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Cognitive Bias Modification for Social Anxiety in Adults Who Stutter: a Feasibility Study of a Randomised Controlled Trial

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Cognitive Bias Modification for Social Anxiety in Adults Who Stutter: a Feasibility Study of a Randomised Controlled Trial Open Access Research BMJ Open: first published as 10.1136/bmjopen-2016-015601 on 22 October 2017. Downloaded from Cognitive bias modification for social anxiety in adults who stutter: a feasibility study of a randomised controlled trial Jan McAllister,1 Sally Gascoine,2 Amy Carroll,3 Kate Humby,1 Mary Kingston,1 Lee Shepstone,4 Helen Risebro,4 Bundy Mackintosh,5 Tammy Davidson Thompson,6 Jo Hodgekins4 To cite: McAllister J, ABSTRACT Strengths and limitations of this study Gascoine S, Carroll A, et al. Objective To determine the feasibility and acceptability Cognitive bias modification of a computerised treatment for social anxiety disorder for ► The study represents the first attempt to use for social anxiety in adults adults who stutter including identification of recruitment, who stutter: a feasibility cognitive bias modification with adults who stutter. retention and completion rates, large cost drivers and study of a randomised ► It provides valuable insights into aspects of the selection of most appropriate outcome measure(s) to controlled trial. BMJ Open design and methodology that will enable us to inform the design of a future definitive trial. 2017;7:e015601. doi:10.1136/ improve these features in a future trial. bmjopen-2016-015601 Design Two-group parallel design (treatment vs placebo), ► We were unable to gather information that would double-blinded feasibility study. Participants: 31 adults explain the relatively high attrition rate among those ► Prepublication history and who stutter. additional material for this who were randomised. Intervention Attention training via an online probe paper are available online. To view these files please visit the detection task in which the stimuli were images of faces displaying neutral and disgusted expressions. journal (http:// dx. doi. org/10. which may compromise many aspects of 1136/ bmjopen- 2016- 015601). Main outcome measures Psychological measures: Structured Clinical Interview Global Assessment of life including relationships, education and Received 8 January 2017 Functioning score; Liebowitz Social Anxiety Scale; Social employment. Up to 60% of adults who are Revised 22 August 2017 Phobia and Anxiety Inventory; State-Trait Anxiety Inventory; seeking treatment for stuttering experience 3 4 http://bmjopen.bmj.com/ Accepted 6 September 2017 Unhelpful Thoughts and Beliefs about Stuttering. Speech social anxiety disorder, compared with fluency: percent syllables stuttered. Economic evaluation: 6.8% of the general adult population.5 In the resource use questionnaire; EuroQol three-dimension wider population of people who stutter, this questionnaire. Acceptability: Likert Scale questionnaire figure may be the same, or it could be lower of experience of trial, acceptability of the intervention and (eg, those with social anxiety disorder may be randomisation procedure. more likely to seek treatment because of the Results Feasibility of recruitment strategy was limitations it places on their lives) or higher 1School of Health Sciences, demonstrated. Participant feedback indicated that the intervention and definitive trial, including randomisation, (eg, avoidant tendencies associated with social University of East Anglia, on September 30, 2021 by guest. Protected copyright. anxiety disorder may make them unwilling to Research Park, Norwich, UK would be acceptable to adults who stutter. Of the 31 1 2Sobell Department of Motor participants who were randomised, 25 provided data at all seek treatment). There is a lack of adequate Neuroscience and Movement three data collection points. provision of speech and language therapy 6 Disorders, University College Conclusions The feasibility study informed components services in the UK : some areas of the country London, London, UK 7 3 of the intervention. Modifications to the design are needed have no service for adults who stutter, and Clinical Psychology, Guy’s & before a definitive trial can be undertaken. Thomas’ NHS Foundation Trust, many speech and language therapists have Trial registration number I SRCTN55065978; Post- London, UK limited formal training in established psycho- 8 4Norwich Medical School, results. logical therapies. With increasing pressure University of East Anglia, on health service resources, an ‘e-mental Research Park, Norwich, UK 9 5 health’ approach, involving online delivery Department of Psychology, INTRODUCTION University of Essex, Colchester, of an intervention that does not require UK Stuttering is a disorder that affects the the presence of a trained therapist, could 6Speech and Language Therapy, fluency of speech. The prevalence of stut- provide a cost-effective means of improving Norwich Community Health and tering among adults has been estimated at the psychological health of adults who stutter. Care NHS Trust, Norwich, UK 0.78%.1 Stuttering is strongly associated with In addition, e-mental health interventions Correspondence to social anxiety disorder, a persistent and exces- have the potential to be more convenient Dr Jan McAllister; sive fear of being humiliated, scrutinised or for clients, including those who would other- j. mcallister@ uea. ac. uk negatively evaluated in social situations,2 wise have to travel long distances to access McAllister J, et al. BMJ Open 2017;7:e015601. doi:10.1136/bmjopen-2016-015601 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2016-015601 on 22 October 2017. Downloaded from the service and those for whom travel is difficult, such as the emotional Stroop task, in which participants have to people with disabilities and parents with young children. name the colour in which words are printed as quickly as However, despite the burgeoning availability of online possible, anxious individuals have longer colour-naming therapies for a wide range of conditions, there is a lack of times for words with negative connotations (such as failure) evidence regarding their effectiveness.10 than for neutral words (such as feature).21 This finding is The primary goal of interventions that address social usually interpreted as reflecting interference between the anxiety in people who stutter must be improvement in automatic processing of the emotional content and the mental health status. However, over half of adults who colour-naming process, though other explanations have stutter cite improvements in speech fluency as their most been proposed.22 Attentional biases feature heavily in important goal when they seek therapy.11 Some people cognitive models of social anxiety.23 Selectively attending who stutter become so ashamed of their speech disorder to threat causes and maintains feelings of anxiety.24 In that they go to great lengths to disguise it via avoid- particular, socially anxious people have been shown to ance techniques; in such cases, the stutter is categorised display attentional biases towards negative facial expres- as ‘covert’, ‘masked’ or ‘interiorized’.12 13 Adults who sions in the early stages of processing.25 26 A technique stutter become more dysfluent in situations that increase that has been used to demonstrate this is called probe their social anxiety,13 14 and recent evidence suggests detection. For example, in one study that used probe that the psychosocial dimension of stuttering must be detection,26 participants were shown pairs of faces at addressed before speech treatment can succeed.15 Given very brief exposure times; the two faces might both have the apparent relationship between anxiety and speech a neutral expression, or one face might have a neutral fluency, in the development of interventions for social expression and the other an emotional expression (angry anxiety in this group, it is desirable to include speech or happy). The participants were asked to respond to a fluency as a secondary outcome measure. visual probe (an upward-pointing or downward-pointing Cognitive behavioural therapy (CBT) is an effective arrow) that appeared in the location previously occu- intervention for social anxiety disorder in adults who pied by one of the faces. A participant who was already stutter,4 and recent trials of internet-delivered CBT for attending to an area of the screen where the probe adults who stutter4 16–18 have produced promising results. appears should respond relatively quickly to the probe; A CBT package tailored specifically to the needs of therefore, relatively short reaction times would indicate people who stutter and delivered by a clinical psycholo- a bias towards the stimulus that previously appeared at gist improved the psychological health of participants,4 that location, and relatively long reaction times a bias and an e-mental health version similarly resulted in away from the earlier stimulus. Non-anxious individuals improved psychological outcomes and achieved good had an attentional bias towards happy faces and away levels of compliance.16–18 However, CBT does not work from threatening faces, while those with high levels of for everyone,19 and in its traditional face-to-face mode of social anxiety exhibited the opposite pattern, attending http://bmjopen.bmj.com/ delivery, it requires the availability of a suitably trained towards threatening faces and away from happy faces.26 health professional. Furthermore, despite the negative There is evidence that non-stuttering anxious people are correlation between social anxiety levels and speech initially hypervigilant for potential sources of threat, but fluency in adults who stutter,13 14 to the authors’ knowl- after about half a second, they then reorient attention edge,
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