Selective mutism: What’s behind the inability to speak?

Do you speak freely with some people in your life, but find it impossible to utter a word around others? Selective mutism (also called situational mutism) is a medical condition in which people speak with ease in some situations, while not being able to speak at all in others. This isn’t a choice not to speak, but rather an inability to talk due to intense anxiety in certain settings.

If you’ve heard of selective mutism but always assumed it was a “kids’ thing”—the truth is that the condition often starts during childhood, around the time that verbal communication is learned, but it can develop at any age, well into adulthood.

Is it about the fear of saying the wrong thing, or something else? The answer: It’s complicated. Keep reading to find out what’s really behind your trouble speaking, how to handle the issue, and when to get professional help. 

What is selective mutism?

Selective mutism is an anxiety disorder that prevents people from being able to speak in certain situations because of anxiety or fear. Many people feel timid in new environments from time to time, but selective mutism is more than just shyness. It’s a paralyzing inability to speak that can have debilitating effects on one’s life.

Selective mutism symptoms

Selective mutism impacts between 1% and 2% of people, making it a more common disorder than once believed. The main symptom is a struggle to communicate in certain situations, but that can take different forms depending on the social setting.

• Total or near-total inability to communicate: In the most severe cases, people with selective mutism will find speaking completely impossible. “It’s possible to be completely mute at times—I have a client that hasn’t spoken at all in 14 months,” says April Kilduff, MA, LCPC, LMHC, therapist and clinical trainer at NOCD.
• Nonverbal communication: This includes making movements or gestures—like nodding or pointing—to avoid speaking out loud.
• Physical symptoms: Because selective mutism is an anxiety-related disorder, it can cause other physical symptoms like tense or stiff posture, blank expressions, or an inability to make eye contact.
• Avoidance behaviors: To avoid social interactions, people with selective mutism may avoid asking for things they need, mumble or whisper, or use single-word responses when possible. Some people choose to completely avoid social situations that trigger mutism.

What causes selective mutism in adults?

Selective mutism may arise in adulthood due to a number of factors including a traumatic experience, problems with speech or sound processing, or a new diagnosis of an anxiety disorder. It can also have a genetic component. That said, sometimes the reason people receive a diagnosis of selective mutism later in life is simply because they had the condition as children but it went undetected (and untreated).

A common misconception is that selective mutism is a form of autism spectrum disorder, but the two communication disorders are diagnosed separately. That said, people with autism are much more likely to have selective mutism.

What does selective mutism feel like?

People with selective mutism describe the inability to speak as a heavy weight on their chest, or the feeling of being asked a question in public and then completely blanking on the answer. 

In a study of five adult patients with selective mutism, one woman said that she can get the words she wants to say in her head, but then a “freeze response” stops her from saying them out loud. Another described “always being stuck outside looking in” when other people are socializing together and you feel you cannot join in on the conversation. Making matters worse, it’s common for those in their orbit to eventually expect they don’t want to speak or contribute in social settings. That leads to extreme feelings of isolation for people with selective mutism. 

Selective mutism vs. social anxiety: Are they the same?

Social anxiety is classified as a fear of group social settings that might make someone more quiet or irritable than usual. It’s based on a fear of doing something embarrassing, and/or being negatively judged. Selective mutism, on the other hand, is a more severe case of social anxiety that makes people nonverbal, often not by choice. Both conditions can impact the ability to make friends, succeed in school or work, and spend time in public spaces, but you can have social anxiety without having selective mutism. 

Other reasons you might struggle to speak

If you repeatedly obsess over whether or not you said the right thing, but don’t experience the freeze response described above, you may have a different communication issue that’s linked to obsessive-compulsive disorder (OCD).

Most people ruminate on social interactions from time to time, but the repetitive obsession about saying the wrong thing can be an OCD-related fear, involving concerns about saying something that is inappropriate, embarrassing, or hurtful. This fear is often part of a larger subtype of OCD called Harm OCD where a person fears being responsible for harm—often centered around the fear of harming others.

For people with OCD, obsessions are repeated thoughts that are intrusive, unwanted, and make most people anxious. Here are some examples:

Obsessions related to the fear of saying the wrong thing:

• Did I say something offensive?
• What if I lost control and yelled a derogatory word right now?
• Does the word I just used make sense?
• If I say something wrong they might not understand me.
• I could be responsible for someone getting hurt if I use the wrong word to describe something.
• Did I call them the wrong name?

How to tell if it’s OCD or selective mutism

“Someone with OCD who might be afraid to say the wrong thing, you would probably see some obsessive slowness from them—they’re going to take time to process before they speak,” says Dr. Patrick McGrath, psychologist and Chief Clinical Officer at NOCD. On the other hand, “a person with selective mutism finds themselves unable to speak at all.”

Another clue that it’s OCD and not selective mutism is the presence of compulsions. When people with the OCD-related fear of saying the wrong thing experience intrusive thoughts that cause distress, they typically engage in mental or physical behaviors done in an attempt to cope with their discomfort. 

Common compulsions related to fears of saying the wrong thing: 

• Repeatedly seeking reassurance by asking questions like “does that make sense?” 
• Mentally reviewing the words/phrases you use
• Ruminating on past situations where you may have possibly said something inappropriate 
• Excessively asking people if they are mad or offended 
• Constantly correcting yourself while talking 
• Planning conversations in advance

Typically, selective mutism and OCD don’t overlap, and treatment for each of them is different, McGrath says. 

How to get help for selective mutism

It’s important to seek treatment if communication challenges are inhibiting your daily functioning. Adults with selective mutism are typically treated with three forms of therapy:

• Cognitive behavioral therapy: Also known as CBT, this behavioral treatment helps people with selective mutism identify the source of the mutism and then, under the guidance of a therapist, slowly test speaking in difficult environments. “For instance, if speaking to strangers is difficult, you might be encouraged to try to just say hello to the checkout person at the grocery store, and then gradually add to that,” says Dr. McGrath.
• Speech therapy: When the root cause of selective mutism is a speech disorder, speech therapy helps to improve your ability to talk and minimize the barriers that might be causing your anxiety.
• Medications: Under the guidance of a psychiatrist, some selective mutism sufferers may benefit from medications that treat the underlying anxiety disorder. Those include selective-serotonin reuptake inhibitors (SSRIs) which are used to treat anxiety and depression.

How to treat OCD-related fears of “saying the wrong thing”

People with OCD who struggle with excessive fear of saying the wrong thing can confront their fears with specialized therapy. Exposure and Response Prevention (ERP) therapy is considered the gold-standard treatment for ROCD (and all other forms of OCD). ERP is unlike traditional talk therapy or general CBT, and without practicing ERP specifically, it’s very likely that your OCD will get worse, not better.

ERP works by gradually exposing you to your triggers, and teaching you response prevention strategies to cope with your distress. One exposure you might be encouraged to try, according to McGrath, is to purposely use “wrong” words when speaking to others, and resist the compulsion to fix them. Over time, when you don’t rely on compulsions, your fears lose their power for you as you learn you’re better able to handle the distress. What’s more, you often learn that the feared outcome doesn’t come true. As the saying goes—fear is not real. The only place that it can exist is in our thoughts of the future.