New Consensus Guidelines Classify Stuttering as a Brain-Based Disorder

An international interdisciplinary panel is providing frontline clinicians clearer guidance on stuttering, a disorder that has been largely overlooked by research and evidence-based medicine. "It's labeled in the DSM, it's in the ICD, but the vast majority of medical clinicians know little about stuttering," Gerald Maguire, MD, told Psychiatric Times.

Maguire, Chair and Director of Residency Training in Psychiatry at College Medical Center, Long Beach, California, founded the Stuttering Treatment and Research Society (STARS) and spearheaded the new consensus guidelines, designed to improve care for the estimated 80 million people worldwide who stutter.

Stuttering Should Be Classified as a Brain-Based Disorder

The panel, which included professionals from psychiatry, neurology, and speech-language pathology as well as people who stutter, reached near-unanimous agreement that stuttering is heterogeneous (91.4%) and most often neuropsychiatric or neurologic in nature. Although there are psychiatric influences and comorbidities, like anxiety and attention-deficit/hyperactivity disorder, “It's a disorder of coordination of the speech motor system to the base of ganglia, the thalamus,” Maguire explained.

Maguire pointed to 2 lines of evidence behind that classification: genetics and, in a subset of cases, autoimmunity. But he said some children develop stuttering only after an immune trigger, a pattern with parallels to pediatric autoimmune neuropsychiatric syndrome (PANS). "Some sort of antigen in the environment, be that a streptococcal infection or something, triggers an inflammatory response, maybe antibodies or others that may attack the basal ganglia," Maguire told Psychiatric Times.

Why the Distinction Carries Real Stakes

In addition to poor recognition, the treatment landscape is problematic, Maguire said. “Over 90% of our panel—which included physicians, speech language pathologists, and persons who stutter—over 90% say the current state of treatment is poor,” he added, noting the lack of good controlled studies across speech therapy, psychotherapy, and medications.

Affecting more than 1% of adults and 4% of children worldwide, the gap carries consequences well beyond the clinic, he said. For instance, although it is not correlated with intelligence, it continues to cost people jobs because most interviews weigh verbal fluency heavily. "If someone's hesitant on their speech, think about how often people are passed up in job interviews," he said, adding that he remains "flabbergasted" that a disorder this common still carries that level of stigma.

What the Guidelines Recommend for Psychiatrists

Maguire said the first step for psychiatrists is a medication review. Stimulants and bupropion, both used for ADHD and depression, can worsen stuttering because the disorder is linked for many patients to dopamine hyperactivity, he said. The key question is when the stuttering began: If it started in adulthood alongside a new prescription, he said the fix may be switching to "another compound that maybe doesn't stimulate the dopamine or act as a dopamine reuptake inhibitor." For childhood-onset cases, clinicians should ask whether past medications ever made symptoms worse and take a family history.

Anxiety can still worsen symptoms. "Everybody's heard the phrase, I was scared and speechless," Maguire said, but that doesn't make it the underlying disorder. "Don't view it as an anxiety disorder. Treat the underlying condition," he said. He pointed to dopamine receptor-blocking agents as a potential option worth exploring, alongside cognitive behavioral therapy coordinated with speech-language pathology, and said the diagnosing clinician shouldn't stop at a referral. "We need to work together," he said, describing an interdisciplinary approach that includes pediatricians, pediatric neurologists, child and adult psychiatrists, neurologists, and primary care physicians working alongside speech and psychotherapy.

The Guidelines Call for More Education and Research

Ultimately, Maguire envisions a better understanding of the disorder and more research will lead to interdisciplinary treatment strategies. Maguire, who has practiced psychiatry for more than 30 years, said he's already watched this trajectory play out with other disorders. “I do believe that as we develop better understandings of the neurologic basis of a condition and even develop potentially biologic therapies, be those neuromodulation or pharmacotherapy, more people will be helped,” he said. "We need better controlled studies, and we're going to get those."

Closing that gap starts with basic awareness and then education, he said, recalling colleagues who've told him, "Wow, I've never been taught anything on stuttering." He said the field needs to break the barriers through knowledge, education, and expanded research. To foster this, STARS will hold its second annual educational CME conference in September in Laguna Niguel; California, which will be complimentary to attend.

Maguire has a simple takeaway message for his colleagues: "You can help us out just by learning and then applying that compassionate, knowledgeable medical care to the millions of persons who struggle with stuttering."