Thought & Speech

Stammering and Stuttering

Stammering (or stuttering) is a disturbance in the normal flow of speech, interrupted by pauses or by the repetition of fragments of words, sometimes accompanied by grimacing or tic-like movements. It commonly begins in early childhood, often improves with time, but can persist into adulthood, where it may re-emerge or worsen at times of significant anxiety.

This has traditionally been noted for how a stammer from childhood, even one that had seemingly resolved, can resurface under conditions of severe stress or during the onset of an acute psychiatric illness, presumably as underlying anxiety brings a previously overcome pattern back to the surface.

Recognition features

• Speech flow is broken by pauses or by repetition of parts of words
• May be accompanied by visible grimacing or tic-like bodily movements
• Usually begins around early childhood and is more common in boys
• Often worsens noticeably under anxiety, even in someone whose stammer had previously improved or resolved

Eliciting it at interview

• Note the pattern and consistency of the disruption during the interview, and ask whether it varies with anxiety, tiredness, or particular situations
• Ask about childhood history, since a stammer that resolved in childhood but has since reappeared under stress is a recognised and clinically relevant pattern
• Consider the social impact directly, since a persisting adult stammer can carry significant social disability worth exploring in its own right

Distinguishing features

• Differs from mutism in that speech is present but disrupted in its flow, rather than absent altogether
• A stammer resurfacing specifically during severe stress or at the onset of acute illness should prompt consideration of a childhood history of the same difficulty
• Grimacing or tic-like movements accompanying the speech disruption are a recognised associated feature rather than a separate finding

Common misconceptions

• That an adult stammer always indicates a new neurological or psychiatric problem; a re-emerging childhood stammer under stress is a well-recognised and usually benign pattern
• That stammering reflects nervousness alone; while anxiety often worsens it, the underlying pattern is usually a longstanding one rather than something arising purely from the current situation

Practice this

Under significant stress, a man's speech becomes broken by pauses and by repetition of parts of words, accompanied by visible grimacing, a difficulty he had as a child but which had resolved years ago. What is this? · A patient sits silently through an entire interview, producing no spoken words at all despite appearing alert and occasionally nodding, though he does eventually write brief answers on a notepad when offered one. Before revealing the answer: is this stammering? · A patient's speech is markedly disrupted. Before revealing the answer, decide what distinguishes stammering (stuttering) from mutism. · You suspect a patient's speech disruption is a stammer. Before revealing the answer, decide how you would assess for this. · Explain why a stammer resurfacing under stress in adulthood is clinically informative, even though the difficulty itself is not new.

Illustration

A 19-year-old man, whose childhood stammer had resolved by the age of ten, finds it returning sharply in the weeks leading up to his university exams, repeating the first syllable of words several times before managing to continue, a pattern that eases considerably once the exam period has passed.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 4, 'Disorders of Thought and Speech'.