The emperor's dsyfluent speech

I have done many therapies, and witnessed many doing therapies. I always find it hard to say whether someone has made some progress or not. Sure, you can see increased fluency for many, but we all know that such an effect is often short-lived. Often, I also hear people report that they "are making progress", but I do not see the progress at all, certainly not on the fluency level. What should I do? Say that I dont see progress? Especially in group sessions where everyone has to report their previous week, people feel the pressure to say positive things, and you can sense that everyone is just "admiring the emperor's speech" even though "he has not fluent speech to show for. (I am refering to the story where thiefs sold the emperor invisible clothes, he walks around "with" them, everyone admires his "clothes", and then a little boy shouts "but he is naked".
On the other hand, gauging progress within myself is difficult. I can get very fluent, but my speech varies a lot from time to time. Or, often people tell me you are much more fluent now, and I think I am not very fluent. And other times, it is the opposite. Well, actually they only tell me when I am more fluent than average, but not when I am less fluent than average.

I am lost.

For some time now, I have the feeling that I am a bit lost and have no really new ideas on stuttering. I also feel that the research has come to some kind of standstill, and I find thinking about new ways forward difficult. The easy things in brain research have been done, for example. My main concern is that the sheer complexity of the brain, the likely existence of sub-types, and the emotional and psychological part of stuttering smearing out any subtle signals, all these issues make it very difficult to dig deeper into stuttering, not to speak about the not-very-good researchers in the fields.

I believe that I can see the contours of what is going on, but I don't have a clear view. Something goes wrong at 3 (either encouraged or caused by genes, or some other incident), bad habits kicking in and so on. The dual path way theory would explain all the peculiarities like being able to sing, and so on. But identifying specific modules is much more tricky.

On the other hand, I don't spend a lot of time thinking about stuttering. I don't sit down and really think about it. I am just reading the abstracts and make judgements...

Spasmodic Dsyphonia a key to PDS?

Hugo sent me a very interesting email. The cartoonist and creator of Dilbert, Scott Adams, has been suffering from spamodic dysphonia after a bout with allergies. He discusses the illness in this post on his blog, see here:

The weirdest part of this phenomenon is that speech is processed in different parts of the brain depending on the context. So people with this problem can often sing but they can’t talk. In my case I could do my normal professional speaking to large crowds but I could barely whisper and grunt off stage. And most people with this condition report they have the most trouble talking on the telephone or when there is background noise. I can speak normally alone, but not around others. That makes it sound like a social anxiety problem, but it’s really just a different context, because I could easily sing to those same people.

Several symptoms are strikingly similar to stuttering, and supports the hypothesis that two systems are involved in speaking/singing. I spoke to Per Alm, and he believes that this effect supports his dual-pathway theory. Therefore, a closer study of spasmodic dysphonia might reveal more information about stuttering itself.

Auditory abilities of recovered stutterers

I found an interesting article by Howell, Davis, and Williams. They claim that children who recover from stuttering have different auditory abilities in the broadband backward-masked stimulus (thresholds being higher for the persistent group). Here is the abstract. I will comment in my next post:

OBJECTIVE: The purpose of this study was to see whether participants who persist in their stutter have poorer sensitivity in a backward masking task compared to those participants who recover from their stutter. DESIGN: The auditory sensitivity of 30 children who stutter was tested on absolute threshold, simultaneous masking, backward masking with a broadband and with a notched noise masker... 12 speakers had persisted and 18 had recovered from stuttering. RESULTS: Thresholds differed significantly between persistent and recovered groups for the broadband backward-masked stimulus (thresholds being higher for the persistent group). CONCLUSIONS: Backward masking performance at teenage is one factor that distinguishes speakers who persist in their stutter from those who recover. Education objectives: Readers of this article should: (1) explain why auditory factors have been implicated in stuttering; (2) summarise the work that has examined whether peripheral, and/or central, hearing are problems in stuttering; (3) explain how the hearing ability of persistent and recovered stutterers may differ; (4) discuss how hearing disorders have been implicated in other language disorders.

Factors increasing stuttering

In my previous post, I asked how to make a stutterer stutter more. Research / therapy always looks at how to increase fluency. But would knowing which factors increase dysfluency not also help to understand stuttering?

Here are a few factors that I came up with:
1) general tiredness,
2) multi-tasking,
3) stress,
4) nervousness,
5) fear,
6) triggers recalling past experiences.

I should probably distinguish between two aspects:
a) decreasing fundamental control of the speech system.
b) triggering behaviours and habits that cause secondary symptoms.

I think a) is impacted by 1) and 2), and to some degree 3), 4) and 5).
And b) is impacted by 3), 4), 5), 6).

This is just brainstorming. I might change my mind. If you have more ideas, pls post them.

How to make a stutterer stutter

I always discuss how to make us more fluent. But how about tricks to make us more dysfluent!!! Please post your best tricks! :-)

Repeated reading makes us more fluent

The more often we read a word or sentence, the more fluent we get. I am not sure exactly why, possibly because the signals to say the word are getting more prominence in the brain and cannot be locked by other signals??

I have seen dramatic effect with one very severe stutterer. He was unable to say the sentence without severe blocks and other symptoms. As this event happened during a therapy, we, the other patients, forced him to say it over and over again. And more and more he became fluent, and at the end he could say it without stuttering and tension...

This fluency-inducing method is different to the fluency-inducing singing, talking in rhythum, with a foreign accent, chorus reading and so on. For such tasks, the speaker only speaks the word/sentence once.

Is brain research brain dead?

For the last months, I have the impression that research relying on brain imaging technology has come to a standstill. No new articles, no new ideas. I find this lack of articles a bit strange, because many different teams are working on experiments, like groups around Ingham, Neumann, Sommer, NIH, and surely others.

Have they hit the complexity wall and are unable to get publishable results? It is pretty straightforward to let stutters speak or stutter in a scanner, look at their brain activities, and detect which brain regions are consistently under or over-activated within people who stutter but not in comparison to fluent people. They have seen differences in activation and structure, on which I have widely written.

However, this epoch is over, and the new theme must be to create experiments driven by theories. Create a theory, create an experimental setup to test the theory, and do the experiment. Such research requires much much more intellectual and theoretical work, as you need to know a lot about stuttering itself and past research.

Another reason is increased complexity. The first order effects have been studied, i.e. put them in a scans and look at the scans, but the second order effects like what is going on functionally is much much more complex, because different stutterers do different things, there might be 2-3 subgroups, stuttering fluctuates, too many interactions between brain regions, not all studies found the same regions and so on.

And another anti-stuttering device...

The latest article published on PubMedLine is about a new device using delayed auditory feedback. The authors study a prototype device using a modification of a currently used bone conduction hearing device with delayed auditory feedback on adult patients with significant stuttering problems.

What have they found? Not surprisingly, they find a positive effect for the immediate 4-week period after the start of use, and a somewhat significant effect for the 2-week period. But no effect at the 6-week follow-up.

They somewhat desperatedly conclude that:

A new antistuttering prototype using a modification of a bone conduction device with delayed temporal feedback is effective in decreasing stuttering in patients over a short time course. Further studies need to be completed to evaluate the long-term effects of the device.

Just based on the abstract, I have the following comments. First, they cannot claim effectiveness, because they have not computed the effect size, but only talk about statistically significant difference (i.e. p-values). Second, the device might well show an effect, but the finding is a bit irrelevant. Every treatment shows some effectiveness over a short time course. What about the placebo effect? Third, I do not understand why they would want to conduct further studies on the long-term effect, because they have already found no effect at the 6-week follow-on?

Nevertheless, I believe that the research was worth conducting, but the authors should have been more honest in their conclusions and not spin them.

Tongue Twisters for twisted tongues?

I am currently reading Stutter by Harvard Professor Shell. He claims that tongue twisters are all always impossible for people who stutter. Is this assertion true?

I can do tongue twisters when I concentrate: How about you?

Maybe, we could even use them to improve our speech control. The secret about tongue twisters is to switch between two very similar sounding words several times within a sentence. Practising switching accurately and maintaining concentration might re-train our speech system. I practised one tongue twister 100 times and afterwards I had the impression of far greater control of my speech. As usual this is temporary, but practising every day might help.

Pls post your tongue twisters! :-)

Out with the stuttering boys

I just came back from drinks with the stuttering boys of Luxembourg. We talked about stuttering, its causes, and how we handle stuttering in our daily life. I talked about the latest research results and about Pagoclone. Einar thought that a therapy is better than medication, but I replied that this is true if it works but many cannot keep the progress on a long term basis. Adrien wondered whether people should maintain eye contact when someone is stuttering or not. We werent sure what is best.

Do pharmaceutical companies hinder sub-typing?

As I said before, I went to a talk on Genetics Of Complex Traits. I asked a question at the end (despite my stuttering :-). She presented work where they found statistical signals on 4-5 genes for a disorder. I asked her what this finding means. Does it mean that you need all 5 genes for the disorder to develop or just one of them or a combination? She said that this cannot be found out by the statistical analysis but by trial and error in the mixing of the compound impacting the genes in a medication.

Then I asked about sub-typing. Couldn't it be that there are 5 subtypes and each one caused by 1-2 genes. She said that sub-typing is very difficult to do. Apparently, pharmaceutical companies don't like to do research on sub-typing, because they prefer to sell a general compound for everyone rather than just for a subset where they make less money!

Genetics of complex traits

Yesterday, I went to a talk on Genetics of Complex traits. I learned a lot about the least advances in genetics. The progress is driven by two fields: new technologies to extract DNA and map the genes from samples, and new statistical methods to extract more information from the gene maps. In the future, we can expect much faster gene mapping and more squeezing out information from gene maps.

So we expect more advances for stuttering. The beautiful thing about genetics of stuttering is that you dont care about stuttering at all! You just talk your stutterers and test them. No need to define what a stuttering incident is, how to measure severity, and so on. No ideological bagagge, you just analyse the sample and see what's happening.

Getting rid of a habit: finally

Some time ago, I reported on my experience to get rid of a habit: see here.

I used to be really bad in swimming crawl, because I had problems with getting the breathing mechanism right. I used to choke when water came in my mouth.

Now it is completely gone. I do not choke any more when breathing doing crawl, because I unlearned a habit.

I am wondering how much bad habit is part of stuttering? Surely, we have habits in stuttering. How can you find out how much is habit and how much is underlying difficulties? Can you say that the more you practise the less stuttering? What are the criteria to distinguish between conditions based on a bad habit or based on more underlying difficulties?

Disclaimer to reports on Pagoclone

My last post was a report of a first-person experience of taking Pagoclone. I am a bit uncomfortable that readers might consider the very positive report as solid evidence for the efficiency of Pagoclone as a medication to reduce stuttering.

There are several issues to consider:

1) A first-person experience is certainly a fact. The person truly does experience what he is reporting.

2) HOWEVER, the interpretation of what he is experiencing and why he is experiencing is an interpretation of reality. He has a theory on what is happening with him. And this is NOT, and I say it again is NOT, necessarily correct. His interpretation, his theory, could be wrong. An example: A man gives a woman flowers. She experiences positive feelings, and interprets that he likes/loves her. Her experience of being given flowers and the feelings associated are true. She also experiences her interpretation of this act, but (as many women know) her interpretation might well be completely wrong and he is just a womanizer!

3) Human often fall prey to logical fallacies, and that's why their interpretation is not be trusted in general, UNLESS the effects reported are very very strong and very many say it. But even then... But their experiences as such are mostly reliable. They truly did experience what they report.

4) Reports are "dangerous" due to the selection bias. Pagoclone might have no effect at all, and lets assume stuttering fluctuates greatly over time (as it does). Then BY CHANCE some will experience a decline in stuttering at the same time as taking Pagoclone. And they and the readers of the reports might associate this correlation with a casual link even though it is just a pure coincidence.

Experience of Pagoclone

A reader has sent me this report on his experience on Pagoclone:

The drug hasn't completely 'cured' me, but has helped tremendously. What I say to the folks in the clinic is -- am I supposed to sound like the folks on tv? So nice and so polished? Sometimes I do. Sometimes after a caffeine high, I just rip through my speech like an auctioneer.

I'm also getting a little more bold. I talk to people in public who I wouldn't have a year ago. At the pizza place, I now ask to change marinara sauce to garlic. Also, I never suffered from anxiety. I'm very laid-back. I have a rough time saying my name and introducing myself. But it's gotten a little better. I still drag out my first syllable, but it's not as long as it used to be. And I'm able to jump right into whatever I need to say so the listener doesn't think twice about it. Honestly, I feel that maybe the drug is relaxing me a bit more. That it's sort of forcing me to slow down my verbal output. It's strange. And as you said about the placebo effect, it's uncertain about what else is happening after I start speaking more fluently -- confidence builds, words are easier, I start smiling more, etc.

I've had absolutely no side effects from this as all. Then again, this is all just me. Your mileage will, of course, vary. I think once the next phase of this trial is over, I might get off the drug for a bit just to see what happens. I'm curious about the confidence effect. And the fact that I'm maybe thinking about slowing things down a lot more to make it easier. I'm also talking to my son more -- and not stuttering. He might have an effect.

Stuttering in Asia

Stuttering is relatively constant across cultures, suggesting that it is a generic problem of speech function rather than a culture-induced one.

Check out Jhong Ren's blog on Asia and stuttering.

Similar in stuttering??

I just read an article that discusses how inefficient information transfer between regions could be at the origin of autism.

Could this mechanism be at play in stuttering, too?

Transfer practise in the virtual world?

Felix wrote to me:

I have found a new study about Reality Virtual and stuttering. I believe it could be very useful for the treatment of stuttering. For the example, desensibilization, learning better the cancellations, pull-outs and onset,…etc,.etc..

The study are is, “Frequency of stuttering during challenging and supportive virtual reality job interviews”.

Link to article is here.

What is your opinion? In the future can there exist a commercial software to treatment the stuttering? Not only in interviews, but also in the bus, underground, nice girl ;-)

I have looked at the article and, to be honest, I am not convinced. It could well be useful to practise speech techniques in a safe environment. But you can do the same in group therapy with the other real participations. In any case, you still need to go out there and practise in real life situations.

And I am not sure I would be as excited by a virtual girl than by a real girl!! :-) But maybe we can have Lara Croft as the virtual girl and we need to try to chat her up! For female stutterers, I am happy for the software maker to make a digital copy of me... :-) Or alternatively, they can practise their techniques by phoning me: 00352 26835033.

Defects somewhere on the medial system?

In a previous post, I put the idea forward that thinking in terms of a defect somewhere on a circuit is a more natural way of thinking about stuttering. It naturally includes the possibility that different malfunctions are causing stuttering and that they all have roughly the same basic symptoms (because they have malfunctions on the same circuit).

The best candidate of such a circuit might be the medial premotor system (the basal ganglia and SMA). Per Alm has put this forward in his PhD thesis. I have written about it extensively, for example here. Roughly, the brain has two parallel dual premotor systems: the medial for automatic speech (where we emphasise on content of speech), and the lateral (where we emphasise on the form of speech). Of course, if we assume that the malfunction can be anywhere along the medial system (and the fibers connecting it to speech/language regions), we will not be able to get clear experimental observations as for each defect another region is affected?