Social Phobia and Selective Mutism

Social phobia (social anxiety disorder) is the third most common mental health disorder after major depression and substance abuse, affecting approximately 10 million Americans, including children and adults. This disorder is defined by marked and persistent fear of social or performance situations in which embarrassment may occur; exposure to the social or performance situation almost always causes an anxiety reaction such as a situationally bound or situationally predisposed panic attack.
The anxiety reaction is not due to psychosis; individuals are able to recognize their fears as excessive and unreasonable. However, the ability to fully comprehend that the reaction is out of proportion to the precipitant may be less complete in children and may depend on their cognitive-developmental level of functioning.
The person's level of functioning (eg, ability to complete required educational, social, or family tasks) is significantly impaired, and the person may experience significant emotional distress (eg, dread, avoidance) as a response to social or performance situations. By definition, social phobia must persist for at least 6 months (in persons <18 y), must not be due to the direct physiological effects of a substance (eg, caffeine) or a general medical condition, and must not be better accounted for by another mental health disorder.
Often, social phobia can coexist with, or be the precursor to, agoraphobia. Agoraphobia is a specific phobia in which the individual fears being in crowded places. People with agoraphobia often become homebound.
Selective mutism is a disorder primarily affecting children, with some adolescents and adults who continue to experience an inability to speak in public. This inability is generally most disabling at school, as the child cannot be assertive and speak when called on by teachers. In adults, functional impairment occurs when public speaking or lecturing are required in one's vocation.
Formerly, selective mutism was called elective mutism in the Diagnostic and Statistical Manual of Mental Health Disorders, Third Edition (DSM-III), which was reflective of a previous view that the child intentionally refused to speak with others who are outside of the immediate family group. Often, the child with selective mutism designates a friend or close family member to serve as an interpreter of communication and whispers in that person's ear, so that communication occurs with the designated person as intermediary.
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Pathophysiology
Serotonin pathways may be involved in the mediation of the anxious and obsessive qualities of both social phobia and selective mutism. This theory is reinforced by animal models of phobic behavior and by response to commonly prescribed medications such as selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, or older heterocyclic-type antidepressants, such as Anafranil (clomipramine).
Frequency
United States
Social phobia is the third most common mental health disorder after depression. Lifetime prevalence ranges from 3-13%. Selective mutism is seen in fewer than 1% of children observed in mental health settings.
Mortality/Morbidity
No mortality occurs except with associated major depression resulting in suicide or reaction to medication treatment (sudden cardiac death with imipramine or clonidine) or adverse reaction such as newly onset suicidality to SSRIs or other antidepressants. A high morbidity rate is observed, with many missed school or workdays; the child often develops associated school refusal because of the anxiety associated with being asked to speak in class.
Age
Onset of social phobia may occur as early as school age but generally occurs by mid adolescence following a childhood history of social inhibition or excessive shyness. Often, onset is abrupt, occurring after a stressor or humiliating social experience.
Onset of selective mutism is typically when a child first attends school (either kindergarten or preschool) and, like social phobia, is often associated with an initial negative school experience, such as a stressor or humiliating social experience.

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