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Original Research (Original Article) 


Mohammed Nasser Alghunaim et al, 2020;4(3):645–651.

International Journal of Medicine in Developing Countries

Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers

Mohammed Nasser Alghunaim1*, Abdulaziz Mamoon Abdullah1, Saleh Alshaibi1, Omar Alfehaid1, Mohammed Albagami1, Aamir Omair1, Irfan Anjum2

Correspondence to: Mohammed Nasser Alghunaim

*College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.

Email: hmmode [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 18 December 2019 | Accepted: 22 January 2020


ABSTRACT

Background:

Stuttering is defined as a difficulty in speaking fluently. It starts in childhood and it can be a lifelong problem. Stuttering can impact the person negatively, affecting their social, educational, and occupational experiences. Psychological issues such as anxiety can be common with the stuttering individuals displaying higher anxiety levels than the non-stuttering individuals. This study aims to assess the level of worry in stutterers compared to non-stutterers. It was hypothesized that stutterers show significantly more anxiety and worry as compared to non-stutterers.


Methodology:

This was a case-control study conducted among stutterers (cases) and non-stutterers (controls) sampled from two hospitals and two stuttering social support groups in Saudi Arabia. The anxiety and worry were measured using the General Anxiety Disorder-7 (GAD-7) and Penn State Worry Questionnaire (PSWQ). The Subjective Stuttering Scale (SSS) was used to measure the severity of stuttering in the cases.


Results:

The study included 90 stutterers and 140 controls. The stuttering group had significantly higher scores on both the GAD-7 and PSWQ (p < 0.01). A positive correlation was found in the stutterers for the severity of stuttering and the GAD-7/PSWQ scores (r > 0.40).


Conclusion:

Stutterers were found to have a higher degree of anxiety and worry as compared to non-stutterers. Also, this level of anxiety and worry was associated with the severity of stuttering. This indicates the importance to increase the level of awareness about the emotional impacts that are associated with stuttering, such as worry and anxiety. Early screening and treatment should be offered to stutterers to reduce emotional distress.


Keywords:

Anxiety, GAD-7, Stutter, Speech difficulty, PSWQ, SSS.


Introduction

Stuttering is a difficulty in speaking fluently, which can affect an individual throughout his or her life. Stuttering is characterized by disturbances in the creation of speech sounds, also called disfluencies [1]. Recent evidence shows that the prevalence of stuttering is about 10%. However, 90% of stutterers recover during childhood [2]. Stuttering has an impact on almost all aspects of an individual’s life and difficulties in social, educational, and occupational experiences are not uncommon [3]. Moreover, individuals experiencing stuttering seem to be worried about negative evaluations from others. Since people who stutter are likely to negatively appraise their communication, they are more likely to experience increased worry [1].

Generalized anxiety disorder (GAD) is described as extreme and inappropriate worrying that is constant and not restricted to specific events [4]. GAD is related to serious psychosocial deterioration, which is often related to comorbid psychological disorders, such as depression and different anxiety disorders. People with GAD experience complaints, such as irritability, restlessness, difficulty in concentration, sleep problems, and easy fatigability [5]. Stuttering is accompanied by numerous negative consequences across the lifespan, which may increase vulnerability to social and psychological difficulties [2]. These negative consequences can begin early with evidence of preschool children who stutter experiencing bullying, teasing, exclusion, and negative peer reactions [6].These consequences are intensified during the school years as children become more involved in social and speaking situations. As a result, children and adolescents who stutter, frequently experience peer victimization, social isolation, and rejection, and they may also be less popular than their non-stuttering peers [7]. Excessive worry may affect their relationships with their family members, friends, and colleagues. It may also lead to other anxiety disorders resulting in withdrawal or avoidance (AVD) of social interactions. This may further lead to an increase in stress habits, such as poor eating, poor sleeping, low confidence, self-esteem, and job performance [8].

The literature review supports the findings that stuttering can have a negative impact on individuals experiencing speech difficulties and subsequent increase in anxiety symptoms and social withdrawal. Worry is a feature of anxiety and creates in individuals with stuttering the fear of negative evaluation from others, and they may be experiencing unrecognized excessive worry or generalized anxiety disorders. A search on PubMed during September 2015 for keywords, such as worry and stutter, speech difficulties and worry, speech problems and worry, and speech impediment and worry, indicated no research articles on this topic.

This study aimed to assess the level of worry in people who stutter compared to people who do not stutter. In addition, to assess the relationship between stuttering and worrying also to determine whether excessive worry is a feature of stuttering rather than a feature of general psychopathology.


Subjects and Methods

This was a case–control study that included stutterers (cases) and non-stutterers (controls). The data were collected from King Abdulaziz Medical City and Prince Sultan Military Medical City, Riyadh, Saudi Arabia. In addition, data were also collected from the Eradah club for stuttering, a stuttering group under the supervision of the Ministry of Labour and Social Development, Saudi Arabia and “We Can Stuttering Club,” an Arabic social media stuttering support group.

The sample was collected by purposive, snowball sampling. The study recruited two groups of participants, such as male adults who stutter and who do not stutter. The onset of stuttering was considered at least 12 months duration and diagnosed by a speech-language pathologist prior to taking part in the study using inclusion criteria which are males, aged between 18 and 40 years, minimum high school graduates, and Saudi nationals. The control group participants were matched by area of residence (i.e., Riyadh/outside Riyadh).

The sample size was estimated using the Piface sample size calculator. The main outcome variable was the score on the Penn State Worry Questionnaire (PSWQ), which has a range of 16–80 scores. The standard deviation for the score on PSWQ was estimated to be ±11 based on a previous study [9]. The required sample size for the cases and controls was estimated to be 60 in each group to identify a minimum difference of 5 between the two groups in the mean score on PSWQ as being statistically significant at α = 0.05 and power of 80%.

Initially, paper-based questionnaires were used to collect data. However, the sample size for the stuttering group was not achieved as estimated. The required sample size was achieved using an identical online-based questionnaire that was shared with the target population. The questionnaires included demographic information, GAD-7 [10], PSWQ [5], and Subjective Stuttering Scale (SSS) [11].

The GAD-7 and PSWQ were administered to both cases and controls, whereas the SSS was used with the stuttering group only. The GAD-7 consists of seven questions with responses of 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. The range of total score for the GAD-7 is from 0 to 21 and the cut-off points of the scoring are 5, 10, and 15, which included 5–9 = mild, 10–15 = moderate, and >15 severe anxiety [10]. The PSWQ is a 16-item scale with a rating from 1 = not at all typical of me to 5 = very typical of me. The minimum and maximum scores possible are 16 and 80. The total score is categorized as 16–39: low worry, 40–59: moderate worry, and 60–80: high worry. The SSS measures three areas, including stuttering severity, locus of control (LOC), and AVD [11]. This questionnaire consists of eight items, out of them, two measure severity, three measure LOC, and three measure AVD. Each item is rated from 1 to 9 in which 1 represents normal and 9 is the most severe. Item number 1 measures the severity of stuttering “today.” All other items measure the severity of stuttering “during the last week.”

The PSWQ and SSS questionnaires were translated by two medical experts competent in Arabic and English language translations. Both questionnaires were translated forward and backward from English to Arabic to English. The research authors discussed the translated questionnaires, differences were highlighted, and a unified translation version was produced. The unified Arabic versions were checked by an Arabic language specialist for grammatical correction. Both questionnaires were checked by a psychiatrist and a speech pathologist.

All the paper-based questionnaires were entered into a database structure using the Microsoft Excel program. The online-based questionnaires were exported to Excel format and were merged with the paper questionnaire data that were already entered into the sheet. Each questionnaire form was given a specific identification number to ensure anonymity and confidentiality. The data were coded before data analysis, and each choice in the questionnaires was given a specific code. The collected data were analyzed using the Statistical Packages for Social Services software v.21.

A descriptive analysis was performed. Numerical data are presented as mean ± SD and categorical data are presented as frequency (%). Inferential statistics were performed to answer the research question, the Chi-square test was used to compare the demographic variables in the stuttering versus non-stuttering groups. Mann–Whitney test was used to examine the difference between PSWQ and GAD-7 variable scores for participants in the stuttering group versus participants in the non-stuttering group. A correlation was performed to examine the association between severity of stuttering (i.e., as measured by SSS) and severity of worry (i.e., as measured by PSWQ) in the stuttering group. A p-value < 0.05 was considered to show a statistically significant difference.Participation in the research was voluntary, and informed written consent was sought from all participants. The researchers aimed to minimize any potential harm from the research. Participants were given the opportunity to discuss any further concerns with the principal investigator (PI) by providing contact information of the PI written in the consent form and were able to contact him up to 3 months after the participation date. Nonetheless, no group of participants received any favorable outcomes.


Results

The collected data were acquired from 230 participants, such as 90 from the stuttering group and 140 from the non-stuttering group. Initially, matching between cases and controls was done by area of residence. However, on analysis, it was found that stutterers were mostly students, and non-stutterers were majority employed (Chart 1). Therefore, further analysis was done on the student and employment groups separately.

Based on the employment status, there were 64 (55%) persons who stutter among the student/intern group; and there were 26 (23%) stuttering among the employment group (Table 1). In the students/interns group, 39 (61%) of the stutterers and 36 (69%) of the non-stutterers were from Riyadh (p = 0.35). In the employed group, 17 (65%) of the stutterers and 71 (81%) of the non-stutterers were from Riyadh (p = 0.10) (Table 1). In the student/intern group, 33 (54%) of the stutterers had an income of SR 10,000 or above as compared to 41 (79%) of the non-stutterers (p = 0.006). In the employed group, 13 (54%) of the stutterers and 70 (79%) of the non-stutterers had an income of SR 10,000 and above (p = 0.01). On the regard to education in the student/intern group, there were 35 (55%) of the stutterers who had bachelor’s degrees or above as compared to 28 (54%) in the non-stuttering group (p = 0.93). In the employed group, there were 17 (71%) of the stutterers and 72 (83%) of the non-stutterers who had a bachelor’s degree or above (p = 0.20) (Table 1).

Chart 1. Employment status between the stuttering vs. Non-stuttering group.

The boxplot (Figure 1) shows the difference between stutterers and non-stutterers on the (PSWQ) score. In the student/intern group, the median in non-stutterer was 42.5 (IQR = 37.50), whereas the median in the stuttering group was 52 (IQR = 43.58) (p > 0.001). In the employed group, the median in the non-stuttering group was 46 (IQR = 36.51), whereas, in the stuttering group, it was 52 (44.58) (p-value = 0.005).

Table 1. Demographic comparison of stutters and non-stutters stratified by employment status.

Student/Intern (n = 116) Employed (n = 114)
Stuttering (n = 64) Not stuttering (n = 52) p-value Stuttering (n = 26) Not stuttering (n = 88) p-value
Age (years) 21.7 (SD 3.1) 21.9 (SD 2.9) 0.74 29.6 (SD 5.1) 31.5 (SD 5.4) 0.12
Area of residence
Riyadh 39 (61%) 36 (69%) 0.35 17 (65%) 71 (81%) 0.10
Other than Riyadh 25 (39%) 16 (31%) 9 (35%) 17 (19%)
Income
Less than 10,000 28 (46%) 11 (21%) 0.006 11 (46%) 18 (21%) 0.01
10,000+ 33(54%) 41 (79%) 13 (54%) 70 (79%)
Education
Up to High School / Diploma 29 (45%) 24 (46%) 0.93 7 (29%) 15 (17%) 0.20
Bachelors & above 35 (55%) 28 (54%) 17 (71%) 72 (83%)

Figure 1. Comparing Penn State Worry Questionnaire (PSWQ) score in stuttering and non-stuttering people.

The boxplot (Figure 2) shows the difference between stuttering and non-stuttering on the (GAD-7) questionnaire scores. In the student/intern group, the median in non-stuttering was 4 (IQR = 2.8), whereas the median in the stuttering group was 7 (IQR = 5.13) (p > 0.001). In the employed group, the median in the non-stuttering group was 6 (IQR = 3.8), whereas, in the stuttering group, it was 7.5 (5.11) (p-value = 0.008).

The scatterplot (Figure 3) shows the correlation between the SSS score and PSWQ score. It shows a positive correlation as the severity of stuttering increases, worry increases with r = 0.42.

The scatterplot (Figure 4) shows the relationship between the GAD7 score and SSS score. It shows a positive correlation in the individuals who are experiencing more stutter are more anxious with r = 0.39.


Discussion

The findings of this study showed that people, who stutter, were significantly more prone to worry than individuals without speech impediments. The research also measured current psychopathology for both stutterers and non-stutterers. The findings showed that people who stutter were not only more likely to show pathological worry but also were significantly more likely to score above the clinical threshold for GAD as measured by the GAD-7 questionnaire compared to participants who did not stutter.

Figure 2. Comparing Generalized Anxiety Disorder–7 (GAD-7) score in stuttering and non-stuttering.

Figure 3. Association between severity of stuttering (SSS) and worry (PSWQ score) in stutterers (n=90).

The severity of stuttering as measured by the SSS revealed that there was a positive relationship between the severity of stuttering with both pathological worry (PSWQ) and GAD. It is difficult to comment on the direction of effect, that is, whether anxiety symptoms were exacerbating stuttering or vice versa. In keeping with the research literature, a plausible explanation is that the increase in stuttering severity caused more pathological worry. Since pathological worry is a key symptom of GAD, those participants with higher levels of pathological worry were more likely to score above the threshold for GAD. Individuals experiencing stuttering may be engaged with a Speech and Language Clinic (SLC). It is unlikely that these clinics screen for anxiety disorders, therefore anxiety problems of the persons with stuttering are unlikely to be noticed. Moreover, given the stigma surrounding mental health issues in Saudi Arabia, the individuals experiencing stuttering and anxiety may have concerns accessing psychological services [12].

Figure 4. Association between severity of stuttering (SSS) and anxiety (GAD-7 score) in stutterers (n=90).

Previous research has shown co-occurrence between stuttering and anxiety problems and given that GAD is a relatively common anxiety disorder, it is noted that little attention has been given to this area in research. The course of GAD is often chronic and unremitting, especially when it is combined with other conditions [13,14]. Episodes for GAD can last for many years and the cost in terms of impairment and social disability can be high [15,16]. Quality of life is often compromised in terms of self-esteem, goals, values of work, money, learning, creativity, and relationships with friends and family [17]. Given the impact of GAD on an individual’s personal and social life, screening for anxiety disorders, especially GAD in SLCs is recommended. The screening process is relatively easy and does not require extensive training. Once GAD is suspected, the SLCs can either provide treatment of anxiety disorders in-house or refer to psychology departments for further psychological treatment.

This study was adequately powered with a good representation in the sample. Due to difficulties with recruitment, online recruitment of participants was also included. Although there are two different methods, participant recruitment is a limitation of this study. Another limitation of this study is the lack of randomization of the sample. This may affect the extent to which the results of the study can be fully generalized.

Further research may look at the feasibility of screening for GAD in SLCs. If GAD is found to be an issue, additional research can identify stigma and access for psychological treatment, and whether reducing GAD results in a reduction in the severity of stuttering. Finally, given the lack of attention in the literature about stuttering and generalized anxiety disorder, increasing awareness for both clinical and research purposes may be fruitful. A positive relationship between stuttering and worry was found with stutterers scoring about the clinical threshold for generalized anxiety disorders compared to non-stutterers. Regular screening for anxiety disorder is recommended with access to psychological services.


Conclusion

Since there is a positive relationship between stuttering and worry, which affect the individuals who experience stuttering in many aspects of their lives, worry should be detected early. If it is not recognized, it can remain untreated resulting in people suffering unnecessarily with pathological worry. Early detection can help to access psychological services and device the psychological treatment. In addition, it is important to increase awareness about the effects of stuttering and worry among individuals.


List of Abbreviations

GAD Generalized anxiety disorder
LOC Locus of control
PI Principal investigator
PSWQ Penn State Worry Questionnaire
SLC Speech and Language clinics
SSS Subjective Stuttering Scale

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

The study (Protocol number #SP16/244) was approved on 24/1/2017 by the Institutional Review Board at King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.


Author details

Mohammed Nasser Alghunaim1, Abdulaziz Mamoon Abdullah1, Saleh Alshaibi1, Omar Alfehaid1, Mohammed Albagami1, Aamir Omair1, Irfan Anjum2

  1. College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
  2. Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK

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How to Cite this Article
Pubmed Style

Alghunaim MN, Abdullah AM, Alshaibi S, Alfehaid O, Albagami M, Omair A, Anjum I. Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers. IJMDC. 2020; 4(3): 645-651. doi:10.24911/IJMDC.51-1575308714


Web Style

Alghunaim MN, Abdullah AM, Alshaibi S, Alfehaid O, Albagami M, Omair A, Anjum I. Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers. http://www.ijmdc.com/?mno=76268 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1575308714


AMA (American Medical Association) Style

Alghunaim MN, Abdullah AM, Alshaibi S, Alfehaid O, Albagami M, Omair A, Anjum I. Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers. IJMDC. 2020; 4(3): 645-651. doi:10.24911/IJMDC.51-1575308714



Vancouver/ICMJE Style

Alghunaim MN, Abdullah AM, Alshaibi S, Alfehaid O, Albagami M, Omair A, Anjum I. Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers. IJMDC. (2020), [cited March 29, 2020]; 4(3): 645-651. doi:10.24911/IJMDC.51-1575308714



Harvard Style

Alghunaim, M. N., Abdullah, . A. M., Alshaibi, . S., Alfehaid, . O., Albagami, . M., Omair, . A. & Anjum, . I. (2020) Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers. IJMDC, 4 (3), 645-651. doi:10.24911/IJMDC.51-1575308714



Turabian Style

Alghunaim, Mohammed Nasser, Abdulaziz Mamoon Abdullah, Saleh Alshaibi, Omar Alfehaid, Mohammed Albagami, Aamir Omair, and Irfan Anjum. 2020. Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers. International Journal of Medicine in Developing Countries, 4 (3), 645-651. doi:10.24911/IJMDC.51-1575308714



Chicago Style

Alghunaim, Mohammed Nasser, Abdulaziz Mamoon Abdullah, Saleh Alshaibi, Omar Alfehaid, Mohammed Albagami, Aamir Omair, and Irfan Anjum. "Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers." International Journal of Medicine in Developing Countries 4 (2020), 645-651. doi:10.24911/IJMDC.51-1575308714



MLA (The Modern Language Association) Style

Alghunaim, Mohammed Nasser, Abdulaziz Mamoon Abdullah, Saleh Alshaibi, Omar Alfehaid, Mohammed Albagami, Aamir Omair, and Irfan Anjum. "Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers." International Journal of Medicine in Developing Countries 4.3 (2020), 645-651. Print. doi:10.24911/IJMDC.51-1575308714



APA (American Psychological Association) Style

Alghunaim, M. N., Abdullah, . A. M., Alshaibi, . S., Alfehaid, . O., Albagami, . M., Omair, . A. & Anjum, . I. (2020) Do males who stutter also experience excessive worry: a case-control study conducted in Saudi Arabia comparing worry among Saudi male stutterers with non-stutterers. International Journal of Medicine in Developing Countries, 4 (3), 645-651. doi:10.24911/IJMDC.51-1575308714