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Solving A ‘Medical Mystery’

Solving A ‘Medical Mystery’Tufts School of Medicine psychiatry professor Dr. Ronald Pies recounts the challenge of treating a silent patient.

Boston [06.28.06] Nearly two decades ago, when a young Cambodian man who hadn’t uttered a word to anyone in more than a year arrived in Dr. Ronald Pies office with his case manager and a translator, the Tufts School of Medicine psychiatry professor was stumped. The silent patient, Pies recounted in a recent article he authored for The Boston Globe, presented a unique challenge.

“By all accounts, my patient said nothing to anybody, anywhere, though he seemed to understand what others were saying to him,” Pies wrote in the Globe. “My patient showed few signs and symptoms of brain damage or major depression, and he seemed to get along fine with others except for his inability -- unwillingness? -- to speak.”

Though the man had been diagnosed with “‘selective mutism’ – a disorder usually associated with social anxiety in children,” Pies was doubtful. The symptoms, Pies wrote, seemed to suggest a different problem: post-traumatic stress disorder (PTSD).

“…I wondered whether his mutism might be a delayed reaction to trauma he had suffered in Cambodia,” Pies wrote about his patient, who had escaped Cambodia in the late 1970s, when millions of people were being killed at the hands of dictator Pol Pot’s soldiers, the Khmer Rouge.

“Had he been brutalized by the Khmer Rouge?” Pies wondered in the Globe. “Was this related in some way to his mutism?”

While Pies was never able to determine what had happened to the young man, he followed his hunch and treated him for PTSD. And he spent nearly a year sitting opposite the young man in silence, hoping for some sort of breakthrough.

“Often, as a psychotherapist, half your job is just sitting quietly and respectfully in the presence of the patient's silence. And this I tried to do, month after month, with my mysteriously silent patient and his case manager,” Pies wrote in the Globe. “At times, if my patient's body language or facial expression changed, I might venture a question, or offer a supportive comment...”

While he often felt the urge to speak just to break up the silence, Pies wrote that being patient was important.

“…Traumas take time to heal, and that time needs to be suffused with trust, safety, and empathy,” he wrote in the Globe. “Sometimes, even when you aren't quite sure what you're doing for the patient, those ingredients eventually work their way into the psychic wound. And sometimes you just catch a lucky break.”

Pies’ “lucky break” came after about a year of treating the young man. Wearing casual clothes, Pies rushed into the office one morning to find the patient and his case manager already there. The young man, Pies recalled in the Globe, began staring at his psychotherapist’s feet.

“…I noticed a softening at the corners of his mouth, as if some granite rock face were about to give way. Suddenly, my patient broke out into a toothy grin,” Pies wrote. “‘Doctor need new shoes!’ [the young man] exclaimed loudly, pointing at my scuffed Hush Puppies,” Pies recalled to the Globe.

It’s a moment that still stands out in his mind.

“My patient was not only getting better, he was giving me good advice,” he wrote in the Globe. “As physicians trained in ‘differential diagnosis,’ psychiatrists earn their keep by helping solve medical mysteries like this one.”


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