# Speech-Language Pathology/Stuttering/Stress-Related Changes

Under stress, people's voices change. They tense their speech-production muscles, increasing their vocal pitch. They try to talk faster. They repeat words or phrases. They add interjections, such as "uh." These are normal dysfluencies. A study found that under stress, non-stutterers went from 0% to 4% dysfluencies, for the simple task of saying colors. Stutterers went from 1% to 9%.
The "conventional wisdom" is that stutterers are always nervous or stressed out. Many psychological studies have proven that this isn't true. But stress has an important role in stuttering.
This next fact is so obvious that you've probably never thought about how important it is. All stutterers can talk fluently. In relaxed, low-stress situations we can say any sound or word fluently. If you're a severe stutterer, there might not be many such situations. But there are some.
In other situations we stutter. How many paraplegics do you know who can walk in some situations, but not other situations? Or people who are blind with certain people, but not with other people? None that I've ever known.
Think about this. Our brains are capable of producing fluent speech. We have all the speech motor programs necessary to produce any speech sound, fluently.
We also have speech motor programs for producing dysfluent sounds. Stutterers have two sets of open-loop speech motor programs. Our brains select one or the other set of speech motor programs, depending on environmental cues—where we are or whom we're talking to.
This is like a person who grew up summers in Massachusetts and winters in Georgia. Such a person would have a set of speech motor programs to speak with a New England accent. And this person would have a set of speech motor programs to speak with a Southern accent. When she's in Massachusetts, hearing people speak with New England accents, her brain automatically selects the New England accent speech motor programs. In Georgia, her brain selects Southern accent speech motor programs.
You always have choices for handling stressful situations. Some choices trigger your brain to automatically select dysfluent speech motor programs. Other choices trigger your brain to select fluent speech motor programs. This chapter will teach you to make choices for handling stress that automatically select fluent, relaxed speech. You'll feel relaxed and speak confidently even when non-stutterers are stressed out.

### Are Responses to Stress Psychological?

According to "conventional wisdom," stuttering is a psychological disorder because stutterers generally speak fluently in low-stress situations, and stutter in high-stress situations.
But many responses to stress are physical. E.g., "fight or flight" increased heart rate. Stress is considered to be a factor in the development of physical disorders, such as heart disease, and a primary factor in gastrointestinal disorders. Why is stuttering considered to be a psychological disorder, but stomach ulcers are considered to be a physical disorder?
This chapter presents how stuttering is a response to stress, and then presents psychological treatments for better handling stress. Although the presented treatments are psychological, I object to referring to responses to stress as psychological responses. You can treat responses to stress physically, such as with medications or using an anti-stuttering device. I've put those treatments into other chapters. Perhaps more than the other factors, responses to stress show that the factors that contribute to stuttering are complex and interconnected.

### Stuttering Reduces Stress

Systolic blood pressure is an indicator of stress. Stuttering reduced stutterers' blood pressure 10%. In contrast, fluent speech, chewing gum, and sitting quietly each reduced blood pressure about 2%.
You're thinking, "No way. Stuttering doesn't relax me. Stuttering doesn't feel like a massage and warm bath."
But think about it. Stutterers are, on average, disfluent on 10% of syllables. We say 90% of syllables fluently. But we don't say one hundred syllables fluently, and then finish a conversation with ten dysfluencies. Stuttering usually occurs on the first sound of the first word, in a stressful situation. I.e., your stress builds up as you anticipate speaking. You stutter, and this releases stress. You then say several syllables fluently.
You then stutter on another syllable, then say several more syllables fluently. Usually your speech improves over the course of the conversation, and your last few sentences are your most fluent.
If your blood pressure were monitored in such a conversation, it might look like this (this is speculative, not based on research):
Stuttering Reducing Stress
Your stress increases as you anticipate speaking. You block on the first syllable. This reduces your stress, and you speak fluently. Your stress builds up again, and you stutter again. This reduces your stress, and the cycle repeats until you're speaking fluently at the end of the conversation.

#### Stuttering Isn't a Good Response to Stress

Stuttering doesn't change the stressful situation. E.g., a highway patrol officer pulls you over for speeding. Stuttering won't make the officer think you weren't speeding.
Stuttering might make the situation worse. E.g., the highway patrol officer mistakes your stuttering for methamphetamine addiction. He handcuffs you and searches your car. This stresses you more, and you stutter more.
Stuttering and stress are a vicious cycle. Stuttering reduces your stress for a few seconds, but then causes more stress. You get stuck in the cycle, unable to break free.
Another study measured listeners' systolic blood pressure. Listening to stuttering made listeners feel stress. The listeners' increased stress may in turn increase the stutterer's stress. Again, stuttering and stress start a vicious cycle.
This chapter will show you that you have other choices for handling stress, instead of stuttering. These other choices reduce stress, instead of throwing you into an endless cycle.

### Distraction and Placebos

The "experts" believe that "Distraction methods can be used to eliminate stuttering temporarily." But if distraction worked, stutterers would work a Rubik's cube or play a pocket video game whenever they wanted to talk fluently.
Two studies tried to distract stutterers from stuttering. In the first study, stutterers stepped on and off a 10-inch platform while reading out loud. In the second study, stutterers manually tracked an irregular line on a rotating drum while speaking. Neither distraction was able to reduce stuttering.
Distraction can cause stuttering. Stutterers often say that they can use therapy skills in a clinical environment, but the distractions of normal conversations make fluent speech difficult.
An "expert" wrote, "if a stutterer were to forget that he was a stutterer, he would have no further difficulty with his speech." Another "expert" wrote, "our beliefs about stuttering seem to be one of the main factors in stuttering severity."
Placebos are pills without medications, or, more generally, an inactive, nonspecific medical treatment that alters the beliefs of a patient. A study found that placebos did not reduce stuttering. Another study also found that placebos had no effect on stuttering—but the placebos caused terrible side effects! Reported placebo side effects included constipation, sexual dysfunction, dizziness, sweating, and tremors. The placebo was six times more powerful than the medication in the study, in producing side effects.
This raises an interesting question. Placebos are effective treatments for almost every disease and symptom:
   Study after study showed that, for virtually any disease, a substantial portion of symptoms—roughly one-third, by most estimates—would improve when patients were given a placebo treatment with no pharmacological activity. Patients simply believed that the treatment would help them, and somehow, it did.
   …for a wide range of afflictions, including pain, high blood pressure, asthma and cough, roughly 30 to 40 percent of patients experience relief after taking a placebo…placebos seem to be most reliably effective for afflictions in which stress directly affects the symptoms…pain, asthma and moderate high blood pressure can become worse when the patient is upset…placebos may work in part by lessening the apprehension associated with the disease [because] the immune system falters under stressful conditions.
Stuttering may be the only disorder that placebos have no effect upon! I.e., stuttering isn't affected by belief, and stutterers can't be "psyched" into fluency. In contrast, heart disease, asthma, etc. appear to be physical diseases but are actually in large part psychological. Could stuttering—long believed to be psychological—actually have no psychological component?

## Good Stress, Bad Stress

We experience many forms of stress. Some forms of stress reduce stuttering. Other forms of stress increase stuttering. Still other forms of stress have no effect on stuttering.

#### Adrenaline and Fluency-Enhancing Stress

In World War Two, a severe stutterer regularly spoke fluently for mortar communication during combat.
One night, a person physically threatened me for several hours. I've never been so fluent in my life! My voice was calm and relaxed as I tried to get the person to calm down.
Noradrenaline and adrenaline compete with dopamine for the binding sites on D4 receptors, and when bound, act as agonists. At the same time, through feedback inhibition, norepinephrine inhibits tyrosine hydroxylase, which in turn inhibits the production of dopamine. Because dopamine in the striatal system increases stuttering (see Genes and Neurotransmitters, and adrenaline blocks dopamine, "fight or flight" situations that increase adrenaline reduce stuttering.
Stutterers report that when the adrenaline wears off, their stuttering increases.

#### Physiological Stress

Physical activities such as running or bicycling elevate heart rate, blood pressure, etc. Dropping a rock on your foot is another form of physiological stress.
Exercise makes you breath harder, with your diaphragm. If your stuttering involves disordered breathing you may stutter more when exercising. On the other hand, if your speech-language pathologist trained you to speak with diaphragmatic breathing, exercise may improve your fluency.
In general, physiological stress has no effect on stuttering.
Progressive relaxation trains you to relax all of your muscles, starting with your toes and ending with your facial muscles. Progressive relaxation has minimal effect on stuttering. Relaxation exercises only reduce stuttering when the focus is on relaxation speech production muscles (respiration, vocal folds, and the lips, jaw, and tongue articulators).

#### Cognitive Stress

Hearing or seeing several things at once, especially if the events contradict each other (cognitive dissonance), increases stuttering.
For example, I can't stand talking to a person who's watching television. Or a person who's playing guitar, or picks up the phone to make a call while I'm trying to talk to him. I have a cousin who watches TV, plays guitar, and makes telephone calls, all at the same time, when I to talk to him. He thinks he's making efficient use of his time, but he wastes my time.
Listeners should give their full attention to stutterers. Turning away to do something else, even if you say, "I'm still listening," will increase the individual's stuttering.
If a listener won't give you his or her full attention, consider whether the conversation matters to you. If not, walk away. Don't consider whether what you're saying is important to the listener. It's obviously not.

#### Time Pressure

Time pressure increases stuttering. At the beginning of this chapter I mentioned a study in which subjects were told to say colors. At first, "red" was written in red on a computer monitor. The screens came faster and faster, to increase time pressure.
Next, cognitive stress was added. E.g., the word "red" was written in yellow on a computer monitor. The subjects had to say "yellow," not "red."
These results were dramatic. Non-stutterers went from 0% dysfluent words, to 2% disfluencies with time pressure, then to 4% with time pressure and cognitive stress.
Stutterers went from 1% stuttered words, to 3% with time pressure, to 9% with time pressure and cognitive stress.
Telling a stutterer to talk faster will have the opposite effect. Instead, tell stutterers to take all the time they need.
Use time pressure to your advantage by limiting what you say. Tell most people to make a five-minute speech and they ramble on for ten minutes, without getting to the point. If you're asked to make a five-minute speech, get to the point in one minute, without the rambling. What you think is one minute will actually take two or three minutes, and then adding in stuttering will make it five minutes. Even when I stuttered severely I had professors compliment my presentations.

#### Pragmatic Speech

Pragmatic speech is intended to cause another person to do a speciﬁc action. This might be telling a co-worker how to send a fax. Don't say, "Let me do it for you."
More stressful is asking someone to do something you want, when you're afraid that the person will say no. E.g., asking your boss for a raise, or asking an attractive person out on a date, or telling your housemate to wash the dishes. The listener is relatively powerful, and you're in a position of relative weakness.
To reduce stress, we usually try to make the question look casual. You "just happen" to run into the attractive person at the health club, and you "just happen" to have tickets to a show in your pocket, and you "casually" ask for a date. Or you wait until you've just landed a big sale for the company, and "jokingly" tell your boss that you deserve a raise.
But then you stutter, belying that this "casual" conversation is stressful for you. Your listener recognizes your weak position and, if he or she has an ego problem, enjoys manipulating you. A powerful person with an ego problem manipulating you is a pretty good description of stress. Instead, use other ways to reduce stress. First, don't make a big effort to set up a "casual"-seeming situation. The more effort you make, the more stress you'll feel that it's "now or never" to get a positive response.
Next, use Winston Churchill's strategy of preparing your points in advance ("I deserve a raise for three reasons…"), anticipating your listener's objections, and preparing responses to those objections. Then use slow speech to explain each point. Pause between points. Use the pause to check that your breathing and vocal folds are relaxed. You'll sound confident and in control.
Lastly, be willing to walk away. Is it the end of the world if your housemate doesn't wash the dishes, or you don't get a date? Visualize what you'll do and how you'll feel if the answer is no.

### Be an Anti-Mirror

People tend to mirror each others' speech patterns. A person speaks fast to you, so you talk fast. A listener jumps in before you finish your sentences, so you interrupt her sentences. A person gets angry at you, so you raise your voice and get emotional.
All of those speech patterns increase stuttering. Instead, be an anti-mirror. The faster people speak to you, the slower you talk. Instead of interrupting, wait for the other person to finish speaking, then count to three before you start to talk. If a person expresses anger, make your voice quieter, slower, and less emotional.

#### Embarrassment and Uncertainty

We fear embarrassment. E.g., I'm about to call you Josh, when I think, "Wait, his name is Joel."
This fear is multiplied when we're speaking to more than one person—saying something embarrassing in front of an audience of a thousand people is more embarrassing than in front of one person.
Lack of feedback increases our fears of embarrassment. I.e., when speaking on television we can't observe the reactions of listeners. You could say something stupid and never know it. You try to remember and analyze the last thing you said while you're saying something else.
If you say something embarrassing, make a joke out of it. E.g., I was waiting for a woman I'd never met. She said she'd arrive at 6pm. At 6:05pm a woman parked in front of my house. I went out and said, "You must be Ariana." She didn't say anything so I said it again. She responded that she wasn't Ariana. I said, "Oh my God, I'm so embarrassed," in a humorous way.
Then there's always the "at my advanced age I can't remember names." That's funny whether you're 90 or 19.
That sounds obvious, but there's a subtle point in there. Acknowledging embarrassment ends embarrassment.

#### Establishing Status

We communicate status largely via speech. We feel anxiety when status is ambiguous.
E.g., you find a large, muscular hoodlum sitting on your car. Do you speak with firm authority, ordering the hoodlum off your car? Do you choose a friendly, buddy-buddy tone of equality? Do you meekly ask if the hoodlum could let you have your car back?
Stuttering doesn't necessarily communicate low status. Embarrassment and anxiety about stuttering communicates low status. Calmly stuttering, while looking the hoodlum in the eye, establishes that you're not afraid to stutter and you're not afraid of the hoodlum.

#### Moral Stress

You did something wrong. You didn't realize it was wrong at the time, but now you're suspected of this minor crime. You make up a lie to eliminate the suspicion. But your lie is caught. Now you're in real trouble.
I'm not going to preach whether "honesty is the best policy" or whether lying your way out of situations sometimes works. What I'll tell you is how to use stuttering to appear to be telling the truth. Interrogations start with "baseline" questions such as your name. But every stutterer blocks on their name! Get into some good dysfluencies on your name. Imagine yourself hooked up to a lie detector machine. Make the needle swing into the red.
Then when you're asked the real question, pause, relax your breathing and your vocal folds, and slowly and fluently tell your story—truthfully or otherwise. A lie detector machine will indicate that you're telling the truth. A human listener will do the same.

#### Categorize Stress to React Rationally

Movies show characters in stressful situations. When watching movies, name the type of stress a character experiences. Soon you should feel an inner voice say "moral stress," or "time pressure" when watching movies.
Then the same light bulb will switch on in your mind when watching people in daily life. When the light bulb switches on in situations stressful to you, you're on your way to eliminating this type of stress.
Stress causes you to react emotionally, not rationally. When reacting emotionally, you react one way. Different people have different emotional reactions, depending on their personality type. E.g., one person might react with outward anger, when another person reacts with inward shame. That doesn't matter. What matters is the automatic, single response to all stressful situations.
Shifting out of an emotion and into "neutral" enables you to see other possible responses, and select the best response. The light bulb switching on enables you to switch gears.

### References

* ^ Caruso, A., et al. "Adults Who Stutter: Responses to Cognitive Stress." Journal of Speech and Hearing Research, 37, 746-754, August 1994.
* ^ Perkins, W., Dabul, B. "The Effects of Stuttering on Systolic Blood Pressure." Journal of Speech & Hearing Research, Vol. 16, No. 4, December 1973.
* ^ Schwartz, Martin. Personal correspondence.
* ^ Kuehn, Donald (1994). Official correspondence from the National Institute of Deafness and Communication Disorders (NIDCD).
* ^ Bloodstein, Oliver (1995) A Handbook On Stuttering, 5th edition, San Diego: Singular Press.
* ^ Bloodstein, Oliver (1996) "Stuttering as an Anticipatory Struggle Reaction," in R. F. Curlee & G. M. Siegel, Nature and Treatment of Stuttering: New Directions. Boston: Allyn&Bacon.
* ^ Neiders, Gunars. Stutt-x e-mail correspondence, December 18, 1997.
* ^ Prins, D., Madelkorn, T., Cerf, A. "Principal and Differential Effects of Haloperidol and Placebo Treatments Upon Speech Disfluencies in Stutterers." Journal of Speech & Hearing Research, 23, 614-629, September 1980.
* ^ Stager, Ludlow, Gordon, Cotelingam, and Rapoport. "Fluency Changes in Persons Who Stutter Following a Double Blind Trial of Clomipramine and Desipramine," Journal of Speech and Hearing Research, June 1995.
* ^ Goleman, Daniel, and Joel Gurin. Mind/Body Medicine, Consumer Reports Books, 1993.
* ^ Brown, Walter A. "The Placebo Effect." Scientific American, January 1998, 90-96.
* ^ Bloodstein, Oliver (1995) A Handbook On Stuttering, 5th edition, San Diego: Singular Press.
* ^ Newman-Tancredi, Adrian. "Noradrenaline and adrenaline are high affinity agonists at dopamine D4 receptors." European Journal of Pharmacology 319 (1997) 379-383. 101511,274@compuserve@com. Valerie Audinot-Bouchez, Alain Gobert, Mark J. Millan, Department of Psychopharmacology, Institut de Recherches, 125 Chemin de Ronde, 78290 Croissy-sur-Seine (Paris), France.
* ^ Bloodstein, Oliver (1995) A Handbook On Stuttering, 5th edition, San Diego: Singular Press.
* ^ Caruso, A., et al. "Adults Who Stutter: Responses to Cognitive Stress." Journal of Speech and Hearing Research, 37, 746-754, August 1994.