From genes to social context - ECSF Antwerp Mar2014 v4... · Not just a consequence of stuttering...

From genes to social context: Understanding and treating stuttering

in a biopsychosocial framework

Antwerp 2014

Dr Tom Weidig ([email protected])

TheStutteringBrain blog

(thestutteringbrain.blogspot.com)

Why do I stutter?

Many different answers basal ganglia, motor control, anal-oral fixation, purely

learned, repair hypothesis, weak fiber connections, genes, EXPLAN, tongue issue, too much or little dopamine, hyper-reactive, psychological issues.

Many theoretical questions Which one is disproven by experiment? Which one is

right? Or are there subtypes? Do they cover different aspects? Original versus maintaining versus modulating cause? How reliable is stuttering research?

Understanding: many factors

• Gene mutation • Neuro-biological anatomical differences • Different levels of neurotransmitters • Differences in brain function • Mal-adaptive conditioning (fear to words or situation) • Mal-adaptive motor codes (secondary behaviours) • Mal-adaptive beliefs & rules (“Try to hide handicap”) • Non-accepting social environment • Non-constructive parental support • Lack of early intervention • Lack of information about stuttering

Treatment: many options

• Protein replacement (in the future?) • Pharmaceutical for fluency • Pharmaceutical for calmness (beta-blocker) • De-conditioning (un-learn an association) • Re-shape secondary symptoms (keep eye

contact) • Speech therapy (fluency shaping) • Talk therapy (change your beliefs: “I have the

right to talk”) • Shaping your social environment (inform

friends)

NDC-4 is a holistic framework for scientific theories on stuttering

Neurobiological Demand and Capacity model

(hide complexity of causal subtypes)

within

4-domain biopsychosocial framework

(acknowledging the re-enforcing adaptive learning)

(the topic of an up-coming book)

All share dysfunction in performance

Stutterers might vary in causes and symptoms, but all say

“I have moments where I can say exactly what I want to say at the moment I want to say it.”

“I have moments where I know exactly what I want to say

but cannot actually say it.”

“Those moments are abnormally frequent and the duration of the jam is abnormally long.“

Much evidence points to a neurobiological abnormality in pws

Many brain findings across studies

Speech and language is neuro-biological.

Not just a consequence of stuttering

•Abnormality in kids

•Abnormality in recovered kids

genes involved in many cases

We need a simple model of the neurobiological basis of stuttering

“Stuttering is

• a result of impaired communications among a network in the left hemisphere.

• Connectivity impairments in this network constitute the neural signatures of stuttering.” (Lu et al. 2009)

Hide complexity

Cater for Subtypes

Explain symptoms

View stuttering as a system issue: connectivity and communication among a

network as a big city highway

Standard 3-lane

2-lane only due to “bad” genes

Damaged 3-lane due to incident

It is a capacity issue, stupid!

Low Capacity is variable

Weather

Car accidents Road works

like levels of brain chemical

Like “tired” brain Interference from other brain regions

Many factors affect the capacity of the highway.

Only jams at mid and high demand

Low demand (Sunday morning) Mid demand (weekday) High demand (rush hour)

A 2-lane is much more sensitive: a) a jam is more likely, b) when it happened, it is a complete breakdown.

Excess demand leads to stuttering

Demand >

capacity

Jamming in system

Delay in speech

initiation

Different reactions to delay

Think neurological demand and capacity

Underlying speech system has an abnormally low neurological capacity

unable to cope with regularly occuring high neurological demands

Many causes to one dysfunction to many symptoms

Demand > capacity

Jamming in system

Delay in speech

initiation

Long pause Block Repetition Filler Stop Switch words Stress ...

Gene A Gene B Virus Gene A + B Blow to head Gene D Gene G + trauma Gene E + male Develop issue A Develop issue D

Decoupling between causes and symptoms

BIOPSYCHOSOCIAL

SUBTYPE 1 SUBTYPE 2 SUBTYPE 3 SUBTYPE 4 SUBTYPE 5 SUBTYPE 6

DERIVE AND USE A CONCRETE BIOPSYCHOSOCIAL FRAMEWORK

From an upcoming book co-written with Dr Michaux, PhD psychology

Need a concrete bps framework!

BIO

SOCIAL PSYCHO

Permanent deficit in one affects others!

NDC

ENVIRONMENT

ORGANISM

ENVIRONMENT

MEMORIES

BODY

ENVIRONMENT

COMMUNICABLE MEMORIES

BODY

CONFINED MEMORIES

Human system consists of 4 domains

Confined to brain

Association MotorcodeEpisodes

individually learned from one’s own environment Shared with animals I learned to juggle, but I cannot transfer this motor memory to others directly.

Directly communicable

MEME (ideas that can spread)

aquired by social learning or ideation mostly from others animals don’t have it or cannot communicate it I learned lots about juggling like facts and instructions, and I can transfer this memory directly to others.

We divide into two types of memories according to their communicability

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The human system divides into four domains again divided up in thousands of elements

Memories Body Environment

Meme 1 Meme 2 Meme 3 Meme 4 Meme 5 Meme 6 Meme 7 Meme 8 Meme 9 Meme 10 Meme 11 Meme 12 Meme 13 Meme 14 .........

AME 1 AME 2 AME 3 AME 4 AME 5 AME 6 AME 7 AME 8 AME 9 AME 10 AME 11 AME 12 AME 13 AME 14 .........

Body 1 Body 2 Body 3 Body 4 Body 5 Body 6 Body 7 Body 8 Body 9 Body 10 Body 11 Body 12 Body 13 Body 14 .........

Env 1 Env 2 Env 3 Env 4 Env 5 Env 6 Env 7 Env 8 Env 9 Env 10 Env 11 Env 12 Env 13 Env 14 .........

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Elements in the 4 domains drive bio-psycho-social processes of the human system




Body 1 Body 2 Body 3 Body 4 Body 5 Body 6 Body 7 Body 8 Body 9 Body 10 Body 11 Body 12 Body 13 Body 14 .........

Env 1 Env 2 Env 3 Env 4 Env 5 Env 6 Env 7 Env 8 Env 9 Env 10 Env 11 Env 12 Env 13 Env 14 .........

20 BIO PSYCHO SOCIAL SOCIAL

Elements in four domains create biopsychosocial processes

Physical

Bio

Psycho

Social

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strictly separate physical domains Overlapping fuzzy influences STATE VIEW PROCESS VIEW

A typical case of developmental stuttering

From a neurobiological deficit to full-blown stuttering symptoms

A child is born with a gene mutation




Body 1 Body 2 Body 3 Body 4 Body 5 GENE MUTATION Body 7 Body 8 Body 9 Body 10 Body 11 Body 12 Body 13 Body 14 .........

Norm of good speech Env 2 Env 3 Env 4 Env 5 Env 6 Env 7 Env 8 Env 9 Env 10 Env 11 Env 12 Env 13 Env 14 .........

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The body is unable to produce the protein necessary to have a normal neurobiology




Body 1 Body 2 Body 3 Body 4 Body 5 GENE MUTATION Body 7 Body 8 Body 9 ABNORMAL NEUROBIOLOGY Body 11 Body 12 Body 13 Body 14 .........

Norm of good speech Env 2 Env 3 Env 4 Env 5 Env 6 Env 7 Env 8 Env 9 Env 10 Env 11 Env 12 Env 13 Env 14 .........

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After the first stuttering utterances, memories and environment adapts. Memories Body Environment

Mum is stressed when i speak Meme 2 Meme 3 Meme 4 Meme 5 Meme 6 Meme 7 Meme 8 Meme 9 Meme 10 Meme 11 Meme 12 Meme 13 Meme 14 .........

D=block AME 2 AME 3 AME 4 AME 5 How it feels to block AME 7 AME 8 AME 9 AME 10 Move head AME 12 AME 13 AME 14 .........


Norm of good speech Env 2 Mum: my child stutters Env 4 Env 5 Env 6 Env 7 Env 8 Env 9 Env 10 Env 11 Env 12 Env 13 Env 14 ......... 25

The adapation becomes more elaborate as the child grows up


I have no girlfriend due to my stuttering Meme 2 Meme 3 Meme 4 Meme 5 Meme 6 Meme 7 Meme 8 I must hide my stuttering Meme 10 Meme 11 Meme 12 Meme 13 Meme 14 .........

D=block AME 2 AME 3 AME 4 AME 5 How it feels to block AME 7 Break eye contact AME 9 AME 10 Move head AME 12 AME 13 AME 14 .........


Norm of good speech Env 2 Mum: my child stutters Env 4 Env 5 John is a stutterer Env 7 Env 8 Env 9 Env 10 Env 11 Env 12 Env 13 Env 14 .........

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Benefits of the BPS2.0 framework

• A systematic approach to record all influencing elements in a consistent way.

• Provides an efficient introduction to the complexity of human system for students and patients.

• Enforces rigour in thinking.

• Easier and faster understanding improves treatment choice.

CASE STUDY: STUTTERING

1. John has been stuttering since the age of three. His mother and maternal uncle also

stutter.

2. His stuttering is moderate, and everyone understands him easily despite his stuttering.

3. He is terrified talking in front of other people, and still remembers the laughter at school.

4. He is more relaxed with friends and family, even though he still stutters.

5. Some weeks he finds speaking easier, and in some weeks he is struggling much more.

But he is always stressed about stuttering publicly.

6. He fears certain words that start with /d/, and avoids those words whenever possible.

7. Once he did an intensive three-week course, came out very fluent, and relapsed after a

few months much to his disappointment. John blames himself for his failure.

8. John is an IT specialist. His boss offered him a promotion but he would need to give public

presentations. John refuses, which leaves him frustrated and depressed.

What are the different options that could

potentially increase John’s well being?

From genes to social context - ECSF Antwerp Mar2014 v4... · Not just a consequence of stuttering...

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