Psych · General adult psychiatry — anxiety disorders
Selective mutism
Also known as SM · Elective mutism (historical, outdated) · Situational mutism · Anxiety-related failure to speak
Exam-exhaustive fellowship reference on selective mutism — DSM-5-TR and ICD-11 criteria, anxiety-chapter reclassification, epidemiology, behavioural inhibition and social-evaluative mechanisms, differentials from SAD, ASD and language disorders, SMQ/SSQ assessment, first-line behavioural/CBT school-inclusive packages (IBTSM, Oerbeck), fluoxetine adjunct evidence, school liaison, multi-board stepped care. FRANZCP-primary, globally tagged.
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- School-entry mutism with cascading academic failure, peer exclusion, or family crisis — treat as high-stakes functional problem requiring multi-agency plan, not 'wait and see until next year'
- Public forcing of speech, shaming, or punitive 'elective' framing that worsens anxiety and is not graded exposure
- Assumed pure oppositionality without anxiety formulation — miss treatable anxiety pathway
- Missed hearing loss, language disorder, or autism spectrum when silence is multi-factorial
- New or worsening suicidal ideation with comorbid depression, or SSRI activation in youth — same-day risk review
- Safeguarding concern when mutism pattern suggests trauma, abuse, or severe neglect rather than classic SM
Meet the patient
A 6-year-old girl is brought in because she "will not speak at school". In the waiting room she chatters non-stop to her mother; the moment you walk in, she freezes, goes blank-faced, and will not answer a single question. Her teacher says she has not said a word all term. Her parents are embarrassed and have started answering for her in shops.[1][3]
Two questions are live. Is this defiance, or is this anxiety? And what is the family's well-meaning rescue doing to the silence? Treat it as naughtiness and you worsen it; answer for her forever and you guarantee it persists. The whole topic turns on reading the silence as frozen anxiety, not choice.[1][2][4]
References14ShowHide
- [1]Viana AG, Beidel DC, Rabian B Selective mutism: a review and integration of the last 15 years Clin Psychol Rev, 2009.PMID 18986742
- [2]Muris P, Ollendick TH Children Who are Anxious in Silence: A Review on Selective Mutism, the New Anxiety Disorder in DSM-5 Clin Child Fam Psychol Rev, 2015.PMID 25724675
- [3]Bergman RL, Piacentini J, McCracken JT Prevalence and description of selective mutism in a school-based sample J Am Acad Child Adolesc Psychiatry, 2002.PMID 12162629
- [4]Cohan SL, Chavira DA, Stein MB Practitioner review: Psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990-2005 J Child Psychol Psychiatry, 2006.PMID 17076747
- [5]Bergman RL, Gonzalez A, Piacentini J, Keller ML Integrated Behavior Therapy for Selective Mutism: a randomized controlled pilot study Behav Res Ther, 2013.PMID 23933108
- [6]Oerbeck B, Stein MB, Wentzel-Larsen T, Langsrud Ø, Kristensen H A randomized controlled trial of a home and school-based intervention for selective mutism - defocused communication and behavioural techniques Child Adolesc Ment Health, 2014.PMID 32878377
- [7]Oerbeck B, Overgaard KR, Stein MB, Pripp AH, Kristensen H Treatment of selective mutism: a 5-year follow-up study Eur Child Adolesc Psychiatry, 2018.PMID 29357099
- [8]Black B, Uhde TW Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study J Am Acad Child Adolesc Psychiatry, 1994.PMID 7961338
- [9]Dummit ES 3rd, Klein RG, Tancer NK, Asche B, Martin J Fluoxetine treatment of children with selective mutism: an open trial J Am Acad Child Adolesc Psychiatry, 1996.PMID 8935208
- [10]Kaakeh Y, Stumpf JL Treatment of selective mutism: focus on selective serotonin reuptake inhibitors Pharmacotherapy, 2008.PMID 18225967
- [11]Chavira DA, Shipon-Blum E, Hitchcock C, Cohan S, Stein MB Selective mutism and social anxiety disorder: all in the family? J Am Acad Child Adolesc Psychiatry, 2007.PMID 18049296
- [12]Muris P, Ollendick TH Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder Clin Child Fam Psychol Rev, 2021.PMID 33462750
- [13]Katzman MA, Bleau P, Blier P, Chokka P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders BMC Psychiatry, 2014.PMID 25081580
- [14]Bandelow B, Allgulander C, Baldwin DS, Costa DLDC, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part I: Anxiety disorders World J Biol Psychiatry, 2023.PMID 35900161