Silence Ends After 17 Days When ECT Discussed: A Rare Volitional Mutism Case

A 42‑year‑old woman was brought to the emergency department after her family reported that she had abruptly stopped speaking and was eating only brown rice. The medical team initiated a comprehensive work‑up: blood tests, metabolic panel, urine analysis, drug screen, thyroid studies, head CT, brain MRI, and EEG. She also received an intravenous lorazepam challenge and two psychiatric medications.

All investigations were normal except for laboratory evidence of starvation. Despite the extensive evaluation, she remained completely silent.

On day 17, a clinician raised the possibility of electroconvulsive therapy (ECT) with her next of kin and the hospital ethics board. At that moment she began to speak.

A Silence That Withstood Exhaustive Medical Evaluation

The case was published in August in the Primary Care Companion for CNS Disorders by Garrett Hill, Gregory Noe, and Sahil Munjal of Wake Forest School of Medicine in Winston‑Salem, North Carolina. The patient had a history of hypothyroidism and major depressive disorder in remission. Her family reported bizarre behavior, prompting evaluation. Laboratory tests showed lactic acidosis and ketonuria consistent with starvation ketosis, while all other studies were unremarkable.

Psychiatry was consulted because the team suspected catatonia or psychotic depression. She underwent a lorazepam challenge—a standard catatonia probe—and was started on mirtazapine and olanzapine. Brain MRI and EEG were normal, and there was no response to verbal or tactile prompts.

However, nursing staff observed features that did not fit classic catatonia: she walked frequently and feigned sleep when approached. Five days after arrival she was transferred to the inpatient psychiatric unit, where she continued to move about the halls without speaking.

Discussion of ECT on Day 17 Prompted Speech

Because concern for catatonia or psychotic depression persisted, the team discussed ECT with the patient’s next of kin and the hospital ethics department. On day 17, when clinicians approached her to discuss this treatment, she abruptly began to speak.

She explained that she had voluntarily undertaken a month‑long fast and a vow of silence as a discipline to prevent speaking before thinking. She described the decision as defiance against an overbearing family and attributed it to a loss of autonomy after moving back with her parents, whose strict religious practices she found oppressive. She denied hallucinations, thought insertion, ideas of reference, or paranoia. Her eating normalized over the next few days, and she engaged in group therapy before being discharged two days later on continued mirtazapine and olanzapine, with tapering to be managed outpatient.

Understanding Volitional Mutism

Mutism can stem from catatonia, psychosis, autism, delirium, akinetic mutism, or selective mutism—an anxiety disorder usually identified in childhood where speech is limited to specific settings. Volitional mutism represents the opposite end of the spectrum: a conscious decision to remain silent without underlying psychiatric illness, neurological disease, or clear secondary gain.

The Wake Forest authors note that, to their knowledge, only one prior case has been reported—a Nepalese soldier who developed mutism and spoke when asked about his homeland. Factitious disorder was considered because removal from a stressful home environment could provide secondary benefit, but it was excluded; the patient openly described her silence as intentional rather than feigned.

From a psychodynamic perspective, the authors view both the silence and restricted eating as expressions of control in a situation where she felt powerless. Refusing to speak and refusing to eat conveyed the same message of autonomy.

Clinical Management Recommendations

Guidelines for similar cases emphasize that volitional mutism often resolves spontaneously. Clinicians are advised against coercive speech‑elicitation or punitive measures, and pharmacologic treatment is not supported when no other psychiatric symptoms are present. The recommended approach is supportive care with ongoing assessment.

In this instance, the patient received a benzodiazepine challenge, two psychiatric medications, and a detailed discussion of ECT before the underlying volitional motive was uncovered. The authors clarify that this sequence was not an error; common and potentially dangerous conditions such as catatonia must be ruled out first, as delayed treatment can be hazardous. Their conclusion is that volitional mutism should be considered part of the differential diagnosis after more common explanations are excluded, but it should not be the primary assumption.

She was lost to follow‑up after discharge, leaving her long‑term outcome unknown.

Sudden changes in speech, eating, or behavior can have medical or psychiatric origins and merit prompt clinical evaluation. This case highlights the importance of thorough assessment and respectful communication when confronting atypical presentations.

Key Questions Answered

What is volitional mutism? It describes a deliberate choice not to speak in the absence of psychiatric illness, neurological disease, or obvious secondary benefit such as avoiding legal consequences.

How is it different from selective mutism? Selective mutism is an anxiety‑related condition where an individual cannot speak in specific settings despite speaking normally elsewhere. Volitional mutism is a conscious, intentional silence that the person can later explain.

What made her start talking? She began speaking when clinicians approached her on day 17 to discuss electroconvulsive therapy. She then disclosed her voluntary month‑long fast and vow of silence.

Why was catatonia suspected? Mutism is a hallmark of catatonia, a potentially dangerous condition if untreated. She underwent a lorazepam challenge—a standard diagnostic test for catatonia—which did not alter her presentation.

Is this common? No. The authors report that only one other case has been documented in the literature.

What is unknown here? Virtually everything regarding her long‑term outcome. The patient was lost to follow‑up after discharge, so no further details about her subsequent care are available.

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