Why is the link to Social Anxiety Disorder made and not a link to other mental disorders like Post -Traumatic Stress Syndrome or Panic Disorder with and without agoraphobia etcetera?
People who stutter may also suffer from PTSD or Panic disorder but the condition that most commonly occurs with stuttering and most accurately describes its general psychosocial impact is Social Anxiety Disorder. Over 50% of people who stutter are thought to suffer Social Anxiety Disorder (Stein et al 1996), (Kraaimaat et al 2002)). Also like stuttering, Social Anxiety Disorder runs in families, occurs in early childhood, and is situationally specific. This is not the case with PTSD or Panic Disorder.
What is the role of the DSM and ICD in this new terminology process?
Both the diagnosis of disorders and diseases, as well as assessment of their severity for third party reimbursement purposes, are made by reference to various diagnostic criteria. The most popular diagnostic criteria sources are the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association and the International Statistical Classification of Diseases and Related Health Problems published by the World Health Organisation. These publications are currently in their 4th and 10th editions respectively as responses are made to new knowledge and understanding.
The DSM has the greatest popularity in the USA and a thorough knowledge of it is considered essential for competent clinical practice for most mental health professionals (psychiatrists, psychologists, psychotherapists, social workers etc.). At present a diagnosis of social anxiety disorder carries the exclusion criteria that prevents a diagnosis if the fear is due to another primary disorder. Specifically if stuttering is present a diagnosis of concurrent social anxiety disorder cannot be made if the fear is of stuttering. Currently the DSM assumes all people who stutter are highly socially anxious as a result of their stuttering. This however is not the case. (Kraaimaat et al 2002 ). To correct this situation it is necessary to introduce the term Stuttered Speech Syndrome. In this way a differentiation can be made between those people who stutter who DO NOT have social anxiety disorder and those that DO.
The ICD is used with another member of the WHO family of international classifications, the ICF (International Classification of Functioning). The ICF is a tool for measuring functioning in society no matter what the reason for one’s impairments. The ICD and ICF are used in combination to create a broad picture of the experience of health. The DSM with its 5 axial assessment system attempts the same process.
However like stuttering, social anxiety disorder exists on a continuum, which means that stuttering with social anxiety disorder is so different an experience from stuttering without it, that both current DSM and ICD/ICF systems struggle to give adequate attention to this difference. Instead “stuttering with social anxiety disorder” or “social anxiety disorder with stuttering” deserves a separate diagnostic label. The new term Stuttered Speech Syndrome is proposed.
Why is stuttering deserving of special attention in its link to social anxiety disorder ? There must be many conditions where symptoms are made worse by anxiety about display of symptoms.
Yes there are other conditions in which it could be argued though that symptoms are made worse by anxiety about their display, (an example is Parkinson’s Disease), and as such social anxiety disorder could be associated with other disorders.
However the combination of stuttering-social anxiety disorder is unique. Stuttering is the only disorder listed as a symptom of social anxiety disorder. (To stress: Parkinson’s disease, or any other disorder, is not listed as symptoms of SAD.)
What is the main value of the term Stuttered Speech Syndrome?
It is hoped the use of the term Stuttered Speech syndrome will increase awareness and understanding of stuttering in a similar way to how a term like Anorexia Nervosa brings understanding to low body weight.
What is the advantage of diagnosing Social Anxiety Disorder over use of existing impact scales like OASES and WASSP?
Social Anxiety Disorder is an accepted pyschological diagnosis, OASES and WASSP are assessment tools. There is no doubt OASES and WASSP are useful scales in bringing awareness to both clinician and client of the impact of stuttering. But use of these scales creates a large number of different assessment states which makes general communication about stuttering impact difficult. In addition whatever the ratings produced by these scales, there is no one therapy that has been proven to be consistently effective. This is not the case with the use of Social Anxiety Disorder. There are generally only 4 diagnostic states (mild, moderate, severe and very severe) and the symptoms of SAD have been shown to respond very well to Cognitive Behavioural Therapy as well as to some pharmacological intervention.
Is there not a danger that relating stuttering to a mental disorder like Social Anxiety Disorder will result in therapy for stuttering being taken from Speech Pathologists and put into the hands of Psychologists and Psychiatrists?
As stuttering is the usual presenting symptom then Speech Pathologists are likely to be the first professional consulted. However diagnosis of the severity of possible comorbid Social Anxiety Disorder is fundamental for successful therapy. It may be that particular Speech Pathologists have special training in treating SAD through Cognitive Behavioural Therapy. Others may chose to refer their clients to a psychologists for specialized intervention should the the severity of SAD be seen to be beyond the Speech Pathologists expertise. Referral to a psychiatrist is appropriate where the use of medication is thought desirable. Speech Pathologists should continue their role as the Managing Health -Care Professional in the delivery of therapy for people who stutter.