Pharmacologic Management of Stuttering: What Psychiatrists Need to Know

CONFERENCE REPORTER

"We can help people who stutter with the tools we have today, but we hope to get better tools yet and discover the cures of tomorrow," said Gerald A. Maguire, MD, "It is a very exciting time for neuropsychiatry... and when you leave this room today, you'll know more about stuttering than 99% of clinicians."

Stuttering is a neurodevelopmental disorder that affects 5% of all children and persists to affect over 1% of all adults, and is a condition that dates all the way back into ancient history (the Egyptians had a hieroglyphic for stuttering, shared Maguire). There are no approved therapies for this condition.

It has a high comorbidity with depression and social anxiety, and can be associated with significant negative impact on quality of life across several aspects (social, academic, occupational). It has been largely ignored by the medical and scientific communities, said Maguire: "We need to change that."

As stuttering is not frequently listed or recognized in medical histories, the condition is misunderstood. Comorbid conditions of stuttering are OCD, ADHD, and tic disorder, based upon their neurologic underpinnings.

"Stuttering is not 1 condition like schizophrenia is not 1 condition, like major depressive disorder is not 1 condition," emphasized Maguire. "Let's begin to change this paradigm."

Maguire explained the neural structures and neurologic pathways involved in stuttering. The medial system involves the natural timing and initiation of speech through the basal ganglia—or striatum. The amygdala is activated in stuttering and plays a central role in an individual's reaction to stress. The lateral system can be activated through an external timer such as singing, which bypasses the striatal circuit.¹

Stuttering has several etiologies,² but has a strong genetic component of multiple genes. Individuals who stutter may also have greater iron deposition, according to some new research out of Germany.

According to his research, dopamine agonists improve stuttering, shared Maguire. Younger individuals appear to respond better.

Agents that may have an impact on stuttering include:

• Haloperidol
• Pimozide
• Risperidone
• Ecopipam
• Gemlapodect (NOE-105)

Off label agents in stuttering include:

• Olanzapine
• Risperidone
• Aripiprazole

Notably, there is a lack of standardized approaches to stuttering. We need to improve the metrics to assess severity of stuttering over time, per the FDA, said Maguire.

Maguire offers the Brief Stuttering Assessment (BSA), a validated metric to measure stuttering severity.

1. How much time while in conversation over the past week did you think about your stuttering?
2. How often did you change, substitute, or avoid words over the past week when you anticipated you might stutter?
3. To what extent did you feel physical tension while you were speaking over the past week?
4. How much energy did you expend over the past week focusing on how you were speaking rather than focusing on what you wanted to say?
5. Over the past week, how often did you avoid or want to avoid a conversation because of fear of stuttering?
6. Over the past week, how would you rate your level of anxiety while stuttering?
7. How would you rate your speech overall over the past week?
8. Over the past week, how would you rate the impact of stuttering on your school or work?
9. Over the past week, how would you rate the impact of stuttering on your social life?
10. Over the past week, how would you rate the global impact of stuttering on your quality of life?

What does stuttering treatment look like today? Maguire suggests:

• Treating comorbidities such as social anxiety and ADHD.
• Intervening early with speech therapy or medications.
• Removing offending pharmacologic agents.
• Utilizing cognitive behavioral therapy when necessary.
• Targeting trauma, as patients who stutter have some elements of trauma, and targeting these could improve symptoms.

In order to improve outcomes, cross-specialty collaboration is essentialy. Neurology, neuroscience, and psychiatry need to work with speech therapists to optimize outcomes, shared Maguire.

References

1. Maguire GA, Riley GD, Yu BP. A neurological basis of stuttering? Lancet Neurol. 2002;1(7):407.

2. SheikhBahaei S, Millwater M, Maguire GA. Stuttering as a spectrum disorder: a hypothesis. Curr Res Neurobiol. 2023:5:100116.