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A patient who had suffered acute trauma to the head is reported. The patient was observed immediately upon admission to the hospital, and he was noted from the outset to have wakeful speechlessness. The evolution and resolution of neurological deficits were also observed. A review of the literature and a discussion of the possible causes of acute traumatic mutism are presented.
Two cancer patients are reported, who presented with altered consciousness 2 and 3 months, respectively, after the administration of 5-fluorouracil derivatives, and progressed to a state of akinetic mutism. At first a presumptive diagnosis of metastatic brain tumor was made. However, the result of a cerebrospinal fluid cytology for malignancy was negative, and computed tomography (CT) scanning revealed diffuse decreased attenuation of the cerebral white matter, indicative of leukoencephalopathy, without association of mass lesion. Upon discontinuing the drugs, both patients made significant recovery and the decreased attenuation on the CT also disappeared. The significance of the early diagnosis of this pathology is emphasized.
Transient mutism, without disorders of consciousness or cranial nerve deficits, arising after surgical operations on the posterior cranial fossa is a recently described entity. To date 22 cases have been reported, to which we add the present case (the first report of the syndrome in an adult). We review the salient features of the syndrome in the light of the published cases and speculate on the underlying physiopathology.
A case of unsuspected quinine overdose is reported in a 14-year-old girl. Presenting symptoms included deafness and mutism. Diagnosis was delayed for approximately 4 hours because of the absence of an accurate history. Case details, laboratory values, and hospital course are discussed. Signs of cinchonism and common ototoxins are discussed. Strategies for the management of quinine overdose are reviewed.
BACKGROUND: Because abnormal Auditory Efferent Activity (AEA) is associated with auditory distortions during vocalization, we tested whether auditory processing is impaired during vocalization in children with Selective Mutism (SM). METHODS: Participants were children with SM and abnormal AEA, children with SM and normal AEA, and normally speaking controls, who had to detect aurally presented target words embedded within word lists under two conditions: silence (single task), and while vocalizing (dual task). To ascertain specificity of auditory-vocal deficit, effects of concurrent vocalizing were also examined during a visual task. RESULTS: Children with SM and abnormal AEA showed impaired auditory processing during vocalization relative to children with SM and normal AEA, and relative to control children. This impairment is specific to the auditory modality and does not reflect difficulties in dual task per se. CONCLUSIONS: The data extends previous findings suggesting that deficient auditory processing is involved in speech selectivity in SM.
Selective mutism (SM) is a rare and interesting condition that has been associated with a wide variety of childhood psychiatric conditions. Historically viewed as more of an oddity than a distinct diagnostic entity, early conceptualizations of the condition were based largely on case studies that tended to link SM with oppositional behavior. More recently, controlled studies have enhanced our understanding of SM. This review summarizes the current conceptualization of SM, highlighting evidence supporting the notion that SM is an anxiety-related condition.
OBJECTIVE: Cerebellar mutism (CM) is a postoperative complication of mainly pediatric posterior fossa surgery. Multiple theories exist for explaining this phenomenon. We have made an attempt to further understand this entity given a particularly interesting case as it relates to multiple pathophysiologic pathways. METHODS: We have reviewed the details surrounding a particularly interesting case of CM. A retrospective analysis of this patient's clinical history and recovery is described. An extensive literature review has been performed in conjunction with an attempt to help elucidate details and a better understanding of CM. RESULTS: A thorough analysis of existing theories as to the pathophysiologic mechanism of CM has been performed as it relates to the details of this particular case. A case is described in which a child exhibiting CM abruptly improved and made a relatively quick recovery after the triggering of the melodic speech pathway by way of watching and beginning to sing along with a video. It appears that this incident involving a familiar song catalyzed various speech pathways, which apparently were in some state of shock. This phenomenon seems to be a temporary entity involving not only the mechanical coordination of speech production, but also the initiation of speech itself. CONCLUSIONS: Evidence exists for a pathophysiologic pathway for speech by way of coordinating phonation and articulation. In addition, there seems to exist a pathway by which the initiation of speech may be altered or halted by posterior fossa pathology, namely, vermian or dentate nuclear injury. In particular to this case, we found that the incidental appreciation of other forms of speech, melodic in this instance, may be the key to help stimulate and accelerate the recovery from CM.
A 42-year-old man presented with akinetic mutism, caused by bilateral thalamic infarction, resulting in a temporary amnesic syndrome and, finally, selective downgaze palsy. Electroencephalographic recording in the initial phase showed generalized spike- and-wave discharges, similar to those found in animal studies after lesion or stimulation of specific thalamic nuclei. Analysis of magnetic resonance images (MRI) of the head showed that the centre of ischemic necrosis particularly involved the intralaminar thalamic nuclei and a small part of the rostral mesencephalon. The findings support the previously suggested involvement of cortico-thalamo-mesencephalic circuitry in the initiation of motor responses, and the association of the non-specific thalamic nuclei with the appearance of generalized epileptiform phenomena in cases of reduced vigilance.
Though it has long been known on the basis of clinical associations and serendipitous observation that speech rate is related to mood and psychomotor baseline, it is less known that speech rate is also related to libido and to immune function. We make the case for a bipolar phenomenon of "psychic tonus," encompassing all these dimensions. The elated, agitated, libidinal, immunofacilitated, and talkative pole is an "approach" disposition primarily activated by the normal left hemisphere-especially, though not exclusively, its frontal lobe. The dejected, lethargic, delibidinized, immunosuppressed, and mute pole is an "avoidance" disposition primarily activated by the normal right hemisphere-especially, though not exclusively, its frontal lobe. In support of this proposed model, we present new evidence, via meta-analysis of previously published single lesion case reports, of a highly significant association between right hemisphere lesions and non-aphasic hyperlalia, and between left hemisphere lesions and non-aphasic mutism.
Elective mutism (EM) is a rare psychiatric condition of childhood involving refusal to speak in social situations. We herewith describe such a case which developed into a full-blown schizophrenic illness. This may be the first detailed report of such an outcome in the literature.
The authors report a case of mutism that was ultimately found to be associated with chronic cocaine use in an adult woman. Brain dysfunction was confirmed by SPECT scan, which revealed reduced cerebral blood perfusion and areas of infarction, presumably consequent to the cocaine addiction. This is the first reported case of such an association.
The relationship between selective mutism (SM) and childhood anxiety disorders is illustrated through an examination of their temperamental, environmental, and biological etiologies. SM is also explored as a symptom of the specific anxiety disorders of social phobia, separation anxiety, and posttraumatic stress disorder. The etiology and symptom overlap demonstrates SM as being an anxiety disorder or a variant of a specific anxiety disorder. The conceptualization of SM as an anxiety disorder is helpful in effectively treating afflicted children. There is enough evidence in the current literature to challenge the current classification, from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders of SM as an Other Disorder of Infancy, Childhood, and Adolescence.
Tacrolimus (FK506), an immunosuppressant, has been associated with mutism in adults after liver transplant. Speech arrest, agitation, tremor, ataxia, and downward gaze deviation in a 5-year-old female 13 days after orthotopic liver transplant are reported. FK506, which began to be administered 12 days earlier, rose to a level of 44 ng/mL (normal range, 10-20 ng/mL) 1 day before neurologic abnormalities began. FK506 dose level was maintained and then reduced. Three days later the patient could say a few single words and extra-ocular movement returned to normal. Four months later, she continued to exhibit decreased fluency and dysarthria with ataxia. One year later, decreased fluency and mild ataxia persists. Rapid identification of speech loss linked to FK506 may be important because reduction or cessation of the drug may be associated with reverse of speech loss.
Cerebellar mutism (anarthria) is a well-described complication of posterior fossa tumor resection. It is accompanied by a characteristic behavior including irritability and autistic features. This syndrome is typically reversible within days to months. Underlying pathophysiology is unknown. We describe two children who presented with a similar clinical finding after nonsurgical cerebellar involvement, hemolytic-uremic syndrome in one and cerebellitis in the other. Postmortem pathologic findings in the first patient indicated cerebellar ischemic necrosis. Single-photon emission computed tomography in the second patient revealed diffuse cerebellar hypoperfusion with no supratentorial abnormalities, refuting a phenomenon of diaschisis between cerebellar and frontal connections. These findings confirm that this clinical syndrome may occur in a nonsurgical, nontraumatic context. They are consistent with recent integrative hypotheses explaining cerebellar anarthria.
The clinical pattern of complete akinetic mutism (AM) was observed in a patient with a bilateral infarction of the anterior cerebral arteries extending to the rostral cingulate cortex and the supplementary motor areas. Since the patient was unable to produce any overt response, event-related brain potentials (ERPs) were used to obtain information about cortical processing of stimuli. Oddball tasks with simple acoustical stimuli and semantic categories were used. Verbal processing was further assessed by comparing event-related potentials to words compatible versus incompatible to the semantic context. Although the pattern of cortical responses was abnormal, differential responses were clearly obtained to semantically different word classes. Thus, the hypothesis about cortical non-responsivity of AM patients, drawn from several previous reports, was not supported. An ERP examination in AM patients can deliver information about their mental state, provided that the stimuli and tasks possess a wide range of informational complexity and motivational value.
The etiology of selective mutism (SM) in children is unknown but is regarded as multifactorial. SM is frequently associated with social anxiety and language disorder or delay. The present study addresses SM and social anxiety as a familial phenomenon by comparing self-reported personality traits and symptom traits (Millon Clinical Multiaxial Inventory) in parents of 50 SM children with control parents. Personality and symptom traits reflecting social anxiety are also explored separately in the parents of SM children with and without a comorbid communication disorder. The results confirm SM and social anxiety as a familial phenomenon. Assessment and treatment planning should take this into account. The family data also suggest different family transmissions of SM and social anxiety in the SM group with and without a comorbid communication disorder.
Selective mutism (SM) is a rare and complex disorder associated with anxiety symptoms and speech-language deficits; however, the nature of these language deficits has not been studied systematically. A novel cross-disciplinary assessment protocol was used to assess anxiety and nonverbal cognitive, receptive language, and expressive narrative abilities in 7 children with SM and a comparison group of 7 children with social phobia (SP). The children with SM produced significantly shorter narratives than children with SP, despite showing normal nonverbal cognitive and receptive language abilities. The findings suggest that SM may involve subtle expressive language deficits that may influence academic performance and raise additional questions for further research. The assessment procedure developed for this study may be potentially useful for language clinicians.
We treated 27 children with idiopathic epilepsy with zonisamide monotherapy over a period of 2 years and observed behaviour disturbances in a prospective study. In all cases, seizure control was excellent; however, two cases (7.4%) had behaviour disturbances. The first (Case 1) was a 14-year-old girl with partial epilepsy which began at age 4 years. Zonisamide was administered at age 6 years, which was effective against her seizures, but selective mutism, violent behaviour, and lack of concentration developed at age 10 years. The second (Case 2) was a 15-year-old girl with generalized tonic-clonic seizures which began at age 10 years. Zonisamide was also effective against her seizures, but obsessive compulsive disorders (OCD) developed at age 13 years. The patients have had no other physical or mental problems and decreasing the dosage of zonisamide reduced the problems. There are few reports of behaviour disturbances provoked by zonisamide monotherapy in epileptic children who are neither physically nor mentally disturbed. While problems can develop several years later, in the present study, decreasing the zonisamide dosage maintained adequate prevention of seizures and eliminated the behaviour disturbances. Zonisamide is still a useful anticonvulsant for epileptic seizures, but physicians should be wary of its adverse behavioural side effects, which may arise several years later.