You are on page 1of 1

Reflection & Reaction

A neurological basis of stuttering?


Many theories of the physiological due to defects in the inner subcortical struggle behaviours and social
basis of stuttering exist. For centuries speech loop, which includes the anxieties. Comprehensive stuttering
it was widely believed that stuttering striatum.4 treatment should target both the
arose from abnormalities of the Others have reported that the underdeveloped left hemisphere (eg,
tongue or larynx and, until recently, right hemisphere of people who through pharmacological inter-
clinicians have tried to treat stuttering stutter is abnormally overactive ventions) and the overcompensated
by manipulating the peripheral compared with the left hemisphere. right hemisphere (eg, through
muscles of speech, albeit with limited Sommer and co-workers point out cognitive or behavioural speech
benefit. However, evidence is now that this increase in right hemispheric therapy).
accumulating to suggest that the activity might represent overcompen- A new era has begun in the
dysfunction of stuttering resides sation for the low functioning of the understanding and treatment of
within the brain and not within the left hemisphere, which could have stuttering. Sommer and others have
tongue or larynx. failed to develop properly. This study, shown that stuttering is associated
The recent study by Sommer and and others, have yet to pinpoint a with abnormal brain functioning, and
colleagues1 builds upon the work of specific cerebral structure involved in hence it should be viewed as
others to suggest that stuttering should stuttering, probably due to the use of a neurological disorder with psycho-
be viewed as a disorder of the brain. different imaging techniques. logical compensations. The challenge
Although this article expands our The low function of the left hemi- now facing physicians and neuro-
understanding and provides insights sphere may be related to abnormally scientists is to understand how
into future research and treatment high inhibition by dopamine.5,6 stuttering develops, why it resolves
directions, the neurological basis of Stuttering shares many similarities spontaneously in some cases, and what
stuttering is still not fully understood. with Tourette’s syndrome, a disorder treatments will ultimately assist
However, the work of Sommer’s group of known dopamine abnormality. individuals who struggle with this
supports the “bottom-up” and “top- Both disorders have their onset in disorder.
down” approach to understanding the childhood, follow a waxing and
physiological basis of stuttering—ie, waning course, present with tics, and Gerald A Maguire, Glyndon D Riley,
studies of pharmacological treatments respond, at least partially, to treatment and Benjamin P Yu
(bottom up) that support the with dopamine antagonists. Previous Correspondence: Gerald A Maguire,
neurological basis of this disorder as imaging studies have shown that the University of California, Irvine Medical
shown by functional imaging studies function of speech areas in the left Center, Department of Psychiatry, Route
88, 101 City Drive, Orange CA 92868
(top down). hemisphere increases in relation to
USA. Email gamaguir@uci.edu
Previous functional brain imaging improved fluency following the
studies have shown that stuttering is administration of dopamine antag- References
associated with abnormally low onists.5,7 The previous finding that low 1 Sommer M, Koch MA, Paulus W, Weiller C,
Buchel C. Disconnection of speech-relevant brain
function of left hemispheric speech activity of the left cortical speech areas areas in persistent developmental stuttering.
areas—which are normally dominant might also be related to abnormally Lancet 2002; 360: 380–83.
2 Wu JC, Maguire GA, Riley G, et al. A positron
in speech function—compared with low function of the left striatum5 is emission tomography [18F] deoxyglucose study of
developmental stuttering. Neuroreport 1995;
analogous areas of the right hemi- not discussed in Sommer’s study. 6: 501–05.
3 Pool KD, Devous MD, Freeman FJ, Watson BC,
sphere.2,3 An interesting clinical Dopamine antagonists have been Finitzo T. Regional cerebral blood flow in
finding, which is often used by shown to increase striatal function and developmental stutterers. Arch Neurol 1991;
48: 509–12.
neuroimagers to investigate stuttering, thus provide a plausible explanation 4 Wu JC, Riley G, Maguire G, Najafi A, Tang C. PET
scan evidence of parallel cerebral systems related to
is that fluency can be induced through for their therapeutic mechanism of treatment effects: FDG and FDOPA PET scan
a variety of techniques such as chorus action in stuttering.8 Unfortunately, findings. In: Hulstijn W, Peters HFM,
Van Lieshout PHHM eds. Speech production:
reading. During induced fluency, the older generation dopamine motor control, brain research and fluency
disorders. Amsterdam: Elsevier Science, 1997:
activity of left hemispheric speech antagonists (eg, haloperidol) are not 329–39.
areas is increased to levels comparable well tolerated and thus have limited 5 Maguire GA, Riley GD, Franklin DL, et al. The
dopamine hypothesis of stuttering and its
with normal controls. Sommer utility. Recent research has shown, treatment implications. Int J Neuropsychopharmacol
2000; 3 (suppl 1): S12.
suggests that chorus reading provides however, that novel dopamine 6 Wu JC, Maguire G, Riley G, et al. Increased
an external clock that decreases antagonists can provide an efficacious dopamine activity associated with stuttering.
Neuroreport 1997: 8: 767–70.
stuttering and induces fluency. and tolerable treatment option for 7 Wood F, Stump D. Patterns of regional
cerebral blood flow during attempted reading
However, a more comprehensive individuals who stutter.9 aloud by stutterers both on and off haloperidol
medication: evidence for inadequate left frontal
explanation may be that induced The overcompensation of the right activation during stuttering. Brain Lang 1980;
fluency tasks bypass the abnormally hemisphere, as described by Sommer, 9: 141–44.
8 Buchsbaum MS, Potkin SG, Siegel BV Jr, et al.
inactive striatum to activate the outer begins to explain some of the possible Striatal metabolic rate in clinical response to
neuroleptics in schizophrenia. Arch Gen Psychiatry
cortical speech loop, which is associated behavioural characteristics 1992; 49: 966–74.
preserved in individuals who stutter. that may develop in relation to 9 Maguire GA, Riley GD, Franklin DL, Gottshalk LA.
Risperidone for the treatment of stuttering.
Spontaneous stuttering is probably stuttering, such as avoidance and J Clin Psychopharmacol 2000; 20: 479–82.

THE LANCET Neurology Vol 1 November 2002 http://neurology.thelancet.com 407