Is It Anxiety? Selective Mutism in Adults: Causes, Treatment Options

You may know the feeling all too well—the words form in your head, but they can’t come out. Perhaps you can speak to close family, but you freeze up in front of strangers. Perhaps reading aloud or making friends was always difficult, and your self-esteem was affected. 

If this sounds like you, you could have selective mutism. What is the disorder, and what are your treatment options? Read on as we uncover selective mutism in adults.

Is Selective Mutism an Anxiety Disorder? 

The latest edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-V) classified selective mutism as an anxiety disorder. It is not a communication disorder, as the ability to speak and understand speech is unaffected. People with selective mutism are unable to speak in specific situations, but have normal speech at other times, such as when they’re at home [1].

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Adults aged 18 to 29 are more prone to anxiety

Studies show that this mental health issue often appears alongside other types of anxiety disorders. Younger children often display shyness, worry, and avoidance before selective mutism becomes obvious. Their normal speech is generally quieter and less spontaneous than expected in early childhood, much like other types of social anxiety disorders [1]. 

Can Adults Suffer From Selective Mutism?

We don’t only see selective mutism in children, even though the vast majority of its research focuses on children and teenagers. Adults can have selective mutism too, but more control over our lives means that it’s easier to avoid situations that seemingly freeze your ability to speak freely [2]. 

Adults with selective mutism often drop out of employment, education, and face-to-face social activities. You could know someone with the disorder without realizing it, through social media groups or as the “quiet one” in your circles [2]. 

Why Can’t People With Selective Mutism Speak?

Anxiety disorders, including selective mutism, are related to dysfunction in the amygdala. This is a part of the brain involved in fear and anxiety, and can contribute to avoidant behavior such as not speaking. A subconscious association between anxiety and public speaking, for example, would activate your amygdala when you have to talk in public [3].

Selective Mutism Symptoms in Adults

Selective mutism has been described by adults as having the right words in your head, but being unable to speak them. A series of interviews with adults include descriptions such as the ability to be yourself in some situations, but as if “it takes over” in triggering environments. “Trying to talk is like a pressure building up”, says another [2]. 

You may also feel detached when you do speak to others. Some describe it along the lines of observing yourself talking, particularly when you have to speak. This has led to suggestions that it may also be a form of dissociative identity disorder [2].

Do I Have Selective Mutism?

To confirm whether you have selective mutism or another disorder, you need personalized assessments from a psychiatrist. However, there are some ways you can tell if you may have this disorder. 

The most important symptom of selective mutism is the ability to speak normally in some situations, but an inability to verbally communicate in others. You can likely form the words in your head, but not make them come out of your mouth [2]. It may feel like stage fright, but in everyday social settings such as a coworker making small talk. 

Selective Mutism in Adults Causes

Almost all adults with selective mutism originally developed the condition in childhood. The average age of onset is four years old, but diagnosis can be delayed into adulthood [4]. 

It is often left untreated as school and other childhood environments allow for more accommodations when a child struggles with difficulty speaking. Parents may speak for children, teachers may provide alternative means of communication, for example [2]. 

There are several theories as to how selective mutism develops. The behavioral theory states that the sympathetic (fight or flight) nervous system takes over in “threatening” social situations, making you “freeze” when you want to speak. In psychodynamic theory, mutism is a defense mechanism, while systemic theory describes a poorer development of independence [5]. 

Additionally, certain genes associated with a risk of anxiety disorders, including selective mutism, have been identified. People with the disorder have a stronger family history of these mental health problems, but it must be remembered that their genetic risk factors are not black and white—they only increase your vulnerability [1].  

How Is Selective Mutism Treated in Adults?

Treatments that address how to overcome anxiety are the mainstays of selective mutism therapy. These include:

• Treating underlying psychological conditions
• Cognitive-behavioral therapy
• Desensitization therapy
• Stimulus fading
• Medication

Treating Underlying Psychological Conditions

Other mental health issues can contribute to selective mutism; it is common to have social phobia or severe anxiety disorder too [1]. Case series have revealed relationships with affective disorders, schizophrenia, and personality disorders too. Treating these disorders can lead to improved speech [6].

Cognitive Behavioral Therapy

Selective mutism treatment has no specific protocols, so cognitive-behavioral therapy (CBT) plans modified for general anxiety disorders are common interventions [2]. 

CBT aims to change thought patterns and behavior to reduce or eliminate harmful ways of thinking and responding. Clinical trials show that CBT can increase speech and lead to maintained improvements when compared to a waiting list [7]. 

One type of modified CBT has demonstrated dramatic relief in only 12 weeks. Sixty-seven percent of children in one trial no longer fit the criteria for having selective mutism, but all children in the control group still had the disorder. These improvements were maintained at least until the end of the study, at three months follow-up [7]. 

CBT had a positive impact on selective mutism in adults, especially when combined with paroxetine
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4620318/

If you are interested in CBT, this Betterhelp review and this Talkspace review may help you decide on future treatment directions. 

Desensitization Therapy

The aim of desensitization therapy is to help conquer fears around other people hearing your voice. It can start in a situation you’re already comfortable with, such as your preferred instant messaging app. You can then progress from text to voice recordings, and then to direct calling [8]. Some forms of desensitization also include relaxation techniques and social skills training [9]. 

Stimulus Fading

Stimulus fading gradually introduces you to communication outside of your current comfort zone. An additional person is first brought into a situation you’re comfortable with, allowing you to ease into speaking with them and eventually to them alone. 

New people are then added in at your own pace. You are not rushed or forced to overcome selective mutism; it is a controlled situation [8]. 

Mental health professionals can adapt stimulus fading to a wide range of situations, including ordering at restaurants or talking to extended family. Research shows that it is effective in expanding the number of people you can speak to, and the social situations where you can speak [9]. 

Medication for Selective Mutism in Adults

You may also benefit from medication to relieve selective mutism. Selective serotonin reuptake inhibitors (SSRIs) could help by reducing anxiety, but studies do show a strong placebo effect too. For example, a trial on SSRIs for children with selective mutism only showed more improvement in the parents’ ratings of symptom severity [8]. 

However, medication must not be seen as an alternative to behavioral therapies, only an accompaniment.

FAQ

What are the most important things to know about selective mutism in adults?

Can You Become Mute Later in Life?

It is rare for this disorder to begin in adulthood, with a study by iSpeak finding the latest age at onset to be 16 years. However, some adults with selective mutism don’t notice they have had it for decades [4]. 

Is Selective Mutism a Trauma Response?

So far, it’s not clear how many cases originate from trauma. One study, for example, found that only four of 30 cases developed after traumatic events. However, this and other studies interviewed parents and teachers, who may not know everything a child experiences or feels [2]. 

Other research found that 47% had parents with difficult marriages. Interviews with several recovered adults described a series of negative events leading up to the onset of mutism, such as moving and losing friends [2]. These may not be trauma in the traditional sense, but an accumulation of “mini-traumas”. 

Can Selective Mutism Be Caused by Depression? 

As of now, this disorder does not seem to be caused by depression. However, it may be the cause of depression, with adults using similar descriptions of loss, loneliness, and regret [2]. 

What Triggers Selective Mutism? 

In children, factors such as overprotective family members, multiple adverse events, and migration to a new country (with having to learn a second language) are linked to higher rates of the disorder [1]. Research overall suggests a combination of genetic, temperamental (behavioral inhibition), and environmental factors. 

Conclusion 

Whether you suspect you have selective mutism, or want to know how to help someone with anxiety, it’s important to know that this type of mental illness isn’t only seen in children. Not only are your struggles valid, but there is hope for effective treatment once the problem is identified.