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Within a two-year period, 15 electively mute children were seen in a single Head Start program. Most were not only silent, but also compliant, reticent, and almost "frozen" around strangers. A small subgroup, in contrast, displayed oppositional behavior. This paper reviews the literature on "elective mutism" and advocates a developmental and familial analysis of the presenting symptoms.
Three cases of bilateral anterior cerebral artery occlusion are presented with akinetic mutism. The anatomical distribution of the infarction in these patients combined with cases in the literature suggests that this syndrome can have a localizing value for the clinician. If increased intraventricular pressure is not present, the clinician can suspect a bilateral lesion of cingulate gyrus, medial nuclei of basal ganglia, and/or anterior and reticular nuclei of the thalamus.
A case of mutism due to left hemisphere infarction is described. Recovery revealed mild motor dysphasia. Review of the literature showed that the case resembles aphemia but is unique by virtue of its duration, and the absence of associated apraxia and paresis.
Transient cerebellar eye closure (TCES) is a complication of cerebellar tumor surgery in children and is almost exclusively observed in the context of the syndrome of mutism and subsequent dysarthria. As knowledge about the course of transient cerebellar eye closure is absent, we describe in detail the clinical picture in a 14-year-old girl. The process of improvement of TCES is characterized by four distinct phases, can last more than 1 month and may be associated with severe persistent cerebellar dysfunction.
The wacinko syndrome in the Oglala Sioux varies from a nonclinical reaction to pathological degrees of anger, pouting, withdrawal, depression, psychomotor retardation, mutism, immobility, and even to suicide. Although indigenous proctitioners recognize the syndrome as a distinctive disorder, it has not been described by non-Indian practitioners. The author presents a case report and suggests that most cases are diagnosable as reactive depressive illness.
To survey parents of children with selective mutism (SM) in regard to (1) the role of the primary care physician in the diagnosis of SM; (2) the social and school consequences of SM; and (3) their opinion of the effectiveness of different treatment modalities, a 39-item written survey was mailed to 27 parents with at least one child diagnosed with SM on the basis of diagnostic and statistical manual IV-text revision (DSM IV-TR) criteria. Twenty-seven parents (100%), with a total of 33 children with SM, completed the survey. There were 24 girls and 9 boys. The mean age when parents had strong concerns about symptoms of SM was 3.8 years, but diagnosis did not occur until nearly a year later. Twenty-three (69.7%) of the children with SM were never diagnosed accurately or referred by their primary care physicians. SM caused important school/social problems for 17 (51.5%) of the children. Speech therapy was provided for 36.4% of children and was thought to have been helpful for 30% of them. Behavior modification was the treatment for 45.5% of children and perceived to be helpful for 66.7% of them. Selective serotonin re-uptake inhibitor pharmacotherapy was prescribed for 17 (51.5%) of the children and believed to be effective for 11 (65%) of them. Primary care physicians in this study rarely diagnosed accurately or referred children with SM in a timely fashion, even though symptoms of the condition were generally very apparent and parents had expressed concern. Behavioral modification, pharmacotherapy with SSRIs, and early intervention are viable treatment options. Early diagnosis is key to preventing long-term effects of this condition.
Conversion mutism is an uncommon disorder that was in the past most frequently reported during wartime. Other than during wartime, young women are the most commonly affected and usually present shortly after a traumatic event. Both psychodynamic and behavioral elements are important etiologically and, thus the treatment should include both psychodynamic and behavioral methods. The patient described in this paper had underlying fears relating to sexual assault as well as behaviorally reinforced perpetuation of her symptom. She regained her speech after four weeks of combined psychodynamic and behavioral therapy.
The authors review the history and current uses of the amytal interview. This technique was quite popular over 50 years ago when it began, but has been ignored for the past ten years. A clinical case of mutism is described in this research to illustrate the usefulness of the amytal interview. In this particular case, the narcosis has permitted the uncovering of delusions and consequently the administration of the appropriate treatment.
Multiple cultural variables have effects on the psychobiology and behavioral manifestations of illness, as do patient and physician perceptions of illness. The interaction among these variables is at the heart of clinical psychiatry. This case of a Vietnamese man with selective mutism underscores the relevance of the 'cultures' of medicine, psychiatry, and war and trauma on the manifestations of illness and illness perceptions by patient and physician. The discussion focuses on how these cultures interact and play a crucial role in formulating diagnosis and treatment planning. Suggestions are given for shifts in medical education that will encourage relevant cultural paradigms to make their way into educational and clinical systems, which in turn should improve cultural competence in clinical psychiatry.
OBJECTIVE: Akinetic mutism (AKM) is an uncommon disorder with a complex neuropathology. There is no generally accepted treatment, and it is not known if late treatments are effective. The relationship between AKM and abulia is uncertain. METHODS: The effects of dopaminergic treatment of a patient with chronic AKM after discrete bilateral infarctions of the mesencephalic ventral tegmental area and the lateral hypothalamus were studied with motor measures, the Functional Independence Measure (FIM), and neuropsychological tests. RESULTS: Treatment with a combination of carbidopa/levodopa and pergolide produced prompt amelioration of AKM with dramatic and rapid improvement in FIM. An apathetic, amotivational state persisted despite resolution of akinesia and normal frontal executive functions. CONCLUSIONS: AKM may respond to dopaminergic treatment even after months of severe akinesia. The mechanism of abulia is more complex than simply a partial dopaminergic deficiency state and may persist even when AKM is treated and frontal cognitive functions are normal.
Transient mutism was observed in a liver transplant patient under immunosuppressant therapy with cyclosporine A and antifungal prophylaxis with amphotericin B. Fluid-attenuated inversion recovery and diffusion-weighted images revealed reversible bilateral symmetric hyperintensity located in the frontal motor cortex and corticospinal tracts. These MRI abnormalities may be caused by acute edema, possibly a combination of cytotoxic and vasogenic edema, which resolved with a prompt change in therapy.
Four liver transplant recipients treated with cyclosporine developed a reversible neurologic syndrome characterized by a speech disorder leading to mutism. This complication, previously reported in a few liver transplant recipients treated with the immunosuppressive drug FK506, had not been described with cyclosporine. Recognition of this syndrome should prompt withdrawal of the drug and avoidance of unnecessary diagnostic procedures.
Peptostreptococcal empyema occurred in a 54-year-old man who had suffered from diabetes mellitus and had been in akinetic mutism. Ultrasonic tomogram was useful to detect the space of empyema and to identify the decrease in volume of the empyema space with treatment.
A case of elective mutism in a 4-yr.-old girl is discussed with reference to symbol use in the phenomenology and treatment of this disorder. Findings are related to current controversies regarding the classification of this rare disorder, which may be associated with more severe psychotic-spectrum disorders of childhood.
A 13-year-old patient developed complete mutism and buccofacial apraxia following toxic vasculitis due to a yellow scorpion sting. Language functions were preserved. A CT scan disclosed mainly biopercular infarcts. It is suggested that the lost control of vocalization and speech is associated with biopercular lesions and that a preserved right opercular region can take over this function in the presence of damage to homologous left opercular region.
The case of a 20-year-old man with obstructive hydrocephalus who suffered multiple shunt failures and shunt revisions is presented. The patient gradually developed a clinical syndrome of akinetic mutism. This behavioral syndrome failed to respond to shunt revisions, but did improve after the administration of a combination of bromocriptine and ephedrine.
A 26-year-old woman with obstructive hydrocephalus caused by a cysticercal cyst blocking the left foramen of Monro was initially treated with an external ventriculostomy and subsequent endoscopically assisted cyst resection and septostomy. Postoperatively, the patient developed the clinical syndrome of akinetic mutism, but her condition improved after the administration of the dopaminergic agonist bromocriptine. This result indicates that a disruption in the ascending dopaminergic pathway involved in behavior formation was likely the cause of these neurological symptoms.
This is the first report that details an association between fragile X syndrome (FXS) and selective mutism (SM). This 12-year-old girl with heterozygous full mutation at FMR1 has a long history of social anxiety and shyness in addition to SM. Her sister also has the full mutation and a history of SM that resolved in adolescence. A beneficial response to fluoxetine and psychotherapy is described. The FMR1 mutation appears to be the first gene mutation associated with SM and further studies are recommended to assess what percentage of patients with SM have the FMR1 mutation.