from genes to social context - ecsf antwerp mar2014 v4... · not just a consequence of stuttering...
TRANSCRIPT
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
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 .........
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
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 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
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 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 .........
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 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
Memories Body Environment
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 .........
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 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?
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