About the Author: Sanjeeva Murthy has a doctorate in Materials science and is currently a faculty member at Rutgers University. He is interested in speech disorders because he is a stutterer, and knows how a speech handicap can affect a person. He was born in India, and came to the United states as a student at the age of 22 in 1972.  Everyone who knew him in India remembers him as someone who stutters.  His stuttering almost disappeared the instant he landed in the U.S., perhaps because no one in the U.S. knew him, but it reappeared without warning on many occasions.  He began to think about this intermittent stuttering and “normal” speech, and published a technical paper in 1980 describing his ideas in terms of a systems model (Integrated Analysis of Stuttering Using a Simple Conceptual Model. Folia phoniat, 1980. 32: p. 285-297). This ISAD article is based on ideas that are in that paper. Sanjeeva Murthy, 37 Bouvant Drive, Princeton NJ 08540, n.sanjeeva.murthy@gmail.com

Abstract

Stuttering is a hidden disability that requires a unique set of resources to manage in public.  Classrooms being the biggest challenge for stutterers, awareness of stuttering and personalized support in schools would help stutters to be comfortable in their manner of speech and with the response of their listeners.  To facilitate teachers and peers see and hear stuttering, I give a glimpse of what goes on inside a stutterer’s head using a simple schematic model.  Stuttering is thought to be due to subtle differences in neural pathways to and from the vocal mechanism.  The model emphasizes the role of the listeners and the environment that cause mis-timed proactive signals and trigger unwarranted feedback in the stutterer’s neural network that processes speech.  Stutterers can achieve a semblance of fluency by circumventing some of these pathways using distraction to substitute anticipatory thoughts about stuttering.  But this practice is unreliable.  More robust remedies take advantage of the neuroplasticity by progressively substituting: (1) impaired feedback pathways with fluency-promoting feedback, and (2) proactive stimuli with constructive forward control. Psychological factors that contribute to stuttering can also manifest as personality traits that need to be addressed by the community around the stutterer.

Keywords:  Stuttering. Anticipatory struggle. Feedback. Proactive stimulus. Neuroplasticity. 

• Introduction

If a person is disfigured, blind or crippled, the disability is obvious and people’s response is predictable. The problem with stuttering is that it is hidden. Typical responses it elicits when it becomes visible make a stutterer shameful and embarrassed.  It is not unusual that when a stutterer begins to speak, and the words don’t come out right, the positive impression that a new acquaintance or audience had about the stutterer quickly devolves into discomfort, tolerance, and even pity.  Such occurrences repeated throughout a stutterer’s life determine his sociability, adversely affect relationships, scar the person, and determine his identity. Only other stutterers can fully appreciate its effect on one’s personality.

I used to think that my experiences as a stutterer were unique.  By reading about other stutterers, I gradually realized that my experiences are not fundamentally different from those of other stutterers, just of a different shade. Yet, publicizing individual experiences would make stuttering visible to the public, benefitting stutterers, with each experience is in fact a case history for clinicians.  My experience begins in childhood, being frustrated and angry at being not able to say my name, and to ask or answer a question in the class.  Later, I felt helpless when I made people uncomfortable by my stuttering.  I was always fearful of the consequences of stuttering.   I consider myself now a borderline stutterer in which speech impediments strike without notice. Even at this late age in my 70’s, it is distressing not to be able to express one’s thoughts properly. Residuals of my life-long stuttering are obvious only to those who knew me till I was twentyish. Others think that I have an abnormal speech pattern because my speech is monotonous and labored, sounds unnatural with wrong intonations, is choppy with abrupt stops and starts. Occasionally, I show the classic stuttering characteristics such as part-word repetition, silent blocks and sound prolongation.  Often, others in the room repeat exactly what I just said in a smooth, rhythmic and effortless delivery, and are more effective.  With some level of controlled fluency that hides my stuttering, my speech is now tolerable. But I feel like an impostor, a stutterer masquerading as a fluent speaker. 

Perception of the stutterers by the community and in the workplace can be normalized by educating the audience. This can be most effectively addressed in a school setting where a stutterer is often most seen and heard. More importantly, a stutterer experiences the most intense distress in classrooms.  Awareness of stuttering in the community of teachers and peers may help a stutterer to cope better by stuttering without embarrassment, and even overcome it. While I was a child, my parents tried without success to treat my stuttering using faith healers and talismans. Growing up, I assumed that stuttering was a handicap that I just have to live with. As an adult, I realized that I could change how I speak by understanding stuttering.  I describe my experiences here by weaving them into a schematic model. 

2. A systems model for stuttering

A model can be useful to explain stuttering to the public. Suppose a motor, such as the one in household air-handling systems, is instructed by a controller to open an air pathway. If the motor fails to respond, the control system senses this failure and resends the instruction. The motor is now caught between its inability to open because of the mechanical fault and the unceasing inputs from the controller to open. This tug-o-war between the expected outcome and the existing state resembles stuttering [1].  Following this analogy, speech can be thought of as being initiated by a hypothetical pattern generator in the brain that prepares a sequence of instructions for the vocal cords (left-third section in Figure 1), The right-third section represents the external factors including listeners that affect speech. The middle-third section represents the pathways that pass signals between the language processor and the vocal cord. Feedback loops are central to such models [2-7].

Figure 1. A schematic of the fluent (top half, open arrows) and stuttered (bottom half, filled arrows) speeches. Treatments are aimed at migration from one set of pathways to the other by taking advantage of neural plasticity.

2.1 Stuttering as impaired signaling pathways:  We think faster than we speak. Stutterers, unlike fluent speakers, appear not able to manage this mismatch in speed. For me, words do not come out the way I see them.  I have to consciously exert myself to hear my own words.  [8].  A failure such as not being able to get word out, which does not perturb a fluent speaker in the least, causes destructive feedback that results in silence and pauses in a stutterer. This can be represented as an impairment of an unconscious feedback that modulates the speech, from the top open backward arrow in fluent speakers to the bottom filled backward arrow in stutterers. The impaired signal pathways are thought to be activated by anxiety. But I do not remember experiencing any moments of anxiety in my pre-teens while I stuttered away, including participating in debates, without considering how others would react to my stuttering.  Only in my teens, I began to feel anxious about speaking and shied away from speaking. I devised ways to reduce my anxiety level to overcome stuttering. I began to substitute problem words to mask my handicap.  In the words of Johnson [9], I just bumbled along, using techniques that seemed to work at that moment. 

The filled forward arrow in Figure 1 represents the development of learned secondary behaviors in confirmed stutterers that exacerbate stuttering.  This includes fear of certain words and situation, escape and avoidance, efforts to conceal the handicap by using starters, explaining the word, and by substitutions (circumlocution) that lead to bad syntax; sometimes what I said would be the exactly opposite of what I meant to say.  The two stuttering pathways at the bottom of the figure represent the conflict during stuttering between urge to speak and not to speak [10, 11],  the opposing forces in a tug-o-war [12], disagreement between the director and the actor in a play.  My stuttering began to diminish once I realized that pathways that cause blockages and unconscious mental inhibition to affect fluency can be overcome.

My stuttering disappeared almost completely when I came to the U.S. when I was 21, where no one knew the old stuttering Me. But during my first visit to India after 4 years, I was taken aback to hear myself stutter as badly as before while talking to my family members and old friends as though mis-wired pathways remained waiting to be triggered by old memories. Even now, I stutter without being aware of it every time I talk to my old acquaintances and relatives who know me as a stutterer.  

2.2 Proactive stimulus and failure to launch. Stuttering almost always occurs at the first syllable.  This can be associated with an erroneously timed speech activation signal caused by a mismatch between the prediction and action. Ms. Lara Trump famously identified this when she mocked Mr. Joe Biden in the 2020 U.S. presidential race by saying “Joe, can you get it out? … Let’s get the words out, Joe.” [13]. When I was 10, I had to give my name to a teacher during registration in a school where they didn’t have my records. Because I couldn’t utter the first syllable my name, which used to be M.N. Sanjeeva Murthy, has become N. Sanjeeva Murthy. To avoid the difficulty with the opening syllable, I often used lead-ins, i.e., utter an unnecessary word prior to and in the same breath as the feared word. 

Proactive stimulus from the brain, based on anticipated action of the vocal cord can explain this inability to start. An imposed rhythm, as it occurs during singing, can replace this stimulus and thus help some stutterers by preventing them from getting ahead of themselves.  I was made aware of my lack of sense of timing while I was navigating a friend through busy Philadelphia streets before GPS era when my friend who was driving said, “you know Sanjeeva, you give me directions for the next turn and the one after it even before I am finished with this turn. It confuses me. Can you wait till I make the turn before you tell me what to do next?”  I realized that is precisely what happens to me while speaking. It is as though the brain is pushing through a syllable through the vocal cord that is still executing the prior instruction. This is similar to the stuttering of the motor in the air-handling system discussed earlier.

3. Mitigation of stuttering

Distraction, in essence, blocks the impaired pathways in Figure 1. Distraction can be brought about by thought substitution that relies on the left prefrontal cortex, or by direct suppression on the right. Chewing is most likely one of the earliest techniques devised to achieve distraction [14]. When I was about 7, I was asked to put a pebble in my mouth while speaking.  This did not help; my stuttering got worse to such a degree I could not even say my name.  In one stretch extending over months, I could not answer roll-call in my classes. One day during this period, I happened to crush my left thumb by a hammer, and was treated with iodine tincture. The next day, I happened to be smelling the iodine on my thumb when my name was called.  To my and everybody’s surprise, I answered the roll call. This way, I discovered distraction as a means to avoid stuttering. Since my difficulty was always in starting a sentence, and because it got harder the more I thought, I tried not to think of the first syllable by distracting myself. I do not stutter in new situations such as speaking to a stranger at a bus stop, or in a critical situation such as angrily arguing with a landlord. Based on such experiences, I began to experiment by imagining or play-acting different scenarios, using a different tone, even pretending to be talking to child. 

Distraction and forgetting being a stutterer can be expedient for achieving fluency, but is not reliable.  The pathways in the middle-third of the diagram in Figure 1 suggest that fluency can be achieved by taking advantage of the neural plasticity [15].  Hypnosis probably works for the same reason [16]. As stutterers grow older, they learn to bypass the impaired pathways, every person finding a unique way to rewire the brain. Borrowing from the computer terminology, this is the equivalent of installing a new software to fix a problem, while issues with hardware (vocalization) and operating system (code preparation in neural networks) over which a stutterer has little control remain. Because of neural plasticity, stutter can be mitigated by speech therapist in children and by self-help in adults.  

4. Personality traits

Stuttering has conditioned my personality. It is also possible that my characteristic traits might have contributed to stuttering. It appears to me that a stutterer has a tendency to miss timing cues.  This could be deep rooted in the brain, and be of genetic origin [17]. Thus, the behavior related to proactive stimulus or premature feedback could manifest in other activities as well, such as untypical haste, inability to wait for their turn to speak and restlessness. I have been faulted for not planning or looking ahead, not being in the moment, and not focused. A stutterer’s tug-o-war between whether to go ahead with a word or hold back is itself a sign of indecisiveness. While growing up, I was aware that people around me thought I behaved differently. Only in my 50’s I realized that my behavior has some characteristics of attention deficit disorders. 

• Conclusions

Knowing that stuttering is often associated with anticipation, anxiety and avoidance, parents, teachers and peers can play an important role in helping a stutterer manage their stuttering. Stuttering can be thought of as mis-wired circuitry with malfunctioning pathways in the form of proactive stimulus and the speech-interrupting feedback. Distracting and making the stutterer forget that he is a stutterer can bypass these pathways, resulting in pretense of normal speech.  Stuttering can be minimized by speaking slowly, reducing tension by proper breathing, maintaining proper eye contact to prevent avoidance, and by proper preparation to the point of rehearsing every sentence before it is uttered. Recognizing neural plasticity and acting on it provides a long-lasting solution. Many achieve fluency as they grow older; some for no obvious reasons, others because of conscious effort, or because of successful treatments. Treatments of stuttering need to be aimed at examining the personality traits and not just disorder in speech.

References

1. Harrison, J.C., Redefining Stuttering: What the struggle to speak is really all about. 2011.
2. Murthy, N.S., Integrated Analysis of Stuttering Using a Simple Conceptual Model. Folia phoniat, 1980. 32: p. 285-297.
3. Civier, O., D. Bullock, L. Max, and F.H. Guenther, Computational modeling of stuttering caused by impairments in a basal ganglia thalamo-cortical circuit involved in syllable selection and initiation. Brain and language, 2013. 126(3): p. 263-278.
4. Levelt, W.J.M., Producing spoken language: A blueprint of the speaker. InC. M. Brown & P. Hagoort (Eds.), The neurocognition of language (pp. 83–122). 1999, Oxford, UK: Oxford University Press.
5. Craig-McQuaide, A., H. Akram, L. Zrinzo, and E. Tripoliti, A review of brain circuitries involved in stuttering. Frontiers in human neuroscience, 2014. 8: p. 884.
6. Hesse, T., Stuttering as a result of a misallocation of attention during speech.  A theory. 2018. p. http://www.stuttering-theory.eu/AAT-2018e.pdf.
7. Levelt, W.J.M., The ability to speak: From intentions to spoken words. European Review, 1995. 3(1): p. 13-23.
8. Brown, S., R.J. Ingham, J.C. Ingham, A.R. Laird, and P.T. Fox, Stuttered and fluent speech production: an ALE meta‐analysis of functional neuroimaging studies. Human brain mapping, 2005. 25(1): p. 105-117.
9. Williams, D., Wendell Johnson and Charles Van Riper: A Remembrance of Them and Their Era. National Council on Stuttering 1999.
10. Sheehan, J.G., Theory and treatment of stuttering as an approach-avoidance conflict. The Journal of Psychology, 1953. 36(1): p. 27-49.
11. Sheehan, J.G. Conflict theory of stunering in J. Eiserson. in Stuttering: A Symposium. 1958.
12. Harrison, J.C., Understanding the Speech Block. 2012. p. https://www.mnsu.edu/comdis/kuster/Infostuttering/Harrison/block.html.
13. Sullenberger III, C.B., Like Joe Biden, I Once Stuttered, Too. I Dare You to Mock Me., in New York Times. 2020: https://www.nytimes.com/2020/01/18/opinion/sully-biden-stutter-lara-trump.html.
14. Mohr, E., Chewing Therapy in Stuttering, in The Chewing Approach in Speech and Voice Therapy. 1951, Karger Publishers. p. 19-38.
15. Guitar, B., Stuttering: An integrated approach to its nature and treatment. 2013: Lippincott Williams & Wilkins.
16. Lovett, L.G., Stuttering and Anxiety Self Cures. 2016: Peace Love & Reason LLC.

17. Frigerio‐Domingues, C. and D. Drayna, Genetic contributions to stuttering: the current evidence. Molecular genetics & genomic medicine, 2017. 5(2): p. 95-102.