Free Self-Treatment Guide & Book

Written by Matthew O’Malley

Introduction
(Skip to “In a Nutshell” section for a brief summary)

Have you ever asked yourself, “Isn’t there someone who has sat down and looked at all the characteristics of stuttering and figured out what’s going on?”

“Isn’t there some researcher somewhere who has put all of these puzzling pieces together to explain stuttering?”

After all, even the lay observer is intrigued by it and has a sense that this enigma is solve-able.  You’d think it would be solved by now.

“Why do people not stutter in some situations and stutter significantly in others?”

“Why is it that a person who stutters can block on a word for a few seconds and then the word all of a sudden comes out? What changed?!”

If you have asked these questions or ones similar, then we have something in common.  I also asked them a number of years ago and there was seemingly nowhere to turn for satisfactory answers.  I had sought out the world’s leading experts on the subject, sought treatment for my own stuttering and was disappointed with both the answers and the results.  I simply wanted sensible explanations and reasonably effective treatment for stuttering and, had I received it, would have walked away from the world of stuttering and never looked back.

That’s not what happened though.

After seeking these answers and receiving various treatments, I was still stuttering and was still mystified by it.  Its accompanying struggles had consumed my life for many years up to that point.  The fact that I could not find a reasonable remedy to deal with my stuttering lead me through some very challenging times in life.  I decided since stuttering was already consuming my life, why not make use of that.

In my asking the question “Isn’t there someone out there who has figured out stuttering and put all the pieces together?” I had received my answer.  The answer was “No”.  So instead of continuing to ask that same question, I started asking a new one. “Why not me?”

In answering this new question, I decided to use my life to serve this cause; to answer these questions.  My inability to resolve my stuttering earlier in my life had caused many challenging times.  It is part of the human journey I have been on; a human journey that involves significant pain and suffering.  While I believe suffering is inherently purposeful, I also hope to transform my own into purpose by giving to this cause.  I consider myself humbly in service to those who have asked or one day will ask these same questions.  I hope to serve well.

Since dedicating to this path about five years ago, I have graduated cum laude with a degree in speech-language pathology.  I have also worked as a developmental therapist treating speech and language delays.  Most importantly however, I have stayed passionately curious and deeply motivated to answer the above questions and have been in the trenches doing just that.  Fortunately, I believe this process is bearing fruit.

Problems in Research/Academia & My Differing Approach

Firstly, I want to state that much good comes out of academia and research.  There are many advantages to the academic process and many intelligent people who part-take in it.  I admire all in the research community and am truly thankful for their hard work and contributions.

At the same time academia and the research process is not flawless nor is it without significant limitation.  This is not news to those within it as researchers have concurred with this view in conversational exchanges we’ve shared.

In getting to it, however, in current and past research on stuttering there is far too little time spent on synthesizing/combining information we already have.  Well-intended researchers end up spending five years on a study which uncovers the most minute new piece of information on stuttering.

Inherent in the above pursuits of new information is a belief that what we need is new information.  However, the problem isn’t so much a lack of information on stuttering.  It is more a problem of lack of competent synthesis of all of the information we have.  Many insights about the condition are ready for the drawing if you zoom out a bit and look at the big picture.

In addition, as many researchers concur, much of the academic process is not conducive to the passionate pursuit of answers.  The process of a research study can become energy-draining and more about paper pushing and meeting obligations than answering the questions you set out to answer in the first place.

As a result of these problems I have taken a different approach.  I have allowed my passionate curiosity to be the unabated director of my pursuit of answers.  I have observed my own stuttering and that of many others and trusted my observations and insights.   I have focused on synthesizing the already-existing information.  I have believed nothing that I did not understand myself.  While I do dive deeply into the tedious details of academic research I also make sure to maintain a level of common sense.  Too many seeking answers end up not being able to see the forest for the trees.  Also to my benefit, we live in the information age and this has yielded many advantages.

Lastly, before diving in, I’d like to share that I work hard to make my explanations of stuttering clear and linear and work to stay away from convoluted academic jargon.  I could write that way but choose not to.  I choose to write with simple clarity (which is actually far more difficult) so the reader, no matter their background, can understand it and evaluate its veracity for themselves.  You don’t need to look for a piece of paper on my wall when evaluating the credibility of my explanations (though I have some) as you can assess the strength and clarity of the logic for yourself.  That being said, know that when I am explaining something, it is going somewhere.  It may seem indirect at times as I must provide some background information, however, it is not.

Revealing Stuttering

What if you learned the severity of the movement disorder Parkinson’s disease fluctuated with changes in the environment just like stuttering?

What if you learned people with Parkinson’s in some circumstances regain virtually normal movement control just like someone who stops stuttering when alone?

What if you learned there were non-speech behaviors that people “stuttered” on?  What if golfers froze mid-swing and lost the ability to complete their swing?  What if sometimes dart-throwers’ arms involuntarily froze under pressure and they could not release the dart? What if these same golfers and dart-throwers could perfectly make these motions in practice but not in competition?  Doesn’t that sound a lot like stuttering?

What if you learned the amount of “stutter-like” behaviors went on and on affecting many different types of behaviors/movements unrelated to speaking?

What if you learned people stuttered in sign language just like they do in verbal speech?

What if you realized that “speaking out loud” was movement of the body and started getting more interested in how movement works?

What if you learned that unconscious processes started making your own movements before you even knew you wanted to make the movement yourself?

What if you learned speaking was mostly an unconscious process?

What if you learned that blocking and stuttering were also unconscious processes and it was possible to understand what factors go into these unconscious processes?

What if you learned the reward system was deeply interlinked with all movements (motor system), including speech movements?  What if you started to understand this link and how it interacts with the environment?  What if this link could explain why stuttering fluctuates so much?

What if you learned the fear of stuttering and the shame that comes with it is rooted in an evolutionary fear of death through social ostracism, abandonment, and rejection?  What if you learned this was why the anxiety could be so powerful?

What if you started seeing speech as movement and learned that based on evolution all movement is goal oriented and the subconscious must deem a movement “rewarding” and beneficial to support it?

Again, what if you learned speech was movement?  What if you learned the subconscious was constantly assessing the environment and preparing what-it-deems-to-be-advantageous movements for that specific environment?  What if each possible movement was assigned a projected reward/punishment outcome?  What if the subconscious in people who stutter equated speech movements with reward-system “punishment” when the environment contained other people in it?  What if it did not prepare nor allow these speech movements as it believed them to result in reward-system “punishment” and even deemed them a threat to survival?

…

What if you learned all of the above was true?  Would this begin changing your understanding of stuttering?  What if you learned we could use all of this “new” information to paint a much clearer picture of the nature of stuttering?  What if you learned we could use this new understanding of stuttering to implement more effective treatment?

Well, the above ‘questions’ are true.

And, yes, we can use their answers to understand stuttering.

And, yes, we can use this new understanding to layout a treatment regimen.

And we not only can, but we are.

Let’s begin.

In a Nutshell

Processes that enable human movement operate below the level  of conscious awareness.  As speech is movement, these unconscious processes are what support, enable, and create both fluent speech as well as “blocked/”stuttered” speaking attempts.  Underlying all human movement, including speech movement, is an unconsciously perceived motive to perform the movement(s).  Determining this motive is an unconscious calculation of each movement’s expected reward/punishment outcome.  For movements to be prepared and supported, their unconsciously projected outcome must be deemed beneficial (rewarding).  If a movement is deemed likely “painful”, “punishing”, or a significant threat to survival, the unconscious motivation necessary to perform the movement will not be provided.  As humans are social animals, ostracism, rejection, and/or abandonment are unconsciously perceived as threats to survival.  In people who stutter, the unconscious processes that underlie movement determine speech movements in certain environments to likely be painful and/or a threat to survival.  As a result they are not supported nor prepared.  The result is an impotent attempt to summon speech movements by the conscious mind (as the person who stutters consciously desires to speak) which results in blocking and stuttering behaviors as speech movement must be supported by unconscious processes to be performed.  These unconscious processes factor in the environment and the calculations change from moment to moment based on environmental changes etc.  Treatment for stuttering should focus on changing the unconscious perception/projection of expected pain linked with speech movements in problematic environments (often ones with other people in it).  The treatments should target the removal of the unconscious expectation of pain.  Anxiety/fear is an indicator of this expectation of pain.  Many have hypothesized on the role of fear in stuttering and there is one.  However, the more important treatment goal should be removing the unconscious expectation of pain (not the anxiety itself) linked with speech movements.  Fortunately for treatment prognosis, these unconscious processes/projections are receptive to alteration.  Treatment outlooks are discussed.  In illuminating the above, the article discusses similarities between Parkinson’s disease and stuttering which includes a phenomenon of Parkinson’s known as kinesia paradoxa.  Kinesia paradoxa is the term describing dramatic alterations in a person with Parkinson’s ability to move based on environmental changes.  At the root of these changes are alterations in unconscious motivation as discussed above.  This is a very brief introduction and these processes are illuminated in clearer language and more detail below.

Full Version

Speech is movement

Speech is a complex task involving the formulation of language.  However, the physical performance of speech is movement.  When a person “speaks out loud”, movements of various parts of the person’s body are required.  The speaker must move their lips, tongue, and jaw which is nothing more than the contraction and relaxation of muscles.  The speaker must move muscles associated with the inhalation and exhalation of the lungs.  They must move muscles that enable vibration of the vocal folds.  The important point here is speech is movement.  When a person speaks out loud, they must move their bodies.  It is a motor act.

Stuttering presents as an inability to perform speech movements as desired

The observable symptom of stuttering is the inability of the person who stutters to make the desired speech movements.  The person who stutters attempts to “say something out loud” (speech movements) and the appropriate movements do not occur.  There can be a complete “block” (no movement) in their speech or there can be repetitions (sound/syllable/word/phrase) or even non-speech-related movements (secondary behaviors).  In any case, the speech movements the person who stutters is attempting to make are not happening.

Based on this, it makes sense that we should take a closer look at how human movement works.

Unconscious processes that underlie movement

In the mid 1980’s, a research study was designed to explore the role of the conscious will in voluntary movement.  The study was performed by a man named Benjamin Libet who was a pioneering scientist in the field of human consciousness.  His study is widely known for its implications surrounding the idea of human free will and its legitimacy.  The findings of the study determined that the processes that are responsible for performing a voluntary movement of the body occur before the individual is even aware of their intention to perform that voluntary movement.  In other words, our nervous systems begin the process of a movement before we are even consciously aware we are going to make that movement.

In an example:  Let’s say I am sitting in a chair.  Then I stand up to get some water.  There was a moment in my conscious mind that I became aware that I was going to stand up to get some water.  There was a moment that I “decided” to stand up.  Libet’s findings reveal that prior to my awareness of my intention to stand up, my nervous system had already initiated the processes necessary for me to make that movement (standing up).  So, my unconscious mind had already begun making the movement (standing up) prior to my own awareness that I wanted to make that movement.

Since speech is movement, and stuttering presents as an inability to make the desired speech movements, the above information is certainly of interest in understanding stuttering.  It demonstrates that there are important processes happening below the conscious level to enable movement.  Let’s look a little closer.

The research shows that the brain begins activating motor circuits responsible for a voluntary movement about 550 milliseconds before the voluntary movement is actually performed; that’s slightly more than a half second (Libet, 1985).  The person’s awareness of their intention to move occurs about 200 milliseconds before the actual movement is performed.  This is slightly less than a quarter of a second.  Doing some basic math, you can see that the brain begins activating for a movement approximately 350 milliseconds before the person’s conscious awareness of their own intention to make that movement.  The above times and information come from Libet’s study in 1985, titled “Unconscious cerebral initiative and the role of conscious will in voluntary action.”  You can find that study here.

This above-discussed unconscious preparatory activity for movements prior to conscious awareness became known as “readiness potentials”.  Remember that term as I will use it later.  A second name for them is Bereitschaftsfeld potentials.  Researchers sometimes use this term instead of readiness potential.  However, I will use readiness potential.

Simple & Concise Recap

1 – Speech is movement.  2 – The unconscious mind begins processes (neurological systems activate) to perform a movement before the person is even aware they are going to make the movement.  3 – About one-third of a second after the unconscious mind has initiated processes for a movement, the person becomes aware of their intention to make the movement.  4 – About one-fifth of a second after the person becomes aware of their intention to move, the movement is made.

People who stutter, readiness potentials, and unconscious processes preceding speech

Walla, Mayer, Deecke, and Thurner conducted a study in 2004 investigating neurological activity leading up to speech in people who stutter and in controls (people who don’t stutter).  Neurological activity leading up to speech in people who stutter was significantly different than in people who don’t stutter.

To measure this, they had people who stutter and people who do not stutter perform speech activities while they monitored brain activity.  As part of the experiment, the experimenters presented a word on a screen to the subjects (included people who stutter and people who do not stutter).  The subjects of the experiment were to say the word upon seeing it.  In people who stutter, there was little if any neurological activity in the brain leading up to saying the word.  There was no “readiness potential” for movement.  In fluent speakers, there was a significant amount of neurological activity leading up to when they said the presented word.  Fluent speakers had readiness potentials.

In restating this, the unconscious preparatory activity (readiness potential) for movement was not present in the people who stutter prior to speaking.  This is deviant from the standard process for movement including speech movements.  In fluent speakers however, neurological preparatory activity (readiness potential) was present leading up to the overt production of the word (speaking out loud).

In supporting the summary I just gave, Walla, Mayer, Deecke, & Thurner (2004) state, “The motivation of this work was to investigate stuttering—a disorder of speech motor control—in the light of preparatory neural activity of voluntary movements related to speech.”  They continue, “Only nonstutterers showed clear neural activity before speech onset, which is interpreted as being linked to visual word presentation and to reflect focused verbal anticipation. This pre-speech activity might reflect the ‘‘Bereitschaftsfeld2’’ (BF2) that is the later component of the ‘‘Bereitschaftsfeld’’ (readiness potential), a well-known preparatory activity described for many other voluntary movements. Our results strongly link the lack of such preparatory brain activity at the single-word level to the disability of fluent speech in stutterers.”

Speech is an automatic ability performed below the level of the conscious mind

We’ve all heard the saying, “It’s like riding a bike.”  What that saying implies is you are just able to hop on the bike and ride it.  However, how is this possible?  If you think about the complexity of this task, it seems like a lot.  You have to coordinate a significant amount of muscles as well as balance etc.

So, how is this possible?

It’s possible because the unconscious mind is doing all the required tasks below the level of conscious awareness.  Riding a bike is an example of what I call an “automatic ability”.  In academia, the term used for the automation of a process such as riding a bike is automaticity.

How it works is, after learning and mastering a motor/movement skill (riding a bike, playing piano, choreographed dancing), it becomes automatic.  It no longer takes a significant amount of attention to do.  The person is just able to do it.  For example, if I go to ride a bike, I do not get on the bike and focus on contracting each leg muscle that is needed etc.  I just hop on the bike and ride it.  My unconscious knows how to do all of the required muscular contractions and balancing etc. without my conscious control.  This is an “automatic ability”.

Speaking is also an automatic ability.  When a person who does not stutter speaks, they are not focusing on contracting and relaxing the speech muscles.  They “just know” how to do it and they “just do it”.  This is because it is an automatic ability.  I mentioned above the number of muscles involved in speaking out loud.  It involves the lips, tongue, jaw, lungs, larynx, etc.  All these muscles are controlled at once and in coordination to speak out loud.  The complexity of this task is far too great for the conscious mind to handle.  It is not possible for the conscious mind to focus on moving the tongue perfectly, the lips perfectly, the lungs, the larynx, etc.  It is far too great a task.  Therefore, any time a person speaks, unconscious processes have a large hand in performing the speech movements.  There is no other way it can happen.

Bottom line: The movements required for speaking are automated.  Speaking out loud is an automatic ability performed by the unconscious mind.  The speaker does partly select and edit the meaning and message we choose to convey, but the speaking movements required to “speak out loud” are automatic and are performed below the level of the conscious mind.

Ruth Mead has also written extensively on this topic.

Before Moving Forward…

In continuing to illuminate stuttering, we are first going to have to compile some information on the relationship between reward and movement.  Below, I dive into academic research to illuminate this relationship.

An Academic Research Review Providing Evidence of the Relationship Between Reward/Punishment & Movement – Parkinson’s Disease, “Kinesia Paradoxa”, Movement, Reward, Punishment

Below are numerous excerpts from articles of interest.  Most do not pertain directly to stuttering but are studies of the relationship between movement and reward.  Their findings, however are highly applicable to understanding stuttering and illuminating its nature.

A large part of the theory being explained relates to the relationship between movement and the reward system.  It is crucial to understand this relationship in understanding stuttering.  I use numerous research articles below to give credibility to claims I make about this relationship.

As stated earlier, the aim is to make the explanations understandable to all regardless of background.  The quotations of the articles, of course, do contain academic language.  They are there for your dissecting if you so please.  However, in line with the aforementioned goal, I also paraphrase the findings and apply them to the understanding of stuttering in clearer terms.  To make this easier to follow, all paragraphs in this section composed of primarily academic excerpts are fully in italics.  The paraphrasing in clearer terms is in normal font.  You should be able to get the bulk of the intended meaning from the paraphrasing.  However, if you combine it even with a vague understanding of the research quotes, you will likely have a more-than-sufficient understanding no matter your background.

Following a review of some applicable research below, I have a section called “More Pertinent Articles & Information”.  This section contains more supporting information and/or important components in explaining the understanding of stuttering I am working to convey.

Following that section, after supporting information has been explained, I have a section called “Synthesis & Conclusion”.  In this section I combine the information that has been shared in the preceding sections and present the theory on stuttering it supports.

Now, let’s dive into the academic research on the relationship between reward and movement.

Article #1 – “The Effect of Motivation on Movement: A Study of Bradykinesia in Parkinson’s disease”

Individuals with the movement disorder Parkinson’s disease (PD) present with bradykinesia (slow movements and an inability to speed them up) as well as tremors.  An invaluable revelation about PD in regards to understanding stuttering is a phenomenon of PD called “kinesia paradoxa”.  Kinesia paradoxa is a temporary regaining of virtually full movement control in people with Parkinson’s.  They are temporarily able to move with normal speed easily and effortlessly seemingly “out of the blue”.  It is triggered by changes in the environment, though it is not well understood.  Of course, this is of high interest in understanding stuttering as speech is also movement and stuttering severity changes based on the environment.

Shiner, Seymour, Symmonds, Dayan, Bhatie & Dolan state (2012), “Recent thinking suggests that bradykinesia may be more than simply a manifestation of motor slowness, and may in part reflect a specific deficit in the operation of motivational vigour in the striatum. In this paper we test the hypothesis that movement time in PD can be modulated by the specific nature of the motivational salience of possible action-outcomes.”

Paraphrasing and interpreting:  In line with recent thinking, Bradykinesia (slowness of movement often present in Parkinson’s Disease) is not the result of direct motor impairment, but instead a deficit in “motivational vigour” to perform movements.  In other words, it is not the motor system itself that is not functioning properly, but it is the underlying motivation (surely subconscious) to perform the movements that result in bradykinesia.

Shiner et. al state (2012), “One of the striking clinical characteristics of bradykinesia in PD is its variability [6], [12], with the same patient being able to achieve very different movement speeds in different contexts. An extreme manifestation of this variability is “kinesia paradoxica” where patients are suddenly able to move at near normal speeds, which usually occurs only in extreme aversive contexts [13], [14]. This class of observation motivated us to examine if winnable rewards and avoidable punishments might have differential effects on movement time.”  They continue, “This notion has been linked to the idea of impaired ‘motor motivation’ in PD, whereby there is a shift in the cost/benefit ratio of moving fast [8]. Crucially, we find that although the response to rewards appears impaired in the PD group when compared with controls, the trial-by-trial response to punishments is not similarly impacted, a fact which has not previously been demonstrated.”  They continue, “Our findings indicate that bradykinesia is not simply related to movement, but rather to the way in which a hypodopaminergic striatum computes action values.”  They continue, “In sum, we provide evidence that bradykinesia is in part a context dependent deficit. We link the cognitive and motor deficits associated with the PD hypodopaminergic state by demonstrating that bradykinetic movements are dependent on the valence frame in which movements are executed. Such modulation is apparent in “kinesia paradoxica”, where PD patients can suddenly move quickly in exceptional circumstances [13], [14]“

Paraphrasing and interpreting the findings:

Bradykinesia symptoms in individuals with Parkinson’s disease (PD) vary widely based on environmental context.  This change in symptoms is most dramatically exhibited when a severe punishment for not moving quickly is present.  When a very adverse outcome is present if a PD patient moves too slowly, this same patient is suddenly able to move at relatively normal speeds.  When this same negative outcome is not present, the person with PD is unable to move this quickly.  This is known as kinesia paradoxa which demonstrates a differing ability to move in patients with Parkinson’s disease based on environmental context.

Seeing this in an example would look like this.  A person with Parkinson’s is sitting outside on a bench.  They want to jump up and quickly go for a run.  However, because they have Parkinson’s, they are unable to perform these movements as quickly as they consciously desire.  When they go to make these movements, the movements are slow in line with bradykinesia symptoms.

This same person with Parkinson’s is sitting on the same bench.  In their peripheral they notice a car is driving off the road right at them.  In this case, their subconscious knows if they do not move with abrupt speed they will die or experience significant pain.  Based on the presence of this threat, the person with Parkinson’s disease is able to jump up off the bench and sprint away with speed.  Their subconscious provides the necessary vigor to perform these movements.  However, when this threat is removed, they again are unable to summon these same speedy movements.  This is the phenomenon known as kinesia paradoxa.  The person’s movement abilities are affected by the threat of painful stimuli if they move too slowly.  They only gain the ability to move more quickly when the environment brings on a sufficient threat.  As a result of the sufficient threat, unconscious processes provide adequate motivation for the body to summon quick movements.

In going back to the article, the last quote is a valuable one.  It states that bradykinesia is not simply related to movement but to “computed action values”.  By “computed action values”, they mean that the brain assigns projected “reward/punishment” values to different movements.  For example, if I move my hand to grab a potato chip and then move it to my mouth, a significant reward is expected.  The subconscious will calculate this “action value” and provide this movement option with “motivational vigour” based on the expected reward.  In other words, the subconscious determines these movements to be of high value based on the expected reward (pleasure-filled eating) of performing them.  It will therefore “steer me” to this option and provide the motivational vigour necessary to perform it.  Bradykinesia, they have hypothesized is not a problem in the motor system but a consistent miscalculation of “action values” by the subconscious resulting in low “motivational vigour” in the performance of movements in individuals with Parkinson’s.  This results in bradykinesia.  Interestingly, in Parkinson’s disease when severely punishing outcomes are likely, the individual with bradykinesia can all of a sudden move much more quickly as illuminated by the example.

Bottom line:  The movement system is deeply intertwined with the reward system.  What underlies all movement is expected reward and/or avoidance of punishment.  In the movement disorder Parkinson’s disease, it is now widely thought that the reward system is actually the area impaired and not the movement system directly.  As I am demonstrating that stuttering is a movement disorder in this article, the fact that the reward system underlies and contributes to all movement has significant implications.

“Blocking”/”stuttering” and fluctuations in speech control I will demonstrate are the result of the subconscious projecting/anticipating the possibility of painful/punishing outcomes for speech movements.  The cost/benefit ratio of performing the speech movements is determined very risky by the subconscious and it therefore decides it is best to not perform them.  As a result, the movements become blocked and/or hard to make.

As the environment changes, the subconscious calculation of risk/reward for speech movements changes as it assesses the probabilities of risk and reward with these changes.  When a person enters a person-who-stutter’s environment, the “risk” of a painful outcome for speech movements has risen significantly as social needs of the human are now threatened.  As a result, the subconscious does not provide “motivational vigour” and the movements become blocked or hard to make.

Article #2 – “Reward/Punishment Dopamine and Mechanisms of Reward and Punishment”

The article states (2017), ““One hallmark of adaptive behavior is the ability to learn from the outcomes of actions, whether these results are positive or negative.”” (Paton and Louie, 2012)

“Recent research suggests that the neurotransmitter dopamine plays a leading role in this adaptive behavior by signaling the difference between a reward and a punishment and selecting the physical action to be taken in response to it.”

“Stimulation of the D1 receptors (the “direct pathway” of dopaminergic signaling in the medium spiny neurons) “increased locomotion and decreased freezing” while stimulation of D2 receptors (the “indirect pathway”) resulted in decreased locomotion, increased freezing, and bradykinesis (slower movement). Thus, the rewarding pathway leads to movement and goal seeking of rewards, while the punishment pathway leads to signs of fear and anxiety (freezing) and depression (slower movement, less movement)”

“Overall, the results of Kravitz et al highlight a fundamental point about decision-making: selecting an action is never truly independent of reward learning (Paton and Louie, 2012).”

Paraphrasing & interpreting the findings:

This article confirms and further illuminates the previous article’s findings.  Important points in this article are the fact that there is a direct statement on how an organism (humans included) responds differently to punishment and reward.  It states that reward stimulates movement and punishment leads to less movement; even “freezing”.  The punishment aspect leading to freezing is particularly illuminating in regards to stuttering and blocking.  Keep this in mind.

The article also dives into “learning”.  Learning is basically adapting behavior based on past experiences.  When an organism performs a movement-behavior and is immediately rewarded (feels good or experiences pleasure etc.) this movement is reinforced.  It is “learned” subconsciously that this movement stimulates reward. As a result in the future this same movement is “allowed” and “encouraged” subconsciously. The opposite happens in regards to movements that have been punished (felt poorly after performing them).  The subconscious learns that these movements are punishing and therefore deems them dis-advantageous to perform.  All this happens far below the level of conscious awareness.

The final quote above from this article is also important.  It states that decision making is never independent from reward learning.

Article #3 – Reward Processing in the Brain: A Prerequisite for Movement Preparation?

Keitz, Martin-Soelch, & Leenders state (2003), “From an evolutionary perspective, a rewarding stimulus can be considered a directional force toward a higher survival value for the species.  Supposedly a complex species could not have survived if it could not learn from experience. A condition for the survival of vertebrate species is the ability to learn from past experience, or in other words to distinguish between rewarding and non-rewarding stimuli to know which stimuli or situations should be approached and which should be avoided.”

They continue, “An impaired motivational background might be the basis for the existence of slowness of movement in dopamine deficiency conditions.”

They continue, “In Parkinson’s disease whether the slowness of movement, rather than being a motor disturbance in itself is actually based on a missing internal motivational not consciously perceived”

Paraphrasing & interpreting the findings:

Evolution has likely designed the reward/punishment system as a guide for behavior in organisms to maximize chances of survival.  Pleasurable and rewarding stimuli are rewarding because they have been deemed beneficial to survival by evolution.  Punishing and painful stimuli have been deemed dis-advantageous to survival.  In order to maximize an organism’s chance of survival this reward and punishment system is in place to encourage and discourage certain behaviors and movements.

What underlies movement disorders like Parkinson’s disease may very well be a disruption/impairment in the reward system underlying all movement.

In applying this to stuttering, because speaking attempts in people who stutter have often been met with punishing outcomes (shame, humiliation), these speech movements and behaviors are deemed disadvantageous to one’s survival.  As a result, unconscious processes deem these speech movements/attempts as likely-to-cause-pain and therefore negatively-impactful on one’s chances at survival. As a result, the subconscious process for movement does not support these movements by not supplying the necessary motivation to perform them and the result is blocking and stuttering.

Article #4 – Dopamine neurons have role in movement, new study finds

According to Science Daily (2016), “Princeton University researchers have found that dopamine — a brain chemical involved in learning, motivation and many other functions — also has a direct role in representing or encoding movement. The finding could help researchers better understand dopamine’s role in movement-related disorders such as Parkinson’s disease.”

It continues, “the mainstream view suggested an indirect role for dopamine: the neurons make it possible for us to learn which actions are likely to lead to a rewarding experience, which in turn enables us to plan to take that action. When dopamine neurons are destroyed due to Parkinson’s disease, the individual cannot learn to plan actions and thus cannot move.”

It continues, “The new study affirmed the role of dopamine in reward-based learning, but also found that in the dorsomedial striatum, dopamine neurons can play a direct role in movement.”

It continues, “The researchers found that the dopamine neurons…did indeed encode reward-prediction cues, which is consistent with previous findings. But they also found that in the dorsomedial striatum, the dopamine neurons carried information about what actions the animal is going to take.  Witten states, (2016)”This idea was that dopamine neurons carry this reward-prediction error signal, and that could indirectly affect movement or actions, because if you don’t have this, you won’t correctly learn which actions to perform,” Witten said. “We show that while this is true, it is certainly not the whole story. There is also a layer where dopamine is directly coding movement or actions.””

Paraphrasing and Interpreting

The above article further confirms the findings of the previous three articles, however it takes it a step further.  It solidifies the reward-punishment role in movement-learning but also illuminates the reward system’s ability to directly control movement.

More Pertinent Articles & Information

Pertinent Information #1 – The ‘Monster Study’ on Stuttering

Note:  This study has been deemed extremely immoral and has been apologized for by the organization that conducted it.  However, it does contain revealing information which can be used to understand stuttering.

Psyblog states (2010), “During the 1930s it was thought that stuttering had an organic or genetic cause. This meant you were born a stutterer (or not) and little could be done.  Dr. Johnson had different ideas. Instead he thought the labelling of children as stutterers could actually make them worse, and in some cases cause ‘normal’ children to start stuttering. To prove his point, he suggested an experiment which has since become known as the ‘Monster Study’”

Psyblog continues (2010), “Twenty-two young orphans were recruited to participate in the experiment. They were then divided into two groups. The first were labelled ‘normal speakers’ and the second ‘stutterers’. Crucially only half of the group labelled stutterers did actually show signs of stuttering.

Pysblog continues (2010), “During the course of the experiment, the normal speakers were given positive encouragement but it was the treatment of the other group that has made the experiment notorious. The group labelled stutterers were made more self-conscious about stuttering. They were lectured about stuttering and told to take extra care not to repeat words. Other teachers and staff at the orphanage were even unknowingly recruited to reinforce the label as the researchers told them the whole group were stutterers.”

Psyblog continues (2010), “Of the six ‘normal’ children in the stuttering group, five began stuttering after the negative therapy. Of the five children who had stuttered before their ‘therapy’, three became worse. In comparison, only one of the children in the group labelled ‘normal’ had greater speech problems after the study.”

Bottom line:  Stuttering was created in five out of six children who were normally speaking up to that point.  This was done based on creating an environment that teaches any disfluency is bad and they should react negatively to them and monitor to make sure they don’t have any.

In the “Synthesis & Conclusion” section I will use this information further.

Pertinent Information #2 – The Existence of Stuttering-Like Behaviors in Sign Language, The Yips, Dartitis, and Stutter-Like Behaviors in other Movements Skills

Snyder states (2006), “While reports of stuttering-like behaviors occurring in sign language have been available for almost 70 years, relatively little attention has been given to its existence and how the existence of stuttered sign may impact our understanding of the stuttering phenomenon.”

Ellen Marie Silverman has also written on the existence of stutter-like behaviors in sign language etc.

The above article by Snyder rightfully acknowledges and documents the existence of stuttering in sign language which certainly has implications for our understanding of the nature of stuttering.  It moves the focus away from the speech mechanism itself.  The article advocates that stutter-like behaviors can impact different areas of expressive communication.  Its claim is the expressive communication aspect is part of the formula which allows for stuttering-like behaviors to manifest.  However, stutter-like behaviors exist in other motor-movement-modalities which lack expressive communication.  While the existence of “stuttering” in sign language is illuminating and paradigm shifting, “stutter-like behaviors” even exist outside of expression.  I have written extensively on that here.  These conditions include “the yips” and “dartitis”.

Expanding on other stutter-like behaviors including the yips & dartitis:

In regards to “the yips”, Wikipedia states (2017):

“Yips or the yips is the loss of fine motor skills in athletes. The condition occurs suddenly and without apparent explanation usually in mature athletes with years of experience. It is poorly understood and has no known treatment or therapy. Athletes affected by the yips sometimes recover their ability, which may require a change in technique. Many are forced to abandon their sport at the highest level.”

“The yips manifest themselves as twitches, staggers, jitters and jerks. The condition occurs most often in sports which athletes are required to perform a single precise and well-timed action such as golf and darts. The condition is also experienced by bowlers in cricket and pitchers in baseball.”

In regards to Dartitis, Wikipedia states (2017):

“Dartitis (pronounced dart-eye-tis) is a condition which can affect darts players, and severely damage their performance. It can be compared to ‘the yips‘, an expression used to describe apparent loss of fine motor skills without any explanation. The term is used in reference to players who struggle with some kind of psychological problem with their technique and/or release of their darts.”

Continuing on stutter-like behaviors:

The list is long in regards to movement skills that can be affected by stuttering-like behaviors.  It includes speaking, sign-language, basketball, golf, cricket, baseball, and on and on.  In all of these movement skills there is an important common denominator among them.  This common denominator is the fact that the performance of these movement skills is immediately followed by reward and punishment.

In all of the movements that stutter-like behaviors can affect, there is a significant reward and/or punishment that follows immediately after performance of the movement.  When a person speaks, they move their speech apparatus.  Immediately following these movements their listener reacts.  This reaction can cause significant positive feelings or negative feelings in the speaker.  If they are approved of, they feel good.  If they are rejected they feel poorly.

Let’s look at this same pattern in other movement skills that can be affected by stutter-like behaviors.  Golf is an activity that has stutter-like behaviors.  When a person swings a golf club and hits the ball, they get immediate feedback from the reward system based on making this movement (the golf swing).  They have either hit a good shot or a bad shot.  They feel good or bad based on the shot’s result.  This is the same pattern identified above.  A movement is performed and immediate reward/punishment is felt following its performance.

Let’s look at this pattern in darts.  When a dart player throws a dart, they perform a movement and immediately get reward/punishment feedback.  If they hit a bull’s eye, they feel good.  If they miss the dart board completely and the spectators see this poor performance, they feel negatively.

I could list these characteristics for every stutter-like movement skill there is.  Any movement that is followed by immediate powerful reward-system feedback is capable of developing stuttering like behaviors around it.

The common denominator in all of them is a relationship between the performance of a movement and immediate powerful feedback of reward and punishment.  Subconscious learning happens based on this and the individual’s subconscious “learns” that certain movements in certain environments can be very painful.  As a result, these movements are suppressed and unconsciously not supported as the unconscious mind equates them with reward-system punishment.

Bottom Line:

In looking at all the known conditions that resemble stuttering and exhibit symptoms very similar to stuttering which include freezing movements and/or jerky control of movement there is a common denominator.  The common denominator that is important in this article is the fact that immediately following the performance of these movement skills there is immediate and powerful reward/punishment feedback.

Pertinent Information #3 – Explaining the “punishment” of stuttering – What is behind the pain, shame and humiliation of stuttering?  An evolutionary perspective on the human as a social animal.

I have written extensively on this here.  Below is enough to suffice for this article.

Also, I have written extensively on the relationship between the reward system and movement above.  Since speech is movement and stuttering is a lack of ability to make the desired speech movements, this relationship between reward and movement is of interest in understanding stuttering.  Speech movements and reward are deeply connected.  They are deeply connected because we are social animals and speaking is a social act which aims to meet the human need of acceptance and approval.  When speaking in a social setting, one will receive either approval or rejection.  Both approval and rejection are powerful feedbacks for the human reward system as we are social animals with a need for acceptance from other people.  This is where speech movements and reward become very interlinked.  When a person speaks (movement) socially, they receive powerful reward-system feedback either positive or negative.  Further illumination is below.  This linking between speech-movement and the reward system is a keystone to the understanding of stuttering.

Further illumination regarding the pain of stuttering:

As humans, we are wired to connect with others.  It is a deep human need which adds much to life.  It is also largely shaped by evolution.  As a child, if we are unable to bond with our caretakers who will meet all of our survival needs, we will die.  In the wild, if a child was “abandoned” because a bond was not formed between caretaker and child, the child would literally die as they are utterly helpless to provide for their own needs.  This is why the experience of abandonment is so deeply painful for humans.  Evolution has shaped our reaction to it as to not bond is to die in some scenarios.

Therefore, to ensure we bond to survive, our system for reward and punishment is aligned with meeting this need.  If we are abandoned, we feel deep pain as evolution has determined we must meet this need to survive.  The reward/punishment system serves as a guide to meeting survival needs.  As such, the feeling of disconnect is deeply painful and deeply punishing in terms of the human reward system.

In addition, as humans, again we are social animals.  Even as adults in the wild, it was quite necessary to be part of a larger group to survive.  A man or woman in the wild is unlikely to survive on their own.  A man or woman who is part of a group is much more likely to survive as the survival needs for protection, food, etc. are better met when in a group.  Again, evolution has shaped our need to connect and be accepted by our fellow human beings.  To be accepted and liked by people is very rewarding and as a result we feel good.  On the contrary to be ostracized, rejected, or abandoned is very painful.

Lastly, for the survival of a species, procreation is required.  To procreate individuals must gain the approval of another and be accepted.  This again highlights the deep human need to gain acceptance and the pain that accompanies not meeting this need; the pain of rejection.

More on this…

Stuttering often is a journey of isolation and loneliness.  It is often a journey which involves shame and humiliation.  These emotions of shame and humiliation are in some ways treated as death subconsciously; as social death; and as such are sometimes even described as “feeling like death”.  They are treated as death because evolutionarily they did equal death.

To stutter in front of others often equals shame and/or humiliation which the subconscious in some ways equates to death.  This is why extreme levels of anxiety in social situations can be triggered in people who stutter as this is treated as a threat similar to death.  It’s also based on past experiences of shame and humiliation in social situations.  The subconscious perceives deeply punishing threats as possibilities on the horizon and as a result enters a fear state.

Bottom-line/How this applies to this post:  To be humiliated, ashamed, or rejected is a severe punishment delivered by the punishment and reward system in the human.  If you are ostracized from a group or rejected by an individual or humiliated, the human reward system will deliver severe punishment for this (you will feel badly) as it treats these experiences as threats to its survival.

This applies significantly to how stuttering is a condition of the movement system as well as the reward system.  As has been and continues to be demonstrated, the reward system underlies one’s ability to move.  There must be sufficient motive to enable movement.  When the subconscious perceives that performing speech movements or attempting to perform speech movements may result in deeply punishing outcomes (shame, humiliation) it does what it can to take that movement option off the table.  The result is stuttering and blocking.

Synthesis & Conclusion

Stuttering is largely a product of how evolution has shaped the relationship between movement, reward, time, and the environment.

The human is the product of billions of years of evolution which have shaped its ability to survive.  Movement itself is a product of evolution, designed to better enable organisms to acquire needed resources and avoid threats.  Reward is also a product of evolution and serves as an organism’s guide in regards to what to do and what not to do to survive.  These two systems (reward and movement) become linked by time.  When a specific movement is performed and reward system feedback is received very quickly in time, the organism (humans in this case) subconsciously associates the specific movement with the received feedback.

This is a process of motor learning (movement) that happens in organisms far less complex than the human.  However, as descendants of these less complex organisms, we, as humans, still possess many of the same systems which operate below the conscious level.

Another important element that contributes to explaining stuttering is the environment.  As organisms finely tuned to survive, time itself, again is of importance.  The ability to react appropriately to the environment and quickly in time is of the utmost importance to survival.  Because of this, as the human both consciously and unconsciously scans their surroundings, the organism as a whole is preparing itself for appropriate actions/movements based on the environment.

Based on the environment the human is in, processes below the level of conscious awareness are preparing appropriate movements based on projected reward calculations.  These reward calculations are based on past experiences in similar environments.

If the subconscious believes that certain movements in certain environments are likely to receive reward-system punishment then it will not support them.  If it believes them to be severely punishing; if it deems them a significant threat to its survival; if it projects a negative “reward calculation”, then it will deem the movement inappropriate for that environment as it believes it to be both punishing and a negative impact on its ability to survive.

The above explained process is what happens with stuttering.  When a human begins speaking (speech is movement), they acquire feedback (reward/punishment) from others based on how they speak and what they say.  This feedback is immediate and can be powerfully positive or negative.  As the human is a social animal with deep needs for acceptance and belonging, receiving immediate and negative feedback following speech movements in the form of social disapproval or rejection is felt as powerful punishment from the reward system.  The resulting feelings are shame etc.  This shame and negative feedback becomes linked subconsciously to speech movements in certain environments and is thus deemed an inappropriate movement in those environments.  As a result speech movements are not prepared subconsciously in certain environments (often environments with other people in it).  This leaves the stuttering speaker powerless to summon the desired speech movements.

Stuttering follows the exact model above.  Speech movements are made in an environment with other people in it.  Immediate feedback is received (sometimes very negative as disapproval/rejection) and processed as reward/punishment.  The subconscious links the speech movements, the environment, and the negative feedback all together and in the future deems speech movements as punishing, risky, and even a threat to survival in these environments.  This process snowballs.  As a result, as the human organism prepares movement options below the level of conscious awareness in similar environments in the future, it deems speech movement as likely painful and as a result does not support these speech movements nor prepare them.

The result is blocking and stuttering in certain environments.

Expanding

In supporting the above claims, I explained the underlying components in more detail in the body of this article.  However, I am going to reiterate some of them here without sources and in less detail.

The processes for all voluntary movement begin before the individual is even aware they want to make the movement themselves.  This is because unconscious processes are assessing the environment and preparing what these unconscious processes deem to be advantageous movements.  For movements that are deemed punishing in certain environments, they will not be properly prepared to be performed.  This is the case with speech movements for people who stutter in certain environments (usually those containing other people).

As the environment changes, the unconscious processes that prepare appropriate movements based on reward projections change their assessment based on the changes in the environment.  For many who stutter, when someone they have a desire to impress enters the environment, their stuttering worsens.  This is because unconscious processes have deemed speech movements to be very risky in this environment and these unconscious processes have therefore not provided these movements as options.  When the person who stutters goes to speak, their conscious mind is utterly impotent to summon the movements as unconscious processes for movement are also necessary.

When the person in the person-who-stutter’s environment is removed from their environment and the person who stutters is now alone, the unconscious reward/punishment projection for speech movements changes.  It is no longer risky as the threat of disapproval has been removed.  As a result the underlying processes for speech movements allows them to be performed without resistance.

More

Something that further illuminates this motor learning in all humans is The Monster Study which was discussed above.  In The Monster Study, six children who were normal speakers up to that point were told they were people who stutter by all the adults around them.  They received immediate and powerful negative feedback each time they had a minor speech mistake.  In the end five of the six formerly normal speakers became people who stutter.  This experience designed by The Monster Study turned normally speaking children into people who stutter at a high rate (5 of 6).

Personally, I do believe there is a predisposition to stuttering so I am not claiming the environment is the one and only factor.  I believe there are likely genetic factors that make a person more likely to develop stuttering.  These predispositions, however, may have nothing to do with “stuttering” itself.  Going further though, all humans have the motor learning system explained above and are likely capable (though some less likely than others) of developing stutter-like behaviors.

More

The fact that stuttering-like behaviors exist in areas away from the speech mechanism strongly indicates that the root is deeper than the speech mechanism.  Stutter-like behaviors also stretch beyond communicative skills into movement skills in general.  The underlying system that contributes stuttering like behavior is the movement system and the reward system

Stuttering is a movement disorder with reward processing at its root.

Implications for Treatment

Fortunately, there are controllable factors that contribute to reward processing which, when controlled properly can promote speech movements and re-teach the movement-reward system that speech movements are rewarding and not punishing.  When this is accomplished, speech movements will start to flow more easily.

Since stuttering and blocking are the result of the subconscious believing speech movements result in pain, treatment should focus on changing this subconscious perception.  While reward processing for movements is largely a subconscious process, we actually are able affect it by what we do with the conscious mind.  What we do with the conscious mind will contribute to how the subconscious calculates if speech movements are appropriate (rewarding) or inappropriate (punishing).  We can also alter the subconscious over time through exercises and practices that re-shape how the subconscious will project reward outcomes for speech movements.  These factors and avenues gives us some power.

I am going to dive more deeply into a treatment plan in my next post.  The treatment plan is based in theory (the one above) and there is a rationale behind each element of it which is more than I can say for a significant amount of stuttering treatments.

Here is a brief introduction to the treatment:

Quick note:  Each person is different and ideally treatment plans would be individualized to meet each person’s needs.  Below are general treatment approaches.

There are only three faculties we have any direct control over as human beings.  These are the only things we have ever directly controlled in our entire lives.  Of these three faculties, we do not have total control but partial.  The three elements are as follows:

1. Attention (What do we focus on?)
2. Mental action (What do we do with our minds? What do we think of?  What do we imagine?)
3. Movement (We have limited control over our voluntary muscles)

Since these are the only things we have ever had any direct control over as humans, we are going to use them to affect change.  What we do with each of them in speaking situations will begin to give you some power over stuttering in the moment.

In addition to that we are going to have exercises that prepare us for interaction.  These exercises are targeted to affect the unconscious perception of speech movements in the presence of others.  When these unconscious perceptions are altered, the subconscious processes that prepare movement will begin to prepare speech movements in situations where we would like it to which will provide more flow to speech movements.  We must alter the unconscious reward/punishment projection for speech movements in the presence of others.  This is what some of the exercises are designed to do.

Exercises that target this:

1. Meditation to enhance attentional control and diminish emotional reactivity
2. Visualization of feared outcomes while remaining calm and serene in the visualization
3. Visualization of fluency in feared situations while remaining calm and serene in the visualization
4. Reliving and re-processing each day’s negative speaking memories
5. Re-processing past painful speaking/stuttering memories
6. Re-living and re-feeling successful interactions

We are also going to build automatic/natural speech

1. Read aloud as much as possible if you are fluent when alone (thoughts provided)
2. Play commentator on TV alone if you are fluent (generating your own thoughts)
3. Write unfiltered and automatically
4. Perform natural and automatic speech in as many situations as you can

Building a very positive and optimistic mentality:

1. Bombard yourself with positive affirmations regarding interaction and in general
2. Believe deeply you will improve anxieties and fluency (fight the “nocebo” effect)
3. Frame each interaction very positively (“this person wants to connect” or “it’s laughable to fear stuttering”)
4. Surround yourself with positive messages and fill yourself with positive input (books, music, etc.)

The above are some general plans for treatment.  I will expand on the ideology and methods in the next post.

More

Fear and Stuttering

There has long been speculation as to the relationship between fear and stuttering.  While there is a place for fear in the role of stuttering, fear is an anticipatory emotion.  The presence of fear is an indicator that you are expecting to experience pain on some level.  Fear indicates that your subconscious is projecting a possibility of pain on the horizon.  Treating stuttering based on the above view is more about changing the expectation of pain than it is removing fear.  The stuttering comes as a result of the expectation of pain; not due to the fear itself.

Inner Speech & Stuttering

Inner speech is simply our inner dialog.  It is auditory thought in the form of words.  In order to please caregivers and/or social situations, children at some point begin inhibiting “out loud speech” in order to gain approval.  The result is the creation or the increase in inner speech.  This inhibition of “out loud speech” and the transition to inner speech likely contributes to onset of stuttering as well as its maintenance.  Much more on this here.

Works Cited

Dartitis. (2017, August 3). In Wikipedia, The Free Encyclopedia. Retrieved

22:43, September 8, 2017

Goodrich, B. G. (2010). We Do, Therefore We Think: Time, Motility, and Consciousness. Reviews in the Neurosciences, 21(5). doi:10.1515/revneuro.2010.21.5.331

Keitz, M., Martin-Soelch, C., & Leenders, K. L. (2003). Reward Processing in the Brain: A Prerequisite for Movement Preparation? Neural Plasticity, 10(1-2), 121-128. doi:10.1155/np.2003.121

Kravitz AV, Tye LD, Kreitzer AC. Distinct roles for direct and indirect pathway striatal neurons in reinforcement. Nat Neurosci. 15(6):816-8 (2012 Jun).

Libet, Benjamin. “Unconscious Cerebral Initiative and the Role of Conscious Will in Voluntary Action.” Behavioral and Brain Sciences 8.04 (1985): 529.

Nathan F Parker, Courtney M Cameron, Joshua P Taliaferro, Junuk Lee, Jung Yoon Choi, Thomas J Davidson, Nathaniel D Daw, Ilana B Witten. Reward and choice encoding in terminals of midbrain dopamine neurons depends on striatal target. Nature Neuroscience, 2016; DOI: 10.1038/nn.4287

Paton and Louie. Reward and punishment illuminated. Nat Neurosci. 15(6):807-9 (2012).

Princeton University. (2016, April 25). Dopamine neurons have role in movement, new study finds. ScienceDaily. Retrieved October 19, 2017 from www.sciencedaily.com/releases/2016/04/160425143110.htm

Reward/punishment dopamine and mechanisms of reward and punishment. (2016). SpringerReference, 19(3). doi:10.1007/springerreference_302700. Retrieved October 22, 2017, from http://www.life-enhancement.com/magazine/article/3568-rewardpunishment-dopamine-and-mechanisms-of-reward-and-punishment

Shadmehr, R., Xivry, J. J., Xu-Wilson, M., & Shih, T. (2010). Temporal Discounting of Reward and the Cost of Time in Motor Control. Journal of Neuroscience, 30(31), 10507-10516. doi:10.1523/jneurosci.1343-10.2010

Shiner, T., Seymour, B., Symmonds, M., Dayan, P., Bhatia, K. P., & Dolan, R. J. (2012). The Effect of Motivation on Movement: A Study of Bradykinesia in Parkinson’s Disease. PLoS ONE, 7(10). doi:10.1371/journal.pone.0047138

Snyder, G. (2006, October 22). The Existence of Stuttering in Sign Language and other Forms of Expressive Communication: Sufficient Cause for the Emergence of a New Stuttering Paradigm? Retrieved October 28, 2017, from http://www.mnsu.edu/comdis/isad9/papers/snyder9.html

Yips. (2017, July 17). In Wikipedia, The Free Encyclopedia. Retrieved

22:43, September 8, 2017