Selective mutism and social anxiety disorders: are they two faces of the same coin?

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Selective mutism is a well-known disorder in International Classification of Diseases, 10th revision and Diagnostic and Statistical Manual of Mental Disorders, 4th ed. This disorder is found in less than 1% of children who are presented to mental health settings. There is a growing consensus among clinicians and researchers that selective mutism is an anxiety-related condition. Research studies on its phenomenology, comorbidities, and treatment are scarce.


The hypothesis of this study was that selective mutism is a form of social anxiety disorder. The study was carried out to identify social anxiety symptoms and disorder in a group of patients with selective mutism.


Eighteen patients with selective mutism were compared with an age-matched and sex-matched group of 18 patients with social anxiety disorder. Assessment of both groups was carried out through detailed assessment of history, examination of mental state, schedule for affective disorders and schizophrenia for school-aged children, present and lifetime version, the social anxiety scale for children, and an especially designed observation sheet. In addition, all patients received 6–12 sessions of behavioral psychotherapy on play therapy bases with family counseling. Patients who failed to provide a response after three sessions of behavioral therapy in addition received fluvoxamine 25–50 mg/day. Both groups were compared in terms of treatment response.


Among the selective mutism group, the mean score on the social phobia scale was 27.3±3.4. Seven patients (38%) had comorbid social anxiety disorder. Comparison of both groups indicated no significant differences between them either in sociodemographic data or in social anxiety symptoms. The selective mutism subgroup with comorbid social anxiety had significantly higher social anxiety symptoms. Combination therapy proved to result in a better response in both groups. Good response was associated with more psychotherapy sessions (3), combination therapy and lower scores on the social anxiety scale at baseline.


There were significant social anxiety symptoms in the entire sample; yet, some participants reached the diagnostic threshold for social anxiety disorder whereas others did not. Selective mutism can be considered as a variant of social anxiety disorder because of the significant overlap in symptoms profile as well as treatment response. Further researches are required to explain the heterogeneity of patients with selective mutism. This will help in tailoring a treatment plan for patients.

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