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Anxiety Disorder, Social Phobia and Selective Mutism: Differential Diagnoses & Workup

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Consultant, Child Guidance Resource Centers, Early Elementary Education Program, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Sep 25, 2009

Differential Diagnoses

Child Abuse & Neglect: Dissociative Identity Disorder
Oppositional Defiant Disorder
Child Abuse & Neglect: Physical Abuse
Personality Disorder: Avoidant Personality
Child Abuse & Neglect: Reactive Attachment Disorder
Pervasive Developmental Disorder
Child Abuse & Neglect: Sexual Abuse
Somatoform Disorder: Somatization
Hearing Impairment

Other Problems to Be Considered

Difficulties with language acquisition (English as a second language)
Expressive-receptive language disorder
Mental retardation
Childhood-acquired aphasia
Apraxia due to head trauma
Cerebral palsy
Panic disorder with or without agoraphobia
Mood disorder
Substance-related disorder
Kleffner-Landau syndrome

Workup

Laboratory Studies

  • If selective mutism is indicated based on history and physical examination, perform the following tests to rule out other medical problems or to assess baseline function prior to starting medication:
    • CBC count - To exclude anemia or another blood dyscrasia as a preexisting condition or contraindication to the use of psychotropic medication
    • Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) - To exclude hypothyroidism, which may also accompany depression as a cause of a hypoglossal nerve motor problem (eg, glossal articulation difficulty causing language disfluency)
    • Metabolic screening for sodium, BUN, and creatinine - To exclude renal impairment or renal failure as a contraindication to medication treatment; especially important because of the potential side effects of hyponatremia resulting from treatment with SSRIs
    • Serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase - To exclude liver problems as a contraindication to medication treatment (prior to initiation).
    • Lead level - To exclude language delay (as evidenced by cognitive delay) due to elevated lead levels15
  • Rule out Landau-Kleffner syndrome (LKS), especially in a child with seizure disorder with a history of loss of previously acquired skills such as toileting, social interaction, or language.16
  • The patient should be carefully monitored when doses are changed or new medications started. When SSRIs or serotonin and norepinephrine reuptake inhibitors [SNRIs]) are started, monitored should occur weekly at first, then every other week, then monthly to detect newly onset suicidality or agitation. Monitor for adverse reactions when psychotropics or antidepressants are prescribed.17,18

Imaging Studies

  • Brain MRI: This is generally performed if an acute or chronic brain abnormality is suspected as a cause of language delay. For example, in a child with an acute change of mental status or functioning, MRI would be used to rule out a brain tumor, especially of the fourth ventricle, which rarely manifests as this type of change.
  • EEG: This can be helpful to diagnose Landau-Kleffner syndrome, a potential cause of language delay.16

Other Tests

  • Language screening - Usually performed by a licensed speech and language pathologist who can also serve as the primary clinician if the child has a language disorder19
  • Screening physical examination, including hearing testing and a screening neurologic examination - To exclude tumors or other disorders (eg, aphasia)19
  • ECG - To exclude any cardiac contraindication to medication treatment, such as a cardiac conduction abnormality or arrhythmia prior to medication treatment13
  • EEG with neurologist consultation - To exclude a neurologic condition, including seizures, and to rule out Landau-Kleffner syndrome, especially if a language delay and seizures are suspected16
  • Structured or semistructured interview - To help to determine past or present history of self-harm or potentially suicidal behavior in the patient or a family history of suicidality
  • Psychometric screening tests - To confirm a diagnosis of selective mutism, to judge treatment responsiveness, and to help assess level of acuity and severity
    • Instruments such as those below are primarily used in research studies but can be helpful for confirming a clinical diagnosis, for monitoring the response to treatment, and for assessing the level of acuity and severity. The following specific anxiety inventories are useful in following response to treatment that may be slow and initially subtle:
      • The Selective Mutism Questionnaire (SMQ) is a 17-item questionnaire that is helpful in assessing severity.20
      • The Multidimensional Anxiety Scale for Children (MASC) is a specific screening test for anxiety and related disorders that was developed by March and colleagues at Duke University.21
      • The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) is a semistructured diagnostic interview for children aged 6-17 years. It was developed as a screening instrument for use by clinically sophisticated (ie, mental health) interviewers. The K-SADS inventory was originally developed by Orvaschel, Puig-Antich, and Chambers to screen for affective disorders, anxiety disorders, schizophrenia, and schizophreniform disorders. K-SADS has been revised and updated by Kaufman, Birmaher, and Brent at Western Pennsylvania Psychiatric Institute.22
      • Screen for Child Anxiety Related Emotional Disorders (SCARED) is a specific screening test for anxiety and phobic disorders. It was developed by Birmaher et al at Western Pennsylvania Psychiatric Institute and is helpful in confirming the clinical diagnosis of anxiety disorders.23
      • The Connors' Parent-Teacher Questionnaire was designed as a checklist. It is generally more accurate in providing corroborating evidence for externalizing disorders such as conduct problems or attention deficit/hyperactivity disorder (ADHD). The questionnaire may be used when an anxiety disorder and an externalizing disorder such as ADHD or conduct disorder are comorbid. The instrument does not, however, clarify the diagnosis when an anxious child is being oppositional in the face of being forced into new situations.
  • Projective testing (eg, Rorschach, Children's Apperception Test) - Should be performed only by a licensed clinical psychologist; not to be substituted for a careful clinical interview by a skilled clinician; especially helpful to rule out personality disorders or psychosis (testing for loss of reality)19

More on Anxiety Disorder, Social Phobia and Selective Mutism

Overview: Anxiety Disorder, Social Phobia and Selective Mutism
Differential Diagnoses & Workup: Anxiety Disorder, Social Phobia and Selective Mutism
Treatment & Medication: Anxiety Disorder, Social Phobia and Selective Mutism
Follow-up: Anxiety Disorder, Social Phobia and Selective Mutism
References
Further Reading
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Keywords

selective mutism, elective mutism, excessive shyness, extreme shyness, social anxiety disorder, panic attack, anxiety reaction, social fear, performance fear, performance anxiety, agoraphobia, mental health disorder, social phobia, situationally bound panic attack, situationally predisposed panic attack, functional impairment, serotonin pathways, depression, expressive-receptive language disorder, speech and language disorders

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Contributor Information and Disclosures

Author

Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Consultant, Child Guidance Resource Centers, Early Elementary Education Program, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia
Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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