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Clinical Atlas Prestige · Evidence-first

Psych VivasGeneral adult psychiatry — anxiety disorders

Psych Vivas · General adult psychiatry — anxiety disorders

Selective mutism — structured clinical viva

Fellowship viva covering selective mutism criteria, anxiety formulation, school-inclusive behavioural therapy, pharmacotherapy stewardship, and engagement with punitive or benzo-only demands.

clinical
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Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar in CAMHS. A 7-year-old boy has not spoken at school for 8 months. At home he is talkative. The deputy principal wants him held back a year unless he 'chooses to speak.' Parents request diazepam before school forever and refuse any school-based sessions. A speech pathologist notes normal language structure on a home video. Discuss criteria (including duration and language exclusions), why elective mutism is outdated, differentials (SAD, ASD, hearing), first-line behavioural ingredients with school involvement, limits of benzodiazepines, and when fluoxetine would be considered with a concrete dosing and monitoring example.

Interpretation

Reveal interpretation

This is classic selective mutism: speech capacity demonstrated at home (and on SLP home video), consistent failure to speak in the expected school setting for 8 months (exceeds ≥1 month; not limited to first school month), with educational impact. DSM-5 frames this as an anxiety disorder, not elective wilful silence.[1]

School-inclusive behavioural care is non-negotiable. Packages such as IBTSM and Oerbeck home/school programmes target graduated speaking in real contexts and reduce accommodation. Refusing all school work while requesting indefinite diazepam is a formulation and engagement problem, not a reason to abandon exposure principles.[2][3]

Benzodiazepines are not disease-modifying first-line care for SM and risk dependence plus interference with learning. Fluoxetine is the most studied SSRI adjunct for moderate–severe cases or partial psychological response, with activation and suicidality monitoring under specialist supervision.[4][5][6]

Key points

Duration trap

≥1 month and not limited to first month of school.[1]

Anxiety, not elective

DSM-5 anxiety-chapter placement; drop "elective" language.[1]

School is the clinic

IBTSM / Oerbeck-style programmes bring treatment into speaking contexts.[2][3]

Fluoxetine adjunct

Most studied SSRI; start low, monitor activation.[4][5]

Escalating viva questions

Examiner prompts: list full DSM criteria A–E; contrast SM with pure SAD and with ASD; outline a six-step school speech hierarchy; explain stimulus fading; state fluoxetine start dose example (5–10 mg orally daily specialist-supervised) and monitoring; discuss family anxiety loading; when to arrange audiology; how to respond to retention threats without colluding with shaming; legal principles if severe parental refusal blocks education supports (jurisdiction-specific — do not invent section numbers).[1][2][3][4][5][6]

References

  1. [1]Muris P, Ollendick TH Children Who are Anxious in Silence: A Review on Selective Mutism, the New Anxiety Disorder in DSM-5 Clin Child Fam Psychol Rev, 2015.PMID 25724675
  2. [2]Bergman RL, Gonzalez A, Piacentini J, Keller ML Integrated Behavior Therapy for Selective Mutism: a randomized controlled pilot study Behav Res Ther, 2013.PMID 23933108
  3. [3]Oerbeck B, Stein MB, Wentzel-Larsen T, et al. A randomized controlled trial of a home and school-based intervention for selective mutism Child Adolesc Ment Health, 2014.PMID 32878377
  4. [4]Black B, Uhde TW Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study J Am Acad Child Adolesc Psychiatry, 1994.PMID 7961338
  5. [5]Kaakeh Y, Stumpf JL Treatment of selective mutism: focus on selective serotonin reuptake inhibitors Pharmacotherapy, 2008.PMID 18225967
  6. [6]Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders BMC Psychiatry, 2014.PMID 25081580