When his legs cramp up while trying to cross, we have him say out loud, “I can do it. I feel calm;” this helps him proceed across the street. We also teach self-empowerment by having him purposely cramp up his legs, then release them to stop the cramping.
Deep breathing/relaxation. We teach Mr. Q progressive muscle relaxation and slow rhythmic breathing exercises, which he does before crossing streets to reduce his anxiety. For homework, he practices these exercises and soaks his legs in warm water for 10 minutes twice daily to relax his muscles and prevent cramping.
Speech therapy. The primary therapist devotes 20 minutes of each session to speech therapy. She employs relaxation training and therapy techniques such as Easy Onset,10 in which the patient stretches each sound, syllable, or word for up to 2 seconds, allowing him to speak at a smooth, slow rate. Mr. Q also practices these speech exercises at home.
After 6 weeks, Mr. Q’s stutter improves slightly but he still has trouble communicating. We refer him to a consulting speech therapist, who sees him twice weekly and leads Easy Onset and relaxation exercises. This gives us more time for supportive psychotherapy.
As his speech becomes more fluent, Mr. Q’s social anxiety and fear of street crossings decreases.
Pharmacotherapy. We instruct Mr. Q to take paroxetine, 20 mg/d, and clonazepam, 0.25 mg bid, 30 minutes before in vivo work to manage his anxiety. We titrate clonazepam to 0.5 mg bid over 1 month. He responds well to this regimen but fears he will become dependent on it.
During therapy, Mr. Q and the therapist rank the above interventions from most to least therapeutic (Box 2) so that we can effectively treat him should he relapse.
The authors’ observations
Although Mr. Q’s case is unusual, we feel our diagnostic and treatment methods can be applied to similar cases. His stutter, however, prevented us from conducting a structured diagnostic interview—which would have uncovered his symptoms more quickly—or performing standard manualized therapy.
Some data11 suggest that combination psychotropics and relaxation therapy can compromise long-term exposure therapy outcomes, as the patient’s fear could return once medication is stopped. Mr. Q’s anxiety was crippling, however, and had to be addressed before we could consider exposure therapy.
More research is needed on overcoming patient communication barriers that can hamper treatment. Rapport with patients often makes or breaks psychiatric treatment, and communication problems can prevent that connection. As clinicians, we must watch for linguistic, cognitive, and cultural impediments to treatment.
FOLLOW-UP: ‘I can cross’
Six months after presentation, Mr. Q crosses all types of streets—from 1-way streets to 6-lane intersections—with minimal anxiety. He has resumed his previous level of functioning and is searching for work. His stutter, though greatly improved, is still audible.
We see Mr. Q monthly. We stop paroxetine after 8 months but continue clonazepam to address his many underlying social anxieties. By November—approximately 1½ years after presentation—we have reduced clonazepam to 0.5 mg each morning. We try reducing the morning dose to 0.25 mg, but Mr. Q’s debilitating anxiety resurfaces.
In December, we increase clonazepam to 0.5 mg bid, then reduce it to 0.5 mg each morning 2 months later. In April, we cut clonazepam to 0.25 mg each morning. So far, Mr. Q is functioning well.
The authors’ observations
Patients who begin antistuttering intervention as adults have a poorer speech improvement prognosis than those who start speech therapy in childhood.12 In leaving his stuttering untreated for 24 years, Mr. Q likely sacrificed quality of life. Speech intervention at an earlier age might have improved his speech and prognosis early on.
Related resources
- Anxiety Disorders Association of America. www.adaa.org.
- Beck AT, Emery G, Greenberg RL. Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books; 1985.
- Leahy RL, Holland SJ. Treatment plans and interventions for depression and anxiety disorders. New York: Guilford Press; 2000.
- Clonazepam • Klonopin
- Paroxetine • Paxil
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.