Advances in PsychiatricChronic

Treatment (2006),
anxiety andvol. 12, 63–68
stammering

Fear of speaking:
chronic anxiety and stammering
Ashley Craig & Yvonne Tran

Abstract Stammering results in involuntary disruption of a person’s capacity to speak. It begins at an early age
and can persist for life for at least 20% of those stammering at 2 years old. Although the aetiological
role of anxiety in stammering has not been determined, evidence is emerging that suggests people
who stammer are more chronically and socially anxious than those who do not. This is not surprising,
given that the symptoms of stammering can be socially embarrassing and personally frustrating, and
have the potential to impede vocational and social growth. Implications for DSM–IV diagnostic criteria
for stammering and current treatments of stammering are discussed. We hope that this article will
encourage a better understanding of the consequences of living with a speech or fluency disorder as
well as motivate the development of treatment protocols that directly target the social fears associated
with stammering.

Stammering (also called stuttering) is a fluency childhood, many recover naturally in early
disorder that results in involuntary disruptions of adulthood (Bloodstein, 1995). We found a higher
a person’s verbal utterances when, for example, prevalence rate (of up to 1.4%) in children and
they are speaking or reading aloud (American adolescents (2–19 years of age), with males in this
Psychiatric Association, 1994). The primary
symptoms of the disorder are shown in Box 1. If
the symptoms are untreated in early childhood, Box 1 Symptoms of stammering
there is a risk that the concomitant behaviours will
become more pronounced (Bloodstein, 1995; Craig Behavioural symptoms
• Involuntary repetition of syllables, especially
et al, 2003a).
Although stammering is classified in DSM–IV as when starting words
• Involuntary prolongation of sounds
a disorder that is typically first diagnosed in
• Unintentional blocking on syllables and
childhood (American Psychiatric Association,
1994), it is found in all age-groups. In the latest words, that is, an inability to utter a sound
research on the epidemiology of stammering (Craig for a brief time, typically 1–3 s
• Unnatural hesitation, interjections, restarted
et al, 2002) we found that most children who
stammer begin to do so before adolescence, most or incomplete phrases and unfinished or
commonly between 2 and 5 years of age, with the broken words
• Concomitant symptoms may include eye
highest peak at around 4 years old. This is called
developmental stammering. Cases of acquired blinks, facial grimacing, jerking of the head,
stammering also occur, where an injury such as arm waving and so on
stroke or trauma to the brain results in brain Psychological and social symptoms
damage. We found the population prevalence of • Emotional struggle when stammering
stammering over the entire lifespan (from 2 • Shyness and social avoidance behaviour due
years to older age) to be 0.72%, with at least a 50% to fear of speaking in specific social contexts
higher prevalence in males. This relatively low • High levels of chronic anxiety, especially
population prevalence is to be expected, because social or phobic anxiety
although 2–4% of people develop a stammer in

Awarded an honoray doctorate in 2002 for his research and clinical work in neurological disorders, Ashley Craig is now Professor of
Behavioural Sciences at the University of Technology, Sydney (Department of Health Sciences, University of Technology, Sydney, New
South Wales, Australia 2007. Tel.: +61 2 9514 1358; fax: +61 2 9514 1359; e-mail: a.craig@uts.edu.au). He also works as an honorary
clinical psychologist at the Royal North Shore Hospital, New South Wales. He has been involved in research into stammering and in its
treatment for the past 20 years. Yvonne Tran is currently a senior research fellow at the Key University Centre in Health Technologies,
University of Technology, Sydney. Her research work has focused on clinical and neuropsychophysiological aspects of diseases such as
spinal cord injury and stammering.

Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/ 63

Craig & Tran

age-group having a fourfold higher prevalence Long-term risks

(Craig et al, 2002).
Over the past 15 years there has been renewed If stammering is left untreated, the risk of developing
interest in the relationship between stammering and an anxiety disorder in later life may be greater.
its potential psychiatric consequences such as Longitudinal research following children with
chronic and social anxiety. The aim of this article is speech or language disorders (including stam-
to examine this relationship in the light of latest mering) from 5 years of age has consistently found
research and to present appropriate clinical that in early adulthood they have increased rates of
approaches to managing the problem. anxiety disorders (mostly social phobia) compared
with other psychiatric illnesses such as schizophrenia
or eating disorder (Beitchman et al, 2001). Negative
Social consequences perceptions and concerns about stammering develop
by about 10 years of age (Hancock et al, 1998).
Talking and speaking fluently and effectively to Certainly, by adulthood, people who stammer
others is a highly valued skill that has many display pervasive negative stereotypes (Craig et al,
ramifications. Having the ability to speak with 2003b). For example, many people with the disorder
fluency and effect will more than likely enhance life hold negative perceptions of themselves (such as
opportunities, whereas dysfluency and inarticulacy believing that they are more anxious), and most
are likely to confer disadvantage. For example, people who do not stammer, regardless of whether
people with aphasia have been found to have a they know someone who does, believe that adults
poorer quality of life (Sorin-Peters, 2003). who stammer are shy, self-conscious, anxious
The negative social consequences begin early for individuals who lack confidence (Craig et al, 2003b).
children who stammer. In primary school they are The above research suggests that as one grows
perceived negatively by their non-stammering older the continued negative effect of a chronic
peers, may be more susceptible to bullying speech disorder such as stammering can be
(Langevin & Hagler, 2004) and have more difficulty debilitating socially and psychologically.
establishing friendships with peers than children
who do not stammer (Davis et al, 2002).
Communication fears have been shown to be The experience of stammering
significantly higher in children who stammer than and its association with anxiety
in children who do not, and these fears increase
with age (Hancock et al, 1998). Reduced ability Stammering becomes more severe when an indi-
to talk fluently owing to a stammer can limit vidual is exposed to threatening or demanding
vocational prospects (Craig & Calver, 1991; stimuli and reduces when the simulus is less
Bloodstein, 1995) and many individuals with a threatening. For instance, anxiety-provoking
moderate to severe stammer perceive it as a barrier situations such as speaking to an audience or to
to effective communication and therefore as a someone in authority, or to a listener who seems to
negative life event (Craig & Calver, 1991; Menzies be impatient or critical, are associated with increased
et al, 1999). stammering (Bloodstein, 1995). Conversely, the
Feeling anxious about one’s stammer might be frequency of stammering is generally reduced in
considered a reasonable reaction because of its situations that are not anxiety-provoking, such as
potential to elicit in listeners mockery, embar- talking to a familiar person or someone not in
rassment, frustration or pity (Bloodstein, 1995; authority.
Menzies et al, 1999). Consequently, as children who Studies have found that, when confronted with
stammer grow into adolescence and adulthood, the threatening social stimuli, people who stammer
risk increases that chronic negative experiences show physical arousal and report increased anxiety
associated with the disorder will precipitate the at the moment of stammering (Bloodstein, 1995;
development of shyness and social avoidance Craig et al, 2003a). Heart rate can accelerate just prior
behaviour, limiting opportunities for psychological to stammering, and when reading aloud people
and educational development (Andrews & Craig, who stammer have been found to have greater heart
1988; Bloodstein, 1995; Craig et al, 2003a). (In rate variability, greater respiration changes and
defence of people who do not stammer, most greater heart rate acceleration than non-stammering
will be unaccustomed to the unusual physical controls (Bloodstein, 1995; Craig et al, 2003a). In
and behavioural symptoms associated with the people who have a stammer, it has also been found
disorder, such as high levels of facial muscle that vasoconstriction is more likely to occur just
tension, facial grimacing, blocking and frequent before stammering than before fluently spoken
repetitions.) words (Bloodstein, 1995).

64 Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/

 Chronic anxiety and stammering

Levels of state anxiety tend to be higher at the Design problems are inherent in such studies (Craig
moment of stammering than at non-stammering et al, 2003a) and a major limitation of almost every
moments and or in non-stammering controls. For study to date is the failure to select a representative
example, Craig (1990) found that people who sample of people who stammer (‘cases’). Most
stammer had substantially higher state anxiety samples consist of individuals who have elected to
levels than non-stammering controls when talking seek therapy for their stammer, and they are
on the telephone, and Gabel et al (2002) found that unlikely to be representative (less than 40% of
people who stammer had higher levels of state people who stammer ever seek therapy; Craig et al,
anxiety when speaking, as did Peters & Hulstijn 2003a).
(1984). Ezrati-Vinacour & Levin (2004) found that To overcome this problem in our own study
severity of stammering correlated significantly with (Craig et al, 2003a) we used a randomised and
state anxiety during speech tasks, whereas no stratified design to recruit representative samples
significant association existed between state anxiety of cases and controls from the general population.
and non-speech tasks. Over 12 000 people were interviewed and people
with a stammer were identified using objective
assessment of speech as well as corroborating
The association of stammering evidence (e.g. that stammering had persisted for
with chronic anxiety more than 3 months). Our findings supported the
view that severity of chronic anxiety in people who
The above evidence demonstrates that the risk of stammer is significantly higher than in non-
stammering increases when an individual with a stammering controls.
stammer engages in an anxiety-provoking social
interaction, and that the moment of stammering is
more likely than not associated with increased Social anxiety and the diagnosis
levels of physiological arousal and anxiety. of stammering
However, the extent to which stammering becomes
associated with chronic levels of anxiety has Social anxiety disorder involves the persistent fear
remained unclarified. Notwithstanding this, recent of embarrassment and humiliation, with sufferers
research suggests that many people who stammer avoiding participating in events they think may
do present with higher than normal levels of be potentially distressing, for example public
chronic anxiety. Indeed, as mentioned above, some speaking, meetings and social occasions. The dis-
have argued that social fears and anxiety are a order is characterised by high levels of generalised
reasonable reaction to the symptoms of stammering anxiety, which can result in severe distress and
(Menzies et al, 1999). impede functioning (American Psychiatric Associ-
Although the available evidence suggests that ation, 1994).
levels of chronic anxiety in children who stammer As discussed above, stammering is characterised
are not any different from levels in children who by a fear of social events that involve speaking,
do not (Hancock et al, 1998; Craig et al, 2003a), the which can result in embarrassment and distress, as
picture is different for adults. The majority of well as by higher than normal levels of chronic
studies suggest that adults who stammer are at anxiety (Craig et al, 2003a). However, DSM–IV
greater risk of developing chronic anxiety. criteria forbid the co-diagnosis of social anxiety
In an exhaustive literature search we identified disorder or phobia in a person diagnosed with
20 studies that investigated levels of chronic and/ stammering (De Carle & Pato, 1996; Stein et al, 1996).
or social anxiety in adults who stammer and non- A diagnosis of social anxiety is permitted only in
stammering controls (a full list of these studies and the absence of a disease or condition (such as
a summary of their results in tabular form are stammering) that is causing the anxiety (American
available as a data supplement to the online version Psychiatric Association, 1994).
of this article, at http://apt.rcpsych.org). Seven Nevertheless, an individual who stammers may
studies concluded that adults who stammer were present with social anxiety of a severity similar to
no more anxious than non-stammering controls, that felt by a person with social anxiety disorder,
whereas 13 concluded that they were more anxious and this anxiety, even though it is probably a
(see online data supplement: Tables 1 and 2). It consequence of the symptoms of stammering, could
should be noted that the average number of be viewed as social phobia (De Carle & Pato, 1996;
participants per group in the seven ‘no-difference’ Stein et al, 1996; Schneier et al, 1997). Stein et al (1996)
studies was only 20, which lessens the confidence found that 12 out of 16 individuals (75%) who were
one should have in their findings. In the 13 seeking therapy for their stammering fitted the
‘difference’ studies the average was 50 per group. DSM–IV criteria for social phobia. However, when

Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/ 65

Craig & Tran

the diagnosis of social phobia included only those To inform any changes to the DSM–IV classifi-
whose anxiety was considered to be in excess of cation, further research is necessary to determine
that expected given the severity of their stam- more precisely the nature of the anxiety suffered by
mering, a sizeable proportion (7 of 16; 44%) still met people who stammer. Studies using representative
the DSM–IV criteria for social anxiety disorder. This samples are needed, and similarities and/or differ-
suggests that the prevalence of social anxiety ences between the social anxieties of people with a
secondary to stammering might be at least 40% in stammer and of people with social anxiety disorder
people who seek treatment for their stammering. need investigation. Furthermore, as recognised by
Further research is required to provide accurate others (Stein et al, 1996), the proportion of people
data on this prevalence. with a stammer who also experience levels of social
Of the 13 studies in our literature search that anxiety disproportionate to the severity of their
found significant difference in levels of anxiety stammering needs clarification.
between cases and controls, seven investigated
social anxiety. All seven showed that people who Management of stammering and related
stammer had higher levels of social anxiety than
non-stammering controls (see online data supple-
anxiety
ment: Table 2). Messenger et al (2004) found that As mentioned above, the evidence we have
this anxiety was associated with social contexts in presented supports the addition of chronic or social
which speech tasks might be required but not with anxiety as a diagnostic feature of stammering,
contexts such as physical danger. Furthermore, especially in adolescents and adults. It is important
although people with a stammer and people with that DSM–IV diagnostic features for stammering
social phobia present with significantly higher include anxiety symptoms, as their current exclusion
levels of social anxiety than do controls, people with can have a detrimental effect on the management
social phobia have been found to have significantly of anxiety. For example, a person who seeks
higher levels of anxiety than people who stammer treatment for their stammering may not be assessed
(Mahr & Torosian, 1999; Kraaimaat et al, 2002). for their level of related anxiety. They might
consequently not be offered appropriate anti-anxiety
treatment, simply because anxiety is not viewed as
Discussion and implications an important component of stammering. Of course,
for treatment although preliminary evidence suggests that anti-
anxiety treatments can have positive effects for
As already mentioned, a proportion of people who people who stammer (Craig et al, 1996; De Carle &
stammer develop social anxiety of a severity Pato, 1996; Hancock et al, 1998), further clinical trials
comparable with that of people who receive a are needed to identify aspects of treatment critical
primary diagnosis of social anxiety disorder. There to success.
is evidence that these individuals can benefit from We believe that a more strategic approach to the
treatment with therapies suitable for social anxiety treatment of stammering is now needed. From the
disorder (Stein et al, 1996; Schneier et al, 1997). evidence shown here, we might conjecture that as
Currently, there is no information regarding many as 40% of people who stammer will present
differences between people who stammer who do with abnormal levels of chronic social anxiety, and
not develop social anxiety and those who do. This that stammering therapies such as fluency shaping
remains a research priority. and stammering modification techniques
The best available evidence on the relationship (Bloodstein, 1995) that are primarily directed at
between stammering and anxiety strongly suggests reducing the stammering behaviour may have
that a rethink of the DSM–IV diagnostic features limited impact on this anxiety component. An
for stammering is needed. These rightly emphasise approach to the management of stammering for
symptoms of the dysfluency such as repetitions of adolescents and adults is outlined in Box 2.
syllables, blocking of sounds and so on. However, Following detailed assessment, specialised stam-
given that research findings reviewed in this article mering treatment should be provided to help the
strongly support the salient role of anxiety (both individual to reduce their stammering by learning
state and chronic socially based anxiety) in the control over behaviours such as involuntary
history of stammering, it seems appropriate that repetitions and blocking and overexcessive muscle
anxiety be considered as an additional diagnostic tension while they struggle to speak. Such therapy
feature of the disorder, especially in adults. It also is usually conducted within a behavioural therapy
seems appropriate to state in the diagnostic features regimen (Craig et al, 1996). Fears and anxieties can
that a proportion of people who stammer present be indirectly addressed by improving fluency skills
with severe social anxiety. as well as reinforcing non-avoidance of situations

66 Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/

 Chronic anxiety and stammering

in addition to the cognitive therapy should be pre-

Box 2 The management of stammering in scribed on an individual basis, for instance if the
adolescents and adults person has real difficulty in lowering their anxiety
Key components of assessment in a feared context (e.g. using the telephone). Finally,
• Diagnosis of the severity of stammering in
some people do not want to receive specialised
various social contexts stammering treatment, preferring instead a therapy
• Diagnosis of the psychological impact of
primarily for their debilitating social anxiety.
stammering, including social anxiety assess- We believe that relying solely on treatment that
ment specifically targets stammering behaviour may not
• Assessment of social skills repertoire speci-
be sufficient for the successful management of the
fically in relation to speech disorder, at least for individuals who have
abnormally high levels of chronic social anxiety. It
Treatment is important for the long-term fluency and quality
• Specialised behavioural treatment that of life of these people that both stammering
reduces stammering symptoms by altering treatments and anti-anxiety therapies be employed
speech patterns (e.g. airflow, fluency in the management of their dysfluency.
shaping, speech muscle tension feedback
and delayed auditory feedback techniques)
• Stammering modification treatments that
Declaration of interest
can reduce dysfluency by altering stam-
mering responses (including self-control None.
techniques, rewards for fluency and mild
punishments for stammering) References
• Cognitive–behavioural therapies for social
American Psychiatric Association (1994) Diagnostic and Statistical
anxieties (e.g. relaxation, social skills and Manual of Mental Disorders (4th edn) (DSM–IV). Washington,
thought-control techniques) DC: APA.
Andrews, G. & Craig, A. R. (1988) Prediction of outcome after
• Pharmacological anti-anxiety therapies for
treatment for stuttering. British Journal of Psychiatry, 153, 236–
those who have difficulty controlling anxiety 240.
using cognitive–behavioural techniques Beitchman, J. H., Wilson, B., Johnson, C. J., et al (2001) Fourteen-
year follow-up of speech/language impaired and control
children: psychiatric outcome. Journal of American Academy of
Child and Adolescent Psychiatry, 40, 75–82.
Bloodstein, O. (1995) A Handbook on Stuttering (5th edn). San
where the person is at risk of stammering while Diego, CA: Singular Publishing Group.
simultaneously rewarding fluency. Craig, A. R. (1990) An investigation into the relationship between
We know that directly treating the stammer can anxiety and stuttering. Journal of Speech and Hearing Disorders,
55, 290–294.
reduce anxiety (Craig, 1990). However, many people Craig, A. R. & Calver, P. (1991) Following up on treated stutterers.
who stammer continue to experience high levels of Studies of perceptions of fluency and job status. Journal of
anxiety even after specialised stammering treatment, Speech Hearing Research, 34, 279–284.
Craig, A., Hancock, K., Chang, E., et al (1996) A controlled trial
and relapse (return of stammering) is a risk if the for stuttering in persons aged 9 to 14 years. Journal of Speech
person is anxious (Craig et al, 2003a). People who and Hearing Research, 39, 808–826.
have difficulties with relapse and anxiety following Craig, A., Hancock, K., Tran, Y., et al (2002) Epidemiology of
stuttering in the community across the entire lifespan. Journal
specific stammering treatments may be those who of Speech, Language and Hearing Research, 45, 1097–1105.
have a high risk of developing social anxiety. That Craig, A., Hancock, K., Tran, Y., et al (2003a) Anxiety levels in
is, their anxiety has become generalised and associ- people who stutter. A randomised population study. Journal
of Speech, Language and Hearing Research, 46, 1197–1206.
ated with many social situations, rather than related Craig, A., Tran, Y., & Craig, M. (2003b) Stereotypes towards
specifically to social speaking, when they may suffer stuttering for those who have never had direct contact with
some understandable embarrassment about their people who stutter. A randomized and stratified study.
Perceptual Motor Skills, 97, 235–245.
stammer. For those with persistent social anxiety, Davis, S., Howell, P. & Cooke, F. (2002) Sociodynamic relation-
anxiety reduction strategies such as cognitive– ships between children who stutter and their non-stuttering
behavioural therapy and anxiolytic drugs should classmates. Journal of Child Psychology and Psychiatry, 43, 939–
947.
be considered as an additional primary focus of De Carle, A. J. & Pato, M. T. (1996) Social phobia and stuttering.
stammering treatment, perhaps in combination if the American Journal of Psychiatry, 153, 1367–1368.
anxiety is resistant to the cognitive–behavioural Ezrati-Vinacour, R. & Levin, I. (2004) The relationship between
anxiety and stuttering: a multidimensional approach. Journal
therapy alone. Cognitive therapies can directly of Fluency Disorders, 29, 135–148.
target the anxiety by addressing negative attitudes Gabel, R. M., Colcord, R. D. & Petrosino, L. (2002) Self-reported
as well as training the individual to be socially anxiety of adults who do and do not stutter. Perceptual and
Motor Skills, 94, 775–784.
assertive and skilled. Relaxation strategies should Hancock, K., Craig, A., Campbell, K. A., et al (1998) Two to six
also be considered. Pharmacological therapy used year controlled trial stuttering outcomes for children and

Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/ 67

Craig & Tran

adolescents. Journal of Speech, Language and Hearing Research, 2 Research has shown that:
41, 1242–1252. a anxiety is associated with the moment of stammering
Kraaimaat, F., Vanryckeghem, M. & Van Dam-Baggen, R. (2002)
Stuttering and social anxiety. Journal of Fluency Disorders, 27, b many people who stammer have high levels of social
319–331. anxiety
Langevin, M., & Hagler, P. (2004) Development of a scale to c anxiety worsens the severity of stammering
measure peer attitude toward children who stutter. In Evidence- d treatment that reduces stammering can reduce chronic
Based Treatment of Stuttering. Empirical Issues and Clinical
anxiety levels
Implications (ed. A. K. Bothe), pp. 139–171. Mahwah, NJ:
Lawrence Erlbaum Associates. e the lifetime population prevalence of stammering is
Mahr, G. C. & Torosian, T. (1999) Anxiety and social phobia. the same for males and females.
Journal of Fluency Disorders, 24, 119–126.
Menzies, R. G., Onslow, M. & Packman, A. (1999) Anxiety and 3 Generally, treatment for stammering should focus
stuttering: exploring a complex relationship. American Journal
of Speech-Language Pathology, 8, 3–10.
primarily on:
Messenger, M., Onslow, M., Packman, A., et al (2004) Social a reducing stammering symptoms and the socially based
anxiety in stuttering: measuring negative social expectancies. anxiety linked to speaking
Journal of Fluency Disorders, 29, 201–212. b reducing stammering alone
Peters, H. F. M. & Hulstijn, W. (1984) Stuttering and anxiety. The c resolving family dynamics
difference between stutterers and nonstutterers in verbal
apprehension and physiologic arousal during the anticipation d reducing chronic anxiety alone
of speech and non-speech tasks. Journal of Fluency Disorders, e reducing fears at the moment of stammering.
9, 67–84.
Schneier, F. R., Wexler, K. B. & Liebowitz, M. R. (1997) Social 4 Stammering is best diagnosed by:
phobia and stuttering. American Journal of Psychiatry, 154, 131.
a measuring social anxiety levels in children using
Sorin-Peters, R. (2003) Viewing couples living with aphasia as
adult learners. Implications for promoting quality of life. validated questionnaires
Aphasiology, 17, 405–416. b measuring family interactions with the stammering
Stein, M. B., Baird, A. & Walker, J. R. (1996) Social phobia in adults person
with stuttering. American Journal of Psychiatry, 153, 278–280. c measuring the stammering behaviour and associated
anxiety levels
MCQs d measuring levels of self-esteem in children
e measuring brain activity levels using electroencephalo-
1 Stammering is considered to be: grams.
a a neurological disorder that results mostly from brain
injury during childhood or adulthood 5 Stammering is classified as:
b a childhood developmental disorder that is believed a a developmental speech disorder
to be inherited and to have a neurological basis b an anxiety disorder
c a psychological disorder caused by being overanxious c a neurological deficit disorder
d a speech disorder caused by parental upbringing d a conduct disorder
e a fluency disorder caused by self-esteem problems. e a learning disorder.

MCQ answers
1 2 3 4 5
a F a T a T a F a T
b T b T b F b F b F
c F c T c F c T c F
d F d T d F d F d F
e F e F e F e F e F

68 Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/