the neurophsiology and pharmacologic treatment of stuttering · the neurophsiology and...
TRANSCRIPT
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The Neurophsiology and Pharmacologic
Treatment of Stuttering
Gerald A. Maguire, M.D.
Professor of Clinical Psychiatry
Kirkup Endowed Chair in Stuttering
Treatment
Senior Associate Dean, Medical Education
University of California, Irvine
School of Medicine
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Disclosure (all funding to UC Irvine School
of Medicine)
Grants: Otsuka, Merck
Speakers Bureau: Sunovion, Lilly, Merck, Novartis,
Lundbeck, Otsuka
Consultant: Merck, Novartis
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The History of Stuttering
Stuttering has
occurred throughout
recorded history in
every culture
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Every Language Has a Word for
Stuttering English stuttering
French begaiement
Spanish tartamudez
Sanskrit Jivha Jarata
Chinese hau hick
Japanese domori
Nigerian nsu
Persian locknatezaban
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Diagnostic Criteria for Stuttering
DSM-IV-TR diagnostic criteria for stuttering
(Code = 307.00) Axis I
A. Disturbance in normal fluency and time patterning of
speech (inappropriate for the individual’s age),
characterized by frequent occurrences of 1 or more of
the following:
(1) Sound and syllable repetitions
(2) Sound prolongations
(3) Interjections
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(4) Broken words (e.g., pauses within a word)
(5) Audible or silent blocking (filled or unfilled pauses in
speech)
(6) Circumlocutions (word substitutions to avoid
problematic words)
(7) Words produced with an excess of
physical tension
(8) Monosyllabic whole-word repetitions
(e.g., “I-I-I-I see him”)
Current Diagnostic Criteria for Stuttering (cont.)
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Current Diagnostic Criteria for Stuttering (cont.)
B. The disturbance in fluency interferes with
academic or occupational achievement or with
social communications
C. If a speech-motor or sensory deficit is present,
the speech difficulties are in excess of those
usually associated with these problems
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Revised Criteria for Stuttering in DSM-
V—Childhood Onset Fluency Disorder Addition of Criterion Concerning Avoidance/Anxiety
(captures “covert” stuttering)
Removal of interjections
Placement of “Developmental” Stuttering as Axis I
condition with onset in childhood.
“Psychogenic” stuttering (termed not used in medicine
or psychiatry) placed as Axis I and termed under
Malingering or Conversion Disorder based on
presentation
“Acquired” Stuttering placed as Axis III
www.psych.org
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Stuttering Statistics
1% of US adult population >2,000,000
4% of US child population >3,000,000
Total in the US (as of 2000) >5,000,000
Membership in National Stuttering Association 4,500
Source: 2000 Census (numbers are rounded). Total US population: 281,421,906. Total US adult Population: 200,948,643. Total US children (under age 19): 80,473,263.
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Historical Stuttering Theories and
Treatments
Believed to be caused by abnormalities of the
tongue or larynx
• Cauterizing or cutting the tongue
• Botulinum toxin injections into the larynx
• Both without efficacy
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Orton and Travis:
A Brain Theory of Stuttering
Stuttering may arise from abnormal cerebral
activity/stuttering viewed as a brain disorder
(cross dominance with handedness)
Believed to be brought about by an incomplete
dominance of the speech centers
Orton ST. Arch Neurol Psychiatry. 1927;18:671-672. Travis EE. Speech pathology; A dynamic neurological treatment of normal speech and speech deviations; 1931.
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Psychoanalytic Theory
Unconscious neurotic need fulfillment
Unresolved oral conflict
“Stuttering results from thoroughly unresolved
pregenital oral sadistic conflict”
Dominic Barbra
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Stuttering Shows Many Similarities
With Tourette’s Syndrome
Both associated with tic motions
Both follow a waxing and waning course
Made worse under anxiety or stress
4:1 male to female ratio
Begins in childhood
Symptoms worsened by dopamine agonists and improved with
dopamine antagonists
Related to abnormalities in the basal ganglia
Genetic linkage postulated1
1. Comings DE. J Am Acad Child Adolesc Psychiatry. 1995;34(4):401-402.
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Etiology of Stuttering (Likely
Multifactorial) Genetics
Abnormal development of basal ganglia and/or
white matter tracts (Maguire et al; Neumann et al; Sommer et al)
Autoimmune Component (i.e. PANDAS) (Maguire et
al. Annals of Clinical Psychiatry.)
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PANDAS Stuttering
Pediatric Autoimmune Disorder Associated with
Streptococcus
Antibodies directed against streptococcal
infection cross-react and attack developing basal
ganglia.
Established etiologic mechanism in Tourette
Syndrome and OCD.
Now described in Stuttering
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Famous Persons Who Stutter(ed)
Alexander the Great
Aristotle
Winston Churchill
Charles Darwin
King George VI
James Earl Jones
Bo Jackson
Somerset Maugham
Marilyn Monroe
Moses
Carly Simon
Bill Walton
Bruce Willis
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PET and SPECT Imaging
Allow measurement of the metabolism of the
living functioning brain
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Brain Imaging Studies of Stuttering (cont.)
Wood, Stump 1980 investigated the effects of
haloperidol on brain activity in stuttering utilizing
SPECT
• Stuttering symptoms improve with haloperidol with
resulting improved fluency associated with increased
brain activity in speech areas
Wood F, et al. Brain Lang. 1980;9(1): 141-144.
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Brain Imaging Studies of Stuttering (cont.)
Pool, Devous, et al. in a large SPECT study
showed stuttering to be associated with no
abnormalities in brain structure (MRI), but
associated with abnormally low brain activity in
left-sided speech cortical areas
Pool KD, et al. Arch Neurol. 1991;48(5):509-512.
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Brain Imaging Studies of Stuttering (cont.)
Left hemispheric speech areas less active
than analogous areas of right hemisphere
Now confirmed with structural (MRI)
studies (Foundas et al; Sommer et al)
Is the increase in right-sided structures a
compensatory effect/therapy effect? May
explain gender differences.
De Nil LF, et al. J Speech Lang Hear Res. 2000;43(4):1038-1053. Fox PT, et al. Nature. 1996;382(6587):158-161. Sommer et al. Lancet 2002
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Brain Imaging Studies of Stuttering (cont.)
Wu, Maguire, Riley, et al. utilized FDG to
measure glucose metabolism in stuttering
• Stuttering associated with abnormal low activity of
speech cortical areas (Broca’s and Wernicke’s)
and striatum
• During induced fluency, cortical speech areas
increase to normal or high normal areas, but
striatum remains low
Wu JC, et al. Neuroreport. 1997;8(3):767-770.
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Two “Loops” of Speech
An inner or medial system
• Abnormal in stuttering
An outer or lateral system
• Can be activated in stuttering through induced fluency
Riley G, et al. PET scan evidence of parallel cerebral systems related to treatment effects. In: Hulstijn W, Peters HFM, eds. Speech production: motor control, brain research, and fluency disorders; 1997.
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Right Left
Dopamine--
GABA
Dopamine
blocker/
Pagoclone
Wernicke’s Area
“O
ute
r lo
op”
“In
ner
loo
p”
Broca’s Area
Possible Neurologic Pathway of Stuttering
Involved in Pharmacologic Treatment
Dopamine lowers
activity of striatum
Olanzapine/
risperidone block
dopamine, leading to
increased activity of
the striatum and
improved fluency
GABA can reduce
dopamine function
(Pagoclone)
–
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Dopamine Theory of Stuttering
Striatal hypometabolism=elevated dopamine1
Dopamine antagonists increase
striatal metabolism1
Dopamine antagonists improve stuttering1
Dopamine activity elevated in persons
who stutter1
Dopamine agonists worsen stuttering2
1. Maguire GA. Lancet-Neurology. 1(7) November 2002. 2. Burd L, Kerbeshian J. J Clin Psychopharmacol. 1991;11(1):72-73.
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Pharmacologic Treatment of
Stuttering
Numerous medications have been studied
but until recently, only those with dopamine
blocking activity have shown confirmed
efficacy
Pagoclone, a GABA selective agonist, has
shown efficacy as well in the largest
pharmacologic trial of stuttering ever
conducted
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Haloperidol
First-Generation Dopamine Antagonist
Associated with improved fluency
However, poor long-term compliance secondary
to disabling side effects (e.g., dysphoria,
sexual dysfunction, extrapyramidal symptoms,
tardive dyskinesia)
Rosenberger PG, et al. Am J Psychiatry. 1976;133:331-334.
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Pimozide/Paroxetine Study
Positive clinical response in those on pimozide
(dopamine antagonist)
Paroxetine (serotonin reuptake inhibitor)
exhibited no clinical response
However, Pimozide associated with limiting side-
effects such as EPS, TD, dysphoria, prolactin
elevation and cardiac conduction concerns Stager S, et al. A double-blind trial of pimozide and paroxetine for stuttering. In: Hulstijn W, et al., eds. Speech Production: Motor Control, Brain Research, and Fluency Disorders; 1997:379-382.
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New Generation Dopamine Blockers
Studied in Stuttering
Risperidone
Olanzapine
These agents have a much lower risk of motor
system side-effects (e.g. tardive dyskinesia) and
are much better tolerated than first generation
agents
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Risperidone Study
n=16
Double-blind, placebo-controlled
6-week duration
Maguire GA, et al. J Clin Psychopharmacol. 2000;20(4):479-482.
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Risperidone Study (cont.)
Ages 20-74 (mean 40.75)
12 males/4 females
Dose 0.5-2.0 mg
Ratings (% SS, duration, % TS, SSI-3)
Maguire GA, et al. J Clin Psychopharmacol. 2000;20(4):479-482.
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Reductions in Severity Scores at best time-point in
Subjects Receiving Risperidone or Placebo
-60
-50
-40
-30
-20
-10
0
% SS Duration % TS SSI-3
RisperidonePlacebo
*p<.01 vs baseline **p<.001 vs baseline
% SS=syllables stuttered; % TS=time stuttering as a % of total time speaking. SSI-3=Stuttering Severity Instrument, Third Edition (measured overall stuttering severity). Maguire GA, et al. J Clin Psychopharmacol. 2000;20(4):479-482.
% R
edu
ctio
n in
Sev
erit
y S
core
s
*
*
**
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PET Imaging of the Effects of
Risperidone in Stuttering
Risperidone is associated with increased activity
in the striatum and cortical speech areas
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Olanzapine: An Atypical Dopamine
Antagonist
In studies of other disorders, olanzapine has different
tolerability than risperidone (less EPS, TD, dysphoria,
sexual dysfunction, and prolactin elevation). Propensity
for greater weight gain, however.
Tran PV, et al. J Clin Psychopharmacol. 1997;17(5):407-418.
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Olanzapine vs Placebo: 3-Month Study
24 adult patients who stutter (ages 18-55)
Multicenter, 3-month, double-blind, placebo-
controlled trial
Dose range 2.5→5 mg
(starting dose 2.5 mg)
Maguire GA, et al. Annals of Clinical Psychiatry
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-60
-50
-40
-30
-20
-10
0
% SS Duration % TS SSI-3 (Overall)
OlanzapinePlacebo
% SS=syllables stuttered; % TS=time stuttering as a % of total time speaking. SSI-3=Stuttering Severity Instrument, Third Edition (measured overall stuttering severity). Maguire GA, et al. Annals of Clinical Psychiatry
% R
edu
ctio
n in
Sev
erit
y S
core
s
*
*p<.044 vs. placebo
Reductions in Severity Scores on the SSI-3
Measures in Subjects Receiving Olanzapine or
Placebo
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-30
-25
-20
-15
-10
-5
0
OlanzapinePlacebo
SSS=Subjective Stuttering Scale Maguire GA, et al. Annals of Clinical Psychiatry
% R
edu
ctio
n in
SS
S
*p<.01
22%*
<1%
Reduction in Subjective Stuttering Scale
in Subjects Receiving Olanzapine
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Results
Olanzapine more effective than placebo in
reducing stuttering on all 3 ratings
(SSI-3, CGI, and SSS)
Olanzapine well tolerated with minimal
side effects
Efficacy continues long-term • Some subjects showed greater efficacy at higher
doses
At the conclusion of the study each subject
requested to remain on olanzapine Maguire GA, et al. Annals of Clinical Psychiatry
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Olanzapine vs. Placebo
Three-month study – Safety results No prolactin related side effects
No changes of fasting blood glucose or development of
diabetes in this study
Weight gain/appetite increase4.0 lbs on olanzapine vs.
<1 lb placebo
Mild sedation
1 subject discontinued study (subject was taking
placebo)
At the conclusion of the study, each subject requested
to remain on olanzapine
Maguire GA, et al. Annals of Clinical Psychiatry
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Asenapine
Not associated with significant weight gain or
glucose/lipid increases
Sublingual administration
Associated with bitter taste but flavored available in
US
Double-blind Placebo-Controlled Trial ongoing
Published data supporting utility in Stuttering (Am. J
Psychiatry—June 2011)
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Quetiapine
Not extensively studied in stuttering
Relatively weak D2 antangonism--
With Histamine blockade—causes
sedation and this side-effect limits its
use in stuttering
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Aripiprazole
Partial dopamine agonist—Lower dosages may work better?
Akathisia can limit utility in stuttering
Published report examining safety and effectiveness in stuttering
Tran NL, Maguire GA. Journal of Clinical Psychopharmacology
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Ziprasidone
Not adequately studied in stuttering but
based on mechanism of action,
promising agent
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Iloperidone
Requires a titration of dosage
Associated with light-headedness
Not adequately studied in stuttering but
based on mechanism of action, promising
agent
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Lurasidone
Well-tolerated except akathisia
Low weight gain/metabolic risk
Not adequately studied in stuttering but
based on mechanism, may be promising
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Pagoclone
Pagoclone, is a selective GABA-A partial agonist
The Largest Pharmacologic Trial of Stuttering Ever
Conducted has now been Completed.
Based on an unclear mechanism for stuttering
treatment—GABA agonism.
J. Clin Psychopharm (2010)
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Pagoclone Program in Stuttering
2 Cases identified in Panic Disorder trial • History of persistent developmental stuttering at entry
• Stuttering improved while on active drug (along with anxiety symptoms)
• Stuttering returned to baseline after trial
Literature: GABA may have role in stuttering
Consultant input on stuttering assessment
Indevus decision to conduct pilot (Phase 2a) trial 039
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Pagoclone Phase IIa Study 039
Double-blind, placebo controlled, 8 weeks
• Titration: 0.15 mg BID x 2 wk, then 0.30 mg BID x 6 wk
• Primary endpoint: change in SSI-3 total score o Secondaries included subcomponents of SSI-3 (% SS),
CGI-I, Liebowitz Social Anxiety Scale
Open label extension
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Pagoclone Phase IIa Study 039 Change from Pre-Treatment in Percentage Syllables Stuttered
Week
4 8 Avg 4 and 8
Pe
rce
nt
Ch
an
ge
fro
m S
cre
en
/Ba
se
line
-30
-25
-20
-15
-10
-5
0
Placebo
Pagoclone
P<0.01
P=0.07 P<0.01
P-values from ANOVA with effects for treatment and center.
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Pagoclone Phase IIa Study 039 Percent of Patients with Improvement as Assessed by CGI-I Severity
LOCF
P-values from CMH controlling for center.
On-Treatment
Week 2 Week 4 Week 8
CG
I Sev
erity
Per
cent
of P
atie
nts
Impr
oved
fr
om P
re-T
reat
men
t
0
10
20
30
40
50
60
Placebo
Pagoclone P<0.01P<0.02
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Pagoclone Phase IIa Study 039 LSAS Total Score – Subset of Patients with Baseline LSAS Total Score > 45
On-Treatment Week
4 8
LS
AS
To
tal S
co
re C
ha
ng
e f
rom
Pre
-Tre
atm
en
t
-20
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
Placebo
Pagoclone
P<0.03
P<0.03
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Over 90% of patients in the 8 week double
blind phase entered the open label extension
Some patients experienced life-changing
benefits (e.g., employment, public speaking)
Very Effective on Social Anxiety associated
with Stuttering
Pagoclone Phase IIa Study 039 Open Label Extension
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Improvements in fluency seen in the double blind
phase increased progressively over 4-6 months of
treatment
• original placebo group showed expected lag in
timecourse
Dosing was 0.6 mg once per day
Starting with second year of extension, added dose
flexibility to 0.6 mg BID
Safety data revealed excellent tolerability
Pagoclone Phase IIa Study 039 Open Label Extension
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Pagoclone Phase IIa Study 039
Percentage Syllables Stuttered – DB + OL
P-values from ANOVA with effects for treatment and center.
Week 4 Week 8
Perc
ent C
hange in %
Sylla
ble
s
Stu
ttere
d C
hang
e F
rom
Base
line
-50
-40
-30
-20
-10
0
Placebo DB
Placebo DB --> Pagoclone OL
Pagoclone DB
Pagoclone DB --> Pagoclone OL
P<0.01
P=0.07
Double-Blind Phase
Month 3Open-Label Phase
N=29 N=53N=41 Placebo, N=82 Pagoclone
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Pagoclone Phase IIa Study 039 Percent of Patients with Improvement as Assessed by CGI-I Severity
P-values from CMH controlling for center.
Week 2 Week 4 Week 8 Month 3 Month 6
CG
I S
eve
rity
Pe
rce
nt o
f P
atie
nts
Im
pro
ve
d
fro
m P
re-T
rea
tme
nt
0
20
40
60
80
100
Placebo DB
Placebo DB --> Pagoclone OL
Pagoclone DB
Pagoclone DB --> Pagoclone OL
P<0.01P<0.02
Double-Blind Phase Open-Label Phase
N=42 for Placebo, N=82 for Pagoclone
N=29 N=56 N=24 N=50
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Pagoclone Phase IIa Study 039 LSAS Total Score – Subset of Patients with Baseline LSAS Total Score > 45
Week 4 Week 8
LS
AS
To
tal S
co
re C
ha
ng
e f
rom
Pre
-Tre
atm
en
t (S
ub
gro
up
)
-30
-25
-20
-15
-10
-5
0
Placebo DB
Placebo DB --> Pagoclone OL
Pagoclone DB
Pagoclone DB --> Pagoclone OL
Double-Blind Phase
Month 3Open-Label Phase
N=27 for Placebo N=37 for Pagoclone N=18 N=23
P<0.03
P<0.03
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Improvements in fluency seen in the double blind
phase increased progressively over 4-6 months of
treatment
• original placebo group showed expected lag in
timecourse
Dosing was 0.6 mg once per day
Starting with second year of extension, added dose
flexibility to 0.6 mg BID
Safety data revealed excellent tolerability
Pagoclone Phase IIa Study 039 Open Label Extension
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Pagoclone Tolerability and Safety
Pagoclone was very well tolerated and resulted in a
“natural” speech
Pagoclone Very Effective in Social Anxiety Associated
with Stuttering
J. Clin. Psychopharm 2010
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Protocol IP456-041
Title of Study: A 3-arm, double-blind, placebo-controlled
clinical trial to assess the efficacy, safety and tolerability of
pagoclone for the treatment of adults with stuttering
Multi-center, randomized, 3-arm, placebo-controlled,
parallel group Phase IIa study involving 24 weeks double-
blind treatment followed by an 8-week double-blind Wash-
out and then a long-term open-label extension phase
Approximately 60 investigational centers in the United
States in around 330 patients
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Pagoclone
Pagoclone Tolerated Very Well
Higher dosages appear to result in higher efficacy
Challenge of accurately measuring stuttering
efficacy—natural variability of the disorder—
accommodation to therapeutic setting
Funding has currently ceased. No further
development planned
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Treatment of Comorbid Conditions
Social Anxiety common stuttering. CBT may be
useful
Comorbid ADHD—stimulants may worsen
stuttering. Perhaps trials of noradrenergic agents
first-line
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Deep Brain Stimulation (DBS)
Approved for Treatment of Parkinson’s, Essential
Tremor
Cases in the literature of treatment of acquired
stuttering
First case published this month (Maguire et al, Am J.
Psych) of treatment of developmental stuttering with
DBS
DBS case replicated in France
Patent filed by Medtronic for DBS treatment of stuttering
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Future Directions in Stuttering
Pharmacologic Research
Trials of Pagoclone at higher dosages?
Trials of other dopamine antagonists
Asenapine trial beginning—case series
published
How do we accurately assess changes in
stuttering severity? Global scales consistent
with treatment effect but what about more
quantitative measures?
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Future Directions (cont.)
What about combining speech therapy with
medication?
What about medication treatment in adolescents?
Lysosomal Storage Modified treatments?
Psychiatrists should be the lead phsicians,
partnering with Speech/Language Pathology in the
Treatment of Stuttering
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Contact Me!
(714)456-5794
www.kirkupcenter.uci.edu
Without Hesitation: Speaking to the Silence and to the
Science of Stuttering. www.westutter.org