When mutism speaks: a case of factitious disorder initially presenting as psychosis

Abstract

When mutism changes with context, the silence itself may become a diagnostic clue. However, when such a presentation mimics severe psychiatric illness, distinguishing genuine symptoms from intentionally maintained ones can be difficult. Factitious disorder may present with psychiatric symptoms that closely resemble psychosis, catatonia, dissociative disorders, or other causes of functional impairment, creating substantial diagnostic difficulty. We report a 23-year-old married woman whose husband lived abroad presented with a two-year history of prolonged mutism, social withdrawal, poor self-care, impaired childcare, and intermittent abnormal behaviour who had previously been treated for a presumed psychotic disorder. During admission, she remained largely withdrawn from others, maintaining limited communication only with her husband. Longitudinal observation revealed marked context-dependent variation in speech. To express her unwillingness to perform MRI, she resumed communication and collateral history identified a similar previous episode. Repeated inconsistencies, absence of a coherent psychotic, catatonic, dissociative, or organic explanation, and psychological assessment indicating intentional maintenance of symptoms led to a final formulation of factitious disorder. Treatment shifted from psychopharmacology toward psychotherapy brought about substantial functional improvement at follow-up. This case emphasizes the importance of longitudinal observation, collateral information, diagnostic flexibility, avoidance of premature diagnostic closure and contribution of psycho-social factors when evaluating atypical mutism.

Bang J Psychiatry 2026;40(1): 24-27