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Mutism in non-catatonic schizophrenia: Psychotic symptom and adaptive behavioral strategy
Schizophrenia Research 168 (2015) 569–570
Contents lists available at ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Letter to the Editor Mutism in non-catatonic schizophrenia: Psychotic symptom and adaptive behavioral strategy
Dear Editors, Mutism in adults has a wide differential, and can be difficult to evaluate. Defined as an absence or reduction of speech, either voluntary or avolitional, mutism is typically associated with catatonia, usually in schizophrenia, but also depression, bipolar disorder, intoxication, and neurological conditions. Mutism in non-catatonic schizophrenia was common before anti-psychotic use, correlating with untreated illness. Case reports continue to appear in developing nations, but accounts of mutism in patients with advanced treatment are scarce (Basanth et al., 2007; Basu et al., 2013; Khairkar et al., 2012). Here we present an unusual case of mutism in non-catatonic schizophrenia, in which it appears as both psychotic symptom and adaptive behavioral strategy. A woman in her 30s was found mute and unresponsive by her husband outside their home. She had been stable for 4 years after three prior hospitalizations for psychosis; the last featured complete mutism. She carried a diagnosis of schizoaffective disorder and was adherent to a regimen of quetiapine 300 mg, lamotrigine 200 mg, and sertraline 100 mg. She had no known manic episodes or family psychiatric history. The patient also suffered from polycystic ovaries and infertility. She took human chorionic gonadotropin to induce ovulation 2 days before she presented. Three months prior, she had tapered to quetiapine from aripiprazole in preparation for pregnancy; earlier, concerns for metabolic syndrome necessitated switching to aripiprazole from olanzapine, her previously favored anti-psychotic. The patient resumed speaking on the inpatient psychiatric unit, detailing a significant, longstanding delusional framework based on the conviction that she was being recorded by hidden audio devices. She
described effectively managing her distress by minimizing non-essential speech, a technique she developed in graduate school, before treatment, to evade malicious recording by her classmates. In this patient, mutism emerged early, and persisted despite medication, serving as an adaptive behavioral strategy to mitigate distress caused by her paranoid delusions. Mutism also disguised her illness, freeing her from the stigma of detectable psychosis and facilitating the achievement of appropriate pre-morbid personal and professional milestones. Indeed, research suggests that nonsymptomatic coping—i.e., coping that conceals psychosis—is more effective than symptomatic coping for managing positive psychotic symptoms (Phillips et al., 2009). Although this patient's mutism originated as part of psychosis, she also used it to thwart reality-based threats. She described going mute to evade certain discussions with her husband. On the unit, she used silence strategically with other patients, her clinicians, and her father. These episodes occurred absent paranoia, and the patient described them in non-psychotic terms as deliberate efforts to avoid conversation. The tendency of schizophrenia to induce infantile regression provides a hypothetical rationale for a late appearance of selective mutism, a childhood condition. Family systems theory regards selective mutism as a maladaptive response to excessive interdependence: children go mute when separated because they fear they cannot function alone (Wong, 2010). Notably, this patient endorsed a pathological enmeshment with her parents, who developed life-threatening illnesses just prior to her decompensation. Behavioral theory regards selective mutism as an adaptation. Faced with repeated aversive events, children develop it as an adaptive behavioral strategy to manipulate their environment (Krysanski, 2003). Indeed, primary gain may also have played a role in the present case, which featured two readmissions. The patient finally stabilized after six courses of right unilateral ECT for depressive episode of schizoaffective disorder; comparable cases also suggest ECT has a role (Basu et al., 2013; Khairkar et al., 2012).
Table 1 Recorded instances of mutism in non-catatonic schizophrenia. Patient
Country
Year
Illness course
2013a Schizophrenia at 21, Maun-Vrat silence ritual at 24 led to 3 years total mutism. 28 M India 2012b Schizophrenia at age 11, total mutism at 12. Untreated for 17 years. 32 M India 2007c Schizophrenia at 15, total mutism at 28. Untreated for 17 years. Multiple Micronesia 1999d Nineteen patients, most male. Often first symptom. Possible cultural influence. Multiple United 1986e Six male patients, age 18–60, over 2 years. Five had some catatonic symptoms. States 26 F
a b c d e
India
Basu et al. (2013). Khairkar et al. (2012). Basanth et al. (2007). Waldo (1999). Altshuler et al. (1986).
http://dx.doi.org/10.1016/j.schres.2015.06.010 0920-9964/© 2015 Elsevier B.V. All rights reserved.
Treatment Refractory to olanzapine 20 mg. Normal speech returned with 12 ECT sessions and switch to haloperidol 30 mg. Refractory to 6 years of anti-psychotics and 20 ECT sessions. Improved with levosulpiride 50 mg and clozapine 450 mg. Refractory to risperidone, olanzapine, three ECT sessions, and clozapine 450 mg. Mutism resolved with anti-psychotics, usually fluphenazine decanoate 25 mg. No case reports available.
570
Letter to the Editor
Here we show that mutism manifests in non-catatonic schizophrenia even with treatment. Mutism may serve as an adaptive behavioral strategy for coping with a paranoid delusional framework; this resembles selective mutism, a childhood condition (Table 1). Contributors This work is the original work of Mr. Kyle P. Smith and Dr. Julie B. Penzner. Conflict of interest The authors have no conflicts of interest to report. Acknowledgments The authors have no acknowledgements or disclosures to report.
References Altshuler, L.L., Cummings, J.L., Mills, M.J., 1986. Mutism: review, differential diagnosis, and report of 22 cases. Am. J. Psychiatry 143 (11), 1409–1414. Basanth, K.K., Gopalakrishnan, R., Jacob, K.S., 2007. Clozapine-resistant mutism in noncatatonic schizophrenia. J. Postgrad. Med. 53 (1), 75–76. Basu, A., Singh, P., Gupta, R., Kundu, S., 2013. Electroconvulsive therapy for long-term mutism in a case of noncatatonic paranoid schizophrenia. Innov. Clin. Neurosci. 10 (7-8), 10–12.
Khairkar, P., Jain, V., Bhatnagar, A., Saoji, N., 2012. 17 Years of treatment-resistant mutism in non-catatonic, childhood-onset schizophrenia: a rare case report. J. Neuropsychiatr. Clin. Neurosci. 24 (1), E39–E40. Krysanski, V.L., 2003. A brief review of selective mutism literature. J. Psychol. 137 (1), 29–40. Phillips, L.J., Francey, S.M., Edwards, J., McMurray, N., 2009. Strategies used by psychotic individuals to cope with life stress and symptoms of illness: a systematic review. Anxiety Stress Coping 22 (4), 371–410. Waldo, M.C., 1999. Schizophrenia in Kosrae, Micronesia: prevalence, gender ratios, and clinical symptomatology. Schizophr. Res. 35 (2), 175–181. Wong, P., 2010. Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry 7 (3), 23–31.
Kyle P. Smith Julie B. Penzner* Department of Psychiatry, NewYork-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, Box 140, New York, NY 10065, USA *Corresponding author. Tel.: +1 212 746 3569; fax: +1 212 746 8886. E-mail address: [email protected]. (J.B. Penzner). 19 December 2014
Contents lists available at ScienceDirect
Schizophrenia Research journal homepage: www.elsevier.com/locate/schres
Letter to the Editor Mutism in non-catatonic schizophrenia: Psychotic symptom and adaptive behavioral strategy
Dear Editors, Mutism in adults has a wide differential, and can be difficult to evaluate. Defined as an absence or reduction of speech, either voluntary or avolitional, mutism is typically associated with catatonia, usually in schizophrenia, but also depression, bipolar disorder, intoxication, and neurological conditions. Mutism in non-catatonic schizophrenia was common before anti-psychotic use, correlating with untreated illness. Case reports continue to appear in developing nations, but accounts of mutism in patients with advanced treatment are scarce (Basanth et al., 2007; Basu et al., 2013; Khairkar et al., 2012). Here we present an unusual case of mutism in non-catatonic schizophrenia, in which it appears as both psychotic symptom and adaptive behavioral strategy. A woman in her 30s was found mute and unresponsive by her husband outside their home. She had been stable for 4 years after three prior hospitalizations for psychosis; the last featured complete mutism. She carried a diagnosis of schizoaffective disorder and was adherent to a regimen of quetiapine 300 mg, lamotrigine 200 mg, and sertraline 100 mg. She had no known manic episodes or family psychiatric history. The patient also suffered from polycystic ovaries and infertility. She took human chorionic gonadotropin to induce ovulation 2 days before she presented. Three months prior, she had tapered to quetiapine from aripiprazole in preparation for pregnancy; earlier, concerns for metabolic syndrome necessitated switching to aripiprazole from olanzapine, her previously favored anti-psychotic. The patient resumed speaking on the inpatient psychiatric unit, detailing a significant, longstanding delusional framework based on the conviction that she was being recorded by hidden audio devices. She
described effectively managing her distress by minimizing non-essential speech, a technique she developed in graduate school, before treatment, to evade malicious recording by her classmates. In this patient, mutism emerged early, and persisted despite medication, serving as an adaptive behavioral strategy to mitigate distress caused by her paranoid delusions. Mutism also disguised her illness, freeing her from the stigma of detectable psychosis and facilitating the achievement of appropriate pre-morbid personal and professional milestones. Indeed, research suggests that nonsymptomatic coping—i.e., coping that conceals psychosis—is more effective than symptomatic coping for managing positive psychotic symptoms (Phillips et al., 2009). Although this patient's mutism originated as part of psychosis, she also used it to thwart reality-based threats. She described going mute to evade certain discussions with her husband. On the unit, she used silence strategically with other patients, her clinicians, and her father. These episodes occurred absent paranoia, and the patient described them in non-psychotic terms as deliberate efforts to avoid conversation. The tendency of schizophrenia to induce infantile regression provides a hypothetical rationale for a late appearance of selective mutism, a childhood condition. Family systems theory regards selective mutism as a maladaptive response to excessive interdependence: children go mute when separated because they fear they cannot function alone (Wong, 2010). Notably, this patient endorsed a pathological enmeshment with her parents, who developed life-threatening illnesses just prior to her decompensation. Behavioral theory regards selective mutism as an adaptation. Faced with repeated aversive events, children develop it as an adaptive behavioral strategy to manipulate their environment (Krysanski, 2003). Indeed, primary gain may also have played a role in the present case, which featured two readmissions. The patient finally stabilized after six courses of right unilateral ECT for depressive episode of schizoaffective disorder; comparable cases also suggest ECT has a role (Basu et al., 2013; Khairkar et al., 2012).
Table 1 Recorded instances of mutism in non-catatonic schizophrenia. Patient
Country
Year
Illness course
2013a Schizophrenia at 21, Maun-Vrat silence ritual at 24 led to 3 years total mutism. 28 M India 2012b Schizophrenia at age 11, total mutism at 12. Untreated for 17 years. 32 M India 2007c Schizophrenia at 15, total mutism at 28. Untreated for 17 years. Multiple Micronesia 1999d Nineteen patients, most male. Often first symptom. Possible cultural influence. Multiple United 1986e Six male patients, age 18–60, over 2 years. Five had some catatonic symptoms. States 26 F
a b c d e
India
Basu et al. (2013). Khairkar et al. (2012). Basanth et al. (2007). Waldo (1999). Altshuler et al. (1986).
http://dx.doi.org/10.1016/j.schres.2015.06.010 0920-9964/© 2015 Elsevier B.V. All rights reserved.
Treatment Refractory to olanzapine 20 mg. Normal speech returned with 12 ECT sessions and switch to haloperidol 30 mg. Refractory to 6 years of anti-psychotics and 20 ECT sessions. Improved with levosulpiride 50 mg and clozapine 450 mg. Refractory to risperidone, olanzapine, three ECT sessions, and clozapine 450 mg. Mutism resolved with anti-psychotics, usually fluphenazine decanoate 25 mg. No case reports available.
570
Letter to the Editor
Here we show that mutism manifests in non-catatonic schizophrenia even with treatment. Mutism may serve as an adaptive behavioral strategy for coping with a paranoid delusional framework; this resembles selective mutism, a childhood condition (Table 1). Contributors This work is the original work of Mr. Kyle P. Smith and Dr. Julie B. Penzner. Conflict of interest The authors have no conflicts of interest to report. Acknowledgments The authors have no acknowledgements or disclosures to report.
References Altshuler, L.L., Cummings, J.L., Mills, M.J., 1986. Mutism: review, differential diagnosis, and report of 22 cases. Am. J. Psychiatry 143 (11), 1409–1414. Basanth, K.K., Gopalakrishnan, R., Jacob, K.S., 2007. Clozapine-resistant mutism in noncatatonic schizophrenia. J. Postgrad. Med. 53 (1), 75–76. Basu, A., Singh, P., Gupta, R., Kundu, S., 2013. Electroconvulsive therapy for long-term mutism in a case of noncatatonic paranoid schizophrenia. Innov. Clin. Neurosci. 10 (7-8), 10–12.
Khairkar, P., Jain, V., Bhatnagar, A., Saoji, N., 2012. 17 Years of treatment-resistant mutism in non-catatonic, childhood-onset schizophrenia: a rare case report. J. Neuropsychiatr. Clin. Neurosci. 24 (1), E39–E40. Krysanski, V.L., 2003. A brief review of selective mutism literature. J. Psychol. 137 (1), 29–40. Phillips, L.J., Francey, S.M., Edwards, J., McMurray, N., 2009. Strategies used by psychotic individuals to cope with life stress and symptoms of illness: a systematic review. Anxiety Stress Coping 22 (4), 371–410. Waldo, M.C., 1999. Schizophrenia in Kosrae, Micronesia: prevalence, gender ratios, and clinical symptomatology. Schizophr. Res. 35 (2), 175–181. Wong, P., 2010. Selective mutism: a review of etiology, comorbidities, and treatment. Psychiatry 7 (3), 23–31.
Kyle P. Smith Julie B. Penzner* Department of Psychiatry, NewYork-Presbyterian Hospital, Weill Cornell Medical College, 525 East 68th Street, Box 140, New York, NY 10065, USA *Corresponding author. Tel.: +1 212 746 3569; fax: +1 212 746 8886. E-mail address: [email protected]. (J.B. Penzner). 19 December 2014