Unveiling the silence: using the PDM lens to assess selective mutism in childhood

Introduction: In current diagnostic classifications (ICD-11, DSM-5-TR, PDM-2), selective mutism is listed above anxiety disorders, with a prevalence ranging from 1-2%. It is characterized by a consistent inability to speak in certain situations while speaking adequately in others. Despite its relatively low prevalence, mutism symptoms often co-occur with other disorders, so it is not so rare in clinical practice. However, mutism can profoundly impact on psychosocial and academic functioning during childhood, underscoring the need for a deeper understanding of its underlying factors. Methods: This study presents two cases involving a 9-year-old girl and a 12-year-old girl who sought therapy for mutism symptoms and underwent psychodynamic assessment and therapy. The Psychodynamic Diagnostic Manual (PDM) approach was used alongside other empirically validated measures to assess personality, general mental functioning, and emotional and behavioral difficulties, in addition to defining symptoms. Results: This comprehensive approach provided insights into the different characteristics of the two cases, revealing significant differences in underlying mental functioning and personality despite their comparable symptomatic presentations. These differences shed light on the individual significance of this specific symptom for each patient and offer different perspectives on the underlying factors contributing to their silence. Moreover, these findings give a nuanced understanding of symptomatology within the context of individual child functioning and relational dynamics. Discussion: By shifting focus from symptomatology to a holistic understanding of patient functioning, this study underscores the value of a clinical case study approach in empirical research. It is also a new perspective on mutism, suggesting that there may be heterogeneous factors at work in mutism beyond its association with anxiety.