CASE: The big freeze
Mr. Q, age 34, is afraid to cross the street. As he steps off the curb, his legs “cramp up.” As the cramping intensifies and his feet stiffen, his heart races, he begins to sweat, and he turns back for fear his legs will buckle in the street. While on the sidewalk, he stays within reach of a building or car in case he falls.
Six months before presentation, Mr. Q walked to church during a blizzard, only to find the church closed because of the storm. He returned home and shoveled snow for 1 hour, during which he repeatedly leaned forward and backward to dump the snow.
The following Sunday, Mr. Q’s legs started to “hurt” as he crossed the street. Thinking he had severely injured himself while shoveling, he began to fear street crossings. At work, he asked coworkers to help him cross over to the subway. By spring, he had become so humiliated by his dependence that he stopped working. His phobia intensified until he presented to us at his family’s urging.
During evaluation, Mr. Q says he can cross only side streets and holds on to his father while crossing. His father, who is retired, spends much of his day helping his son get around.
Complete physical exam by Mr. Q’s primary care physician reveals a possible pulled muscle in his right leg but no other medical problems. Neurologic exam results are normal, ruling out nerve damage.
Later in the evaluation, Mr. Q mentions that at age 10 he was struck by a car. The impact fractured the left side of his skull and left leg, and he temporarily lost consciousness.
Shortly after the accident, Mr. Q developed mild memory and concentration impairments and a moderate stutter. He also experienced nightmares, but they disappeared within days. He says he never received speech therapy or other psychiatric treatment because his family did not have medical insurance.
Mr. Q did not lose function after the accident, but in college his stuttering led to difficulty speaking in class and interacting socially. He suffered panic attacks while on the telephone or during job interviews. He now mostly stays home, where he lives with his parents and a nephew. He interacts only with family members.
During the evaluation, Mr. Q effortlessly walks around the therapist’s office and reports no trouble walking at home. He says the cramps almost never surface at home because he feels “calm” with walls close by. When trying to cross the street, he manages to turn back without falling despite the cramps.
Upon considering this conflict, Mr. Q seems to realize that his fear of street crossings protects him from social situations. His stuttering, however, confounds the evaluation because he has trouble communicating his symptoms.
Mr. Q’s affect is constricted as he describes his anxiety and fear. He says he feels limited and at times depressed by his inability to cross streets, yet shows little dysphoric affect or mourning and seems unusually calm when discussing the problem. He appears relaxed knowing that he can keep avoiding social situations.
The authors’ observations
Mr. Q’s history of fearing interviews and telephone conversations suggests social anxiety, and his fear and avoidance of street crossings suggest a specific phobia. Panic disorder with agoraphobia is not present because the patient never experienced spontaneous panic attacks.
Anxiety is more prevalent among persons who stutter than in fl uent speakers.1,2
Persons who stutter:
- more commonly report speech anxiety3
- are significantly more uneasy in social situations and tend to avoid them4,5
- might not be motivated to eliminate barriers that thwart social interaction.
Worse, his stuttering makes it difficult to ascertain his symptoms or plan treatment because it takes him so long to finish a sentence.
EVALUATION: Flashing back
Later in the evaluation, Mr. Q says that whenever he considers or tries crossing a street, he recalls his childhood vehicular injury and fears he will be struck again. He has nightmares of being run over, and these nightmares and flashbacks have been occurring twice weekly since the snowstorm.
During the mental status examination, Mr. Q is well related with fair to poor eye contact, probably because of his stutter; he looks away from the speaker when his stuttering intensifies. His nightmares and flashbacks suggest comorbid posttraumatic stress disorder (PTSD), although he has no persistent symptoms of increased arousal. He also shows no evidence of acute mood disorder, psychosis, or cognitive disturbance.