Kaplan + Sadock's Synopsis of Psychiatry, 11e

1149

31.4d Social (Pragmatic) Communication Disorder

Treatment Evidence-based treatments for stuttering are emerging in the literature. One such treatment is the Lidcombe Program, which is based on an operant conditioning model in which parents use praise for periods of time in which the child does not stutter, and intervene when the child does stutter to request the child to self-correct the stuttered word. This treatment program is largely administered at home by parents, under the supervision of a speech and language therapist. A second treatment program being investigated in clinical trials is a family-based, parent-child interaction therapy that identi- fies stressors possibly associated with increased stuttering and aims to diminish these stressors. A third treatment currently under investigation in clinical trials is based on the knowl- edge that speaking each syllable in time to a particular rhythm has led to diminished stuttering in adults. This treatment pro- gram appears to be promising when administered early on, to preschoolers. Distinct forms of interventions have historically been used in the treatment of stuttering. The first approach, direct speech therapy, targets modification of the stuttering response to flu- ent-sounding speech by systematic steps and rules of speech mechanics that the person can practice. The other form of therapy for stuttering targets diminishing tension and anxiety during speech. These treatments may utilize breathing exer- cises and relaxation techniques, to help children slow the rate of speaking and modulate speech volume. Relaxation tech- niques are based on the premise that it is nearly impossible to be relaxed and stutter in the usual manner at the same time. Current interventions for stuttering use individualized combi- nations of behavioral distraction, relaxation techniques, and directed speech modification. Stutterers who have poor self-image, comorbid anxiety dis- orders or depressive disorders are likely to require additional treatments with cognitive-behavioral therapy (CBT) and/or pharmacologic agents such as one of the selective serotonin reuptake inhibitor (SSRI) antidepressants. An approach to stuttering proposed by the Speech Foun- dation of America is labeled self-therapy, based on the prem- ise that stuttering is not a symptom, but a behavior that can be modified. Stutterers are told that they can learn to control their difficulty partly by modifying their feelings about stutter- ing and attitudes toward it and partly by modifying the deviant behaviors associated with their stuttering blocks. The approach includes desensitizing; reducing the emotional reaction to, and fears of, stuttering; and substituting positive action to control the moment of stuttering.

During this phase, children stutter most often when excited or upset, when they seem to have a great deal to say, and under other conditions of communicative pressure. 00 Phase 2 usually occurs in the elementary school years. The disorder is chronic, with few if any intervals of normal speech. Affected children become aware of their speech dif- ficulties and regard themselves as stutterers. In phase 2, the stuttering occurs mainly with the major parts of speech— nouns, verbs, adjectives, and adverbs. 00 Phase 3 usually appears after the age of 8 years and up to adulthood, most often in late childhood and early adoles- cence. During phase 3, stuttering comes and goes largely in response to specific situations, such as reciting in class, speaking to strangers, making purchases in stores, and using the telephone. Some words and sounds are regarded as more difficult than others. 00 Phase 4 typically appears in late adolescence and adulthood. Stutterers show a vivid, fearful anticipation of stuttering. They fear words, sounds, and situations. Word substitutions and circumlocutions are common. Stutterers avoid situations requiring speech and show other evidence of fear and embar- rassment. Stutterers may have associated clinical features: vivid, fear- ful anticipation of stuttering, with avoidance of particular words, sounds, or situations in which stuttering is anticipated; and eye blinks, tics, and tremors of the lips or jaw. Frustration, anxiety, and depression are common among those with chronic stuttering. Differential Diagnosis Normal speech dysfluency in preschool years is difficult to dif- ferentiate from incipient stuttering. In stuttering occurs more nonfluencies, part-word repetitions, sound prolongations, and disruptions in voice airflow through the vocal track. Children who stutter appear to be tense and uncomfortable with their speech pattern, in contrast to young children who are nonfluent in their speech but seem to be at ease. Spastic dysphonia is a stuttering-like speech disorder distinguished from stuttering by the presence of an abnormal breathing pattern. Cluttering is a speech disorder characterized by erratic and dysrhythmic speech patterns of rapid and jerky spurts of words and phrases. In cluttering, those affected are usually unaware of the disturbance, whereas, after the initial phase of the disor- der, stutterers are aware of their speech difficulties. Cluttering is often an associated feature of expressive language disturbance. Course and Prognosis The course of stuttering is often long term, with periods of partial remission lasting for weeks or months and exacerba- tions occurring most frequently when a child is under pressure to communicate. In children with mild cases, 50 to 80 percent recover spontaneously. School-age children who stutter chroni- cally may have impaired peer relationships as a result of teasing and social rejection. These children may face academic difficul- ties, especially if they persistently avoid speaking in class. Stut- tering is associated with anxiety disorders in chronic cases, and approximately half of individuals with persistent stuttering have social anxiety disorder.

31.4d Social (Pragmatic) Communication Disorder

Social (pragmatic) communication disorder is a newly added diagnosis to DSM-5 characterized by persistent deficits in using verbal and nonverbal communication for social purposes in the absence of restricted and repetitive interests and behaviors. Deficits may be exhibited by difficulty in understanding and