Saturday, October 29, 2005

KST: Day 14-17 More transfer

The last days of the therapy went by quite fast. Not much new. The point was to practise transfer situations like phone calls, talking in front of people (we visited a school of speech and language therapists), and daily tasks like ordering in a restaurant or shop. Most patients were very fluent, except possibly two. Some used the techniques, some to some extent, and others didnt. We were recorded on video. On the last day, everyone had to conduct an interview with by-passers in a shopping mall. It was amazing to see the videos and compare them to the before-therapy recordings of the same situation. Especially one video struck me. Before therapy he was stuttering severely and really came across as a troubled man: no smiling, lots of tension, somber look. But the video at the end of the therapy was very different. He didnt stutter, smiled at the by-passer, and was relaxed. He was someone you would happily invite to your barbecue to get the vibes going... Just shows how much a speech impediment can impact on the expression of the real personality.

And now a more critical note. Most were very fluent, but virtually all had seeds for relapse. The point is that many who experienced fluency did not use the techniques a lot. And from my own experience I know that sooner or later the old habits and blocks are coming back slowly unless you keep them at bay and constantly (even obsessively) praticise and use the techniques. I am wondering whether therapists can predict who will relapse and who will not. I once asked Eva Heuer who worked for the KST who said that she could not really detect a pattern. I should really ask all the therapists about it. If any of you is a therapist, let me know whether you think you can. I did the analysis of the KST data for long-term outcome, and we couldnt find anything except severity of stuttering before therapy, which is not very promising.

Friday, October 28, 2005

Franz's claim for fame

The traffic to my blog has constantly increased since the beginning in May. There are also more people who comment to me on my blog. One of them is Frank Jassens, but everyone calls him Franz. He had the audacity to complain that I had never mentioned his name before in the connection with the KST!!! So this post is for you, Franz!

Franz has done the therapy 3 years ago, and now works as a therapist and project manager for the KST. He now speaks very well without any apparent symptoms to me. I have not known him before therapy, so I cannot judge the severity of his stuttering before. But his video before therapy is quite infamous for its pronounced secondary symptom which was quite situational dependent. I am always curious to ask why people think they have become more fluent. Franz said that he has consistently used the speech techniques over several months after the therapay, and it just went away...

This post would be incomplete without mentioning the true love in his life: his "Schaeferhund" or German sheperd dog. :-) I always see them together. They fit so well together, also colourwise... He also has a girlfriend, but I havent really met her yet! ;-)

If you also want to complain that you have not been mentioned on my blog, please send me an email. I would be delighted to write a post on you!!!!!!!!!!

Tuesday, October 25, 2005

Changing behaviour.

A recurring theme on my blog is that stuttering therapies are behavioural therapies and that behavioural therapies always show good short-term results, but rather poor long-term outcomes. It is easy to get someone fluent but difficult to maintain the fluency. I possibly obsessively compare stuttering to overweight and drug addiction. You can loose weight rather quickly with a strict diet over 2-3 months, and you can loose your physical and psychological addition to drugs, be it alcohol, smoking, or heroine, within weeks.

However, the hidden bleak fact about behavioural therapies is relapse. It is the norm that people relapse rather than the exception. I always cite an article, which followed 500 people during a diet over 2 years. They volunteered to participate in a diet, and virtually everyone benefited. I remember reading about an average weight loss of about 10 kg. The controlled diet went over three months. At the end of this period, the patients were given instructions to maintain their lower weight, in short: balanced meals with a lot of vegetables, and sport activities. What wer the result? Only 5% mantained the lower weight, and on average the weight was above the weight before the diet!!!

I have been thinking about the dynamics leading to relapse. I view the human being as two different entities interacting: the cortex (which does the rational thinking), and the limbic system (which generates the emotions). During a diet, my cortex will run the show if I decline a piece of chocolate, and my limbic system will win whenever I eat the piece of the chocolate. The irony really is that everyone on a diet has made the rational long-term choice to go on a diet, but the emotional short-term urges might have different plans.

A solution is to reduce or eliminate the emotional short-term urges. Let me just briefly say something positive about emotional short-term urges. They are essential for our survival. Our brain needs to make us feel hungry, angry, or lonely to ensure a better survival. We also need to feel comfort in our habits, the things that we know from past experiences. Without our habits, we could not live a simple life without thinking about every tiny activity. The problem is that our limbic system cannot think, but only associates to each activity or situation or idea an emotion like good or bad irrespective of its true usefulness. Also, it is essential that we have trouble to unlearn a habit quickly.

Using this framework, I see two ways of reducing or eliminating the emotional short-term urges. First, a stronger traffic from the cortex to the limbic system, i.e. your cortex send more and stronger messages to your limibic system and overriding the limbic system. Second, the urges are weaker or eliminated by changing the emotional association to an activity or situation or idea.

To achieve a stronger traffic from the cortex, you need to tell yourself constantly what you want, that means constant broadcast the right message: I like to eat an apple instead of chocolate. Chocolate made me sick last time. I eat chocolate tomorrow but not now. (Dont worry if you lie to yourself, your limbic system buys the lie.) This self-talk goes under the name of auto-suggestion. Write down the things you want to think, and repeat them to you over and over again. To achieve a re-programming of the limbic system, you need to teach the limbic system the right association you want to have. For example, you are scared of spiders. You need expose yourself bit by bit several times in a quick succession to the situation, and slowly you will learn a new association.

So how does this understanding help with avoiding relapse? I want to generalise this question a bit and include: How can I make myself not forget to speak slower, make more pauses, or use a gentle onset? First, use auto-suggestion and write down messages that you want to broadcast to yourself constantly, for example: I like to make pauses, or Pauses make me feel comfortable. Say them to yourself as often as possible with positive emotional intensity... ideally you do this broadcast obsessively. Second, you need to get into real situations and learn a positive association to your new behaviour. For example, if you get nervous or scared when you pause, go on the street and ask people for a direction, say Hello, and then count until 2 until you ask for direction. do this 10 times in a rapid sucession. if you want, start doing this method first on your own, then ask your dog whether he would be willing to listen, then a friend, and so on...

I am 100% sure that these methods work very efficiently when used. At the beginning, you detect no significant impact, but after 2-3 weeks you will be amazed how you are suddenly doing (or even have to do) these things automatically. I have tried myself and the methods work. But there is one big problem, that I also experienced a lot. I forget to do it or somehow invent millions of excuses for not doing. :-) You either need to have a determination to follow through. Also, guidance from a therapist ideally in the settings of an intensive therapy course is essential. It is easier if you are put under some pressure and in an environment with low distraction.

The question is also how much pressure should a therapist exercise on a patient that, for example, wants to use a technique but consistently failed to do so. One way would be to put pressure on the patient and tell the patient off and say that s/he must work harder. Another way would be that patient need to realise him/herself and if they fail to use a method, they dont really want to change. I believe the best way forward is the middle way in that the therapist should make the patient manipulate him/herself via autosuggestion and provide a very strict framework to change association to activities or situations. So you can tell a patient to slow down, or can give feedback "you have not slowed down" and work indirectly by adding "I speak slower" in the auto-suggestion repertoire.

OK. That is enough. Many ideas, but possibly not 100% coherent... :-)

KST Day 10-13: Tom's twin brother

The last days have been filled with excercises aimed at practising the learned techniques in realistic speaking situations.

Saturday was the information day of the KST. The idea is to invite the families of the participants and people who have voiced interest in the therapy. Every participant had to introduce him/herself and talk a bit about the past days. Videos from before therapy were shown. The differences are really striking, but of course the yard stick is the long-term success. I saw my video from three years ago, and I stuttered quite a bit on the phone: long and intense "ehhhhhhh"s. But during the presentation I was fluent. I was speaking using gentle onsets and I slowed down. It went quite well. I even made the audience laugh as I told them that the person who they saw stuttering severely was actually my twin brother!! It is not me. I am not a freak :-)

On Sunday and Monday, everyone had to go home and explain to their work colleagues or class mates what they had been doing in the therapy. The feedback was mostly positive, but some family members did not like the new way of speaking of the participants. The idea at the KST is to speak in a new way at least in the beginning to speak without symptoms and slowly mix it with natural speech.

Today (Tuesday) everyone was back in Kassel, and we prepared for a talk that everyone is giving in front of a group of speech and language therapists.

Friday, October 21, 2005

Freak show

I am probably getting into trouble for writing this post. It is about the great variability of secondary symptoms stuttering is producing, and how people react to their own stuttering. For example, here at the Kassel Stuttering Therapy, patients see their own video and are shown other people's video (with those people's consent of course!). A few dont want their video to be shown. But the majority is initially shocked by their symptoms, especially as they do not realise they do certain things. But now after a few viewing, some (including myself) really find them seriously comical really. (I can say it as I stutter myself!). Some examples include people who: slap themselves on the cheek to get out of a block, swing the arm to get going, twist the tongue out, say "ehhhhhh" every 3 seconds for half a second (THAT IS ME), make extreme face grimaces, or turn the head upwards as if a fishhook from an angler had caught their right lip. If you dont know about stuttering, you would just be like "Oh my God, what a freak". But then, they put down the phone and say "Oh this was a bad phone call. Lets go for lunch" in perfect fluency, no the slightest symptoms. Or when they use the techniques, all symptoms are just gone, and out comes eloquent speech with utter calm, not the slightest sign of freakiness. It still amazes me after so many years.

Maybe I should do a Top Ten Worst Stuttering Symptoms... Sorry I do not take life too seriously... And for those who stutter and do find it embarassing and painful. I think it is important to get some emotional detachment. After all, if you find it embarassing and painful, your avoidance and suffering will be far greater than for someone who can also make fun of him/herself...

KST 7-9: Transfer

We have started to transfer the learned techniques into a real life environment. Every patient had to introduce him/herself briefly to students at a police training school, and then ask questions about the work of the police. The police students also asked questions about stuttering. We also practised making phone calls, and we went into the town centre and practised on by-pasers or shop assistents. This is quite a novel and frightening experience for many people who stutter. But I think most mastered the situations quite well, and many experience for the first time in their life some more or less inner calm in talking in such situations.

The biggest problem really is to use the techniques (like gentle onset or connecting syllables) in all situations. Most patients have no problem using the techniques when asked to do so. And they speak very well without any apparent symptoms, even for many people with severe stutters. But once the therapy session is over, they immediately switch to the old speech pattern with stuttering symptoms. This is also one of the main criticism of fluency shaping therapies. Patients have to learn a new way of speaking, this new way sounds and feels strange, and patients will revert to the old way of speaking (sorry stuttering). It is certainly true that change requires hard work, and for some especially with severe stuttering the end product will be decent fluency but with some unnaturalness to the speech like long onsets or slowing down speech. On the other hand, this is hundred times preferable for the listener that hearing hAAAAAArd and loooonnnng blocks and seeing pronounced face grimaces. But for people who experience relative fluency and stutter without severe and long blocks, the costs of fluency at the cost of unnaturalness might seem and feel too high. However, the answer of fluency shaper would surely be that they can use softer version of the taught techniques and mix them with their natural speech. A careful listener might spot the gentle onset but the average listener will not. The real difficulty is to find the right balance, and this is hard work.

Wednesday, October 19, 2005

Joe on 2 loop

Here is a interesting comment from Joe D.:

There is the 2 loop theory of stuttering which comes close to your own theory. Riley et al. (1997) discussed the medial or inner loop system which may be “abnormal “ in PWS. The authors suggest that this inner loop is concerned with spontaneous speech and is regulated by the striatum (part of the basla ganglia involved in the planning of movement and of other processes of executive function).

The more “active” the striatum, the more fluent the speaker. However, increased dopamine in the striatum will cause hypometabolism (less activity) and prevent it from working efficiently. This is the basic assumption of the dopamine theories of stuttering.

Riley and McGuire’s work states that the striatum can be avoided all together by using the outer loop. The outer loop is “activated” by using fluency shaping techniques, sticking a device in your ear, chorale reading or basically anything different from the typical speech process.

This theory fits in nicely with the new theories on drugs and stuttering. Basically, if you reduce the levels of Dopamine in the striatum pharmacologically , then it will work more efficiently. joe D.

Yes, I am aware of their work, vaguely. Actually Per Alm mentions them in his article and PhD thesis. It makes a lot of sense, and gives flexibility to accomodate of the idiosyncracies of PDS. However, I am still unsure how this fits with structural and functional differences in PDS brains. But certainly, we are moving into an area where theories (like this one) can be tested in experiments.

Tuesday, October 18, 2005

KST Day 5-6: Go signal

I had several chats with Alex von Gudenberg, and how to structure an evaluation of the therapy. We also exchanged ideas on which elements are crucial and which ones are not. The best method would obviously be to start from a well-establish theory of PDS, which we do not have right now. However, I think that one theory or rather observation is an important one and likely true: stuttering is caused by a failure to initiate the first sound. This is a conceptual statement. A more physical statement (but slightly different issue) is that the region that sends the motor plan to the muscles does not receive a GO signal (to initiate the sound). Why this is so is another story and not directly relevant. If we assume that the stuttering event starts with a failure to initiate the (first) sound, a therapy should reduce the occurence of such failures. Fluency shaping might do it by teaching people a gentle onset. The effect is 1) the gentle onset trains the ability to initiate (as you have to concentrate before speaking) AND 2) allows to start gently which makes it mechanically impossible to block. Van Ripper style therapies might also train the ability to initiate by doing block modification. So possibly both very different approaches work on the failure to initiate, but dont know it! The big question is whether any other exercise would more efficiently train this, possibly only phonation could help. I think this is also what Prof Ingham has been/is trying. He sent me an article some time ago. I have to re-read it again... Sorry this paragraph is a bit messy, it need to get it clearer in my mind.

Regarding the therapy, we have moved into using the speech technique in more realistic settings. Currently, we over-do the technique (gentle onset, connecting syllables), and the patients need to practice also outside the therapy session. However, that´s very difficult for some. Also for me, I want to apply it all the time, but I often forget... An hour ago, I recorded myself unintentionally, and when I listened to the recording I did not apply the techniques all the time and had dysfluencies. But the strange thing is that I did notrealizee my dysfluencies, only after I listened to the recording. But I am pretty good at getting into the techniques. Some patients have trouble to stay in technique more and show stuttering symptoms. But even for them, if they repeat it again, they become pretty fluent. It is really amazing how fluent even the worst stuttering can become... This still leaves me wondering whether a cure (or much more efficient therapy) is not possible in some way. If they can speak fluent, it must be possible to get this sorted somehow.

Sunday, October 16, 2005

Fluency without psychology

This is a question on a ISAD conference page to which I replied:

Most of stutterers are almost fluent if they speak with loud voice being alone. Also I can forget my stuttering and speak expeditiously and absolutely fluently when I am alone in room or in car etc - I know that in fact nobody can hear me, although I imagine that I talk to other people. When I really talk to other people (even friends), I start to stutter quite strongly. WHY I can’t in this case to speak fluently like being alone? WHY I can’t transfer exercising situation to real life? How could I talk to other people as fluently as alone? Actually I have some answers (psyhological tension, etc) but I’m not satisfied with these answers. Still I do not realise very well, why I can’t talk to other people in the same fluent way like alone. Maybe this point (speaking with other people in the same way as speaking alone) could be bigger part of stuttering therapy for adults.

This is one of the most intruiging aspects of persistent developmental stuttering. It is the main challenge for people who believe that psychological issues are only consequences or re-enforcers of symptons. Many things about PDS are still uncertain, but I think there is/are explanations.

1) We need to realise that such effects not only happen in PDS. For example, a friend of mine is a doctor, and he told me that many Parkinson patients have very little shaking before the doctors enter the room, and heavily start shaking during the visit! Or nearly deaf people also have good and bad days and good and bad situations where their hearing deteriorates or becomes better. But no-one would suggest that the variability of their condition is proof of a psychological origin of their condition.

2) Situations with increased stuttering are typically situations where the brain has more work to do. When you are alone, your brain has far less work. But when you are around people (or think that you are around people), your brain has so much more workload: applying a social filter, coordinating the appropriate body language, increased stress, increased tension, responding to other people's ideas, future scenario analysis of your planned message and so on. If you think of stuttering as an unstable speech system, it is clear that more work means less stability. Like a road with road repairs is free of traffic jam on a Sunday, but not a Monday morning at 8.

3) Point two only explains why in some situations we should stutter more on average. But it does not say why sometimes we can be very fluent, even in situations of more workload. So I now distinguish between variability of stuttering, and fluency-enducing effect. Often, we mix the two: we put "less stuttering" equal to "more fluency". The two might well not be the same!!

4) According to a theory developed by Per Alm, Uni Lund, broadly speaking, there might be TWO pathways in the brain that regulate speech: an automatic one, and an active-control one. When you focus on your message, your brain runs the speaking for you (you speak without thinking about how to speak), and when you are focused on how you want to speak, you take control of your speech system. Once you have accepted this theory and you assume that PDS is instability of the automatic mode, everything makes more sense. If a person with PDS uses his active-control mode (like speaking with a foreign accent, imitating someone, speaking loudly, speaking in chorus, speaking in rhythm and so on), s/he becomes more fluent, because the unstable automatic mode is not used or only partially used. This would in my view explain the phenomena. OK, the details might turn out to be different, but at the very least I (or rather Per Alm) have shown that it is POSSIBLE to explain the effect WITHOUT mysterious and vague reference to psychological factors.

Check out my previous posts on Per Alm's work: here, and here.

KST Day 2-4: Facing reality

Not too much has happened during Friday and Saturday. (Sunday was a day-off). I concentrated mostly on the therapy, and did not spend much time on the therapy evaluation scheme. But I do keep a diary and write down my impressions. I make a list of suggestions that could improve the therapy. From tomorrow onwards, I will spend more time of the general framework of the therapy evaluation. My idea is to treat a therapy as a list of therapy components, and each components has different properties like a description, time needed, financial costs, applicability to everyone, dependance on other therapy components, and so on. I am working on the list. And the idea is to fully document the therapy in this way. And then I want to collect as many therapy components as possible from other therapies. And then it is easier to compare. Hey, that is the theory... not sure how it works out in practise.

So over the last days I have been practising on the computer, and during free time. It is very difficult to practise during the free time. Many patients do not manage, forget and speak normally. I have the impression that unlike the therapy 3 years ago I manage to apply the technique more consistenly during free time. The most frightening session was on Friday afternoon. We had to watch the videos made before the therapy. And several patients were very taken back by the own stuttering video. This was the first time that they saw themselves stuttering: shaking their heads, putting out their tongues, making facial grimaces, many filler, and so on. But everyone survived the ordeal... I am a strong believer in that you need to let everyone face reality... no sugar coating of reality... OK I make the exception for people who cannot handle the experience psychologically. But this is may be 5% at most, and it is the art of the therapist to know who that is.

Thursday, October 13, 2005

KST Day 1

I spent most of the day as a patient, and practised the fluency shaping techniques on the bio-feedback software, Flunatics. As I had done such practise for a whole year three years ago, I reached a very good level within a day. I think my major challenge is to use it during normal speech. But I think/hope it will be much easier than 3 years ago.

Concerning the KST evaluation project, I didnt have much time today, and only spoke briefly with Alex, the founder of the therapy. But I was chatting to several therapists and patients informally. I also listened to myself, and my old memories and thoughts on which part of the therapy I find useful and which I dont came back. The real problem is really that everyone has (good) ideas, but it is just too chaotic. There is a real need for project management and define processes to collect, analyse and takes decisions. What I will do over the next days is to write out all the important dimensions of a therapy compoments and evaluation. Here are some example: Cost-benefit ratio, crucial for therapy or not, long-term effect with training?, explanation of usefulness and more. I also have to look closer at what success is, and which dimensions may exist, e.g. greater fluency, less avoidance, fewer effort for maintenance, etc.

The KST deal

I am currently at the Kassel Stuttering Therapy (KST) in Germany; I spoke about the KST before: here, here, and here. Alex von Gudenberg, the founder of the intensive therapy course, has invited me back to Kassel to give critical feedback on the therapy. The KST started seven years ago, and they have been implementing the original therapy concept ever since. As the storms of starting-up a therapy and getting it approved by the health insurers are now settling, Alex has decided that it is about time to look back over the last years, use the experiences made and see whether improvements can be made to the therapy. Such a non-dogmatic attitude is certainly admirable. However, his choice of letting me drive this effort is certainly a dangerous one, giving my reputation of zero hesitation to question someone´s cherishedly held beliefs if they do not make sense logically or clash with reality!! :-) Over the next 2 and a half weeks, I will work out a detailed project plan on how to conduct the review most effectively. The actual work would then be done over the coming year; either by me, or someone else, possibly with the help of students doing their thesis or traineeship.

But this is just half of the deal. In return for my help, I will participate in the therapy as a client over the next 2 and half weks. I did the intensive therapy course nearly three years ago. I benefited from the therapy a lot fluency wise, but the effect gradually weakened. I practised a lot (every day 10-15 minutes fluency shaping techniques on the bio-feedback software for a year), but less on real people. I am the kind of person who gets easily distracted by other things (like defending an idea or suddenly having a new idea) and completely forgets about everything. And I am also very very slow in loosing habits and learning new concepts, but once I get it I can be lethally effective! Well, that´s my construct, which might also make no sense logically and clash with reality! :-)

So over the next 2 and half weeks, I will post ideas on therapies, and possibly about my progress on my own therapy. Now how schizophrenic is that? Being the patient and researcher on the patient at the same time... But a warning... I wont tell you everything... I dont want to go into KST interna, but rather foccus on general key issues that needs addressing for the review.

Tuesday, October 11, 2005

A magazine article

I have written an article for a friend of mine, who is president of the Luxembourg Society of Psychologists. It will appear in their quarterly magazine.

Why do people stutter?

This question has been and is puzzling people who stutter, people who hear them stutter but speak fluently themselves without even thinking how they speak, and the health professionals who try to help alike. Scientific and folk theories have been floating around through the centuries. Aristotle, who stuttered himself, thought of a malfunctioning tongue. Or, the people who stutter are just extra nervous when speaking, because everyone experiences stuttering in extreme situations. Psychoanalysts see clear underlying psychological conflicts arising from childhood, or suggest neurosis: people who stutter might subconsciously derive gains. Asking people who stutter does not help much either. They generally have no clue why they stutter, but they can often predict when they will stutter, but not always. Treating stuttering has again been a true source of ingenuity. Some German surgeons advocated cutting out a part of the tongue. Another treatment involved not talking for 5 weeks. Yet other treatments include talking in rhythmic manner, antidepressants, or searching why you subconsciously want to stutter.

Stuttering is a puzzling disorder. People who stutter report that they are unable to say certain words even though they know exactly what they want to say, but they just cannot say them. Stuttered speech involves hesitations, blocks, fillers like ehhhh, word substitution, avoidance of eye contact, face grimaces and more. Paradoxically, people who stutter are able to speak completely fluent under certain circumstances, e.g. talking alone, singing, speaking with a foreign accent, or in rhythm. On good days, they can be fluent, and on bad days they stutter on every second word. Sometimes they are stuttering mildly, but suddenly have a block and become much more disfluent, or the other way around. Some stutter openly and do not avoid speaking situations. Others stutter mildly, but their life is filled with fear and anxiety and centres around avoiding speaking situations whenever possible. They switch words around, get other people to make important phone calls, forget the answer even though they know the answer, order water rather than b-b-beer, and love emails. They look and behave like everyone else, not less intelligent, more nervous, or more psychologically disturbed. Stuttering is not a language problem, because people who stutter do not have language problems. It does not really seem to be a speech problem either, because people who stutter have the ability in some circumstances to speak completely fluently.

There are a few established facts about stuttering. Stuttering is really only a symptom of a disorder, persistent developmental stuttering or PDS. It is persistent, because it is not a temporary inability to speak fluently but persists from early childhood onwards. It is developmental, because it starts in early childhood when the child develops his or her speech capabilities. At around the age of 3, some children go through a period of disfluency. Most children recover naturally to become fluent speakers, but about 20% do not and their stuttering persists. They quickly develop secondary symptoms and suffer psychologically and socially. There are also forms of acquired stuttering, which is due to a stroke or neurological incident in late adulthood. About 1% of a population has PDS. There are about three to four times more men with PDS than women. Occurrence of PDS often runs in families, and there are even extended families in Cameroon and Pakistan where most family members stutter. There is much more to PDS than overt stuttering. The analogy of the iceberg is often used to suggest that much suffering is hidden underneath unknown to the listener. Paradoxically, the bigger handicap arising from PDS is very often the psychological and social avoidance and suffering rather than the stuttering itself. Stuttering tends to increase when the workload of the brain increases during stress and emotionally or grammatically difficult speech.

There have been many treatment approaches, but none can be considered a cure. However, the consensus is that someone having from PDS can significantly reduce the psychological and social suffering and become an effective, if not always a fluent, speaker. Unfortunately, relapses in fluency are common occurrence, and lasting success requires a lot of patience and efforts. Often, people make sensational improvements and are shown on TV, but many experience a relapse when the camera is switched off. The effect is rather similar to a diet: the difficulty is not to loose weight, but not to regain weight within a year! It also depends on the individual, and whether their stuttering is mild or more severe, and how much avoidance behaviour exists. There are two main schools of thoughts to make people more fluent: teach them speech techniques that insure fluent speech or teach them how to stutter more mildly. In fluency shaping, the patients learn how to speak more fluently by using techniques like gentle onset, slowed down speech, connecting syllables, and more. As they speak fluently, they do not have secondary symptoms and psychological and social issues should dissolve. In stuttering modification, the patients learn to deal with their stuttering to consciously allow stuttering but with less tension and reduction of secondary symptoms. Both approaches can be effective, and often have similar results. Another approach is to mainly work on psychological and social issues. This can be effective for very mild stuttering (or patients with psychological issues), and helpful for more severe stuttering in reducing the significant handicap that psychological and social effects brings about, but rarely does it bring fluency. All three approaches can happen within self-help groups, intensive stuttering therapy programs, or with a local speech and language therapist. However, local speech and language therapists often have little experience with treating stuttering and resort to their own creativity to treat. Therefore, the author strongly recommends to only work with a therapist who has specialised in PDS. Finally, treatment with drugs is gaining grounds. Several drugs seem to reduce stuttering but with some side effects. Clinical studies are underway.

Why do people stutter? Stuttering is a highly complex disorder on a social, psychological, behavioural and neurological level with all levels interacting with each other. Despite a century long effort, it is fair to say that no-one really understands the underlying mechanism of stuttering nor does anyone have a theory of stuttering that can be and has been verified. Better therapy has mostly come from trial and error rather than a fundamental understanding of the disorder. The problem lies deeper than overt speech production, and probably involves language, speech planning and execution inside the brain. Unfortunately, until recently, there had been no useful tools available to study the living brain. But, it is now possible to look directly at the living brain in detail and a revolution is currently under way. The emerging consensus is that the brains of people with PDS show clear activation and structural differences to the normal population. Firstly, at rest, the activation level of the PDS brain compared to control subjects are the same. Secondly, there are clear differences during speech in the activation levels in various regions. Thirdly, in comparison, the speech-dominant left brain is less activated and the right brain is more activated. Fourthly, even during fluent speech of people with PDS, there are differences in activation. Moreover, several groups now claim that the left brain also shows a structural abnormality (which would fit with the different activation level). This is promising news, but theory building becomes important now. The experimental results need to be separated between causes and effects. On another front, genetics research has signalled out chromosomes (packages of genes) that are directly correlated with occurrence of PDS. Stuttering tends to run in families to the same degree that for example increased risk of breast cancer or heart attacks runs in families.

What is the most likely mechanism for stuttering? The best guess is that something goes wrong on the neurological level at around an age of three, at the time when the language and speech region need to produce grammatically correct sentences. There might exist a structural weakness, most likely influenced by genetic predisposition or a neurological incident (like a blow to the head or an illness). Then the young brain must cope by recruiting other brain regions, most likely in the right brain. This compensatory system corrects the deficiencies, but is more sensitive to interference. This may explain why people with PDS can be perfectly fluent and will stutter when the compensatory region suffers from work overload during stress and emotionally or grammatically difficult speech. Childhood disfluency evolves by learning secondary symptoms like blocks, reduced auditory feedback, fillers, avoidance and fears. The secondary symptoms reinforce and make stuttering much worse, which in turn creates very complex and very individual psychological reactions and social behaviour, which in turn maked stuttering a serious handicap.

The next years are going to be exciting as our understanding of PDS will get better. But, there is no doubt in the author's mind that a better understanding of stuttering on a fundamental level is our best possible way forward towards more efficient therapy with fewer relapses. Every breakthrough in any field has been marred by setbacks, errors and delays. The key to success is to never ever give up!

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Friday, October 07, 2005

My fav ISAD pages

I am spending more time on the ISAD conference. It is interesting, but I really dont like the format of the posts. There is no possibility to correct spelling mistakes (which really annoys me), and the system does not allow for carriage return so the post is one biiiggg paragraph....

Here are the most interesting discussions:

General questions

On Genetics

On medication

Saturday, October 01, 2005

The ISAD online conference

You should definitely check out the International Stuttering Awareness Day Online Conference 2005 , which is an annual event organised by Judy Kuster, the good soul of Stuttering Online!

There are many articles on there and discussions with the authors are possible. So I have taken this opportunity to post some questions or comments, and will do so until October 27th. I LOVE to ask questions, as this is far easier than answering them!

You should also have a look at her website The Stuttering Homepage, which is the largest collection of stuttering-related material on the Internet. It's always worth looking around from time to time. What I do miss is that it is really a collection of material and not an meta-analysis or synthesis of material. But I guess that is not the aim of the website anyway.