eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Anxiety Disorder, Social Phobia and Selective Mutism

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

Introduction

Background

Selective mutism is a disorder in which an individual cannot or will not speak in specific situations when there is an expectation of conversational speech.1 Communicative language is generally intact in such individuals, although selective mutism can coexist with language and communication disorders. Selective mutism is accompanied by shyness and anxiety in many cases.2

Selective mutism is defined by the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition Text Revision (DSM-IV-TR) as a disorder primarily affecting children. In some cases, adolescents and adults continue to experience an inability to speak in public. This inability is generally most disabling at school, as the child cannot be assertive and speak when called on by teachers. In adults, functional impairment occurs when public speaking or lecturing are required in one's vocation.

Formerly, selective mutism was called elective mutism in the Diagnostic and Statistical Manual of Mental Health Disorders, Third Edition (DSM-III), which was reflective of a previous view that the child intentionally refused to speak with others outside of the immediate family group. Often, the child with selective mutism designates a friend or close family member to serve as an interpreter of communication and whispers into that person's ear, so that communication occurs with the designated person as intermediary.

Often, selective mutism can coexist with social phobia, which can be the precursor to agoraphobia. Agoraphobia is a specific phobia in which the individual fears being in crowded places. People with agoraphobia often become homebound.

This disorder is defined by marked and persistent fear of social or performance situations in which embarrassment may occur; exposure to the social or performance situation almost always causes an anxiety reaction such as a situationally bound or situationally predisposed panic attack.

The anxiety reaction is not due to psychosis; individuals are able to recognize their fears as excessive and unreasonable. However, the ability to fully comprehend that the reaction is out of proportion to the precipitant may be less complete in children and may depend on their cognitive-developmental level of functioning.

Selective mutism significantly impairs the individual's level of functioning, as the individual is unable to complete required educational, social, and family tasks, and the emotional distress engendered in situations requiring the person to speak out loud can result in school refusal.3

Selective mutism is a disorder that first occurs in childhood and can continue into adolescence and adulthood. In adults with this disorder, functional impairment occurs when public speaking or lecturing are required in one's vocation. Severe social anxiety may not be evident, as the person may actually function in a relaxed manner when using nonverbal (ie, gestures, signing) communication styles.4

Pathophysiology

Serotonin pathways may be involved in the mediation of the anxious and obsessive qualities of selective mutism. This theory is reinforced by animal models of phobic behavior and by response to commonly prescribed medications such as selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, or older heterocyclic-type antidepressants (eg, clomipramine [Anafranil]).5

Frequency

United States

Social phobia is the third most common mental health disorder after depression.6 Bergman et al (2002) reported that the prevalence rate of selective mutism was 0.71% but ranged from 0.08% to 1.9% depending on the population studied.7

Selective mutism is seen in fewer than 1% of children observed in mental health settings and is reported about 2-2.5 times more often in females than in males.8

Mortality/Morbidity

Generally, mortality does not result directly from selective mutism, except in cases of associated major depression resulting in suicide or reaction to medication treatment (sudden cardiac death with imipramine or clonidine) or adverse reaction such as newly onset suicidality following therapy with SSRIs or other antidepressants. A high morbidity rate is observed, with many missed school or workdays; the child often develops associated school refusal because of the anxiety associated with being asked to speak in class.8

Sex

Selective mutism is diagnosed more often in females than in males, with a female-to-male ratio of about 2-2.5:1.7

Age

Onset of selective mutism may occur as early as school age but generally occurs by mid adolescence following a childhood history of social inhibition or excessive shyness.2

The onset of selective mutism is often abrupt, occurring after a stressor or humiliating social experience and typically occurs when a child first attends school (either kindergarten or preschool). Over time, anxiety levels tend to increase as children do not "grow out of" selective mutism.9 Selective mutism persists as low self-confidence, shyness, and discomfort in social situations, often persisting into adulthood when speaking in public is required.10

Clinical

History

Careful attention to a history of caffeine overuse can be helpful, as caffeinism commonly mimics symptoms of anxiety. The family history often includes anxiety disorders (both social phobia and selective mutism). Selective mutism may frequently coexist with other speech and language disorders (eg, expressive-receptive language disorder, expressive writing disorder). Social or performance situations (eg, public speaking, performing in a school play) are typically avoided (or barely endured) by persons with social phobia and those with selective mutism.

DSM-IV diagnostic criteria for persons younger than 18 years state that, to be considered selective mutism, symptoms must persist for at least 6 months, must not be due to the direct physiological effects of a substance (eg, caffeine) or to a general medical condition, and must not be better accounted for by another mental health disorder (eg, depression, acute psychosis).1

The Bayley-Infant Neurodevelopmental Screener is commonly used in children younger than 3 years who generally have low birth weight and suspected intellectual disability.11

Causes

The etiology of selective mutism is multifactorial. Some children develop selective mutism after a stressor such as illness, separation from their caregiver, or other traumatic experiences such as abuse or neglect.12

Other children with selective mutism have an underlying language delay or disorder (most often expressive language disorder) or severe social anxiety and shyness. Some children report fearing the sound of their own voice. Adverse peer interactions frequently include peer social rejection and scapegoating directly related to the selective mutism.2

No specific genetic locus has been found; however, genetic factors may eventually be identified because a higher incidence of social phobia and selective mutism occurs in families with first- and second-degree family members with a history of panic disorder or other anxiety disorders.12

Instances of family members "speaking for" the children with selective mutism serve as positive reinforcement for not speaking, and this may also be self-reinforcing, as the child does not have to separate from them.2

  • Children with selective mutism are at higher risk for developing other developmental disorders, such as enuresis, encopresis, and abnormal EEG findings (because of immaturity), as well as developmental speech and language disorders. These disorders are also associated with increased incidence among first- or second-degree relatives.2
  • Mitral valve prolapse has not been associated with anxiety disorders in general and social (anxiety) phobia specifically.13
  • A cross-cultural perspective is essential. In Japan and Korea, what persons living in the West classify as social phobia may manifest as persistent and excessive fears of offending others in social situations instead of embarrassment (ie, taijin kyofusho), including fears that blushing, eye-to-eye contact, or one's body odor could be offensive to others.14

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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