AJSLP
Review
Anxiety and Stuttering: Continuing
to Explore a Complex Relationship
Lisa Iverach,a Ross G. Menzies,a Sue O'Brian,a
Ann Packman,a and Mark Onslowa
Purpose: The relationship between anxiety and stuttering
has been widely studied. However, a review conducted more
than 10 years ago (Menzies, Onslow, & Packman, 1999)
identified 5 methodological issues thought to preclude con-
sistent research findings regarding the nature of this relation-
ship. The purpose of the present review was to determine
whether methodological improvements have occurred since
the Menzies et al. (1999) review.
Method: Literature published since the Menzies et al. review
was evaluated with regard to the 5 methodological issues
identified in that review: (a) the construct of anxiety, (b) trait
anxiety measures, (c) participant numbers, (d) treatment
status of participants, and (e) speaking tasks.
A
nxiety is a complex psychological construct com-
posed of verbal-cognitive, behavioral, and physio-
logical components (Ezrati-Vinacour & Levin, 2004;
Menzies, Onslow, & Packman, 1999). It is also considered
to include both transient (state) aspects and more general-
ized and stable (trait) characteristics (Menzies et al., 1999;
Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). The
experience of anxiety can include thoughts and expectan-
cies of negative events, escape or avoidance of feared situ-
ations, and physical sensations such as muscle tension and
heart palpitations (Kraaimaat, Vanryckeghem, & Van Dam-
Baggen, 2002; Menzies et al., 1999). Numerous measures
have been developed to evaluate anxiety, including uni-
dimensional measures that assess anxiety as a single or
global construct, such as the State-Trait Anxiety Inventory
(Spielberger et al., 1983), and multidimensional measures
that regard anxiety as composed of numerous components,
such as the Endler Multidimensional Anxiety Scales (Endler,
Edwards, & Vitelli, 1991).
a
Australian Stuttering Research Centre, The University
of Sydney, Australia
Correspondence to Mark Onslow: mark.onslow@sydney.edu.au
Editor: Laura Justice
Associate Editor: Patrick Finn
Received October 28, 2010
Revision received February 23, 2011
Accepted March 17, 2011
DOI: 10.1044/1058-0360(2011/10-0091)
American Journal of Speech-Language Pathology • Vol. 20 • 221–232 • August 2011 • A American Speech-Language-Hearing Association
Results: Despite some remaining ambiguous findings, re-
search published since the Menzies et al. review has provided
far stronger evidence of a relationship between stuttering
and anxiety, and has focused more on social anxiety, expec-
tancies of social harm, and fear of negative evaluation.
Conclusion: The aims of future research should be to im-
prove research design, increase statistical power, employ
multidimensional measures of anxiety, and further develop
anxiolytic treatment options for people who stutter.
Key Words: stuttering, anxiety, review, social phobia,
fear of negative evaluation
Anxiety and Stuttering
Anxiety is one of the most frequently observed and widely
studied psychological concomitants of stuttering (Ingham,
1984; Peters & Hulstijn, 1984). There are a number of reasons
this association between anxiety and stuttering has been so
widespread. In particular, speech is fundamental to daily
functioning and to the development and maintenance of so-
cial networks and relationships (Messenger, Onslow, Packman,
& Menzies, 2004). However, many people who stutter face
considerable difficulties when trying to speak (Packman,
Menzies, & Onslow, 2000). Added to this, stuttering is asso-
ciated with negative consequences that can adversely affect
social and emotional functioning, relationships, quality of
life, and mental health (Craig, Blumgart, & Tran, 2009). In
fact, the negative consequences of stuttering can begin shortly
after onset during the preschool years (Ezrati-Vinacour,
Platzky, & Yairi, 2001; Langevin, Packman, & Onslow, 2009)
and can continue across the lifespan to include negative
listener reactions and stereotypes, bullying and teasing, social
isolation and rejection, relationship difficulties, educational
and occupational underachievement, expectancies of so-
cial harm, and fear of speaking in social situations (Blood &
Blood, 2007; Cream, Onslow, Packman, & Llewellyn, 2003;
Davis, Howell, & Cooke, 2002; O’Brian, Jones, Packman,
Menzies, & Onslow, 2011; Turnbaugh, Guitar, & Hoffman,
1979).
As a result, anxiety in speaking-related or social situations
can be considered a predictable outcome of the negative
communication consequences experienced across the life-
span for people who stutter (Bloodstein, 1995; Ingham, 1984;
221
Miller & Watson, 1992). Therefore, understanding the nature
of the relationship between anxiety and stuttering is an im-
portant issue (Kraaimaat et al., 2002). However, the nature
of this relationship and the mechanisms underlying it have
previously been poorly understood, and past scientific evi-
dence has been regarded as ambiguous and difficult to inter-
pret (Andrews et al., 1983; Attanasio, 2000; Blood, Blood,
Bennett, Simpson, & Susman, 1994; Craig, Hancock, Tran, &
Craig, 2003; Ezrati-Vinacour & Levin, 2004; Ingham, 1984;
Kraaimaat et al., 2002; Menzies et al., 1999). The incon-
sistent nature of research findings regarding anxiety and
stuttering has been discussed in past reports (Craig & Tran,
2006; Ingham, 1984; Menzies et al., 1999).
Ingham’s (1984) Review
In 1984, Ingham made a significant contribution to the
field by reviewing the principle theoretical models under-
pinning associations between anxiety and stuttering. In par-
ticular, Ingham reviewed the influence of psychological
theories on the development of stuttering treatments and
evaluated anxiety-modification techniques used to treat stut-
tering. Ingham also reviewed research regarding the phys-
iological factors associated with anxiety and stuttering,
including the experience of physical tension during moments
of stuttering. He argued that conclusive evidence of such a
relationship was not apparent in his review of the research
literature at the time. In particular, Ingham suggested that
research evidence regarding the causal effect of physiolog-
ical tension associated with stuttering was unclear, and that
physiological evidence of anxiety could not necessarily be
taken to indicate the actual presence of anxiety. In addition,
Ingham argued that the theoretical foundations underpinning
some anxiety-reduction approaches to stuttering were ques-
tionable and lacking in objective speech data.
Ingham (1984) highlighted a number of methodological
flaws in the stuttering literature that were thought to explain
why a clear and systematic relationship between anxiety and
stuttering had not become apparent. According to Ingham,
these inadequacies included the use of anecdotal reporting,
the lack of independent measures of state anxiety, and fail-
ure of anxiety treatments to result in stuttering reductions.
Ingham also suggested that a linear relationship between
stuttering and anxiety should not be assumed for all people
who stutter, and that state anxiety might have a facilitative
rather than debilitating effect on stuttering in some cases.
Overall, Ingham concluded that “the overall tenor of the find-
ings from the studies reviewed is that there is little evidence
of a clinically significant, or even theoretically palpable,
relationship between stuttering and anxiety” (p. 132).
Menzies et al.’s (1999) Review
Fifteen years after Ingham’s (1984) review of what he
considered to be “relatively unprofitable research” (p. 133),
Menzies et al. (1999) conducted a review of the literature
to further explore the complex and often poorly understood
relationship between anxiety and stuttering. In their review,
Menzies et al. identified five core methodological issues
in the literature thought to preclude clear and consistent
222 American Journal of Speech-Language Pathology • Vol. 20 • 221–232 • August 2011
research findings regarding the nature of anxiety and stutter-
ing. These methodological issues included use of (a) phys-
iological measures of anxiety, rather than self-report or
behavioral measures of anxiety (such as situation avoidance),
fear of negative evaluation, and expectancy of social harm;
(b) unidimensional measures of trait anxiety rather than
multidimensional measures designed specifically to evaluate
social anxiety; (c) small sample sizes with insufficient power
to detect significant differences; (d) participants who had
received treatment for stuttering in the past or who were
seeking or currently undergoing speech treatment rather than
participants who had never received treatment; and (e) sin-
gle speaking tasks in order to elicit or manipulate anxiety
in people who stutter rather than multiple or individualized
behavioral tasks. A number of these methodological issues
have been highlighted by other researchers (e.g., Craig,
1990).
Menzies et al. (1999) concluded that the relationship
between anxiety and stuttering could not be fully understood
until the above methodological limitations had been over-
come. In a similar manner to Ingham (1984), they also argued
that
the inadequate literature on anxiety and stuttering is not
just an academic problem. On the contrary, an ambiguous
literature on the role that anxiety plays in the condition
impairs clinical practice and retards the development of
novel clinical procedures. Until the precise nature of the
relationship between anxiety and stuttering is understood,
fully appropriate treatment of adult stuttering cannot be
offered. (p. 8)
Hence, Menzies et al. highlighted the need for improve-
ments in research design in stuttering research, including
the use of larger sample sizes to increase statistical power,
and the application of multidimensional measures of anxiety
(Blomgren, Roy, Callister, & Merrill, 2005; Craig et al.,
2003; Ezrati-Vinacour & Levin, 2004; Menzies et al., 1999).
They also underscored the need to provide anxiolytic treat-
ments for people who stutter and who report anxiety.
The Present Review
Although the Menzies et al. (1999) review shed necessary
light on the “long and tangled” relationship between anxiety
and stuttering (Attanasio, 2000, p. 89), over a decade has
passed since its publication. Therefore, it is timely to inves-
tigate whether any changes in research design or method-
ological improvements have occurred since publication of
the Menzies et al. review. As a result, the purpose of the
present review is to (a) determine whether the five method-
ological issues identified by Menzies et al. are still rele-
vant to research published since their review, (b) establish
whether research evidence regarding the relationship be-
tween anxiety and stuttering has become less ambiguous and
more conclusive since the Menzies et al. review, (c) identify
any further methodological issues apparent in the research
regarding anxiety and stuttering, and (d) determine whether
any methodological improvements in anxiety research since
the Menzies et al. review have resulted in changes to clini-
cal practice and the treatment of anxiety in stuttering.
Methodological Issues
The Construct of Anxiety
The first methodological issue highlighted by Menzies
et al. (1999) relates to the construct of anxiety. In particular,
Menzies et al. argued that much of the research at the time
of their review had not taken into account the multidimen-
sional nature of anxiety. Instead, a sizable proportion of
research had focused on the physiological component of
anxiety, which Menzies et al. argued was possibly the least
useful indicator of social anxiety. Not only are the results
of physiological measures of social anxiety thought to vary
across individuals, thereby making it difficult to interpret the
findings of such evaluations, but they are also poorly cor-
related with the verbal-cognitive and behavioral components
of anxiety (Menzies et al.). Ingham (1984) also suggested
that “physiological evidence of anxiety is not necessarily
evidence that the subject actually experiences anxiety” (p. 129).
Therefore, Menzies et al. argued that the use of physiological
measures of anxiety reduces the likelihood of clearly iden-
tifying anxiety, whereas self-report and behavioral measures
may provide more sound indications of anxiety, at least with
research about social anxiety and stuttering.
In addition, Menzies et al. (1999) suggested that evalua-
tion of expectancies of social harm, fear of negative eval-
uation, and anticipation of stuttering is also of particular
importance when evaluating the relationship between anxiety
and stuttering (Ginsberg, 2000; Ingham, 1984; Menzies
et al., 1999). Fear of negative evaluation and expectancies of
harm are central constructs in the experience and assessment
of anxiety (Messenger et al., 2004). Adults who stutter tend
to fear speaking situations (Mahr & Torosian, 1999), and
negative social evaluation is thought to be one of the most
likely mediators of speech-related anxiety for adults who
stutter (Menzies et al., 1999). However, at the time of the
Menzies et al. review, only a single study (Poulton & Andrews,
1994) was identified that evaluated social expectancy and
subjective anxiety during a speaking task. Therefore, Menzies
et al. recommended the incorporation of self-report and
behavioral measures of anxiety into future research, includ-
ing measures of expectancies of social harm and negative
evaluation.
Since the Menzies et al. (1999) review, a small number of
studies have continued to explore the physiological com-
ponent of anxiety. For instance, Dietrich and Roaman (2001)
investigated the relationship between perceptions of speech-
related anxiety and physiological arousal in specific speak-
ing situations in a sample of 24 adults who stuttered. They
found no correlations between participants’ predictions of
speech-related anxiety in 20 hypothetical speaking situations
and actual skin conduction responses during enactment of
four speaking situations. In addition, Alm (2004) reviewed
findings regarding the propensity for adults who stutter to
demonstrate reductions in heart rate in stressful speaking sit-
uations (e.g., Peters & Hulstijn, 1984; Weber & Smith, 1990).
Alm suggested that parasympathetic suppression of heart
rate might be caused by speech-related anticipatory anxiety
in people who stutter and argued that anticipatory anxiety
in speaking situations might be a conditioned response to
previous stuttering experiences.
A more substantial number of studies have investigated
the socially evaluative aspects of anxiety in stuttering, in-
cluding use of self-report measures of anxiety and fear of
negative evaluation such as the Endler Multidimensional
Anxiety Scales-Trait (EMAS-T; Endler et al., 1991) and the
Fear of Negative Evaluation Scale (FNE; Watson & Friend,
1969). Findings from these studies have highlighted the
propensity for people who stutter to experience anticipatory
anxiety and fear of being penalized by listeners (Cream et al.,
2003; Plexico, Manning, & Levitt, 2009).
Messenger and colleagues (2004), in particular, explored
the relationship between stuttering, social anxiety, and nega-
tive social expectancies. They found that scores on the
FNE and the Social Evaluation and New/Strange Situations
subtests of the EMAS-T were significantly higher for a sam-
ple of 34 adults who stuttered than for 34 controls. These
findings, which confirmed the socially evaluative nature of
anxiety in stuttering, have also been supported by further
research. For instance, Blumgart, Tran, and Craig (2010)
reported that the mean FNE score for a large sample of
200 adults who stuttered was significantly higher than the
mean score for 200 controls. Similarly, Iverach, O’Brian,
et al. (2009) administered a number of anxiety-related self-
report measures, including the FNE and the EMAS-T, to a
large sample of 92 stuttering adults. Results revealed that the
adults who stuttered were characterized by increased fear
of negative evaluation and anxiety in socially evaluative or
new/strange situations when compared with matched con-
trols. However, these anxiety levels were not as high as those
reported for clinically anxious or socially phobic samples.
Mahr and Torosian (1999) also reported that adults who
stutter may have increased levels of social anxiety and avoid-
ance compared to nonstuttering controls, but that they may
not experience fear of negative evaluation to the same degree
as individuals with social phobia. In particular, Mahr and
Torosian compared anxiety and fear of negative evaluation
in a sample of 22 adults who stuttered with nonstuttering
controls and adults with social phobia. FNE scores for the
stuttering group did not differ significantly from nonstutter-
ing controls but were significantly lower than scores for
participants with social phobia. In addition, social anxiety and
distress scores for the stuttering group were significantly
higher than controls but significantly lower than participants
with social phobia. The stuttering group also demonstrated
significantly higher anxiety symptoms than controls and sig-
nificantly lower social and agoraphobia symptoms than the
social phobia group.
Findings regarding anxiety and fear of negative evalua-
tion in stuttering may be relevant for older adults who stutter.
For instance, Bricker-Katz, Lincoln, and McCabe (2010)
conducted a qualitative study of 11 stuttering adults over the
age of 55 years; the authors reported that some participants
continued to fear negative evaluation in socially evaluative
situations. Further, Bricker-Katz, Lincoln, and McCabe (2009)
reported that scores on the FNE for a small sample of 12 older
adults who stuttered were in the social phobia range and
were significantly higher than scores for a sample of 14 con-
trols. In addition, scores on the EMAS-T for socially eval-
uative trait anxiety and anxiety related to physical danger
were also significantly higher for older adults who stuttered
Iverach et al.: Anxiety and Stuttering 223
than for controls, even though scores for both groups fell
within the average range. These findings correspond largely
with those of Messenger et al. (2004), indicating that fear
of negative evaluation and socially evaluative anxiety may be
apparent for older adults who stutter.
Anxiety and fear of negative evaluation have also been
investigated among adolescents who stuttered. Mulcahy,
Hennessey, Beilby, and Byrnes (2008) reported that a sample
of 19 adolescents who stuttered exhibited significantly
higher trait and state anxiety and significantly higher fear of
negative evaluation than 18 nonstuttering controls. This sug-
gests that increased anxiety and fear of negative evaluation
for those who stutter have the potential to commence during
the “socially difficult adolescent years” (Huber, Packman,
Quine, Onslow, & Simpson, 2004, p. 176). However, fur-
ther research regarding the development of fear of negative
evaluation and social anxiety among children and adolescents
is required.
Overall, the above findings highlight the potential for
stuttering to be associated with fear of negative evaluation
and expectancies of social harm. This corresponds with a
growing body of evidence regarding the presence of social
anxiety or social phobia among people who stutter (Schneier,
Wexler, & Liebowitz, 1997; Stein, Baird, & Walker, 1996),
to be discussed below.
Trait Anxiety Measures
The second methodological issue identified by Menzies
et al. (1999) related to the use of trait anxiety measures in
stuttering research. Menzies et al. criticized the administra-
tion of trait anxiety measures in situations characterized by
heightened state anxiety, such as making a phone call. A fur-
ther criticism was drawn against the use of unidimensional
measures of trait anxiety such as the State-Trait Anxiety
Inventory (STAI; Spielberger et al., 1983), which regard
anxiety as a single or global construct.
More recent conceptualizations of anxiety have high-
lighted its multidimensional nature (Endler et al., 1991).
Consequently, unidimensional measures of anxiety may not
be sensitive enough to detect or discriminate between the
various facets of speech-related anxiety for people who
stutter (Ezrati-Vinacour & Levin, 2004; Menzies et al., 1999)
and have subsequently yielded mixed results in the field of
stuttering (Craig & Tran, 2006). Hence, the previous lack
of research regarding the multidimensional nature of anxiety
in stuttering may in part explain why “fine tendencies in
the stuttering-anxiety connection have not been detected”
(Ezrati-Vinacour & Levin, 2004, p. 138).
Since the Menzies et al. (1999) review, one of the most
significant methodological improvements in stuttering re-
search has been the use of self-report measures and diagnostic
assessments of anxiety and social phobia. These studies build
on the important work of earlier research (e.g., Schneier
et al., 1997; Stein et al., 1996) and contribute to a growing
body of evidence regarding the presence of social anxiety or
social phobia in adults who stutter. Social phobia, in partic-
ular, is characterized by significant, excessive, and persistent
fear of humiliation, embarrassment, or negative evaluation
in social interactional situations (e.g., initiating or maintaining
224 American Journal of Speech-Language Pathology • Vol. 20 • 221–232 • August 2011
conversations, meeting new people, being assertive, or speak-
ing to authority figures) and performance situations (e.g.,
public speaking or performing in front of others; American
Psychiatric Association, 2000; Orsillo & Hammond, 2001).
Prior to the Menzies et al. (1999) review, Stein et al. (1996)
and Schneier et al. (1997) contributed valuable research
evidence regarding the presence of social anxiety and social
phobia in adults who stutter. This evidence base has grown
considerably since the Menzies et al. review with the addi-
tion of larger scale studies. For instance, Kraaimaat et al.
(2002) administered a social anxiety inventory to a sample
of 89 adults who stuttered and 131 nonstuttering controls. In
their study, the stuttering group demonstrated significantly
higher emotional discomfort in social situations than the con-
trols did, and the stuttering group also reported significantly
less social response than controls. Further, scores for the
stuttering group on emotional discomfort in social situa-
tions were comparable to a normative sample of psychiatric
patients, even though they were lower than scores for psy-
chiatric patients diagnosed with social phobia. These findings
correspond somewhat with those previously reported by Mahr
and Torosian (1999), who found that adults who stuttered
demonstrated significantly increased anxiety symptoms and
social avoidance and distress than nonpatient controls, yet
when compared to social phobics, they exhibited significantly
lower fear of negative evaluation, social avoidance, and dis-
tress, and fewer social phobia and agoraphobia symptoms.
However, more comprehensive evidence regarding social
anxiety and stuttering has been obtained in studies that have
used diagnostic assessments of anxiety rather than self-report
measures and inventories. It is possible that the use of such
assessments may contribute a less ambiguous picture of
anxiety in stuttering. For instance, in the Menzies et al. (2008)
clinical trial of cognitive behavior therapy (CBT) for the
treatment of anxiety in stuttering, clinical psychologists con-
ducted comprehensive assessments with adults who stuttered
to determine the presence of social phobia prior to speech
treatment only versus speech treatment plus CBT. Sixty per-
cent of the Menzies et al. sample received a social phobia
diagnosis at pretreatment, but none of the participants who
received CBT treatment for anxiety met criteria for social
phobia following treatment.
Iverach, O’Brian, et al. (2009) also comprehensively eval-
uated the presence of anxiety disorders, including social
phobia, in a large sample of 92 adults who stuttered, accord-
ing to the diagnostic criteria employed by the Diagnostic
and Statistical Manual of Mental Disorders (DSM–IV–TR;
American Psychiatric Association, 2000) and the Interna-
tional Classification of Diseases (ICD-10; World Health Or-
ganization, 1993). When compared with matched controls,
the stuttering adults exhibited six- to sevenfold increased
odds for any DSM–IV–TR or ICD-10 anxiety disorder and
16- to 34-fold increased odds for DSM–IV–TR or ICD-10
social phobia. This same sample of adults seeking treatment
for stuttering were also found to be at increased risk of meet-
ing first-stage screening criteria for anxious personality dis-
order (Iverach, Jones, et al., 2009b), which is considered to
be a more severe form of social phobia (Reich, 2000).
In a related manner, Blumgart et al. (2010) investigated
social anxiety in a large sample of 200 adults who stuttered
and 200 nonstuttering adults by administering a variety of
anxiety measures, including the STAI, the FNE, and the
Social Phobia and Anxiety Inventory (Turner, Beidel, &
Dancu, 1996). In addition, the Psychiatric Diagnostic Screen-
ing Questionnaire (Zimmerman & Mattia, 2001) was used
to screen for social anxiety disorder (also known as social
phobia) and generalized anxiety disorder in a subsample of
50 adults who stuttered and 50 controls. Results revealed that
the adults who stuttered had significantly higher trait and
social anxiety than the controls, with moderate to large effect
sizes. Of particular interest, the adults who stuttered had sig-
nificantly elevated specific fears about embarrassing them-
selves in situations such as public speaking, eating in public,
saying stupid things, asking questions in a group, business
meetings, and social gatherings or parties. Further, in the
Blumgart et al. study, the stuttering group demonstrated a
significantly higher risk for social anxiety disorder than con-
trols, indicating a spot prevalence of 46%. This estimate cor-
responds with the prevalence rate of 44% reported by Stein
et al. (1996).
These findings highlight the prevalence of anxiety and
social phobia among adults who stutter. However, findings
by Blumgart et al. (2010) and Iverach, Jones, et al. (2009b)
should be viewed with caution on the grounds that they
used screening instruments rather than full diagnostic inter-
views to evaluate the presence of social anxiety disorder
(Blumgart et al., 2010) and anxious personality disorder
(Iverach, Jones, et al., 2009b). Also, of course, a caveat to
those findings is that they pertain to clinical cohorts and
cohorts seeking self-help group support.1 Despite this, ad-
vances in the methods used to assess anxiety in stuttering
allow us to more fully appreciate the nature of this relation-
ship. That is, they provide a methodological leap from the
unidimensional anxiety measures that have been used before.
However, a number of studies since the Menzies et al.
(1999) review have continued to employ unidimensional or
trait measures of anxiety. For instance, Alm and Risberg
(2007) investigated trait anxiety and neuromuscular activ-
ity in a sample of 32 adults who stuttered and 28 controls.
The stuttering group demonstrated significantly higher trait
anxiety when compared with controls, but trait anxiety was
not found to be related to sensorimotor activity, as evaluated
by the startle response. In addition, Blomgren et al. (2005)
investigated the affective functioning of 19 adults who com-
pleted a 3-week intensive stuttering modification treatment
program. Although significant improvements in psychic and
somatic anxiety were found up to 6 months posttreatment,
trait and state anxiety as measured by the STAI was not found
to decrease significantly over the same posttreatment period.
Ezrati-Vinacour and Levin (2004) also compared anxiety
in 47 adults who stuttered and 47 nonstuttering controls. Trait
anxiety, as measured by the STAI, was higher in the stuttering
group when compared with controls, and state anxiety in
social communication was higher for severe stutterers when
compared with mild stutterers and nonstuttering controls.
1
Methodological issues with the Iverach, Jones, et al. (2009a) report have
been discussed extensively elsewhere: Manning and Beck (2011) and
Iverach, Jones, et al. (2011).
That is, state anxiety, but not trait anxiety, was found to be
associated with stuttering severity, whereby individuals with
more severe stuttering were found to exhibit higher state
anxiety. Ezrati-Vinacour and Levin concluded that anxiety
is a personality trait that gradually develops over time for
people who stutter.
In addition, Craig et al. (2003) conducted a randomized
population study of the prevalence of stuttering in 4,689
Australian households. Trait anxiety scores for 63 residents
identified as people who stuttered were compared with scores
from a sample of 102 matched controls from a previous study
(Craig, 1990). Although trait anxiety scores for adults in the
stuttering group who had not received stuttering treatment
did not differ from nonstuttering controls, scores for adults
who had received previous treatment for stuttering did differ
significantly from nonstuttering controls. However, no sig-
nificant differences in anxiety were found between stuttering
adults who had received stuttering treatment and those who
had not, or between those with more or less severe stuttering.
Overall, Craig et al. concluded that assessments of anxiety
in adults who stutter may be influenced by whether partici-
pants have received previous stuttering treatment or whether
they are currently seeking treatment.
A number of the above-mentioned studies attributed dis-
crepancies and ambiguities in their findings to the complex
and multidimensional nature of anxiety, as highlighted by
Menzies et al. (1999). That is, by treating anxiety as a single
construct, the STAI limits the ability to detect the presence
of specific dimensions of anxiety (Blomgren et al., 2005)
and may not be sensitive enough to measure, or differentiate
between levels of, speech-related anxiety experienced by
adults who stutter (Ezrati-Vinacour & Levin, 2004).
Despite this, unidimensional trait anxiety measures have
also been used in a small number of studies of anxiety in
children and adolescents who stutter. According to Craig and
Tran (2005), however, very few of these studies have re-
ported significant differences between stuttering and non-
stuttering participants. For instance, Hancock et al. (1998)
investigated the long-term effectiveness of three stuttering
treatments in a large sample of children and adolescents age
11 to 18 years, as originally reported by Craig et al. (1996).
Seventy-seven participants completed the STAI for chil-
dren at 12 months posttreatment, and 62 participants completed
the STAI for children between 2 and 6 years posttreatment.
No significant differences in state or trait anxiety were found
between groups or over time.
Similarly, Davis, Shisca, and Howell (2007) investigated
state and trait anxiety in a sample of children and adolescents
age 10 to 17 years, including 18 participants with persis-
tent stuttering, 17 who had recovered from stuttering, and
19 nonstuttering controls. To evaluate trait anxiety, partici-
pants completed the STAI for children. State anxiety was
assessed with a scale consisting of four different speaking-
related situations, including asking for help in a shop, talking
on the phone to a friend, talking with a group of friends,
and answering a question in class. Overall, trait anxiety was
not found to differ significantly between groups, although
the persistent group exhibited higher state anxiety on three
of the four speaking situations than the recovered and control
groups.
Iverach et al.: Anxiety and Stuttering 225
 Finally, Mulcahy et al. (2008) also used the STAI and the
FNE to assess social anxiety in a sample of 19 adolescents
who stuttered in comparison with 18 nonstuttering controls.
In their study, the stuttering group demonstrated significantly
higher state, trait, and social anxiety than controls. Further-
more, state and trait anxiety for the stuttering group was sig-
nificantly associated with communication difficulties in daily
situations. Again, it is possible that the inconsistent nature
of findings in these studies may, in part, be attributable to the
use of unidimensional trait anxiety measures.
As suggested by Menzies et al. (1999), more consistent
results may be obtained with multidimensional measures
of anxiety among children and adolescents who stutter, such
as the Revised Children’s Manifest Anxiety Scale (RCMAS;
Reynolds & Richmond, 2000). The RCMAS evaluates the
level and nature of anxiety symptoms in children and ado-
lescents and is composed of four nonoverlapping subscales
regarding physiological anxiety, worry/oversensitivity, social
concerns/concentration, and social desirability. Blood and
Blood (2007) utilized the RCMAS in their investigation of
anxiety and vulnerability to bullying in 18 children who stut-
tered and 18 nonstuttering controls, age 11 to 12 years. In
comparison with controls, the stuttering group demonstrated
a significantly higher total RCMAS anxiety score and a sig-
nificantly higher score on the social concerns scale, indicat-
ing heightened anxiety regarding the expectations of others.
Blood, Blood, Maloney, Meyer, and Qualls (2007) also
investigated the relationship between anxiety and self-esteem
in a sample of 36 adolescents who stuttered and 36 adoles-
cents who did not stutter. Although scores on the RCMAS
were within the normal range for the large majority of partici-
pants in both the stuttering and control groups, the stuttering
group demonstrated significantly higher levels of anxiety
when compared with the controls. Overall, further studies are
required regarding the development of anxiety and social
phobia in children and adolescents who stutter. This would
include the use of direct measures or diagnostic assessments
of social anxiety. We concur with Davis et al. (2007) that
“the work on children who stutter is of great potential impor-
tance as it may provide an indication about the role of anxiety
in the development of stuttering” (p. 400).
In sum, the accumulation of research evidence since the
Menzies et al. (1999) review has improved our understand-
ing of anxiety and stuttering with the implementation of
diagnostic assessments and multidimensional measures of
anxiety and social phobia. However, mixed results continue
to emerge when unidimensional trait anxiety measures are
employed. Regardless, the current evidence base highlights
the urgent need for clinical assessment, management, and
treatment of anxiety and social phobia among adults who
stutter (Iverach, O’Brian, et al., 2009). Implications for treat-
ment will be discussed below.
Participant Numbers
The third methodological issue identified by Menzies
et al. (1999) pertained to the application of small sample
sizes and insufficient statistical power. In particular, Menzies
et al. stated that the issue of statistical power may not be
critical in cases where a significant difference between groups
226 American Journal of Speech-Language Pathology • Vol. 20 • 221–232 • August 2011
is identified, yet it is of substantial importance in cases where
there is insufficient power to detect a significant difference.
Hence, Menzies et al. suggested that insufficient power in a
large proportion of research studies regarding the presence
of anxiety in stuttering may have resulted in the failure to
obtain significant results. Therefore, they advocated the use
of more rigorous methods and sample sizes based on power
calculations, with a minimum 80% chance of detecting a
significant effect or difference.
Other authors have echoed this call (Craig, 1990; Craig
& Tran, 2006). For instance, Craig et al. (2003) suggested
that small participant numbers in studies investigating anx-
iety and stuttering have potentially increased the risk of
committing Type II statistical errors, thereby restricting the
ability to detect true differences between stutterers and non-
stutterers in terms of anxiety levels, as well as failing to
guarantee a representative sample. In addition, Craig and
Tran (2006) recently identified 20 studies that investigated
anxiety in people who stuttered in comparison with nonstut-
tering controls. Of these 20 studies, 13 concluded that adults
who stuttered were more anxious than controls, whereas
seven studies did not find a significant difference in anxiety
levels between groups. Of particular interest, Craig and
Tran reported that the seven studies reporting nonsignificant
results had a mean of 20 participants per group, whereas the
13 studies with significant differences between groups had
a mean of 50 participants per group. This discovery supports
Menzies et al.’s (1999) claim that insufficient power may
be one factor responsible for the lack of consistency in find-
ings regarding anxiety and stuttering.
However, a number of studies during the last decade have
employed medium to large sample sizes and have reported
significant findings (e.g., Ezrati-Vinacour & Levin, 2004;
Ginsberg, 2000; Kraaimaat et al., 2002). Other studies have
also conducted power analyses to determine suitable sam-
ple sizes (e.g., DiLollo, Manning, & Neimeyer, 2003). For
instance, in evaluating the presence of DSM–IV–TR and
ICD-10 anxiety disorders in a large sample of 92 adults who
stuttered and 920 matched controls, Iverach, O’Brian, et al.
(2009) reported 80% power to detect 2.5 increased odds
with a 5% level of significance. In addition, Blumgart et al.
(2010) reported higher than 90% power to detect a signifi-
cant difference in social anxiety between 50 adults who
stuttered and 50 controls.
Other studies since the Menzies et al. (1999) review have
reported significant results with moderate to large sample
sizes, although not all of these have conducted power analy-
ses to confirm the ability to detect significant differences
between groups. For instance, Iverach, Menzies, et al. (2011)
investigated the prevalence of social phobia and anxious
personality disorder in a sample of 140 adults who stuttered,
and the authors found that roughly one quarter of participants
met criteria for social phobia, and roughly one third of
participants met screening criteria for anxious personality
disorder. Ezrati-Vinacour and Levin (2004) also found that
trait anxiety for a sample of 47 adults who stuttered was
higher than 47 nonstuttering controls. Furthermore, Kraaimaat
et al. (2002) also reported significant differences between
89 adults who stuttered and 131 nonstuttering controls in
terms of emotional discomfort in social situations.
 Significant results have also been reported with small to
moderately sized samples of adults and adolescents who
stuttered (e.g., Alm & Risberg, 2007; Blood et al., 2007;
Craig et al., 2003; Gabel, Colcord, & Petrosino, 2002; Mahr
& Torosian, 1999; Menzies et al., 2008; Mulcahy et al.,
2008). However, a number of other studies have utilized
small to moderate samples of people who stuttered and have
reported less consistent results. For example, Dietrich and
Roaman (2001) investigated the extent to which perceptions
of speech-related anxiety correlated with physiological
arousal in specific speaking situations in a sample of 24 adults
who stuttered; they found no correlation between predictions
of speech-related anxiety in 20 hypothetical speaking situ-
ations and skin conduction responses during enactment of
four speaking situations. Similarly, Davis et al. (2007) reported
no significant differences in trait anxiety between 35 adoles-
cents and children who stuttered and 19 nonstuttering con-
trols. However, state anxiety for participants with persistent
stuttering was found to be higher than for participants who
had recovered from stuttering and nonstuttering controls.
Furthermore, Blomgren et al. (2005) reported that state and
trait anxiety (as measured by the STAI) was not found to
change following stuttering treatment with a sample of
19 adults who stuttered.
Overall, it appears that use of larger sample sizes in the
stuttering literature since the Menzies et al. (1999) review
has resulted in a less ambiguous picture of the relationship
between anxiety and stuttering. However, this increased
clarity of evidence may also stem from the use of measures
of anxiety and social phobia that are multidimensional or
diagnostic in their assessment. Regardless, it is imperative
for future research in this area to contain a priori power anal-
yses to ensure sufficient statistical power to detect significant
differences.
Treatment Status of Participants
The fourth methodological issue identified by Menzies
et al. (1999) pertained to the treatment status of participants.
In particular, it has been suggested that research findings
regarding the link between anxiety and stuttering may be
confounded by the inclusion of both treated and untreated
adults who stutter (Craig, 1990; Craig et al., 2003; Craig &
Tran, 2006). For instance, Craig has argued that speech treat-
ment may potentially reduce anxiety and negative expec-
tancies, which means that the inclusion of adults who have
received treatment for stuttering has the potential to reduce
the likelihood of identifying anxiety in stuttering samples.
This may also be the case for adults who are attending stut-
tering support groups (e.g., Mahr & Torosian, 1999).
Given the difficulties inherent in obtaining sizable sam-
ples of adults who stutter but have never received treatment,
Menzies et al. (1999) suggested that future research would
benefit from dividing samples into those who have and have
not received treatment, thereby gauging the potential impact
of speech treatment on anxiety levels. At the time of the
Menzies et al. review, no study had divided samples based on
treatment status, nor had any study investigated the presence
of anxiety in a sample composed only of untreated adults
who stuttered.
Changes regarding the treatment status of participants
since the Menzies et al. (1999) review have been lacking. In
particular, the large majority of studies regarding anxiety
and stuttering have included samples of adults who had re-
ceived treatment in the past or who were currently seeking
or receiving treatment for stuttering (e.g., Blomgren et al.,
2005; Blumgart et al., 2010; Ezrati-Vinacour & Levin, 2004;
Gabel et al., 2002; Ginsberg, 2000; Iverach, Menzies, et al.,
2011; Iverach, O’Brian, et al., 2009; Kraaimaat et al., 2002;
Mahr & Torosian, 1999). This has also been the case in
studies of children and adolescents who stutter (e.g., Blood
et al., 2007; Davis et al., 2007; Mulcahy et al., 2008).
To our knowledge, only one study since the Menzies et al.
(1999) review has divided samples into participants who
have and have not received treatment for stuttering (Craig
et al., 2003). As previously mentioned, Craig et al. (2003)
conducted a randomized population study to investigate
anxiety in treated and untreated adults who stuttered. Of
63 stuttering adults who completed the STAI, 33 reported
no previous treatment for stuttering. Trait anxiety for these
33 participants did not differ significantly from nonstutter-
ing controls, yet stutterers who had received previous treat-
ment demonstrated significantly higher trait anxiety than
controls. These findings suggest that there may be differ-
ences in anxiety levels for adults who received treatment for
stuttering versus those who have not received treatment.
In sum, the above research suggests a difficulty inherent
in recruiting stuttering samples from those who have never
sought treatment for stuttering. Further research is required
to determine whether differences in anxiety exist between
samples of treated and untreated adults who stutter. In addi-
tion, it may be useful for future research to investigate whether
adults who are currently seeking treatment are more or less
anxious than adults who have received treatment in the past
but who are not currently seeking treatment. Having said
this, the comorbid presence of anxiety and stuttering may in-
crease the chances that an individual will seek treatment for
his or her stuttering (Iverach, O’Brian, et al., 2009). Further-
more, it is likely that adults who stutter may have an increased
risk of experiencing anxiety regardless of whether they
have received treatment for stuttering (Craig et al., 2009).
Speaking Tasks
The final methodological issue highlighted by Menzies
et al. (1999) pertained to the use of single speaking tasks (e.g.,
speaking on the telephone) to elicit or manipulate anxiety
in people who stutter. In particular, Menzies et al. argued that
no single speaking task is capable of eliciting anxiety in all
participants, and the authors suggested that future research
would benefit from the use of individualized behavioral
assessment tasks to maximize the chances of eliciting and
detecting anxiety. That is, participants could be assigned
individualized behavioral tasks specifically aimed at maxi-
mizing the experience of anxiety, rather than simply assigning
the same task for all participants.
Since the Menzies et al. (1999) review, only a small num-
ber of studies have attempted to manipulate anxiety in people
who stutter. Of particular note, Gabel et al. (2002) inves-
tigated differences in self-reported anxiety for 10 adults who
Iverach et al.: Anxiety and Stuttering 227
stuttered and 10 matched controls. In a similar manner to
in vivo cognitive assessments used in cognitive behavioral
treatments, all participants rated their anxiety at specific
moments during a diagnostic speech assessment, including
(a) three baseline reports, (b) four reports during a period
in which they were thinking about their speech (“the thinking
period”), and (c) six reports during speaking tasks (“the
speaking period”). Overall, the adults who stuttered reported
significantly more anxiety throughout the diagnostic assess-
ment than controls and were more likely to report anxiety
in speaking situations than in other situations.
Similarly, Ezrati-Vinacour and Levin (2004) developed
an assessment of task-related anxiety for their sample of
47 adults who stuttered and 47 controls. Participants were
asked to evaluate their anxiety after performing two speech
tasks and two nonspeech tasks: (a) a conversation about
personal information, (b) reading a passage aloud, (c) silent
reading of a passage, and (d) listening to a recorded passage.
Participants rated their anxiety in each of these situations
on a scale ranging from “extremely anxious” to “not at all
anxious.” Anxiety in speech-related tasks was found to be
higher for adults with more severe stuttering, indicating that
stuttering severity may play a role in the experience of anx-
iety in social communication situations.
These studies provide valuable information about the
assessment of anxiety across multiple tasks. However, the
anxiety assessments used in both studies were not inclusive
of a wide range of anxiety-provoking situations for people
who stutter (e.g., ordering food, taking in front of a group,
or talking in a public place), nor were they individually as-
signed to maximize the experience of anxiety for individual
participants. Further limitations also apply to other studies
that have attempted to evaluate anxiety across speaking
tasks. For instance, although Davis et al. (2007) evaluated
participants’ self-perceived state anxiety in four different
speaking situations, this was done by self-report, not by
actual exposure to these situations. Likewise, a small number
of studies have also utilized routine and challenging phone
calls as the basis for calculating stuttering frequency for
adults who stuttered in their samples, including ratings of
participants’ subjective units of distress following each call
to gauge how anxiety-provoking the phone call was (e.g.,
Iverach, Jones, et al., 2009a; Menzies et al., 2008). However,
these studies did not include any other individually assigned
behavioral tasks specifically aimed at eliciting anxiety.
To our knowledge, only one study since the Menzies et al.
(1999) review has utilized individualized behavioral experi-
ments as a means of treating anxiety in adults who stutter.
Helgadottir, Menzies, Onslow, Packman, and O’Brian (2009b)
reported on the use of a web-based CBT program for the
treatment of anxiety in two stuttering adults diagnosed with
social phobia. As part of the computerized program, partic-
ipants engaged in individually formulated behavioral experi-
ments to facilitate exposure to feared situations or experiences.
This also included the provision of additional cognitive
restructuring exercises. Therefore, the methodological issues
regarding speaking tasks used in stuttering research as raised
by Menzies et al. still requires attention in future research
and may benefit from applications to treatment of anxiety in
adults who stutter.
228 American Journal of Speech-Language Pathology • Vol. 20 • 221–232 • August 2011
Further Considerations
In addition to the methodological issues outlined above, a
number of further considerations pertain to future research
regarding the relationship between anxiety and stuttering.
The Development of Anxiety Across the Lifespan
Since the Menzies et al. (1999) review, a number of studies
have contributed to our understanding of anxiety in children
and adolescents who stutter (e.g., Blood & Blood, 2007;
Davis et al., 2007; Mulcahy et al., 2008). However, we cur-
rently know very little about the development of anxiety in
children (Furnham & Davis, 2004). Studies regarding the
progression of anxiety over the lifespan could be of signifi-
cant benefit to our understanding of the etiology, management,
and treatment of anxiety (Craig & Tran, 2005). In particular,
Craig and Tran (2005) have suggested the following:
What is really needed is an investigation that measures
the progression of anxiety in PWS [people who stutter] in
the community using randomized and stratified selection
procedures. Such a sample is far more likely to provide
data representative of the population of people who
stutter. (p. 44)
This could also include investigations regarding differences
between stuttering people who develop social anxiety and
those who do not (Craig & Tran, 2006).
The Relationship Between Anxiety
and Stuttering Severity
There are some indications in the literature that a rela-
tionship may exist between anxiety and stuttering severity.
However, current research evidence regarding this relation-
ship is inconclusive. For instance, Blumgart et al. (2010)
reported that stuttering severity was not associated with any
anxiety measure or with increased symptoms of social anx-
iety disorders. Other studies have also reported a null rela-
tionship between stuttering severity and trait anxiety (e.g.,
Alm & Risberg, 2007; Ezrati-Vinacour & Levin, 2004;
Miller & Watson, 1992), between stuttering severity and
social phobia (Menzies et al., 2008), and between pretreat-
ment stuttering severity and the presence of mental health
disorders (Iverach, Jones, et al., 2009a). However, Ezrati-
Vinacour and Levin (2004) reported that adults in their sam-
ple with more severe stuttering exhibited higher state anxiety.
Craig et al. (2009) have also suggested that stuttering se-
verity may increase the risk of poorer emotional functioning.
Perhaps these inconsistent findings relate to the different
strategies used by those affected to cope with stuttering
(Plexico et al. 2009). Therefore, future research would bene-
fit from explorations of the relationship between stuttering
severity and the experience of anxiety in social situations.
Treatments for Anxiety in Stuttering
Ingham’s (1984) review mentioned a number of anxiety-
modification techniques used to treat stuttering, including
reciprocal inhibition, hypnotherapy, drug therapy, and bio-
feedback. He noted the use of reciprocal inhibition therapy
(Wolpe, 1958) to systematically desensitize and inhibit anxi-
ety in people who stutter, including the application of relax-
ation techniques and psychotherapy. Ingham suggested
that, in some cases, the theoretical foundations underpinning
these approaches were “shaky” (p. 135) and lacking objective
speech behavior data obtained in “clinically meaningful
speaking situations” (p. 141). Moreover, treatment effects
reported for such approaches were typically not associated
with reductions in stuttering and were not sufficient to justify
their primary use. Thus, Ingham concluded, “Against this
backdrop of relatively unprofitable research, it seems unlikely
that treatments directed towards anxiety reduction would
prove to have general therapeutic merit” (p. 133).
However, research evidence regarding the relationship
between anxiety and stuttering since Ingham’s (1984) review
has become more robust and convincing, and evidence for
treatment practices such as CBT has grown. Consequently,
the urgent need for clinical assessment, management, and
treatment of anxiety and social phobia among adults who
stutter has been highlighted in a number of reviews (e.g.,
Menzies et al., 2008).
One of the most compelling reasons why treatment of
anxiety in adults who stutter is of crucial importance is based
on findings that mental health disorders, including anxiety
disorders, have the potential to result in failure to maintain
the benefits of speech-restructuring treatment in the short
and medium term (Iverach, Jones, et al., 2009a). In addition,
the presence of anxiety disorders has also been associated
with increased avoidance of speaking situations following
treatment for stuttering (Iverach, Jones, et al., 2009a). Not
surprisingly, adults who stutter have also been found to report
that stuttering treatment does not adequately address speaking-
related fears and concerns (Cream et al., 2003; Yaruss,
Quesal, & Murphy, 2002), and some adults who stutter may
still report considerable levels of anxiety following speech
treatment (Craig & Tran, 2006). Therefore, the success of
speech treatment may depend on prior or concurrent manage-
ment of anxiety (Attanasio, 2000).
CBT is the most efficacious intervention available for
treating social anxiety (Andrews, Crino, Hunt, Lampe, &
Page, 2003) and has been evaluated extensively in non-
stuttering populations (Heimberg, 2002). Presumably this
has prompted a number of studies that have reviewed or
investigated the use of CBT in the treatment of anxiety in
adults who stutter (Kawai, 2010; Menzies, Onslow, Packman,
& O’Brian, 2009; Neilson, 1999; Stein et al., 1996). In the
first randomized controlled trial of CBT treatment, Menzies
et al. (2008) reported that CBT for anxiety was associated
with significant reductions in anxiety and avoidance, as well
as the elimination of social phobia diagnoses at 12-month
follow-up. The CBT treatment package was also associated
with significant improvements in global functioning even
though there were no significant differences in rates of flu-
ency for the CBT group and the group that received speech
restructuring only. In contrast, 50% of participants who had
received speech restructuring only still met criteria for social
phobia at 12-month follow-up. These findings highlight the
utility of CBT for social anxiety among adults who stutter.
Helgadottir, Menzies, Onslow, Packman, and O’Brian
(2009a, 2009b) also reported on the development of a
web-based CBT program for the treatment of social anxiety
among adults who stutter. This web-based program was
designed to imitate the complex relationship between a client
and therapist by using individualized formulations based on
Clark and Wells’s (1995) cognitive model of social phobia.
One of the most significant benefits of this program is that it
facilitates accessible and cost-effective treatment for social
phobia for adults who stutter without reliance on adminis-
tration by clinicians. Preliminary evidence from a Phase I
trial has demonstrated the utility of this online CBT program
in eliminating social phobia in adults who stutter and sig-
nificantly improving unhelpful cognitions, fear of negative
evaluation, behavioral avoidance, quality of life, and low
mood (Helgadottir et al., 2009b).
In addition to clinician- or computer-delivered CBT, mea-
sures regarding the cognitions associated with anxiety in
stuttering have also been developed. For instance, Iverach,
Menzies, et al. (2011) and St Clare et al. (2009) reported
on the validation of the Unhelpful Thoughts and Beliefs
About Stuttering (UTBAS) scales, which were developed to
evaluate the frequency of negative thoughts and beliefs as
well as anxiety associated with stuttering. The UTBAS was
originally developed via a comprehensive file audit of un-
helpful cognitions of adults who stuttered involved in a CBT
program for anxiety over a 10-year period (St Clare et al.,
2009). St Clare et al. reported that the UTBAS was capable
of discriminating between unhelpful thoughts related to so-
cial anxiety for the adults who stuttered and control partic-
ipants, and was also sensitive to changes in social anxiety
following CBT treatment.
Following on from this, Iverach, Menzies, et al. (2011)
administered the UTBAS scales to a sample of 140 adults
seeking treatment for stuttering; the authors found that mean
UTBAS scores were significantly higher for participants
who met criteria for social phobia and first-stage screening
criteria for anxious personality disorder. These findings
support the use of the UTBAS scales in assessing negative
thoughts related to anxiety among adults who stutter. There-
fore, a tutorial has been developed for speech-language pa-
thologists regarding the use of CBT with adults who stutter,
including application of the UTBAS to identify unhelpful
thoughts and beliefs associated with stuttering (Menzies et al.,
2009).
On the basis of the above evidence, it is clear that future
collaboration between speech-language therapists, psychia-
trists, and clinical psychologists in the assessment and
treatment of stuttering is warranted (Ginsberg, 2000; Iverach,
O’Brian, et al., 2009). It may also be necessary for psycho-
logical measures and treatment strategies to be integrated
into standard speech treatment practices (Craig & Tran, 2006).
This could also include more adequate training for speech-
language pathologists in terms of addressing anxiety-related
aspects of the disorder.
DSM–IV–TR Social Phobia Exclusion Criteria
for Adults Who Stutter
The DSM–IV–TR currently prohibits a diagnosis of social
phobia in cases where social anxiety and avoidance relate to a
general medical condition such as stuttering. This exclusion
Iverach et al.: Anxiety and Stuttering 229
criterion is at odds with growing evidence of clinically signifi-
cant levels of social anxiety among adults who stutter (Iverach,
O’Brian, et al., 2009; Stein et al., 1996) and also has the
potential to limit treatment options for adults who stutter
(Craig & Tran, 2006). In particular, Stein et al. (1996) have
argued, “Prohibiting a diagnosis of social phobia is likely
to lead clinicians, under the misconception that social phobia
is an inevitable, expected concomitant of stuttering, to ig-
nore clinically relevant social anxiety when it occurs in their
patients who stutter” (p. 279).
In countries such as Australia, government rebates for
mental health treatment are only available for people with a
mental health diagnosis. This poses a significant limitation
for stuttering adults who cannot receive funded treatment for
social phobia without an appropriate diagnosis. Therefore,
changing the DSM–IV–TR exclusion criterion for the release
of the fifth edition of the DSM in 2012 is critical in terms
of increasing anxiety treatment options for adults who stutter,
as well as for improving the quality of life of these individ-
uals (Blumgart et al., 2010). Once this exclusion criterion
has changed, it will be interesting to see the impact this has
on treatment options for stuttering people who report debili-
tating levels of social anxiety.
Conclusion
More than 2 decades ago, Ingham (1984) reviewed the
literature regarding anxiety and stuttering, and concluded
that “the overall tenor of the findings from the studies re-
viewed is that there is little evidence of a clinically significant,
or even theoretically palpable, relationship between stuttering
and anxiety” (p. 132). Over a decade later, Menzies et al.
(1999) conducted a further review to shed more light on the
poorly understood relationship between anxiety and stuttering.
Menzies et al. highlighted five core methodological issues
in the research and concluded that the relationship between
anxiety and stuttering could not be fully understood until the
above methodological limitations had been overcome.
The aim of the current review was to review the research
to date with reference to these methodological issues. Over-
all, research since the Menzies et al. (1999) review has
produced far stronger evidence for a relationship between
stuttering and social anxiety. However, a number of method-
ological issues and theoretical gaps in the literature persist
and require further exploration. Future research efforts should
be aimed at improving research design, increasing statisti-
cal power, employing diagnostic assessments and multi-
dimensional measures of anxiety, and developing anxiolytic
treatment options for stuttering people who report anxiety.
Acknowledgment
This review was supported by Program Grant 633007 from the
National Health and Medical Research Council of Australia.
References
Alm, P. A. (2004). Stuttering, emotions, and heart rate during
anticipatory anxiety: A critical review. Journal of Fluency
Disorders, 29, 123–133.
230 American Journal of Speech-Language Pathology • Vol. 20 • 221–232 • August 2011
Alm, P. A., & Risberg, J. (2007). Stuttering in adults: The acous-
tic startle response, temperamental traits, and biological factors.
Journal of Communication Disorders, 40, 1–41.
American Psychiatric Association. (2000). Diagnostic and sta-
tistical manual of mental disorders (4th ed., text revision).
Washington, DC: Author.
Andrews, G., Craig, A., Feyer, A., Hoddinott, S., Howie, P.,
& Neilson, M. (1983). Stuttering: A review of research find-
ings and theories circa 1982. Journal of Speech and Hearing
Disorders, 48, 226–246.
Andrews, G., Crino, R., Hunt, C., Lampe, L., & Page, A.
(2003). The treatment of anxiety disorders: Clinician guides and
patient manuals (2nd ed.). Cambridge, England: Cambridge
University Press.
Attanasio, J. (2000). A meta-analysis of selected studies in anxiety
and stuttering: Response to Menzies et al., 1999. American
Journal of Speech-Language Pathology, 9, 89–91.
Blomgren, M., Roy, N., Callister, T., & Merrill, R. M. (2005).
Intensive stuttering modification therapy: A multidimensional
assessment of treatment outcomes. Journal of Speech, Language,
and Hearing Research, 48, 509–523.
Blood, G. W., & Blood, I. M. (2007). Preliminary study of self-
reported experience of physical aggression and bullying of
boys who stutter: Relation to increased anxiety. Perceptual
and Motor Skills, 104, 1060–1066.
Blood, G. W., Blood, I. M., Bennett, S., Simpson, K. C., &
Susman, E. J. (1994). Subjective anxiety measurements and
cortisol responses in adults who stutter. Journal of Speech and
Hearing Research, 37, 760–768.
Blood, G. W., Blood, I. M., Maloney, K., Meyer, C., & Qualls,
C. D. (2007). Anxiety levels in adolescents who stutter. Journal
of Communication Disorders, 40, 452–469.
Bloodstein, O. (1995). A handbook on stuttering (5th ed.). San
Diego, CA: Singular.
Blumgart, E., Tran, Y., & Craig, A. (2010). Social anxiety
disorder in adults who stutter. Depression and Anxiety, 27,
687–692.
Bricker-Katz, G., Lincoln, M., & McCabe, P. (2009). A life-
time of stuttering: How emotional reactions to stuttering impact
activities and participation in older people. Disability and
Rehabilitation, 31, 1742–1752.
Bricker-Katz, G., Lincoln, M., & McCabe, P. (2010). Older
people who stutter: Barriers to communication and perceptions
of treatment. International Journal of Language & Communi-
cation Disorders, 45, 15–30.
Clark, D. M., & Wells, A. (1995). A cognitive model of social
phobia. In R. Heimberg, M. Liebowitz, D. A. Hope, & F. R.
Schneier (Eds.), Social phobia: Diagnosis, assessment, and
treatment (pp. 69–93). New York, NY: Guilford Press.
Craig, A. (1990). An investigation into the relationship between
anxiety and stuttering. Journal of Speech and Hearing Disorders,
55, 290–294.
Craig, A., Blumgart, E., & Tran, Y. (2009). The impact of stut-
tering on the quality of life in adults who stutter. Journal of
Fluency Disorders, 34, 61–71.
Craig, A., Hancock, K., Chang, E., McCready, C., Shepley, A.,
& McCaul, A. (1996). A controlled clinical trial for stuttering
persons aged 9 to 14 years. Journal of Speech and Hearing
Research, 39, 808–826.
Craig, A., Hancock, K., Tran, Y., & Craig, M. (2003). Anxiety
levels in people who stutter: A randomized population study.
Journal of Speech, Language, and Hearing Research, 46,
1197–1206.
Craig, A., & Tran, Y. (2005). The epidemiology of stuttering: The
need for reliable estimates of prevalence and anxiety levels over
the lifespan. Advances in Speech-Language Pathology, 7, 41–46.
Craig, A., & Tran, Y. (2006). Fear of speaking: Chronic anxiety
and stammering. Advances in Psychiatric Treatment, 12, 63–68.
Cream, A., Onslow, M., Packman, A., & Llewellyn, G. (2003).
Protection from harm: The experience of adults after therapy
with prolonged-speech. International Journal of Language &
Communication Disorders, 38, 379–395.
Davis, S., Howell, P., & Cooke, F. (2002). Sociodynamic rela-
tionships between children who stutter and their non-stuttering
classmates. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 43, 939–947.
Davis, S., Shisca, D., & Howell, P. (2007). Anxiety in speakers
who persist and recover from stuttering. Journal of Communi-
cation Disorders, 40, 398–417.
Dietrich, S., & Roaman, M. H. (2001). Physiological arousal and
predictions of anxiety by people who stutter. Journal of Fluency
Disorders, 26, 207–225.
DiLollo, A., Manning, W. H., & Neimeyer, R. A. (2003). Cogni-
tive anxiety as a function of speaker role for fluent speakers and
persons who stutter. Journal of Fluency Disorders, 28, 167–186.
Endler, N. S., Edwards, J. M., & Vitelli, R. (1991). Endler
Multidimensional Anxiety Scales ( EMAS): Manual. Los Angeles,
CA: Western Psychological Services.
Ezrati-Vinacour, R., & Levin, I. (2004). The relationship be-
tween anxiety and stuttering: A multidimensional approach.
Journal of Fluency Disorders, 29, 135–148.
Ezrati-Vinacour, R., Platzky, R., & Yairi, E. (2001). The young
child’s awareness of stuttering-like disfluency. Journal of Speech,
Language, and Hearing Research, 44, 368–380.
Furnham, A., & Davis, S. (2004). Involvement of social factors in
stuttering: A review and assessment of current methodology.
Stammering Research, 1, 112–122.
Gabel, R. M., Colcord, R. D., & Petrosino, L. (2002). Self-
reported anxiety of adults who do and do not stutter. Perceptual
and Motor Skills, 93, 775–784.
Ginsberg, A. P. (2000). Shame, self-consciousness, and locus of
control in people who stutter. The Journal of Genetic Psychology,
161, 389–399.
Hancock, K., Craig, A., McCready, C., McCaul, A., Costello, D.,
Campbell, K., & Gilmore, G. (1998). Two- to six-year
controlled-trial stuttering outcomes for children and adolescents.
Journal of Speech, Language, and Hearing Research, 41,
1242–1252.
Heimberg, R. G. (2002). Cognitive behavioral therapy for social
anxiety disorder: Current status and future directions. Biological
Psychiatry, 51, 101–108.
Helgadottir, F., Menzies, R., Onslow, M., Packman, A., &
O’Brian, S. (2009a). Online CBT I: Bridging the gap between
Eliza and modern online CBT treatment packages. Behaviour
Change, 26, 245–253.
Helgadottir, F., Menzies, R., Onslow, M., Packman, A., &
O’Brian, S. (2009b). Online CBT II: A Phase I trial of a stand-
alone, online CBT treatment program for social anxiety in
stuttering. Behaviour Change, 26, 254–270.
Huber, A., Packman, A., Quine, S., Onslow, M., & Simpson, J.
(2004). Improving our clinical interventions for stuttering: Can
evidence from qualitative research contribute? Advances in
Speech-Language Pathology, 6, 174–181.
Ingham, R. (1984). Stuttering and behavior therapy: Current status
and experimental foundations. San Diego, CA: College Hill
Press.
Iverach, L., Jones, M., Menzies, R. G., O’Brian, S., Packman, A.,
& Onslow, M. (2011). Response to Walter Manning and J. Gayle
Beck: Comments concerning Iverach, Jones et al. (2009a).
Journal of Fluency Disorders, 36, 66–71.
Iverach, L., Jones, M., O’Brian, S., Block, S., Lincoln, M.,
Harrison, E., . . . Onslow, M. (2009a). The relationship
between mental health disorders, stuttering severity and treat-
ment outcomes among adults who stutter. Journal of Fluency
Disorders, 34, 29–43.
Iverach, L., Jones, M., O’Brian, S., Block, S., Lincoln, M.,
Harrison, E., . . . Onslow, M. (2009b). Screening for personal-
ity disorders among adults seeking speech treatment for stutter-
ing. Journal of Fluency Disorders, 34, 173–186.
Iverach, L., Menzies, R. G., Jones, M., O’Brian, S., Packman,
A., & Onslow, M. (2011). Further development and valida-
tion of the Unhelpful Thoughts and Beliefs About Stuttering
(UTBAS) Scales: Relationship to anxiety and social phobia
among adults who stutter. International Journal of Language
and Communication Disorders, 46, 286–299. doi:10.3109/
13682822.2010.495369.
Iverach, L., O’Brian, S., Jones, M., Block, S., Lincoln, M.,
Harrison, E., . . . Onslow, M. (2009). Prevalence of anxiety
disorders among adults seeking speech therapy for stuttering.
Journal of Anxiety Disorders, 23, 928–934.
Kawai, N. (2010). An overview of cognitive-behavioral therapy
strategies for stuttering. Japan Journal of Logopedics and
Phoniatrics, 51, 269–273.
Kraaimaat, F. W., Vanryckeghem, M., & Van Dam-Baggen, R.
(2002). Stuttering and social anxiety. Journal of Fluency Dis-
orders, 27, 319–331.
Langevin, M., Packman, A., & Onslow, M. (2009). Peer responses
to stuttering in the preschool setting. American Journal of
Speech-Language Pathology, 18, 264–276.
Mahr, G. C., & Torosian, T. (1999). Anxiety and social phobia
in stuttering. Journal of Fluency Disorders, 24, 119–126.
Manning, W., & Beck, J. G. (2011). Comments concerning
Iverach, et al., Screening for personality disorders among adults
seeking speech treatment for stuttering. Journal of Fluency
Disorders, 36, 61–65.
Menzies, R. G., O’Brian, S., Onslow, M., Packman, A., St Clare,
T., & Block, S. (2008). An experimental clinical trial of a cog-
nitive behavior therapy package for chronic stuttering. Journal
of Speech, Language, and Hearing Research, 51, 1451–1464.
Menzies, R. G., Onslow, M., & Packman, A. (1999). Anxiety
and stuttering: Exploring a complex relationship. American
Journal of Speech-Language Pathology, 8, 3–10.
Menzies, R. G., Onslow, M., Packman, A., & O’Brian, S.
(2009). Cognitive behavior therapy for adults who stutter: A
tutorial for speech-language pathologists. Journal of Fluency
Disorders, 34, 187–200.
Messenger, M., Onslow, M., Packman, A., & Menzies, R.
(2004). Social anxiety in stuttering: Measuring negative social
expectancies. Journal of Fluency Disorders, 29, 201–212.
Miller, S., & Watson, B. C. (1992). The relationship between
communication attitude, anxiety, and depression in stutterers
and nonstutterers. Journal of Speech and Hearing Research,
35, 789–798.
Mulcahy, K., Hennessey, N., Beilby, J., & Byrnes, M. (2008).
Social anxiety and the severity and typography of stuttering in
adolescents. Journal of Fluency Disorders, 33, 306–319.
Neilson, M. D. (1999). Cognitive-behavioral treatment of adults
who stutter: The process and the art. In F. Curlee (Ed.), Stutter-
ing and related disorders of fluency (2nd ed., pp. 181–199).
New York, NY: Thieme.
O’Brian, S., Jones, M., Packman, A., Menzies, R., & Onslow, M.
(2011). Stuttering severity and educational attainment. Journal of
Fluency Disorders, 36, 86–92.
Orsillo, S. M., & Hammond, C. (2001). Social phobia: A brief
overview and guide to assessment. In M. M. Antony, S. M.
Orsillo, & E. Roemer (Eds.), Practitioner’s guide to empirically
based measures of anxiety (pp. 159–164). New York, NY:
Kluwer Academic/Plenum.
Iverach et al.: Anxiety and Stuttering 231
Packman, A., Menzies, R. G., & Onslow, M. (2000). Anxiety
and the anticipatory struggle hypothesis. American Journal of
Speech-Language Pathology, 9, 88–89.
Peters, H. F. M., & Hulstijn, W. (1984). Stuttering and anxiety.
Journal of Fluency Disorders, 9, 67–84.
Plexico, L. W., Manning, W. H., & Levitt, H. (2009). Coping
responses by adults who stutter: Part I. Protecting the self and
others. Journal of Fluency Disorders, 34, 87–107.
Poulton, R., & Andrews, G. (1994). Appraisal of danger and
proximity in social phobics. Behaviour Research and Therapy,
32, 639–642.
Reich, J. (2000). The relationship of social phobia to avoidant
personality disorder: A proposal to reclassify avoidant person-
ality disorder based on clinical empirical findings. European
Psychiatry, 15, 151–159.
Reynolds, C. R., & Richmond, B. O. (2000). Revised Children’s
Manifest Anxiety Scale (RCMAS): Manual. Los Angeles, CA:
Western Psychological Services.
Schneier, F. R., Wexler, K. B., & Liebowitz, M. R. (1997).
Social phobia and stuttering. American Journal of Psychiatry,
154, 131.
Spielberger, C. D., Gorsuch, R. L., Lushene, R. E., Vagg, P.,
& Jacobs, G. (1983). Manual for the State-Trait Anxiety Inven-
tory. Palo Alto, CA: Consulting Psychologists Press.
St Clare, T., Menzies, R. G., Onslow, M., Packman, A.,
Thompson, R., & Block, S. (2009). Unhelpful thoughts and
beliefs linked to social anxiety in stuttering: Development of a
measure. International Journal of Language & Communication
Disorders, 44, 338–351.
232 American Journal of Speech-Language Pathology • Vol. 20 • 221–232 • August 2011
Stein, M. B., Baird, A., & Walker, J. R. (1996). Social phobia
in adults with stuttering. American Journal of Psychiatry, 153,
278–280.
Turnbaugh, K. R., Guitar, B., & Hoffman, P. R. (1979). Speech
clinicians’ attribution of personality traits as a function of stut-
tering severity. Journal of Speech and Hearing Research, 22,
37–45.
Turner, S. M., Beidel, D. C., & Dancu, C. V. (1996). Social
Phobia and Anxiety Inventory: Manual. Toronto, Ontario,
Canada: Multi-Health Systems.
Watson, D., & Friend, R. (1969). Measurement of social-evaluative
anxiety. Journal of Consulting and Clinical Psychology, 33,
448–457.
Weber, C. M., & Smith, A. (1990). Autonomic correlates of
stuttering and speech assessed in a range of experimental tasks.
Journal of Speech and Hearing Research, 33, 690–706.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford,
CA: Stanford University Press.
World Health Organization. (1993). The ICD-10 classification
of mental and behavioural disorders: Diagnostic criteria for
research. Geneva, Switzerland: Author.
Yaruss, J. S., Quesal, R. W., & Murphy, B. (2002). National
Stuttering Association members’ opinions about stuttering
treatment. Journal of Fluency Disorders, 27, 227–242.
Zimmerman, M., & Mattia, J. I. (2001). A self-report scale to
help make psychiatric diagnoses: The Psychiatric Diagnostic
Screening Questionnaire. Archives of General Psychiatry, 58,
787–794.
 Anxiety and Stuttering: Continuing to Explore a Complex Relationship

Lisa Iverach, Ross G. Menzies, Sue O'Brian, Ann Packman, and Mark Onslow
Am J Speech Lang Pathol 2011;20;221-232; originally published online Apr 8, 2011;
DOI: 10.1044/1058-0360(2011/10-0091)

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