اضطراب اجتماعی در لکنت زبان: اندازه گیری انتظارات منفی اجتماعی

Much research has suggested that those who stutter are likely to be anxious. However, to date, little research on this topic has addressed the role of expectancies of harm in anxiety, which is a central construct of anxiety in modern clinical psychology. There are good reasons to believe that the anxiety of those who stutter is related to expectancies of social harm. Therefore, in the present study, 34 stuttering and 34 control participants completed the Fear of Negative Evaluation (FNE) Scale and the Endler Multidimensional Anxiety Scales-Trait (EMAS-T). The FNE data showed a significant difference between the stuttering and control participants, with a large effect size. Results suggested that, as a group, a clinical population of people who stutter has anxiety that is restricted to the social domain. For the EMAS-T, significant differences between groups were obtained for the two subtests that refer specifically to people and social interactions in which social evaluation might occur (Social Evaluation and New/Strange Situations) but not for the subtests that contained no specific reference to people and social interactions (Physical Danger and Daily Routines). These results were taken to suggest that those who stutter differ from control subjects in their expectation of negative social evaluation, and that the effect sizes are clinically significant. The findings also suggest that the FNE and the EMAS-T are appropriate psychological tests of anxiety to use with stuttering clients in clinical settings. The clinical and research implications of these findings are discussed, in terms of whether social anxiety mediates stuttering or is a simple by-product of stuttering. Possible laboratory explorations of this issue are suggested, and potential Cognitive Behavior Therapy packages for stuttering clients who might need them are discussed.

Early writings about the disorder of stuttering contain references to anxiety (e.g., Despert, 1946, Goodstein, 1958, Honig, 1947 and Schultz, 1947), and a belief that anxiety is common among those who stutter is reflected in writings of modern authorities (Andrews et al., 1983 and Bloodstein, 1995; Brutten & Shoemaker, 1971; Ingham, 1984, Johnson, 1955 and Van Riper, 1982). For example, in one of the more widely used and cited textbooks on stuttering, Guitar (1998) refers many times to anxiety and anxiety management. The link between anxiety and stuttering has been described from the viewpoint of those who stutter and their clinicians by Lincoln, Onslow, and Menzies (1996), who showed that the majority of both groups reported that those who stutter commonly report and/or experience speech anxiety. Lincoln et al. also found that a third of clinicians surveyed reported using anxiety management procedures with their stuttering clients. Although the research literature on this topic is methodologically problematic and has produced inconsistent results, some of its findings have been nonetheless consistent (for a complete review, see Menzies, Onslow, & Packman, 1999). In the case of state anxiety, Craig (1990) and Ezrati-Vinacour and Levin (2004), for example, showed that a clinical sample of stuttering subjects scored higher than controls. Further, stuttering has been shown to vary under conditions intuitively associated with state anxiety, such as the size of an audience and the perceived status of a conversational partner (Porter, 1939; Siegel & Haugen, 1964). The Speech Situations Checklist (SSC) (Brutten, 1975) elicits responses about speaking situations that directly and indirectly relate to state anxiety. Bakker (1995) reported that a 31-item subset of SSC was able to provide statistically powerful distinctions between stuttering and control subjects, independent of speech data about stuttering rate or severity. In the case of trait anxiety, Craig (1990) and Ezrati-Vinacour and Levin (2004) also found higher scores for stuttering subjects than controls, and Craig and colleagues subsequently replicated this finding with a large population sample (Craig, Hancock, Tran, & Craig, 2003). There have also been some consistent physiological findings about stuttering and anxiety. Leanderson and Levi (1967) found that those who stutter may have higher levels of catecholamine excretion than control subjects, and physiological arousal has been shown to correlate with stuttering severity (Weber & Smith, 1990). In a review of the area, Alm (2004) formed the interesting conclusion, based on available data, that those who stutter appear to exhibit an anxiety related “freezing response” of reduced heart rate, rather than increased heart rate. Further, Kraaimaat, Janssen, and Brutten (1988) reported that autonomic arousal related to poor treatment outcomes. In short, there are good reasons to believe that there is a relationship between stuttering and anxiety that is clinically important, and that clinicians will encounter many stuttering clients for whom anxiety is an issue. Therefore, as Kraaimaat, Vanryckeghem, and Van Dam-Baggen (2002) noted, for many clients, management of anxiety is likely to be an important element in the management of chronic stuttering. However, as Kraaimaat et al. further argue, it is necessary to know not only the extent to which anxiety is involved in stuttering, but also precise details of the nature of that involvement. Indeed, as Menzies et al. (1999) note, on balance, authorities generally are willing to admit that anxiety can be associated with stuttering, but they are uncertain about the exact nature of that relationship (Andrews et al., 1983, Bloodstein, 1995 and Ingham, 1984). In the continued development of measurement procedures for anxiety in clients who stutter, then, attention needs to be paid to exactly what components of anxiety should be measured. Modern clinical psychology incorporates the notion of “expectancy of harm” as fundamental in the construct of anxiety (see Beck & Emery, 1985). In other words, it is generally thought that anxiety will not be present without such perceived danger or harm. Additionally, recent conceptualizations of trait anxiety from the field of psychology disavow the notion that it is a monolithic construct, and emphasize different components, such as social anxiety, novel situation anxiety, and physical anxiety (Endler, Magnusson, Ekehammar, & Okada, 1976). With regard to these concepts of anxiety, there are good reasons to believe that the apparent link between stuttering and anxiety would concern expectancy of some kind of social harm, in the domains of social anxiety and novel situation anxiety, but not the domain of physical anxiety. Speech is the fundamental mechanism underpinning day-to-day interactions with others, around which social and networks are established, developed, and sustained. Expectancy of social harm, then, might accompany stuttering because the disorder disturbs that basic social function in a disfiguring way. Accordingly, social anxiety might well be expected to occur in such circumstances (Poulton & Andrews, 1994). Some data are available to confirm that normal social and occupational functioning is disturbed with the population of those who stutter. Data indicate, for example, that those who stutter are evaluated negatively, particularly by teachers and employers, with considerably deleterious life effects (Cooper & Cooper, 1996; Cooper & Rustin, 1985; Craig & Calver, 1990; Crichton-Smith, 2002; Hayhow, Cray, & Enderby, 2002; Silverman & Paynter, 1990). Virtually every adult who stutters reports that stuttering has negative effects on life during the school years (e.g., Crichton-Smith, 2002 and Hayhow et al., 2002). Data show that primary school children are perceived negatively by peers (Langevin & Hagler, 2004), and are rejected by peers more often than children who do not stutter (Davis, Howell, & Cooke, 2002). Perhaps for these reasons, primary school children who stutter are more likely to be bullied than their peers (Langevin, Bortnick, Hammer, & Wiebe 1998). It is not surprising, then, that there is a set of research findings to suggest that chronic stuttering in adulthood is associated with social anxiety. Consistent findings have emerged from self-report inventories of social anxiety (e.g., Kraaimaat, Janssen, & Van Dam-Baggen, 1991; Kraaimaat et al., 2002; Maher & Torosian, 1999). Further, there are case reports in the psychiatric literature of stuttering adults with comorbid social phobia who have been treated with pharmacological interventions (e.g., Paprocki & Rocha, 1999). Stein, Baird, and Walker (1996) demonstrated that 44% of clients seeking treatment for stuttering warranted a comorbid diagnosis of social phobia, having social anxiety to a level clearly excessive for the severity of their stuttering. Subsequently, Schneier, Wexler, and Liebowitz (1997) confirmed Stein et al.'s finding that those who stutter can have social anxiety at similar levels to patients with social phobia. More recently, Kraaimaat et al. (2002) reported that about 50% of the scores of 89 stuttering subjects, on a scale of social discomfort, “fell within the range of a group of highly socially anxious psychiatric patients” (p. 319). In short, it appears that comorbid social anxiety and stuttering is common, and that expectancy of social threat or harm in such anxiety is likely. Therefore, it seems essential to include measures of such social threat or harm in the search for clinical measures of anxiety called for by Kraaimaat et al. (2002). However, such measures have not been included in anxiety stuttering research to date. The Inventory of Interpersonal Situations (Van Dam-Baggen & Kraaimaat, 1999) used in the recent Kraaimaat et al. (2002) report focuses on “discomfort and frequency of occurrence scales, which investigate, respectively, anxiety and emotional tension in social situations and the frequency with which social responses or skills are performed” (p. 322). To our knowledge, there has been only one study of stuttering that has involved direct measures of expectancy of social harm. In the context of a study of social phobia, Poulton and Andrews (1994) happened to incorporate a control group of stuttering subjects. Among other tests, these subjects were required to complete the “Negative Social Evaluation Scale” (Morris-Yates, 1993) before and after giving a speech to an audience, to describe how they felt during the speech. Items on this scale were “people will find fault with you,” “people will see you as incompetent and foolish,” “people will see that you are anxious and not like you,” “people will laugh at you,” and “you will make a scene in front of others” (Poulton & Andrews, 1994, p. 640). Poulton and Andrews reported that the scores of the group of stuttering subjects indicated highest appraisal of danger during, rather than before or after, the speaking task. In summary, empirical study of the relation between stuttering and anxiety will require the development of anxiety measurement tools that capture all aspects of the anxiety of those who stutter. Although there is good reason to implicate expectancy of social harm in the anxiety associated with stuttering, at present there has been no reported empirical study of such an effect in a population of people who stutter. Should such an effect exist, the establishment of a tool for its measurement will be important in the development of clinical procedures for the disorder. Consequently, the present research was designed to determine whether expectancy of social harm is associated with speech related anxiety in those who stutter.