How do you manage psychogenic stuttering?

Management of Psychogenic Stuttering

Psychogenic (functional) stuttering requires a combined approach of speech therapy targeting symptomatic fluency techniques and concurrent psychological intervention addressing underlying anxiety, depression, and psychosocial stressors, with mental health disorders treated first or simultaneously as they prevent maintenance of treatment gains. 1, 2

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by identifying key distinguishing features:

• New onset in adulthood without prior developmental speech difficulties 1, 3
• Unusual patterns including stuttering on every syllable/word, increased dysfluency with simple tasks, or lack of improvement with activities that typically promote fluency 1
• Internal inconsistency in presentation or paradoxically extreme consistency compared to developmental stuttering 1
• Associated psychological stressors such as relationship conflict, workplace stress, trauma, or recent illness 3, 4

Treatment Priority: Address Mental Health First

Treat comorbid depression or anxiety disorders first or concurrently with speech therapy, as these conditions significantly worsen outcomes and prevent maintenance of fluency gains. 2

Pharmacological Management

• Initiate SSRI antidepressants as first-line treatment for comorbid depression or anxiety 1, 2
• Consider low-dose amitriptyline as an alternative option 1, 2
• Refer to psychiatry for medication management and ongoing monitoring 2

Psychological Interventions

• Refer for structured psychotherapy, particularly cognitive-behavioral therapy (CBT), acceptance and commitment therapy, or other evidence-based approaches 1, 2
• CBT effectively decreases anxiety and social avoidance while increasing engagement in speaking situations 5, 6
• Address approximately 50% of adults who stutter who may have social anxiety disorder 5

Concurrent Speech Therapy Approach

Symptomatic Techniques

Reduce excessive musculoskeletal tension in head, neck, shoulders, face, and mouth muscles associated with speech production. 1

Implement distraction and redirection strategies:

• Use dual tasking while speaking (e.g., walking, tapping fingers) to distract from dysfluent patterns 1
• Invite non-speech articulation such as singing to demonstrate normal function 1
• Employ nonsense words or syllable repetitions to show potential for normal fluency 1
• Redirect patient focus from speech mechanics to conversational content, monitoring contexts where speech improves 1

Speech modification techniques:

• Slow speech down or elongate sounds rather than building tension, explained as "resetting the system" 1
• Introduce mindfulness during speech tasks to maintain focus on easy, smooth movements 1
• Advance communication with higher cognitive linguistic content in hierarchical fashion 1

Psychological Components Within Speech Therapy

Address cognitive and behavioral features:

• Target locus of control, executive function, abnormal illness beliefs, and hypervigilance to speech difficulties 1
• Provide education about the physiology of anxiety and the anxiety arousal curve 1
• Emphasize avoiding avoidance behaviors that reinforce stuttering patterns 1, 2
• Help patients gain insight into positive changes and how they achieve more normal control over speech movements 1

Communication counseling:

• Address predisposing, precipitating, and perpetuating psychosocial issues related to symptom onset and maintenance 1, 2
• Explore conflicts in close relationships or difficulties expressing negative emotions 1, 2
• Evaluate workplace stress, particularly situations involving high responsibility where speaking out is difficult 3, 2
• Screen for trauma history including PTSD, recent accidents, or illness 3, 2

Multidisciplinary Collaboration

Consider collaborative treatment with physiotherapy or occupational therapy for cases with functional facial weakness, spasm, or trismus. 1

Ensure ongoing psychiatric follow-up for medication management and psychotherapy when significant anxiety or psychological distress is present. 2

Treatment Hierarchy and Prognosis

Prognosis should be guarded when depression or other mental health disorders are present, as these significantly impact the ability to maintain fluency improvements. 2

Treatment of a single communication problem (if functional voice or other fluency problems coexist) may result in resolution of all communication symptoms. 1

Critical Pitfalls to Avoid

Do not focus exclusively on speech symptoms while ignoring psychological factors, as this approach leads to treatment failure and relapse. 3, 2

Do not provide communication aids (e.g., electronic devices) that perpetuate avoidance patterns; encourage direct communication without technological supports that reinforce dysfluent behaviors. 1, 2

Do not assume absence of a clear psychological trigger excludes a functional diagnosis; functional stuttering can occur without obvious precipitating events. 3, 7

Do not delay mental health referral when significant anxiety or depression is present, as these conditions must be addressed for successful stuttering treatment. 2, 5