Selective Mutism: History, Diagnosis Criteria, Causes, and a Nod to Rajesh Koothrappali
4 min read time
You must remember Rajesh Koothrappali, the brilliant astrophysicist from the show The Big Bang Theory(TBBT). He was well accomplished in his field, with a keen interest in showmanship. But, he went mute in certain social situations. Specifically, Raj could not talk to women. He went mute as soon as he was in a room with one. Let's look into what we know about mutism and specifically selective mutism, an inability to speak during certain situations.
History
Adolf Kussmaul in the 19th century coined the term aphasia voluntaria, which means, a person who can speak but decides not to in certain situations.
In 1934 Swiss child psychiatrist, Mortiz Tramer coined the term elective mutism, with emphasis on 'elect'. The term defined a person refused to speak in certain situations.
Torey L Hayden conducted a study in 1980, with 68 subjects who showed signs of elective mutism. All the subjects were children. He had set in good criteria for inclusion, he ended up rejecting 270 participants for possible contaminating factors. He found 4 subtypes of elective mutism in his study:
Symbiotic Mutism: This was the most common subtype. One of the caregivers - usually the mother - was dominant and took care of all the needs of the child, they were also openly jealous of the relationships that the child had with others. The other caregiver - usually the father - was absent. Despite being shy and clingy, the child was negativistic towards controlling adults. Lastly, it was found that these children use mutism to control their environment in a manipulative manner.
Speech Phobic Mutism: The rarest of them all, this group had subjects who were phobic to their voice, they even tried to leave the room when they heard their voice on tape. They had ritualistic behaviours called 'magic spells'. The purpose of these behaviours was to keep talking or to protect others from the effect of their speech. He also noticed that this group had a variety of obsessive-compulsive behaviours, they were not related to speech.
Reactive Mutism: This was considered the most genuine out of all the groups. Mutism stems from the experience of traumatic events.
Passive-Aggressive Mutism: This group used silence as a form of weapon, they were trying to be hostile by not speaking. Most of the subjects lacked facial expression and they had control over affect.
It is important to note that there hasn't been enough evidence to support all of the categories. Research on them is still going on to this date. Elective mutism is an outdated term.
DSM and Mutism
DSM III, included elective mutism, maternal overprotection, excessive shyness and anxiety-related traits were noted to be several associated characteristics. But in 1994, DSM IV redefined the term and changed it into selective mutism, which means that the person is unable to speak in 'select' situations. Selective mutism was first placed in the category of "Disorders usually first diagnosed during Infancy, Childhood or Adolescence". When DSM V was published it was reorganised into anxiety disorders.
Diagnostic Criteria according to DSM V TR
A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations.
B. The disturbance interferes with educational or occupational achievement or with social communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
Well looking at all the criteria it is safe to say that Rajesh Koothrappali from The Big Bang Theory suffered from selective mutism.
There are various etiological theories on selective mutism:
Psychodynamic School of Psychology
Psychodynamic theorists see selective mutism as manifestations of unresolved conflicts. The child could be regressing to a previous stage of development and could be displacing some anger towards their parents. Mutism is a way to cope with anxiety.
Example: A child who is orally fixated denies talking to punish his parents.
Behaviour School of Thought
Behaviourists say that mutism is adapted but not pathological. They say that not speaking is used as a way to manipulate the environment. Mutism can also be reinforced. Let's look at an example to better understand it.
The child doesn't answer when the teacher repeatedly asks the question, after a while the teacher just withdraws from the situation, and this reinforces the child negatively. When the child uses nonverbal forms of communication the child is positively reinforced.
This makes it harder to treat a child diagnosed with selective mutism.
Anxiety Disorder
Many argue that selective mutism is a variant of social phobia. Many studies have found that the subjects could also be diagnosed with social anxiety. DSM V categorises this under anxiety disorders.
Family System Perspective
It is viewed that the child is involved in a faulty family relationship. A neurotic relationship between the mother, father and child. This neurotic relationship is carried onto the real world. Families in which a child is selectively mute are characterized by
Intense attachments (i.e., dominance, overprotectiveness, and strictness)
Interdependency
Fear and distrust of the outside world
Fear and distrust of the stranger
Language and cultural assimilation difficulties
Marital disharmony
Withholding of speech practised by one or more of the parents in the home
Whatever the cause of the mutism, researchers agree that it can be properly diagnosed and conceptualised only by investigating the child's case history.
Selective mutism is a rare disorder. A lot of research has not been done on it. Various researchers have concluded that it affect around 1% of the population.
There is no cultural or ethnic commonness but it is important to note that it is more prevalent in girls than boys.
The disorder is more likely to manifest in young children than adults and adolescents.
Cognitive Behavioural Therapy (CBT) and Behavioural Therapy can be used to treat selective mutism. Techniques such as graded exposure, successive approximation/shaping, stimulus fading, desensitisation can be used to treat selective mutism.
ps: floof
Such an amazing insight!
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