P-values for the primary outcome: 12-month
prevalence of any DSM-IV or ICD-10 anxiety disorder as well as
specic anxiety disorders, with sufcient numbers to obtain valid
estimates. There was 80% power to detect 2.5 increased odds of
having any anxiety disorder with a 5% level of signicance. One-
month prevalence rates were also estimated for the specic
anxiety disorders, with statistical comparisons made only for those
disorders which demonstrated a signicant difference between
groups for 12-month prevalence. Data from all other self-report
measures (FNE, EMAS-T, STAI-T, and ASR) were reported descrip-
tively (means, standard deviations, and ranges) and presented
alongside data from stuttering, control and social phobia/anxiety
samples. Indirect comparisons based on 2-sample t-tests were
used to compare the self-report measures of the present study with
the previous samples.
2. Results
2.1. Demographic characteristics of adults who stutter
Participants consisted of 94 adults seeking speech therapy for
stuttering, including 72 males (76.60%) and 22 females (23.40%),
ranging in age from 18 to 73 years of age mean = 32.8, S.D. = 12.0.
As illustrated in Table 1, participants were drawn from a wide and
diverse population. In terms of stuttering history, 64.90% of
participants reported a family history of stuttering (n = 61), and
81.91% reported receiving previous treatment for stuttering
(n = 77). Of the 94 adults in the present sample, 92 completed
the CIDI-Auto-2.1, and a minimumof 92 participants completed all
other self-report measures.
2.2. Age- and gender-matched controls
Based on Hennessy, Bilker, Berlin, and Strom (1999), 10 age-
and gender-matched controls were randomly selected and
matched to each of the 92 adults in the stuttering group who
completed the CIDI-Auto-2.1, resulting in a sample of 920 matched
controls. A limitation of this control group is the expectation that a
small proportion may have been stuttering adults. However, as this
proportion is expected to be less than 1%, the impact on the
comparison should be negligible.
Table 1
Demographic data for 94 adults seeking speech therapy for stuttering.
Demographics % (n)
Marital status Married In a relationship Single Separated/divorced Not specied
26.6 (25) 21.3 (20) 44.7 (42) 6.4 (6) 1.1 (1)
Employment Full-time Part-time/casual Studying Not employed Not specied
51.1 (48) 18.1 (17) 11.7 (11) 10.6 (10) 8.5 (8)
Household income
a
$019,999 $20,00039,999 $40,00079,999 $80,000+ Not specied
9.6 (9) 11.7 (11) 31.9 (30) 22.3 (21) 24.5 (23)
Education Did not nish high school Completed high school Tertiary degree/diploma Masters/PhD Not specied
6.4 (6) 28.7 (27) 50.0 (47) 11.7 (11) 3.2 (3)
a
Australian dollars per annum, 20062008.
L. Iverach et al. / Journal of Anxiety Disorders 23 (2009) 928934 930
2.3. Prevalence of anxiety disorders
Table 2 reports the 12- and 1-month prevalence rates of DSM-IV
and ICD-10 anxiety disorders for 92 adults seeking speech therapy
for stuttering and 920 matched controls.
As can be seen in Table 2, 12-month prevalence of any DSM-IV
or ICD-10 anxiety disorder for adults seeking speech therapy for
stuttering was signicantly higher than the rate for matched
controls, demonstrating six to seven-fold increased odds. Twelve-
month prevalence of DSM-IV and ICD-10 social phobia was also
signicantly higher for the stuttering group when compared with
matched controls, indicating 16- to 34-fold increased odds. One-
month prevalence of any anxiety disorder and social phobia was
also signicantly higher in the stuttering group than controls.
In addition, 12-month prevalence of DSM-IV generalized
anxiety disorder (GAD) was signicantly higher for adults seeking
speech therapy for stuttering than matched controls, demonstrat-
ing four-fold increased odds. Furthermore, 12-month prevalence
of ICD-10 panic disorder (PD) was higher for the stuttering
group when compared with matched controls, demonstrating
Table 2
Prevalence of anxiety disorders for 92 adults seeking speech therapy for stuttering and 920 age- and gender-matched controls.
Anxiety disorder Stuttering group (N = 92) % (n) Controls (N = 920) % (n) Odds ratio (95% CI) P-value
Any anxiety disorder
DSM-IV
12-Month 27.2 (25) 5.3 (49) 7.31 (4.1113.03) <.001
1-Month 21.7 (20) 3.9 (36) <.001
ICD-10
12-Month 33.7 (31) 7.3 (67) 6.68 (3.9911.17) <.001
1-Month 22.8 (21) 4.5 (41) <.001
Social phobia
DSM-IV
12-Month 21.7 (20) 1.2 (11) 34.17 (12.7491.66) <.001
1-Month 18.5 (17) 1.0 (9) <.001
ICD-10
12-Month 26.1 (24) 2.5 (23) 16.62 (8.2233.57) <.001
1-Month 19.6 (18) 1.5 (14) <.001
Generalized anxiety disorder
DSM-IV
12-Month 8.7 (8) 2.1 (19) 4.49 (1.9110.96) .001
1-Month 4.4 (4) 1.9 (17) .12
ICD-10
12-Month 2.2 (2) 2.2 (20) 1.00 (0.234.31) .99
1-Month 2.2 (2) 1.5 (14)
Panic disorder with/without agoraphobia
DSM-IV
12-Month 1.1 (1) 0.9 (8) 1.26 (0.1510.34) .83
1-Month 0 (0) 0.2 (2)
ICD-10
12-Month 4.4 (4) 0.8 (7) 6.14 (1.7221.95) .005
1-Month 0 (0) 0.1 (1)
*
Obsessive compulsive disorder
DSM-IV
12-Month 3.3 (3) 0.9 (8) 3.75 (0.9914.14) .051
1-Month 3.3 (3) 0.7 (6)
ICD-10
12-Month 0 (0) 0.3 (3)
* *
1-Month 0 (0) 0.2 (3)
Posttraumatic stress disorder
DSM-IV
12-Month 1.1 (1) 10 (1.1) 1.00 (0.137.81) .99
1-Month 0 (0) 5 (0.5)
ICD-10
12-Month 1.1 (1) 1.9 (17) 0.58 (0.084.43) .60
1-Month 0 (0) 1.2 (11)
Agoraphobia with/without panic disorder
DSM-IV
12-Month 0 (0) 0.2 (2)
* *
1-Month 0 (0) 0.1 (1)
ICD-10
12-Month 1.1 (1) 0.8 (7) 1.44 (0.1712.17) .74
1-Month 1.1 (1) 0.5 (5)
*
Insufcient data.
L. Iverach et al. / Journal of Anxiety Disorders 23 (2009) 928934 931
a signicant difference and six-fold increased odds. However, the
stuttering and control groups did not differ signicantly in terms
of 1-month prevalence of DSM-IV GAD and ICD-10 PD. Moreover,
the prevalence of 12-month ICD-10 GAD and DSM-IV PD did not
differ signicantly between groups.
Twelve- and 1-month prevalence rates for all other DSM-IV and
ICD-10 anxiety disorders, including obsessive compulsive disorder
(OCD), posttraumatic stress disorder (PTSD), and agoraphobia
(AG), were not found to be signicantly higher in the stuttering
group when compared with prevalence rates for matched controls.
2.4. Self-report measures of anxiety and fear of negative evaluation
Table 3 presents mean scores on the EMAS-T, FNE, STAI-T and
ASR for adults who stutter, compared with mean scores from
previous samples of adults who stutter, community control
samples, and social phobia/anxiety samples, using indirect
comparisons based on 2-sample t-tests. Comparison samples
were Australian in all but 3 cases.
As illustrated in Table 3, the mean score for the stuttering group
on the Anxiety Problems DSM-IV-Oriented Scale of the ASR was
signicantly higher than the mean score for a normative sample.
Secondly, the mean STAI-T score for adults who stutter was
signicantly lower than the mean score for a social phobia sample,
but signicantly higher than a community control sample and a
previous stuttering sample. Thirdly, the mean score for the
stuttering group on the Social Evaluation Scale of the EMAS-T
was signicantly lower than mean scores for a social phobia
sample and a previous stuttering sample, but not signicantly
different from a community control sample. Fourthly, the mean
score for the stuttering group on the New/Strange Situations Scale
of the EMAS-T was signicantly lower than the mean score for a
clinically anxious sample, but signicantly higher than a commu-
nity control sample. Finally, the mean FNE score for the stuttering
group was signicantly lower than the mean score for a social
phobia sample, equivalent to a previous stuttering sample, and
signicantly higher than a community control sample.
3. Discussion
To our knowledge, the present study is the rst to comprehen-
sively assess presence of DSM-IV and ICD-10 anxiety disorders in a
large sample of adults seeking speech therapy for stuttering. In
support of the rst hypothesis, the 12-month prevalence of any
DSM-IV or ICD-10 anxiety disorder for adults seeking speech
therapy for stuttering was signicantly higher than matched
controls. More specically, adults in the stuttering group had six-
to seven-fold increased odds of meeting criteria for a 12-month
diagnosis of any ICD-10 or DSM-IV anxiety disorder, respectively,
when compared with matched controls. This result is startling, and
points towards the potential for adults seeking treatment for
stuttering to experience debilitating anxiety.
In terms of specic DSM-IV and ICD-10 anxiety disorders, adults
in the stuttering group demonstrated signicantly higher 12-
month prevalence rates for social phobia, DSM-IV GAD, and ICD-10
PD, when compared with matched controls. Of particular interest,
adults seeking treatment for stuttering had 34- and 16-fold
increased odds of meeting criteria for a 12-month diagnosis of
DSM-IV and ICD-10 social phobia, respectively. More specically,
the 12-month prevalence rate of DSM-IV and ICD-10 social phobia
in the stuttering group was 21.7 and 26.1%, respectively, which
was signicantly higher than the rate of 1.22.5% for matched
controls, and is also substantially higher than 12-month pre-
valence rates reported in large national epidemiological surveys
Table 3
Mean scores on the EMAS-T, FNE, STAI-T and ASR for 94 adults seeking speech therapy for stuttering, compared with previous stuttering, community control and social
phobia/anxiety samples.
Measure Sample n Mean S.D. P-value
*
EMAS-T Social Evaluation Scale (range 1575) Stuttering group
a
94 47.8 9.3
Previous stuttering sample
b
34 51.8 10.3 .039
Community control sample
b
34 44.6 10.3 .097
Social phobia sample
c
57 54.8 4.3 <.0001
EMAS-T New/Strange Situations Scale (range 1575) Stuttering group
a
94 44.2 9.4
Previous stuttering sample
b
34 47.1 10.0 .13
Community control sample
b
34 38.2 9.4 .0018
Clinically anxious sample
d
189 53.6 13.1 <.0001
FNE (range 030) Stuttering group
a
94 15.6 7.8
Previous stuttering sample
b
34 15.6 7.1 .99
Community control sample
b
34 10.7 5.7 .0011
Social phobia sample
e
133 22.9 5.0 <.0001
STAI-T (range 2080) Stuttering group
a
94 41.9 10.4
Previous stuttering group
f
63 38.5 9.6 .040
Community control sample
g
102 35.8 7.0 <.0001
Social phobia sample
h
51 46.8 14.8 .022
ASR (range 014) Stuttering group
a
94 5.2 3.2
Previous stuttering sample
Normative sample
i
1767 3.7 2.5 <.0001
Social phobia sample
*
Based on t-test comparison with the present stuttering group (i.e., 94 adults seeking speech therapy for stuttering).
a
Missing data for the present sample of 94 adults were minimal: 1 participant did not complete the FNE, STAI-T, or ASR; and 2 participants did not complete the EMAS-T.
b
Messenger et al. (2004). For the EMAS-T, Messenger et al. (2004) utilized a 5-point rating scale ranging from0 to 4 rather than the standard 15 rating scale. Therefore, the
EMAS-T mean scores and ranges reported in the above table for Messenger et al. (2004) have been adjusted to reect the use of the standard 15 rating scale.
c
Kocovski, Endler, Rectora, and Flett (2005); non-Australian sample.
d
Kocovski, Endler, Cox, and Swinson (2004); non-Australian sample.
e
Rosser, Erskine, and Crino (2004).
f
Craig et al. (2003)
g
Craig (1990); Craig et al. (2003).
h
Heimberg, Makris, Juster, O

st, and Rapee (1997).

i
Achenbach and Rescorla (2003); non-Australian sample includes mean score for males only.
L. Iverach et al. / Journal of Anxiety Disorders 23 (2009) 928934 932
which generally range between 2 and 7% (Fehm, Pelissolo,
Furmark, & Wittchen, 2005; Lampe et al., 2003; Ruscio et al.,
2008; Wells et al., 2006). Furthermore, nearly one-fth (18.5
19.6%) of the stuttering group met criteria for DSM-IV and ICD-10
social phobia in the previous month compared with only 1.01.5%
of matched controls, indicating the potential for many adults who
stutter to have a current social phobia diagnosis.
Unlike the ICD-10, the DSM-IV does not allow the diagnosis of
social phobia in cases where anxiety relates only to the fear of
stuttering (Moutier & Stein, 1999). Despite this, the present study
found high rates of social phobia among adults who stutter using
either set of diagnostic criteria. Our ndings support previous
claims that a signicant proportion of adults who stutter may
experience clinically relevant levels of social anxiety that is out of
keeping with the actual demands of their social encounters
(Schneier et al., 1997; Stein et al., 1996). Stein et al. (1996) argue
that, Prohibiting a diagnosis of social phobia is likely to lead
clinicians, under the misconception that social phobia is an inevitable,
expected concomitant of stuttering, to ignore clinically relevant social
anxiety when it occurs in their patients who stutter (p. 279). The
present authors strongly agree, and suggest that the DSM-IV
exclusion criteria related to stuttering be dropped.
In terms of other anxiety disorders, adults who stutter in the
present sample were also found to report a signicantly higher rate
of 12-month DSM-IV GAD. This suggests that anxiety for some
adults who stutter may extend beyond speech-related anxiety to a
more generalized experience of anxiety or worry. This is not
surprising when considering the high rate of comorbidity between
GAD and social phobia (Henning, Turk, Mennin, Fresco, &
Heimberg, 2007). What is more surprising, however, is the
signicantly higher rate of 12-month ICD-10 PD in adults who
stutter when compared with matched controls. To our knowledge,
such a result has not been reported before, and requires further
exploration. Obviously, greater attention needs to be paid to the
presence and impact of anxiety and its numerous disorders among
adults who stutter.
In terms of other self-report measures, the hypothesis that
adults who stutter would demonstrate heightened levels of self-
reported anxiety and fear of negative evaluation when compared
with normative data was also largely supported. On the whole,
these results correspond with previous research (Messenger,
Onslow, Packman, & Menzies, 2004), and indicate that adults
who stutter may be characterized by heightened levels of anxiety
and fear of negative evaluation when compared with controls.
However, these levels may not be as high as typical social phobia
groups in the clinic.
The high rate of anxiety found in this sample of adults who
stutter may be the consequence of the bullying, social isolation and
humiliation experienced across the lifespan by people who stutter.
It is also plausible that the lack of occupational and educational
attainment often reported by adults who stutter may stemnot only
fromchronic communicationdifculties, but also fromdebilitating
levels of social phobia. Individuals with social phobia often
demonstrate behavioral decits in social situations, including
poor conversation skills and eye contact, which may result in
negative reactions from others and exacerbated anxiety in social
interactions. Therefore, for individuals who stutter, the comorbid
presence of an anxiety disorder may amplify poor social skills,
increase functional impairment, and interfere with treatment
effectiveness, accounting somewhat for the high rate of relapse and
poor long-term outcome data for adults seeking treatment for
stuttering (Block et al., 2006).
It is important to note that adults in the present study were
seeking treatment for stuttering. It is reasonable to expect that
adults seeking treatment may exhibit higher rates of anxiety
disorders than would be found in community samples of
individuals who stutter. It is possible that the comorbid presence
of an anxiety disorder and stuttering may increase the chances that
an individual will seek treatment for their stuttering. Having said
this, it should be remembered that Craig, Hancock, Tran, and Craig
(2003) found higher trait anxiety scores in a community sample of
adults who stuttered (i.e., a nontreatment seeking sample) than in
a matched control sample. Further, regardless of possible
differences between clinical and community samples, the dis-
covery of such high rates of anxiety disorders among adults
seeking treatment is alarming and signicant, and remains an
important nding with considerable implications for clinical
practice. Social phobia in adults who stutter has largely gone
untreated in the past, and this trend may continue unless adults
who stutter with debilitating social anxiety are afforded an
appropriate diagnosis. Menzies et al. (2008) have shown that
treatment directed at social anxiety among adults who stutter can
effectively eliminate social phobia diagnoses at long-term follow-
up, and can dramatically improve overall functioning and
engagement in everyday activities. It seems highly appropriate
for the assessment and treatment of anxiety disorders among
adults who stutter to be a signicant priority. There is an urgent
need for further research exploring the management of anxiety
among adults who stutter to enhance their overall functioning
(Ballenger et al., 1998; Menzies et al., 2008; Schneier et al., 1997),
including further studies of CBT and pharmacological treatments
for social phobia in stuttering. Undoubtedly, psychiatrists and
clinical psychologists have a great deal to offer in this pursuit.
References
Achenbach, T. M., & Rescorla, L. A. (2003). Manual for the ASEBA adult forms & proles.
Burlington: VT University of Vermont, Research Centre for Children, Youth &
Families.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (revised 4th ed.). Washington, DC: American Psychiatric Association.
Andrews, G., Henderson, S., & Hall, W. (2001). Prevalence, comorbidity, disability and
service utilization: overview of the Australian National Mental Health Survey. The
British Journal of Psychiatry, 178, 145153.
Andrews, G., & Peters, L. (1998). The psychometric properties of the Composite Inter-
national Diagnostic Interview. Social Psychiatry and Psychiatric Epidemiology 33.
Australian Bureau of Statistics. (2000). Mental health and wellbeing of adults, Australia,
1997: condentialised unit record le. Canberra: Australian Bureau of Statistics.
Ballenger, J. C., Davidson, J. R. T., Lecrubier, Y., Nutt, D. J., Bobes, J., Beidel, D. C., et al. (1998).
Consensus statement on social anxiety disorder from the International Consensus
Group on depression and anxiety. Journal of Clinical Psychiatry, 59, 5460.
Block, S., Onslow, M., Packman, A., & Dacakis, G. (2006). Connecting stuttering manage-
ment and measurement: IV. Predictors of outcome for a behavioural treatment
for stuttering. International Journal of Language & Communication Disorders, 41,
395406.
Blood, G. W., & Blood, I. M. (2004). Bullying in adolescents who stutter: communicative
experience and self-esteem. Contemporary Issues in Communication Sciences and
Disorders, 31, 6979.
Blood, G. W., & Blood, I. M. (2007). Preliminary study of self-reported experience of
physical aggression and bullying of boys who stutter: relation to increased anxiety.
Perceptual & Motor Skills, 104, 10601066.
Bloodstein, O., & Bernstein Ratner, N. (2008). A handbook on stuttering (6th ed.). Clifton
Park, NY: Thomson Delmar.
Craig, A. (1990). An investigation into the relationship between anxiety and stuttering.
Journal of Speech and Hearing Disorders, 55, 290294.
Craig, A. (2003). Clinical psychology and neurological disability: psychological thera-
pies for stuttering. Clinical Psychologist, 7, 93103.
Craig, A., Hancock, K., Tran, Y., &Craig, M. (2003). Anxiety levels inpeople who stutter: a
randomized population study. Journal of Speech Language and Hearing Research, 46,
11971206.
Durm, M. W., & Glaze, P. E. (2001). Construct validity for self-acceptance and fear of
negative evaluation. Psychological Reports, 89, 386.
Endler, N. S., Edwards, J. M., & Vitelli, R. (1991a). Endler Multidimensional Anxiety Scales
(EMAS): manual. Los Angeles, California: Western Psychological Services.
Endler, N. S., Edwards, J. M., Vitelli, R., & Parker, J. D. A. (1989). Assessment of state and
trait anxiety: Endler Multidimensional Anxiety Scales. Anxiety Research, 2, 114.
Endler, N. S., Parker, J. D., Bagby, R. M., & Cox, B. J. (1991b). Multidimensionality of state
and trait anxiety: factor structure of the Endler Multidimensional Anxiety Scales.
Journal of Personality and Social Psychology, 60, 919926.
Fehm, L., Pelissolo, A., Furmark, T., & Wittchen, H. U. (2005). Size and burden of social
phobia in Europe. European Neuropsychopharmacology, 15, 453462.
Garcia-Lopez, L. J., Olivares, J., Hidalgo, M. D., Beidel, D. C., & Turner, S. M. (2001).
Psychometric properties of the Social Phobia and Anxiety Inventory, the Social
L. Iverach et al. / Journal of Anxiety Disorders 23 (2009) 928934 933
Anxiety Scale for Adolescents, the Fear of Negative Evaluation Scale, and the Social
Avoidance and Distress Scale in an adolescent Spanish-speaking sample. Journal of
Psychopathology and Behavioral Assessment, 23, 5159.
Heimberg, R. G., Makris, G. S., Juster, H. R., O

st, L., & Rapee, R. (1997). Social phobia: a

preliminary cross-national comparison. Depression and Anxiety, 5, 130133.
Hennessy, S., Bilker, W. B., Berlin, J. A., & Strom, B. L. (1999). Factors inuencing the
optimal control-to-case ratio in matched casecontrol studies: a brief original
contribution. American Journal of Epidemiology, 149, 195197.
Henning, E. R., Turk, C. L., Mennin, D. S., Fresco, D. M., & Heimberg, R. G. (2007).
Impairment and quality of life in individuals with generalized anxiety disorder.
Depression and Anxiety, 24, 342349.
Kocovski, N. L., Endler, N. S., Cox, B. J., & Swinson, R. P. (2004). The differential
assessment of state-trait anxiety and depression in a clinically anxious sample.
Journal of Psychopathology and Behavioral Assessment, 26, 165172.
Kocovski, N. L., Endler, N. S., Rectora, N. A., & Flett, G. L. (2005). Ruminative coping
and post-event processing in social anxiety. Behavior Research & Therapy, 43,
971984.
Lampe, L., Slade, T., Issakidis, C., & Andrews, G. (2003). Social phobia in the Australian
National Survey of Mental Health and Well-Being (NSMHWB). Psychological Med-
icine, 33, 637646.
Langevin, M., Packman, A., & Onslow, M. (2009). Peer responses to stuttering in the
preschool setting. American Journal of Speech-Language Pathology [Epub ahead of
print].
Menzies, R. G., OBrian, S., Onslow, M., Packman, A., St Clare, T., & Block, S. (2008). An
experimental clinical trial of a Cognitive Behaviour Therapy package for chronic
stuttering. Journal of Speech, Language and Hearing Research, 51, 14511464.
Menzies, R. G., Onslow, M., & Packman, A. (1999). Anxiety and stuttering: exploring a
complex relationship. American Journal of Speech-Language Pathology, 8, 310.
Messenger, M., Onslow, M., Packman, A., & Menzies, R. (2004). Social anxiety in
stuttering: measuring negative social expectancies. Journal of Fluency Disorders,
29, 201212.
Moutier, C. Y., & Stein, M. B. (1999). The history, epidemiology, and differential
diagnosis of social anxiety disorder. Journal of Clinical Psychiatry, 60, 48.
Neilson, M. D. (1999). Cognitive-behavioral treatment of adults who stutter: the
process and the art. In: R. F. Curlee (Ed.), Stuttering and related disorders of uency
(2nd ed., pp. 181199). New York: Thieme Medical Publishers Inc.
Onslow, M. (2004). Treatment of stuttering in preschool children. Behaviour Change, 21,
201214.
Peters, H. F. M., & Starkweather, C. W. (1989). Development of stuttering throughout
life. Journal of Fluency Disorders, 14, 303321.
Rosser, S., Erskine, A., & Crino, R. (2004). Pre-existing antidepressants and the outcome
of group cognitive behaviour therapy for social phobia. Australian and New Zealand
Journal of Psychiatry, 38, 233239.
Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., & Kessler, R. C. (2008).
Social fears and social phobia in the USA: results from the National Comorbidity
Survey Replication. Psychological Medicine, 38, 1528.
Schneier, F. R., Wexler, K. B., & Liebowitz, M. R. (1997). Social phobia and stuttering.
American Journal of Psychiatry, 154, 131.
Shamir-Essakow, G., Ungerer, J. A., & Rapee, R. M. (2005). Attachment, behavioral
inhibition, and anxiety in preschool children. Journal of Abnormal Child Psychology,
33, 131143.
Snyder, G. J. (2001). Exploratory research in the measurement and modication of
attitudes toward stuttering. Journal of Fluency Disorders, 26, 149160.
Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (FormV). Palo Alto,
CA: Consulting Psychologists Press.
Stein, M. B., Baird, A., & Walker, J. R. (1996). Social phobia in adults with stuttering.
American Journal of Psychiatry, 153, 278280.
Stopa, L., & Clark, D. M. (2001). Social phobia: comments on the viability and validity of
an analogue research strategy and British norms for the Fear of Negative Evaluation
questionnaire. Behavioural and Cognitive Psychotherapy, 29, 423430.
Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of
Consulting and Clinical Psychology, 33, 448457.
Wells, J. E., Oakley Browne, M. E., Scott, K. M., McGee, M. A., Baxter, J., & Kokaua, J.
(2006). Prevalence, interference with life and severity of 12 month DSM-IV
disorders in Te Rau Hinengaro: the New Zealand Mental Health Survey. Australian
and New Zealand Journal of Psychiatry, 40, 845854.
Willoughby, F. W., & Edens, J. F. (1996). Construct validity and predictive utility of the
Stages of Change Scale for alcoholics. Journal of Substance Abuse, 8, 275291.
Wittchen, H. (1994). Reliability and validity studies of the WHO-Composite Interna-
tional Diagnostic Interview (CIDI): a critical review. Journal of Psychiatric Research,
28, 5784.
World Health Organisation. (1993). The ICD-10 classication of mental and behavioural
disorders: diagnostic criteria for research. Geneva: World Health Organisation.
World Health Organization. (1997). CIDIauto version 2.1: computerised version of the
Composite International Diagnostic Interview (CIDI), core version 2.1: manual. Gen-
eva: World Health Organisation.
Yairi, E., Ambrose, N., & Cox, N. (1996). Genetics of stuttering: a critical review. Journal
of Speech and Hearing Research, 39, 771784.
Yaruss, J. S. (2001). Evaluating treatment outcomes for adults who stutter. Journal of
Communication Disorders, 34, 163182.
L. Iverach et al. / Journal of Anxiety Disorders 23 (2009) 928934 934