Fear of Negative Evaluation, Trait Anxiety, and Judgment Bias in Adults who Stutter Purpose Persons who stutter (PWS) and those with social anxiety disorder may exhibit fear of negative evaluation (FNE) and anxiety in social situations. However, the information processing biases that perpetuate these characteristics have had limited investigation. This study investigated judgment bias in social situations. Method Participants included 50 ... Research Article
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Research Article  |   May 17, 2017
Fear of Negative Evaluation, Trait Anxiety, and Judgment Bias in Adults who Stutter
 
Author Affiliations & Notes
  • Shelley B. Brundage
    George Washington University, Washington, DC
  • Katherine L. Winters
    George Washington University, Washington, DC
  • Janet M. Beilby
    Curtin University, Perth, Western Australia, Australia
  • Disclosure: The authors have declared that no competing interests existed at the time of publication.
    Disclosure: The authors have declared that no competing interests existed at the time of publication. ×
  • Correspondence to Shelley B. Brundage: brundage@gwu.edu
  • Editor: Julie Liss
    Editor: Julie Liss×
  • Associate Editor: J. Scott Yaruss
    Associate Editor: J. Scott Yaruss×
Article Information
Speech, Voice & Prosodic Disorders / Fluency Disorders / Research Articles
Research Article   |   May 17, 2017
Fear of Negative Evaluation, Trait Anxiety, and Judgment Bias in Adults who Stutter
American Journal of Speech-Language Pathology, May 2017, Vol. 26, 498-510. doi:10.1044/2017_AJSLP-16-0129
History: Received July 28, 2016 , Revised October 31, 2016 , Accepted January 13, 2017
 
American Journal of Speech-Language Pathology, May 2017, Vol. 26, 498-510. doi:10.1044/2017_AJSLP-16-0129
History: Received July 28, 2016; Revised October 31, 2016; Accepted January 13, 2017

Purpose Persons who stutter (PWS) and those with social anxiety disorder may exhibit fear of negative evaluation (FNE) and anxiety in social situations. However, the information processing biases that perpetuate these characteristics have had limited investigation. This study investigated judgment bias in social situations.

Method Participants included 50 adults who stutter and 45 age- and gender-matched fluent persons who do not stutter (PWNS), who made up the control group. Participants completed the Interpretation and Judgmental Questionnaire (Voncken, Bögels, & deVries, 2003), and threat scores were calculated.

Results There were no significant differences between PWS and PWNS in social threat or nonsocial threat scores. When the PWS group was divided on the basis of FNE and compared with PWNS participants without heightened anxiety (n = 35), the PWS with high FNE had significantly higher total social threat scores than the PWS with low FNE. The three groups did not differ in threat ratings for ambiguous or profoundly negative social situations.

Conclusions Judgment bias in PWS is mediated by the magnitude of FNE present; not all PWS exhibit judgment bias for social situations. Treatment implications include the need for psychosocial support addressing the negative impacts on quality of life and restrictions on social engagement that stuttering may cause in some individuals.

A recent meta-analysis of research in stuttering disorders suggested a correlation between social anxiety disorder (SAD) and stuttering, in that the two disorders can occur concurrently (Craig & Tran, 2014). It has been argued that the two populations share symptomatology, including fear of negative evaluation (FNE); content-specific fear or anxiety toward social situations; and the use of avoidance or safety behaviors, such as avoiding eye contact (Iverach & Rapee, 2013; Lowe et al., 2012; Mahr & Torosian, 1999; Messenger, Onslow, Packman, & Menzies, 2004). These findings, however, have been challenged due to concerns about diagnosis and sampling procedures, as well as the additional burden on the individuals of potential labels and associated stigma (Manning & Beck, 2011). Although the two disorders appear to share some presenting symptoms, the underlying mechanisms responsible for SAD have only recently begun to be systematically investigated in persons who stutter (PWS). This article explores symptoms and underlying mechanisms of SAD, specifically judgment bias, in a sample of PWS and in age- and gender-matched persons who do not stutter (PWNS).
The American Psychiatric Association (2013)  publishes the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DSM-5), in which various disorders are defined and assessment and treatment procedures are described. In the DSM-5, SAD is characterized by intense fear of social or performance-based situations where evaluation by others may occur. Additional diagnostic criteria include the following: (a) anxiety and avoidance of social situations that interfere with one's social or occupational routine; (b) fear, anxiety, and avoidance for a duration of at least 6 months; and (c) a recognition that one's fear associated with social situations is extreme. In confirming the diagnosis of SAD, the person must exhibit fear or anxiety in social situations that is deemed to be “out of proportion to the actual threat posed by the social situation” (DSM-5, p. 203; Heimberg, et al., 2014). In earlier versions of the diagnostic definition of SAD, the presence of stuttering was an exclusionary criterion for social anxiety in the DSM, fourth edition, Text Revision (American Psychiatric Association, 2000; Iverach, Menzies, O'Brian, Packman, & Onslow, 2011), meaning that a person could not be diagnosed with SAD if they also stuttered. The American Psychiatric Association (2013)  recently revised its definition of social anxiety in the DSM-5 to include fear or anxiety in response to a social situation that is “out of proportion to what would normally be felt” for an individual presenting with an additional diagnosis such as stuttering (DSM-5, p. 203). This change in definition allows PWS to be diagnosed with SAD if indeed they demonstrate reactions that are out of proportion to given social situations.
Somewhat surprisingly, the DSM-5 does not specify the comparison group for determining whether a reaction is out of proportion to the actual threat involved. Instead, the DSM-5 states that the clinician should make the decision about whether a given response is “out of proportion to the actual threat” because “individuals with social anxiety disorder often overestimate the negative consequences of social situations” (DSM-5, p. 204) and therefore may not be in a position to accurately judge their own responses. However, making the clinical decision regarding out-of-proportion responses is challenging, due to the lack of norms regarding what constitutes an out-of-proportion response to a given situation. Until normative data become available for determining what constitutes out-of-proportion responses in the general population, it seems reasonable to use the clients' own responses to nonsocial situations as baselines for comparison, rather than relying on clinicians to make these decisions.
Stuttering is a speech disorder that may lead to affective, cognitive, and behavioral reactions. Disruptions in the forward flow of speech often lead to affective reactions such as anxiety, behavioral avoidance of social situations, and negative thoughts about oneself as a speaker (Manning, 2010). PWS can experience difficulty with social communication and are at risk for disabilities or handicaps as a result of their speech difficulties. For example, PWS can experience negative cognitive reactions or feelings associated with their stuttering that limit and ultimately handicap their ability to participate in social situations (Yaruss, 2007). Although this parallels the content-specific fear associated with SAD (DSM-5), these negative thoughts or feelings may not be “out of proportion to what would normally be felt” in all PWS.
Current Relationship Between Stuttering and Social Anxiety
FNE and social anxiety are considered major components in the maintenance of stuttering and also in individuals with SAD (Amir & Bomyea, 2010; Craig & Tran, 2014; Iverach & Rapee, 2013; Iverach, O'Brian et al., 2009; Mahr & Torosian, 1999; Messenger et al., 2004). Symptoms associated with SAD include FNE; expectancies of social harm; negative cognitions; attention biases; and the use of avoidance and safety behaviors, such as avoiding eye contact (Clark & Wells, 1995; Iverach & Rapee, 2013; Rapee & Heimberg, 1997; Rapee & Spence, 2004; Rodebaugh et al., 2004). These characteristics have also been reported in PWS using self-report scales (Blumgart, Tran, & Craig, 2010; Iverach, O'Brian et al., 2009; Iverach & Rapee, 2013; Messenger et al., 2004). In addition, PWS have reported increased trait anxiety and content-specific anxiety toward social situations (Craig, 1990; Ezrati-Vinacour & Levin, 2004; Iverach & Rapee, 2013; Iverach, O'Brian et al., 2009). A recent hallmark meta-analysis found evidence of elevated trait and social anxiety in PWS (Craig & Tran, 2014).
Although these studies suggested that a relationship exists between stuttering and SAD, they do not provide evidence that anxiety is a cause of stuttering. In fact, recent research suggests that stuttering appears first, and social anxiety may develop in response to the stuttering (Alm, 2014; Iverach, Jones et al., 2009; Iverach, Jones et al., 2011). Furthermore, the magnitude of the relationship between stuttering and SAD remains equivocal. Some studies report FNE in PWS as significantly greater than fluent controls (Messenger et al., 2004), but others indicate that FNE and trait anxiety in PWS are significantly lower than those exhibited in persons with SAD (Mahr & Torosian, 1999). Some previous research pertaining to reported heightened social anxiety in PWS can be challenged on the basis of criteria for subject selection. The methodologies have included the exclusive recruitment of adult PWS, who have actively sought treatment and are therefore not typical of the population as a whole, as well as control groups that are unmatched or include individuals with personality disorders (Iverach, Jones et al., 2009; Mahr & Torosian, 1999). Manning and Beck (2011)  further highlighted these methodological drawbacks by emphasizing the negative impact and stigmatization of this research on PWS. Additional research studies suggest that the co-occurrence of SAD and stuttering is infrequent and caution against the impact of inaccurately labeling PWS with anxiety disorders (Craig, Hancock, Tran, & Craig, 2003; Hinshaw & Stier, 2008; Manning & Beck 2011).
As mentioned earlier in this review, persons with SAD exhibit a fearful or anxious response to social situations that is “out of proportion” to the potential threat in those situations (DSM-5). The same is required for PWS if a SAD diagnosis is in fact to be made: The fear or anxiety in response to social situations must be either “unrelated” to stuttering or “out of proportion to what would normally be felt” by either adults with typical speech (DSM-5) or PWS. Despite the reported incidence of heightened fear or anxiety in PWS, conclusions cannot be drawn regarding the magnitude of the response by PWS to social situations without first defining “what would normally be felt” by typically fluent adults without heightened anxiety, and then comparing the responses of PWS to the responses of those typically fluent adults and to other PWS. The next section discusses how individuals without heightened anxiety make decisions in everyday social situations.
Heuristics and Cognitive Biases
In the context of daily living, humans encounter numerous social and nonsocial situations that warrant an appropriate response to avoid social stigma or ostracism. These situations can be positive, negative, or ambiguous. The number and variety of situations encountered require constant information processing, judgment making, and dynamic problem solving. Research indicates that despite being equipped with cognitive processes for interpreting new and uncertain information, people without heightened anxiety do not form generalizations or make predictions in ways that statistics or logic would suggest. Instead, individuals make quick, intuitive judgments—called heuristics—about situations in their daily lives on the basis of their experience. The way in which individuals retrieve information is heavily dependent upon those aspects of the encounter that are most salient to them personally (Mayer, 1983; Tversky & Kahneman, 1974). Heuristics allow for rapid, dynamic decision making and are often successful short cuts to problem solving (Kahneman, 2011). However, heuristics can lead to errors in decision making; these judgment errors are referred to as cognitive biases. Cognitive biases occur when evaluating all types of problems, from the important (e.g., when making medical decisions; Hall, 2002) to the mundane (e.g., judging whether the letter “r” appeared most often in the first or third position of a word in the English language; Tversky & Kahneman, 1973). In their seminal study on heuristics and decision making, Tversky and Kahneman (1974)  identified three heuristics that biased decisions: representativeness, availability, and adjustment from an anchor. The representativeness heuristic comes into play when people are asked, for example, how representative or probable a given situation is in relation to others. The availability heuristic occurs when persons judge the easiest-to-remember events as the most frequent or plausible. Anchoring is involved in number estimation; it occurs when numeric estimates are influenced by numbers (i.e., anchors) that are not related to the task at hand.
Many additional heuristics have been identified in the literature, and research indicates that individuals use many different social heuristics when evaluating social situations (Bauman & Skitka, 2010; Chambers & Windschitl, 2004; Ross, Amabile, & Steinmetz, 1977). Although social heuristics are often helpful in making quick social decisions, they can lead to inaccurate judgments in social perception (Kumbasar, Romney, & Batchelder, 1994), just as decision-making heuristics do. These inaccurate social decisions have the potential to lead to social stereotyping (Snyder, Tanke, & Berscheid, 1977). Therefore, the accuracy of judgments within social situations is paramount because social decision making drives professional and personal relationships. Accurate judgment within social contexts can lead to more fulfilling social interactions and better behavioral outcomes. On the other hand, quick decisions that lead to cognitive biases can negatively affect social interactions and the behavioral outcomes of those interactions (Hall, 2002; Schwab, 2008).
Relationship Between SAD and Information Processing Biases
Although all humans are susceptible to biases that influence their decision making, individuals with SAD often have cognitive biases that lead to inaccurate evaluations of social events and responses that are out of proportion to what would typically be experienced in the general population (DSM-5). This can result in erroneous decision making within social situations and the perpetuation of content-specific anxiety. The issue remaining to be investigated is the nature of the cognitive biases that ultimately lead to these inaccurate evaluations of social events.
Heinrichs and Hofmann (2001)  suggested four underlying mechanisms in SAD: attention bias, memory bias, interpretation bias, and judgment bias. These mechanisms not only influence how individuals with social anxiety process social information as threatening, but, on the basis of the responsiveness to treatment, they are also causally implicated in SAD (Amir & Bomyea, 2010; Taylor & Alden, 2010). That is, if these mechanisms are amenable to treatment, the threat perception of social information and social anxiety is decreased. Recent research in the stuttering disorders literature highlights the implication that these mechanisms may be present in individuals living with a stutter and are ultimately manifest in lack of social engagement and self-stigma (Boyle, 2013).
Attention Bias
Persons with SAD exhibit attention biases toward threatening stimuli, in that they attend more readily to socially threatening stimuli compared with other types of information (Amir & Bomyea, 2010). This bias toward threatening information has been observed in both persons with SAD and PWS using a modified Stroop task, where both groups named the color of socially threatening words (e.g., failure) significantly more slowly than neutral words (e.g., session) when reaction time of responses was compared with typical fluent, control participants without heightened anxiety (Amir, Freshman, & Foa, 2002; Heinrichs & Hofmann, 2001; Hennessey, Dourado, & Beilby, 2014; Hope, Rapee, Heimberg, & Dombeck, 1990). In addition, for individuals with SAD, attention bias for threatening stimuli has also been observed in probe detection tasks and in facial-recognition, face-in-the-crowd investigations (Amir, Elias, Klumpp, & Przeworski, 2003; Gilboa-Schechtman, Foa, & Amir, 1999; Musa, Lépine, Clark, Mansell, & Ehlers, 2003). A recent study comparing attention bias in adult PWS without heightened anxiety and a group of control subjects with typical speech (Lowe et al., 2016) found no between-group differences in overall attention bias. However, within the PWS group, trait anxiety scores were correlated with attention toward negative faces. Similar evidence of attention bias for sad faces has been demonstrated in children who stutter (McAllister, Kelman, & Millard, 2015).
It is important to note that these attention biases toward threatening stimuli appear to be amenable to treatment. Individuals with social anxiety demonstrate decreased attention to threatening stimuli after treatment (Pishyar, Harris, & Menzies, 2008; Schmidt, Richey, Buckner, & Timpano, 2009; Tobon, Ouimet, & Dozois, 2011).
Memory Bias
Individuals experiencing SAD may have further difficulties that affect their social engagement and quality of life if they experience difficulties in accurate memory recall. Individuals with SAD encode and recall socially threatening information differently from other types of information (Amir, Coles, Brigidi, & Foa, 2001; Ledley & Heimberg, 2006). More specifically, Amir, Foa, and Coles (2000)  found that individuals with SAD demonstrate a memory bias for socially threatening sentences. Other studies that have used social and nonsocial word categories or facial expressions of positive and negative emotions have shown findings supportive of a memory bias toward socially threatening information in individuals with SAD (Amir, Bower, Briks, & Freshman, 2003; Amir et al., 2001). To date, there has been no research addressing the possibility of memory bias for socially threatening information in PWS. However, clinical experience provides anecdotal information that PWS may recall socially threatening information differently than other types of social or nonsocial information.
Interpretation Bias
Social situations can be positive, negative, or ambiguous. In order to be diagnosed with SAD, the individual's fear or anxiety in response to a variety of social situations must be disproportionate to the actual threat involved in the situation (DSM-5). This could be manifest in a variety of ways; for example, an individual with social anxiety might misinterpret ambiguous events as threatening (Amir, Foa, & Coles, 1998), or they might misinterpret positive events as negative. Interpretation bias has been measured in SAD using a variety of methodologies, including written social scenarios; video vignettes; and photos representing neutral, positive, and negative emotions or social events (Amir, Beard, & Przeworski, 2005; Richards et al., 2002; Stopa & Clark, 2000; Voncken, Bögels, & deVries, 2003). Taken together, studies indicate that individuals with social anxiety interpret positive and negative social events significantly more negatively (Alden, Taylor, Mellings, & Laposa, 2008; Voncken et al., 2003), or even catastrophically (Stopa & Clark, 2000), compared with those of control participants.
As with attention biases, treatment of interpretation biases can significantly reduce anxiety in individuals with heightened anxiety (Hallion & Ruscio, 2011). The population of adults living with a stuttering disorder has been shown to experience heightened anxiety in social, vocational, and public speaking situations (Ezrati-Vinacour & Levin, 2004; Siegel & Haugen, 1964; Yaruss, 2007), so it is worth investigating to ascertain if similar interpretation bias may be present in PWS. If PWS exhibit interpretation biases, these biases should be amenable to treatment, just as they are in typically fluent persons with heightened anxiety.
Judgment Bias
Judgment bias is another contributing factor to the disproportionate anxiety toward social situations observed in persons with SAD. Judgment bias occurs when persons overestimate the probability that a negative event will occur and exaggerate the negative consequences or cost should the event occur (Foa, Franklin, Perry, & Herbert, 1996). Individuals with SAD demonstrate higher estimates of probability and cost to social threats when compared with controls without heightened anxiety and to populations with other disorders, such as persons with depression (Butler & Mathews, 1983; Lucock & Salkovskis, 1988; Voncken, Bögels, & Peeters, 2007; Voncken et al., 2003). Voncken et al. (2003)  developed the Interpretation and Judgmental Questionnaire (IJQ) and quantified judgment bias by calculating a “threat score” (multiplying ratings of perceived likelihood and perceived cost of various social and nonsocial events). They found increased estimates of threat for different types of social events in persons with SAD compared with controls without heightened anxiety. As with attention and interpretation biases, judgment bias has been a focus of various treatments in persons with SAD. Decreased judgment bias has been documented following safety behavior reduction, exposure therapy (Taylor & Alden, 2010), and cognitive behavior therapy (Moscovitch et al., 2012).
Aims and Hypotheses of the Present Study
Despite the potential relevance for PWS, neither interpretation bias nor judgment bias has been extensively investigated in this population. It is relevant to study judgment bias in PWS for two reasons. First, if PWS exhibit SAD, knowledge of the underlying mechanisms that drive SAD would be useful for broadening the theoretical constructs underpinning this disorder. Second, positive treatment outcomes have been demonstrated for persons with SAD. If PWS exhibit similar judgment biases, then expanding current behavioral and cognitive treatment techniques to include therapies and support addressing these issues may improve the prognosis for long-term durability of therapeutic gains over time. This study investigated judgment bias in social situations. In particular, our research questions included the following items:
  1. Across all types of social situations, is the threat associated with social situations—relative to nonsocial situations—greater for PWS than for persons who do not stutter (PWNS) who do not exhibit heightened anxiety?

  2. Do PWS and controls without heightened anxiety differ in their estimates of threat for different types of social situations (e.g., positive, ambiguous, mildly negative, and profoundly negative)?

  3. For PWS, does FNE moderate threat scores for different types of social situations?

It is hypothesized that if persons who stutter exhibit characteristics similar to those of individuals with SAD (namely, FNE and trait anxiety), they may overestimate the probability and cost for social situations, as evidenced by an increased threat score for social situations compared with nonsocial situations. In addition, such individuals may overestimate the probability for negative social events more than negative nonsocial events, when compared with age- and gender-matched controls with typical speech. Furthermore, these individuals could also overestimate the cost of ambiguous and negative social events (Carleton, Collimore, & Asmundson, 2010) when compared with control participants. This overestimation of probability and cost of social versus nonsocial situations would represent a reaction that is out of proportion to the threat of the situation.
Method
Participants
Two groups of participants were recruited for the study. Fifty PWS and 45 control participants with typical speech who were age-matched and gender-matched to the PWS group were recruited. These two groups are described next, and demographic characteristics are summarized in Table 1.
Table 1. Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Characteristic Group
PWS PWNS
Gender (male/female) 38/12 31/14
Age 33 (19.25) 33 (27)
Race/ethnicity (n/%)
 Caucasian 35/70 31/69
 Asian 10/20 0/0
 African American 2/4 0/0
 Did not report 3/6 14/31
Education (n/%)
 Less than high school 2/4 0/0
 High school 8/16 6/13.3
 Two-year degree 3/6 2/4.4
 Four-year degree 23/46 21/46.7
 Advanced degree 13/26 15/33.3
 Did not report 1/2 1/2.2
Table 1. Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Characteristic Group
PWS PWNS
Gender (male/female) 38/12 31/14
Age 33 (19.25) 33 (27)
Race/ethnicity (n/%)
 Caucasian 35/70 31/69
 Asian 10/20 0/0
 African American 2/4 0/0
 Did not report 3/6 14/31
Education (n/%)
 Less than high school 2/4 0/0
 High school 8/16 6/13.3
 Two-year degree 3/6 2/4.4
 Four-year degree 23/46 21/46.7
 Advanced degree 13/26 15/33.3
 Did not report 1/2 1/2.2
×
PWS Group
In total, 50 PWS (38 men, 12 women) with a median age of 33 years participated in the study. This gender ratio of 4:1 males to females is consistent with that reported in the literature and therefore constitutes a representative sample of adults who stutter (Manning, 2010).
Participants were recruited from the Curtin University Stuttering Treatment Clinic in Perth, Australia; the George Washington University Speech and Hearing Clinic in Washington, D.C.; the National Stuttering Association Chapters local to the Washington, D.C., area; the National Stuttering Association Annual Conference in Washington, D.C.; the Speak Easy Association of Australia; and snowball sampling of PWS and PWNS participants. Two certified speech-language pathologists (SLPs), each with over 15 years of experience in the assessment and treatment of stuttering, confirmed the stuttering diagnosis of all participants (the first author in the United States, and the third author in Australia).
PWS participants self-reported attending treatment for 0–2 years (n = 16; 32%), 3–5 years (n = 8, 16%), 6–10 years (n = 3, 6%), greater than 10 years (n = 6, 12%), or not at all (n = 7, 14%); 10 PWS did not report their treatment history (20%). Of those who participated in treatment, 26% reported using fluency shaping, 11% reported using stuttering modification, 20% reported experience with a combination of techniques, and 43% did not specify a treatment type. All participants reported the absence of diagnoses of general anxiety disorder, psychiatric disorders, or any speech or language disorder other than stuttering. The majority (90%) of participants were not currently receiving treatment.
Control Group With Typical Speech
The control group (PWNS) consisted of 45 adults (31 males, 14 females) with a median age of 33 years who had no experimenter-observed or self-reported speech or communication difficulties. The PWNS participants were recruited via flyers at the George Washington University and Curtin University campuses, and by snowball sampling of the PWS participants. The PWNS participants were age-matched to PWS participants to within 6 years of age. That is, participants in the control group were within 6 years of age of members of the comparison group described above. All participants reported the absence of diagnoses of general anxiety disorder, psychiatric disorders, or any speech or language disorder.
The PWS and PWNS groups did not differ in age (U = 1,043, p = .77). To assess whether educational attainment was similar in both groups, we quantified educational attainment as follows: less than high school = 10 years, high school diploma = 12 years, bachelor's degree = 16 years, and all advanced degrees = 18 years. The two groups did not differ in educational attainment (U = 994.5, p = .29).
Self-Report Measures
All participants completed three self-report measures: the Fear of Negative Evaluation (FNE; Watson & Friend, 1969), the State-Trait Anxiety Inventory-Trait Scale (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983), and the Interpretation and Judgmental Questionnaire (IJQ; Voncken et al., 2003).
The FNE is a 30-item questionnaire that measures respondent's concern for perceptions of other people in social situations. Respondents answered true or false for statements such as, “I feel very upset when I commit some social error” and “Other people's opinions of me do not bother me.” Scores are determined by assigning a value of 1 to each item answered that matches the key (17 true items) and reporting a sum ranging from 0 to 30. The FNE was normed on 297 men and women without any known clinical pathology; the mean score of the FNE was 13.97 for males and 16.1 for females in this sample (Watson & Friend, 1969). Scores of 18 or above are in the top 25% of the distribution of FNE scores. The authors suggest that persons exhibiting FNE scores of 18 or above “might be expected to be most affected by the possibility of disapproval” (p. 454). The FNE has a high level of internal consistency, with Kuder-Richardson coefficient (KR-20) values between .92 and .94 (Leary, 1991); the Kuder-Richardson coefficient is a recognized measure of internal consistency for items with a dichotomous scale (Cortina, 1993).
The STAI-T (Spielberger et al., 1983) is a standardized self-assessment of respondents' perceived overall anxiety levels. Respondents rate 20 self-descriptions such as “I am content” on a scale from 1 (almost never) to 4 (almost always), with higher scores indicating the absence of anxiety, and “I lack self-confidence” on the same scale, with higher scores indicating the presence of anxiety. Responses for anxiety-absent items are reversed and then summed with the anxiety-present responses, resulting in a trend for higher sums to reflect greater trait anxiety. Scores can range from 20 to 80. Spielberger et al. (1983)  reported the average scores for typical males (M = 34.89; SD = 9.19), typical females (M = 34.79; SD = 9.22), and male neuropsychiatric patients (M = 46.62; SD = 12.41) and good correlation with other widely used anxiety scales such as the Beck Anxiety Inventory (Beck & Steer, 1993).
Interpretation and Judgmental Questionnaire (IJQ)
The IJQ (Voncken et al., 2003) has good internal consistency and an intraclass coefficient (ICC) of .88 (Voncken et al., 2007). The IJQ discriminates between persons with social phobia and/or depression from those who do not exhibit these disorders (Voncken et al., 2003, 2007). The IJQ quantifies interpretation and judgment bias for 24 situations ranging from profoundly negative (e.g., “A friend tells you that a colleague dislikes you.”), to mildly negative (e.g., “The newly introduced person doesn't say anything to you.”), to ambiguous (e.g., “Somebody you know looks in your direction.”), to positive (e.g., “Someone makes a compliment about your looks.”). Part I presents the participants with 20 social situations (e.g., “You are with a group of people. When you start talking, nobody looks at you.”) and four nonsocial situations (e.g., “There is a lot of money debited from your bank account. However, you have never given this order.”). Participants are asked to provide written responses to questions associated with social situations (i.e., “Why is nobody looking at you?”) and nonsocial situations (i.e., “What do you think will happen to your money?”). Data from this section are not reported here.
In Part II, participants are presented with the same 24 situations and four possible interpretations specific to each situation. For each situation, there is one profoundly negative, one mildly negative, one neutral, and one positive interpretation. Participants are asked to read the situation and complete three different ratings. In this study, participants were asked to rank the four possible interpretations from the most probable to least probable, using the number “1” to indicate the most probable, “2” to indicate the next most probable, and so on. Next, participants used a visual-analog (VA) scale to rate the probability or likelihood that the worst-case scenario would occur in that situation. To rate probability, participants read each scenario and then placed a vertical line on the VA scale anchored from 0% on the left to 100% on the right. For example, participants used a VA scale to indicate the following: “How probable do you think it is that they really don't want you in the group because they don't think you are interesting?” VA ratings were measured in millimeters from the left anchor (i.e., from 0%) using a ruler. Last, participants used a VA scale to rate the cost or severity of the consequence for themselves in the event of the worst-case scenario. To rate cost, participants read each scenario and then placed a vertical line on a second VA scale anchored from not bad at all on the left to very bad on the right. For example, participants used this VA scale to indicate the following: “How bad would it be for you if they really don't want you in the group because they don't think you are interesting?” VA ratings were measured in millimeters from the left anchor (i.e., from “not bad at all”) using a ruler.
Scoring the IJQ
Calculating Threat Scores
The IJQ consists of 20 social situations (five each of ambiguous, profoundly negative, mildly negative, and positive) and four nonsocial situations. A Threat score was calculated for each of the 24 situations for each participant by multiplying the probability and cost VA values and then multiplying the product by 100, per the original IJQ scoring instructions (Voncken et al., 2003). The 20 social threat scores were summed to yield a Total Social Threat score. The four nonsocial threat scores were summed to yield a Total Nonsocial Threat score.
To calculate a threat score for each type of social situation, the threat scores for each of the situations were summed and then divided by 5 to arrive at a threat score for that specific social situation (e.g., probability + cost for all ambiguous situations/5 ambiguous situations = threat score for ambiguous social situations). This procedure yielded perceived threat scores for ambiguous, profoundly negative, mildly negative, and positive social situations.
Calculating Threat Ratio Scores
In order to quantify if participants' responses were “out of proportion” to what is typically felt, an Overall Threat Ratio for each participant was calculated by dividing his/her Total Social Threat score by his/her Total Nonsocial Threat score. By using a ratio, participants served as their own controls, allowing for individual differences in how people react to perceived threats in different situations. Threat ratios were also calculated for each type of social situation by dividing the Total Threat score for the situation by the Total Nonsocial Threat score (e.g., threat score for ambiguous situations/total nonsocial threat score = threat ratio for ambiguous situations). It was deemed appropriate to use participants as their own controls in the absence of normative values for threat scores for each social situation, and the hypothesis was that the threat ratios for PWNS would be lower than the threat ratios for PWS.
Procedures
This study was approved by the Curtin University Human Research Ethics Committee and The George Washington University Institutional Review Board. After reviewing an information sheet about the study and verbally consenting to participate in the study, all participants completed a brief demographic interview with an investigator, who documented the participant's demographic information, prior treatment, and verified the presence or absence of stuttering. Participants then completed the FNE, STAI-T, and IJQ questionnaires in randomized order.
Data Coding
Demographic information and participant responses for the FNE and STAI-T were recorded in a spreadsheet. Scoring of the FNE and STAI-T followed the original test instructions. Data entry was verified for FNE and STAI-T scores, and disagreements were resolved by reference to original test documents. Interrater reliability for IJQ visual–analog scoring (described above) was obtained by a second judge. This judge was in agreement with the visual–analog probability and cost measurements of the first judge 96% of the time.
Results
Power Calculations
We performed an a priori power calculation using G*Power (Faul, Erdfelder, Lang, & Buchner, 2007), setting our desired power at .80 for our anticipated calculations. In order to detect an effect size of .8, with a two-tailed test and α = .05, 52 participants (n = 26 per group) were needed. However, visual inspection of the obtained Total Social Threat, Total Nonsocial Threat, and Overall Threat Ratio scores revealed nonnormal distributions for each of these variables for all groups, and this was verified by SPSS. As a result, nonparametric statistics were used for calculations. We then performed a post-hoc analysis of achieved power, using G*Power and rules for calculating power for nonparametric statistics (Lehmann, 1975). Post-hoc analysis achieved power was .97 (with an effect size of .8, two-tailed test, α = .05, and two groups of n = 50 and n = 45). All statistical analyses were performed using SPSS version 22 (IBM Corporation, 2013).
Comparing PWS and PWNS Groups
Medians for FNE and STAI-T scores for the PWS (n = 50) and PWNS (n = 45) groups are in Table 2. A Mann–Whitney test revealed a significant difference in FNE scores (U = 1,456, p = .007). The PWS group exhibited significantly higher FNE scores. The two groups did not differ in STAI-T score (U = 1,247, p = .27).
Table 2. Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
FNE 17 (15) 7 (12)
STAI-T 42 (15.5) 38 (17)
Table 2. Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
FNE 17 (15) 7 (12)
STAI-T 42 (15.5) 38 (17)
×
Table 3 contains median threat scores for the PWS and PWNS groups. A Mann–Whitney U test revealed no significant differences between groups in Total Social Threat scores (U = 1,101, p = .99), Total Nonsocial Threat scores (U = 871, p = .08), or Overall Threat Ratio (U = 1,252, p = .13). Taken together, these findings suggest that, as a group, PWS and PWNS do not differ in their reactions to social situations. However, both groups had a subset of participants with FNE scores in the top 25% of the score distribution (Watson & Friend, 1969). In order to address research question 3, we decided to divide the PWS group into two groups, one with high FNE and one with low FNE, and compare their threat scores with the subset of PWNS with FNE scores in the typical range (procedures described below).
Table 3. Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
Total Social Threat 6.69 (15.27) 5.88 (7.88)
Total Nonsocial Threat 8.06 (13.69) 12.86 (25.9)
Overall Threat Ratio 0.89 (1.28) 0.68 (0.69)
Table 3. Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
Total Social Threat 6.69 (15.27) 5.88 (7.88)
Total Nonsocial Threat 8.06 (13.69) 12.86 (25.9)
Overall Threat Ratio 0.89 (1.28) 0.68 (0.69)
×
Assigning Participants to Groups According to FNE Scores
The participants were placed into three groups according to their stuttering status and scores on the FNE (Watson and Friend, 1969). The 50 participants in the PWS group were divided into two experimental groups on the basis of their FNE scores (seeTable 4). The 24 PWS with FNE scores of 18 or higher were placed in the PWS–High FNE group, as these scores are in the top 25% of the distribution of FNE scores in the normative sample (Watson & Friend, 1969). The PWS–High FNE group (19 men, 5 women) ranged in age from 18 to 70 years. The median STAI-T score for this group was 49, indicating elevated trait anxiety.
Table 4. Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.
Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.×
Variable Group
PWS–High FNE PWS–Low FNE PWNS
Age 33.00 (18.00) 35.00 (17.00) 33.00 (28.00)
FNE 23.00 (5.75) 8.00 (11.00) 5.00 (6.00)
STAI-T 49.00 (12.50) 36.00 (14.00) 36.00 (18.00)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.×
Table 4. Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.
Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.×
Variable Group
PWS–High FNE PWS–Low FNE PWNS
Age 33.00 (18.00) 35.00 (17.00) 33.00 (28.00)
FNE 23.00 (5.75) 8.00 (11.00) 5.00 (6.00)
STAI-T 49.00 (12.50) 36.00 (14.00) 36.00 (18.00)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.×
×
The 26 PWS with FNE scores below 18 were placed in the PWS–Low FNE group. The PWS–Low FNE group (19 men, 7 women) ranged in age from 20 to 64 years. The median STAI-T score for this group was 36.0, indicating self-perceived anxiety in the typical range.
The PWNS group was divided into two groups on the basis of their FNE scores. The 35 PWNS (24 men, 11 women) participants who had FNE scores below 18 (median = 8.00, indicating low fear of negative evaluation) were placed in the PWNS control group with typical anxiety. This group had a median age of 33 years. The median STAI-T score for the PWNS group was 36, indicating self-perceived anxiety in the typical range. The 10 remaining PWNS (7 men, 3 women) participants had high FNE scores and were excluded from further analyses, as our research questions were concerned with comparing PWS to control participants with typical anxiety who did not stutter.
Visual inspection of the FNE and STAI-T scores revealed nonnormal distributions for each of these variables for all three groups, and this was verified by SPSS. As a result, nonparametric statistics were used for calculations. A Kruskal–Wallis test revealed significant differences in FNE scores between groups, H(2) = 51.46, p = .001. Follow-up pairwise comparisons (with Bonferroni correction) revealed significant differences in FNE scores between the PWNS and PWS–High FNE groups (U = 6.78, p = .001), and between the PWS–High FNE and PWS–Low FNE groups (U = −5.68, p = .001). The FNE scores of the PWNS and the PWS–Low FNE groups were not significantly different (p = .50).
A Kruskal–Wallis test revealed significant differences in STAI-T scores between the three groups, H(2) = 24.32, p = .001. Follow-up pairwise comparisons (with Bonferroni correction) revealed significant differences in STAI-T scores between the PWNS and PWS–High FNE groups (U = 4.00, p = .001), and between the PWS–High FNE and PWS–Low FNE groups (U = −4.61, p = .001). The STAI-T scores of the PWNS and the PWS–Low FNE groups were not significantly different (p = .32).
Total Threat Scores Between the Three Groups
Medians for the three groups for Total Social Threat score and Total Nonsocial Threat score are given in Table 5. A Kruskal–Wallis test revealed significant differences in Total Social Threat scores between the three groups, H(2) = 8.03, p = .01. Follow-up pairwise comparisons revealed significant differences in Total Social Threat scores between the PWS–High FNE and PWS–Low FNE groups (U = −19.00, p = .006). No other pairwise comparisons were significant for Total Social Threat score. Total Nonsocial Threat scores were not significantly different between groups, H(2) = 1.72, p = .42.
Table 5. Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Score Group
PWS–High FNE PWS–Low FNE PWNS
Total Social Threat 12.70 (14.18) 3.08 (9.58) 5.01 (6.80)
Total Nonsocial Threat 8.37 (17.70) 6.05 (11.86) 12.35 (25.21)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
Table 5. Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Score Group
PWS–High FNE PWS–Low FNE PWNS
Total Social Threat 12.70 (14.18) 3.08 (9.58) 5.01 (6.80)
Total Nonsocial Threat 8.37 (17.70) 6.05 (11.86) 12.35 (25.21)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
×
Overall Threat Ratio Scores Between the Three Groups
Medians for Overall Threat Ratio scores for the three groups of participants are given in Table 6. A Kruskal–Wallis test revealed significant differences in the distribution of Overall Threat Ratio scores between PWS–High FNE, PWS–Low FNE, and PWNS groups, H(2) = 7.19, p = .02. Follow-up pairwise comparisons (with Bonferroni correction, α = .05/3 = .016) revealed significant differences in Overall Threat Ratio scores between the PWNS and PWS–High FNE groups (U = 2.54, p = .011). No other pairwise comparisons were significantly different.
Table 6. Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Situation type Group
PWS–High FNE PWS–Low FNE PWNS
Ambiguous 1.45 (2.57) 0.87 (0.90) 0.68 (0.91)
Profoundly negative 1.07 (1.84) 0.75 (1.38) 0.77 (0.88)
Mildly negative 1.00 (0.95) 0.40 (1.00) 0.35 (0.55)
Positive 0.73 (1.52) 0.29 (0.63) 0.37 (0.35)
Overall Threat Ratio score 1.02 (2.20) 0.75 (1.00) 0.63 (0.72)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
Table 6. Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Situation type Group
PWS–High FNE PWS–Low FNE PWNS
Ambiguous 1.45 (2.57) 0.87 (0.90) 0.68 (0.91)
Profoundly negative 1.07 (1.84) 0.75 (1.38) 0.77 (0.88)
Mildly negative 1.00 (0.95) 0.40 (1.00) 0.35 (0.55)
Positive 0.73 (1.52) 0.29 (0.63) 0.37 (0.35)
Overall Threat Ratio score 1.02 (2.20) 0.75 (1.00) 0.63 (0.72)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
×
Threat Ratio Score by Type of Situation
Median Overall Threat Ratio scores for different types of situations for PWS–High FNE, PWS–Low FNE, and PWNS groups are summarized in Table 6. Series of independent-samples Kruskal–Wallis tests, with Bonferroni correction (α = .05/4 = .013), were conducted to evaluate differences among the three groups on the distribution of Overall Threat Ratio scores for ambiguous, profoundly negative, mildly negative, and positive situation types.
There were no significant differences in Overall Threat Ratio scores between groups for ambiguous, H(2) = 4.74, p = .09, or profoundly negative, H(2) = 4.34, p = .11, situations. These findings suggest that all three groups found ambiguous and profoundly negative social situations equally threatening.
There were significant differences between groups for mildly negative social situations, H(2) = 12.26, p = .002. Pairwise comparisons revealed that the PWS–High FNE group had significantly higher Overall Threat Ratio scores for mildly negative situations than the PWS–low FNE group (U = −3.11, p = .006) and the PWNS group (U = 3.09, p = .006) did. The Overall Threat Ratio scores for mildly negative social situations did not differ between the PWS–Low FNE and PWNS groups (p = .83). For mildly negative social situations, the PWS–High FNE group reported the highest Overall Threat Ratio scores (e.g., the most out-of-proportion scores), followed by the PWNS group and the PWS–Low FNE group.
There were significant differences between groups for positive social situations, H(2) = 11.89, p = .003. Pairwise comparisons revealed that the PWS–High FNE group had significantly higher Overall Threat Ratio scores for positive situations than the PWS–low FNE group (U = −3.19, p = .004) and the PWNS group (U = 2.90, p = .004) did. The Overall Threat Ratio scores for positive social situations did not differ between the PWS–Low FNE and PWNS groups (p = .62). For positive social situations, the PWS–High FNE group reported the highest Overall Threat Ratio scores (e.g., the most out-of-proportion scores), followed by the PWS–Low FNE and the PWNS groups.
Discussion
The most significant finding from the present study is that not all PWS exhibit judgment bias for social situations. Social Threat scores and Overall Threat Ratios were similar for our two large groups of PWS and PWNS. It was only when the PWS group was divided on the basis of FNE score that group differences emerged: PWS with high FNE scores reported Overall Threat Ratios that were significantly higher than those for PWNS group that showed typical anxiety. This suggests that the presence of high FNE, as opposed to the clinical diagnosis of stuttering, may be a contributing factor for fear or anxiety that is “out of proportion to what would normally be felt” (DSM-5). Because the responses of the PWS with low FNE group mirrored those of the PWNS adults without heightened anxiety, judgment bias itself does not appear to be a perpetuating factor of fear or anxiety in all PWS.
In terms of Overall Threat Ratio scores for specific situation types, when compared with the other two groups, the PWS–High FNE group had significantly higher threat ratios—that is, significantly out-of-proportion scores—for mildly negative and positive social situations. However, the three groups (PWS–High FNE, PWS–Low FNE, and PWNS) did not differ in threat ratio scores for ambiguous and profoundly negative social situations, suggesting that all three of the groups, regardless of FNE and STAI-T score, find these types of social situations high in perceived threat.
These findings highlight the need to be mindful of the nature of the comparison group when characterizing the magnitude of judgment bias in a given client who stutters. Comparison to population norms, when they become available, will allow SLPs to decide if their client's performance is out of proportion to that of the general population. Comparing a given client's performance to that of other PWS allows clinicians to define their client's “individual strengths and weaknesses and areas in need of treatment/accommodation” (Strauss, Sherman, & Spreen, 2006, p. 47), as long as “the severity and nature of the impairments” match those of the client (Brookshire & McNeil, 2015, p. 72). Although SLPs cannot diagnose the presence of SAD, they can address clients' affective, behavioral, and cognitive reactions to communicative situations when providing treatment.
Implications for Stuttering Treatment
The present study highlights the importance of measuring FNE in PWS, as the FNE evaluation appears to influence how social situations are judged. PWS with high FNE reported significantly higher threat ratio scores for mildly negative and positive situations than PWS with low FNE or PWNS. The implication is that FNE evaluation may be a determining factor for the ways in which PWS approach different types of social situations. For example, in PWS who also exhibit high FNE, a therapy program that fails to assess and manage FNE evaluation is not assisting the individual who stutters with managing the challenges in their daily social living. In contrast, in PWS with low FNE, it would be inefficient to use valuable treatment time addressing FNE.
All PWS, regardless of FNE status, consider ambiguous and profoundly negative situations equally threatening, which is in contrast to many traditional theories of social anxiety (Carleton et al., 2010; Foa et al., 1996). This finding has implications for stuttering treatment programs that use situational hierarchies of increasing speaking difficulty (Manning, 2010). Such hierarchies are often used in systematic desensitization and to assist in generalization of therapy gains (Manning, 2010). The findings of the current study suggest that profoundly negative situations may not lead to reactions that are out of proportion for most PWS. PWS with high and low FNE as well as persons with typical anxiety who do not stutter estimate similar probability and cost values for ambiguous and profoundly negative social situations, and because PWS do not overestimate probability and cost for profoundly negative situations, there may not be a benefit in practicing these specific types of situations. It is interesting to note that the supposedly less threatening scenarios (i.e., mildly negative and positive) engendered differences in perceived threat between groups, suggesting that these types of scenarios may prove to be fertile ground for practicing fear-reduction strategies. PWS with high FNE interpret these types of scenarios more negatively than PWS with low FNE and PWNS. However, PWS with high FNE may exhibit interpretation biases similar to those reported for persons with SAD (Voncken et al., 2003). This finding warrants further exploration if positive treatment outcomes are to be integrated into daily living and sustained long term in PWS. Cognitive biases exhibited in persons with SAD are amenable to treatment and result in effective therapeutic outcomes in the reduction of characteristics perpetuating social anxiety (Moscovitch et al., 2012; Pishyar, et al., 2008; Taylor & Alden, 2010; Tobon, et al., 2011); it seems reasonable to explore the usefulness of such treatments in PWS who exhibit high FNE. Work has begun in this area, and a general cognitive behavior therapy program was successful in reducing characteristics of social phobia in a group of PWS (Menzies et al., 2008).
The results from this study, specifically, the key findings of significantly higher overall threat scores and higher threat scores for mildly negative and positive social situations for PWS with high FNE, underscore the rationale for integrated holistic treatment approaches supporting the positive management of stuttering beyond the surface speech changes. Manning (2010)  suggested that true efficacious therapy is positive therapy that is built on successes beyond the person's typography of stuttered speech. Thus, if PWS exhibit out-of-proportion responses to social situations, then these responses make reasonable treatment targets. In contrast, if PWS evaluate certain types of social situations in the same way as individuals with typical speech and typical anxiety, then therapy should not highlight these situations. It is unrealistic to expose clients to situations and insist on challenges beyond those that typical adults embrace.
There is new wave of contemporary treatments that integrates positive social engagement with fluency strategies known as Acceptance and Commitment Therapy (ACT; Beilby & Byrnes, 2012; Beilby, Byrnes, & Yaruss, 2012). The findings in the current study provide an endorsement for this future treatment direction that supports values-based decisions, mindfulness, and exploration of experiential avoidance. Such an integrated future therapeutic paradigm promotes awareness and understanding of the context for the speaker rather than targeting direct changes to the content of thought in and of itself (Beilby et al., 2012). A recent comparison of treatments mediating social anxiety indicated that the rate of change for improved experiential avoidance is a mechanism specific to ACT and not cognitive behavior therapy in general (Niles et al., 2014). ACT provides strategies to decrease judgment bias and “diffuse” the individual from their disorder. That is, following ACT, the person no longer defines themselves according to their problem, but chosen outcomes are directed at values-based living instead (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).
SAD and FNE respond to holistic ACT in that ACT addresses the responses in the individual's mindset that are indeed negative and “out of proportion” to the actuality of the situation. ACT can improve social engagement by directly managing experiential avoidance on the part of the speaker (Hayes et al., 2004). Avoidance may be at different levels for PWS (i.e., word avoidance, situation avoidance, or the lack of or restriction of social interaction). In general, ACT focuses on trying to increase psychological flexibility, defined by Hayes et al. (2006, p. 7)  as “the ability to contact the present moment more fully as a conscious human being, and to change or persist in behaviour when doing so serves valued ends.” Research analyzing ACT treatment with PWS has implemented six core processes to manage and increase psychological flexibility: self-concept, diffusion, acceptance, mindfulness, values, and committed action (Beilby & Byrnes, 2012). The results are promising in terms of an integrated treatment that provides fluency support while concurrently improving engagement and reducing the burden of the stuttering disorder (Beilby, Byrnes, & Yaruss, 2012).
Limitations and Future Directions
A recent meta-analysis by Craig and Tran (2014)  suggested that higher levels of trait and social anxiety predominate in PWS. Some of the PWS participants in the current study exhibited high FNE and trait anxiety, similar to those reported by Craig and Tran. However, half of the PWS group in the current study, in fact, did not exhibit high FNE or trait anxiety scores. The majority (90%) of participants in the present study reported that they were not seeking or desiring active treatment, and many were recruited from self-help organizations across the United States and Australia. Individuals participating in protective activities, such as social support networks, are likely to increase psychological resilience and improve quality of life (Boyle, 2015). Additional factors contributing to resilience in PWS include increased self-efficacy and healthy social functioning, and these factors are related to lower levels of psychopathology (Craig, Blumgart, & Tran, 2011). Increased self-efficacy, social support, and healthy social functioning through participation in self-help groups may have influenced the responses of our participants who stutter. Thus, the findings of the current study cannot be generalized to PWS who do not participate in protective activities such as those noted above.
An additional limitation of the current study is that the effects of high FNE and high trait anxiety scores cannot be separated. That is, the PWS with high FNE scores also reported high trait anxiety. It would be interesting, though perhaps difficult, to study PWS who have high FNE but report low trait anxiety, to see if the judgment biases noted in the current study pertain to that group as well. This would allow for a more detailed analysis of the possible mediating effects of FNE and trait anxiety on judgment bias in PWS. Other researchers have also noted the need to include PWS with high and low social anxiety in future studies of possible underlying biases of social anxiety in PWS (Lowe et al., 2016). In addition, comparing PWS to groups of PWNS with high FNE, as well as to PWNS with clinical diagnoses of SAD, might prove fruitful in describing possible subtle differences in social perceptions in these groups.
Future research should distinguish PWS with high and low FNE in order to accurately identify and ultimately support each of these different groups of PWS. Research questions should address any differences between these groups with respect to other cognitive biases and with respect to their general attitudes in approaching different social situations. Investigating cognitive biases exhibited by PWS, such as disparate or faulty attention (Hennessey et al., 2014; Lowe et al., 2016) or interpretation bias, may be a significant adjunct for successful therapeutic outcomes and engagement for adults living with stuttered speech.
Conclusion
The findings of the present study indicate that not all PWS exhibit an out-of-proportion response to social situations. The magnitude of the responses varies as a function of FNE. PWS with high FNE evaluation report significantly higher threat scores for certain types of social situations compared with PWS with low FNE evaluation and when compared with PWNS controls.
Acknowledgments
This project was completed in partial fulfillment of the second author's master's thesis at George Washington University. The first and second authors received Columbian College of Arts and Sciences dean's travel funds in support of this project. This project was supported in part by a Curtin University Research Fellowship to the first author. We thank the National Stuttering Association for assistance with participant recruitment. We thank Kathy Viljoen for her assistance with participant recruitment, and Emily Lowther and Daniela DiGuido for their assistance with data entry. We thank Adrienne Hancock and Michael Bamdad for comments on an earlier version of this manuscript.
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Table 1. Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Characteristic Group
PWS PWNS
Gender (male/female) 38/12 31/14
Age 33 (19.25) 33 (27)
Race/ethnicity (n/%)
 Caucasian 35/70 31/69
 Asian 10/20 0/0
 African American 2/4 0/0
 Did not report 3/6 14/31
Education (n/%)
 Less than high school 2/4 0/0
 High school 8/16 6/13.3
 Two-year degree 3/6 2/4.4
 Four-year degree 23/46 21/46.7
 Advanced degree 13/26 15/33.3
 Did not report 1/2 1/2.2
Table 1. Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for age and education, and demographic characteristics for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Characteristic Group
PWS PWNS
Gender (male/female) 38/12 31/14
Age 33 (19.25) 33 (27)
Race/ethnicity (n/%)
 Caucasian 35/70 31/69
 Asian 10/20 0/0
 African American 2/4 0/0
 Did not report 3/6 14/31
Education (n/%)
 Less than high school 2/4 0/0
 High school 8/16 6/13.3
 Two-year degree 3/6 2/4.4
 Four-year degree 23/46 21/46.7
 Advanced degree 13/26 15/33.3
 Did not report 1/2 1/2.2
×
Table 2. Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
FNE 17 (15) 7 (12)
STAI-T 42 (15.5) 38 (17)
Table 2. Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for Fear of Negative Evaluation (FNE; Watson & Friend, 1969) scores and State-Trait Anxiety Inventory-Trait Scale (STAI-T; Spielberger et al., 1983) scores for persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
FNE 17 (15) 7 (12)
STAI-T 42 (15.5) 38 (17)
×
Table 3. Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
Total Social Threat 6.69 (15.27) 5.88 (7.88)
Total Nonsocial Threat 8.06 (13.69) 12.86 (25.9)
Overall Threat Ratio 0.89 (1.28) 0.68 (0.69)
Table 3. Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.
Median (interquartile range) for total threat scores and overall threat ratio scores for the persons who stutter (PWS) and persons who do not stutter (PWNS) groups.×
Score Group
PWS PWNS
Total Social Threat 6.69 (15.27) 5.88 (7.88)
Total Nonsocial Threat 8.06 (13.69) 12.86 (25.9)
Overall Threat Ratio 0.89 (1.28) 0.68 (0.69)
×
Table 4. Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.
Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.×
Variable Group
PWS–High FNE PWS–Low FNE PWNS
Age 33.00 (18.00) 35.00 (17.00) 33.00 (28.00)
FNE 23.00 (5.75) 8.00 (11.00) 5.00 (6.00)
STAI-T 49.00 (12.50) 36.00 (14.00) 36.00 (18.00)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.×
Table 4. Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.
Median (interquartile range) for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups for age (in years) and self-report measures.×
Variable Group
PWS–High FNE PWS–Low FNE PWNS
Age 33.00 (18.00) 35.00 (17.00) 33.00 (28.00)
FNE 23.00 (5.75) 8.00 (11.00) 5.00 (6.00)
STAI-T 49.00 (12.50) 36.00 (14.00) 36.00 (18.00)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter; STAI-T = State Trait Anxiety Inventory-Trait Scale.×
×
Table 5. Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Score Group
PWS–High FNE PWS–Low FNE PWNS
Total Social Threat 12.70 (14.18) 3.08 (9.58) 5.01 (6.80)
Total Nonsocial Threat 8.37 (17.70) 6.05 (11.86) 12.35 (25.21)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
Table 5. Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Total Social Threat scores and Total Nonsocial Threat scores for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Score Group
PWS–High FNE PWS–Low FNE PWNS
Total Social Threat 12.70 (14.18) 3.08 (9.58) 5.01 (6.80)
Total Nonsocial Threat 8.37 (17.70) 6.05 (11.86) 12.35 (25.21)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
×
Table 6. Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Situation type Group
PWS–High FNE PWS–Low FNE PWNS
Ambiguous 1.45 (2.57) 0.87 (0.90) 0.68 (0.91)
Profoundly negative 1.07 (1.84) 0.75 (1.38) 0.77 (0.88)
Mildly negative 1.00 (0.95) 0.40 (1.00) 0.35 (0.55)
Positive 0.73 (1.52) 0.29 (0.63) 0.37 (0.35)
Overall Threat Ratio score 1.02 (2.20) 0.75 (1.00) 0.63 (0.72)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
Table 6. Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.
Median (interquartile range) Threat scores and Overall Threat Ratio scores for specific types of social situations, for PWS–High FNE (n = 24), PWS–Low FNE (n = 26), and PWNS (n = 35) groups.×
Situation type Group
PWS–High FNE PWS–Low FNE PWNS
Ambiguous 1.45 (2.57) 0.87 (0.90) 0.68 (0.91)
Profoundly negative 1.07 (1.84) 0.75 (1.38) 0.77 (0.88)
Mildly negative 1.00 (0.95) 0.40 (1.00) 0.35 (0.55)
Positive 0.73 (1.52) 0.29 (0.63) 0.37 (0.35)
Overall Threat Ratio score 1.02 (2.20) 0.75 (1.00) 0.63 (0.72)
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.
Note. PWS = persons who stutter; FNE = Fear of Negative Evaluation; PWNS = persons who do not stutter.×
×