Is There Selective Mutism in PTSD?

Summary: Yes, in some cases, there is selective mutism in PTSD, a.k.a. post-traumatic stress disorder, when an individual stops talking as a response to a traumatic event or series of traumatic events.

Key Points:

• Selective mutism (SM) is not a refusal or choice to remain silent. It’s an anxiety disorder with a primary symptom of being unable to speak in some or all situations.
• Selective mutism is rare appears most often in children, with symptom onset commonly occurring between ages 2 and 4.
• Selective mutism associated with PTSD in children is uncommon and more often associated with anxiety than trauma.
• In adulthood, selective mutism may be present due to untreated selective mutism in childhood but may also develop as a response to a traumatic event or series of traumatic events during adolescence, young adulthood, or adulthood.

What is Selective Mutism?

We’ll define selective mutism in children first, since we have more information on the phenomenon in children, and many of the same criteria apply to the appearance of SM in PTSD in adults. We’ll share this definition from a comprehensive review on the disorder called “Selective Mutism: A Review of Etiology, Comorbidities, and Treatment”:

“Selective mutism is a rare and multidimensional childhood disorder that typically affects children entering school age. It is characterized by the persistent failure to speak in select social settings despite possessing the ability to speak and speak comfortably in more familiar settings.”

The Diagnostic and Statistical Manual of Mental Disorders, Volume 5 (DSM-V) identify the following five criteria for diagnosis of SM:

1. Consistent inability to speak in specific social situations where speaking is expected, e.g. at school, despite speaking in other situations
2. Inability to speak interferes with school and work performance achievement and/or with communication in social situations.
3. Disruption/interference persists for a minimum of one (1) month.
4. Inability to speak is not caused by lack of knowledge or comfort with spoken language commo in the expected situation.
5. The inability to speak cannot be caused by a communication disorder, autism spectrum disorder, schizophrenia, or psychotic disorder.

In children, the inability to speak during the first month of school does not count toward the one month required for diagnosis.

Selective mutism appears in between 0.7 percent and 2 percent of people in the U.S. As we mention in summary and key points above, it’s most often a childhood condition that resolves before adolescence. However, experts observe the following:

“If left untreated, SM can take a chronic course and affect social–communicative capacity, mental health and quality of life in adolescence and adulthood.”

Now let’s look at the phenomenon of selective mutism in adulthood.

Selective Mutism in Adulthood Carried Over From Childhood

When selective mutism persists into adulthood due to an absence of diagnosis and treatment, it can cause significant complications. A person may go years with attenuated communication habits that can affect both family and peer relationships and have a negative effect on school and work performance and achievement.

Adults with untreated SM from childhood may attend fewer years of school and make less money over time. Common symptoms of childhood onset that persists into adulthood include:

• Avoiding social contact
• Extreme shyness
• Severe/intense emotional response when thinking about social situations
• Reluctance to make eye contact
• Remaining completely silent in social situations, can occur when addressed directly
  • Often mistaken for rudeness/aloofness
• Pronounced, observable physical stiffness and tension in common social situations

Adults with persistent SM identify the following situations that may trigger SM:

• Crowds, large groups of people
• Novel/new situations
• Situations demanding participation in group activities, or where participation in group activities is expected
• Unstructured, chaotic environments

We can see that SM can be a problem for adults, when untreated and present from childhood. However, it’s important to differentiate that type of mutism from post-traumatic mutism, caused by brain injury, and traumatic mutism, clinically identified as psychogenic or dissociative mutism.

Selective Mutism in PTSD: What’s Different?

Here’s how we can understand selective mutism in the context of trauma and PTSD, in comparison to selective mutism that develops during childhood:

“In some [trauma] survivors, speaking becomes impossible in specific situations or with specific people, not because they lack words, but because the anxiety response is severe enough to shut speech production down entirely. This isn’t a developmental disorder in this context; it’s a trauma response.”

Features that differentiate trauma- or PTSD-related selective mutism from developmental selective mutism include:

• Rapid, adult onset
• Appears following traumatic event:
  • PTSD-related
• Appears following a series of traumatic events
  • Complex PTSD-related
• Inability to speak may occur:
  • In all situations
  • Only in specific situations/places
  • Only in presence of specific person/people

Those symptoms can cause significant disruption in daily functioning. They can also create substantial emotional distress and may exacerbate the emotion-centered symptoms of PTSD such as fear, worry, and anxiety. In some cases, this can lead to withdrawal, isolation, and escalating psychological and emotional discomfort.

Here’s something important to know:

With evidence-based treatment, a patient can address and significantly improve the symptoms of selective mutism in PTSD.

Treatment for Selective Mutism in PTSD: Trauma-Informed Cognitive Behavioral Approaches

While treatment for SM in children may involve typical psychotherapy, play therapy, and family-centered therapy, treatment for PTSD-related selective mutism requires a trauma-informed approach.

To learn more about trauma-informed care, please read this article on our blog:

What is Trauma-Informed Care for Mental Health Disorders?

The most effective modalities for selective mutism in PTSD include the following, when adapted to account for the principles of trauma-informed care:

Cognitive behavioral therapy (CBT):

• CBT addresses the connection between thought, emotions, and behavior to resolve dysregulated outcomes associated with cognitive distortions and subsequent maladaptive behavior.

Trauma-focused cognitive behavioral therapy (TF-CBT):

• TF-CBT combines techniques of trauma-informed care with core CBT approaches.

Cognitive processing therapy (CPT):

• CPT is a well-established cognitive behavioral approach to PTSD, may be adapted to treat selective mutism in PTSD

Dialectical behavior therapy (DBT):

• DBT focuses on distress tolerance and managing emotional reactivity, characterized by practical tools to manage acute emotion, often applies mindfulness-derived techniques.

Eye Movement Desensitization and Reprocessing (EMDR):

• EMDR relies on a brain function called adaptive information processing (AIP), which helps patients access and process traumatic memories in a healthy and productive manner.

Exposure response prevention therapy (ERP):

• ERP involves intentional, sequential exposure to traumatic memories in order to decouple the memory from extreme emotional responses, which gradually enables a patient to manage those memories without distress.

Trauma-informed speech therapy:

• When trauma compromises specific areas of the brain associated with speech, a trauma-informed speech therapist can help patients restore core speech functions.

Trauma-informed care is highly individualized and relies on a positive therapeutic alliance between patient and provider. The first priority of all trauma-informed care is to avoid re-traumatization. This requires an atmosphere that’s safe, open, honest, and defined by compassion, empathy, and a full understanding of the impact of trauma on an individual.

In treatment for selective mutism in PTSD, some patients may experience full restoration of speech in all situations, others may experience full restoration of speech in most areas, and still others may require significant time to restore speech in the presence of triggers for trauma. The most effective approach is a combination of treatment that targets the resolution of traumatic memories, i.e. psychotherapy, and deficits in speech, i.e. speech therapy.

People with selective mutism caused by PTSD should understand that treatment is effective, can significantly improve most symptoms, and restore typical functioning in most areas of life.