Author: Dr Halit Ibrahimi, MD

Resident in Psychiatry, 3rd year

Clinical University Centre of Kosova, Prishtina
Address: “Mbreti Bardhyl” 3
10 000 Prishtina, Kosovo
E-mail: halitbeselica@yahoo.com
Cell phone: +377/44 419 245
Office: +381/38 500 600 2838

Case of the Week: Social withdrawal and bizarre behavior in

an 18 years old man

Section 1: Background

An 18-year-old man presents to the emergency psychiatric unit

with a relatively long (about a year – pro anamnesis) history of
“bad dreams, heart pains, insomnia, and lack of appetite”
(quotation). From the hetero-anamnesis (father) we understand
that the condition of the patient, which left school about a year
ago, is worsened in the last week, with signs such as:
disorientation, talking to itself, purposeless walking in the
bedroom during the night, laughing while alone - with no reason,
nervousness. We also learn that the patients mother, a long time
ago, was hospitalized in Psychiatry, and that she, even nowadays,
continues with psychiatric treatment. (Later we saw that she has
been dismissed from the Psychiatry with the diagnosis:
Conversive disorder). This is the fist time the patient came to
seek psychiatric help, not voluntarily, but because father insisted
to do so. He has taken no medications recently and he denies any
illicit drug use.
On physical examination, his oral temperature is 37.0°C. His pulse
has a regular rhythm with a rate of 90 bpm. His blood pressure is
125/80 mm Hg. He is noted to be very distressed, because didn’t
think that needs psychiatric treatment. The examination of his
head and neck reveals a moderate strabismus. While examining
the thorax, we notice the presence of pectus infundibulum. His
lungs are clear to auscultation with normal respiratory effort.
His S1 and S2 heart sounds are normal. His abdomen is soft and
without pain or distress during palpation. The peripheral arterial
pulses in the lower extremities are palpable.

The laboratory analysis, including a complete blood count and a

basic metabolic panel, is normal. The CT (computerized
tomography) of the brain reveals the presence of nasal polyps,
with no other changes. The posteroanterior chest radiograph is
normal. EEG is within normal parameters. Psychological testing
reveals a marked regression, infantile personality traits with an
IQ=80, without organicity. Cardiologist and abdominal surgeon
didn’t find any sign of heart, abdominal or other diseases.

Section 2: Hint

Have in mind the changes in the patient’s behavior from his

father’s point of view, his own complaints, and the mother’s
medical past, too.

Section 3: Answer

Simple schizophrenia

Section 4: Discussion
Schizophrenia is a clinical syndrome of variable, but profoundly
disruptive, psychopathology that involves cognition, emotion,
perception, and other aspects of behavior. The expression of
these manifestations varies across patients and over time, but
the effect of the illness is always severe and is usually long
lasting. The disorder usually begins before age 25, persists
throughout life, and affects persons of all social classes. Both
patients and their families often suffer from poor care and social
ostracism because of widespread ignorance about the disorder.
Although schizophrenia is discussed as if it is a single disease, it
probably comprises a group of disorders with heterogeneous
etiologies, and it includes patients whose clinical presentations,
treatment response, and courses of illness vary.

According to the ICD-10, Simple Schizophrenia is an uncommon

disorder in which there is an insidious but progressive
development of oddities of conduct, inability to meet the
demands of society, and decline in total performance. Delusions
and hallucinations are not evident, and the disorder is less
obviously psychotic than the hebephrenic, paranoid, and catatonic
subtypes of schizophrenia. The characteristic "negative"
features of residual schizophrenia (e.g. blunting of affect, loss of
volition) develop without being preceded by any overt psychotic
symptoms. With increasing social impoverishment, vagrancy may
ensue and the individual may then become self-absorbed, idle, and
aimless.
Simple schizophrenia is a difficult diagnosis to make with any
confidence because it depends on establishing the slowly
progressive development of the characteristic "negative"
symptoms of residual schizophrenia without any history of
hallucinations, delusions, or other manifestations of an earlier
psychotic episode, and with significant changes in personal
behaviour, manifest as a marked loss of interest, idleness, and
social withdrawal. The syndrome must be differentiated from
depression, a phobia, a dementia, or an exacerbation of
personality traits.

DSM-IV-TR Research Criteria for Simple Deteriorative

Disorder (Simple Schizophrenia)

A. Progressive development over a period of at least a year of

all of the following:
1. marked decline in occupational or academic functioning
2. gradual appearance and deepening of negative
symptoms such as affective flattening, alogia, and
avolition
3. poor interpersonal rapport, social isolation, or social
withdrawal
B. Criterion A for schizophrenia has never been met.
C. The symptoms are not better accounted for by schizotypal
or schizoid personality disorder, a psychotic disorder, a
mood disorder, an anxiety disorder, a dementia, or mental
retardation and are not due to the direct physiological
effects of a substance or a general medical condition.

Differential Diagnosis

Secondary Psychotic Disorders

A wide range of nonpsychiatric medical conditions and a variety

of substances can induce symptoms of psychosis and catatonia.

Other Psychotic Disorders

The psychotic symptoms of schizophrenia can be identical with
those of schizophreniform disorder, brief psychotic disorder,
schizoaffective disorder, and delusional disorders.

Mood Disorders

A patient with a major depressive episode may present with

delusions and hallucinations, whether the patient has unipolar or
bipolar mood disorder.

Personality Disorders

Various personality disorders may have some features of

schizophrenia. Schizotypal, schizoid, and borderline personality
disorders are the personality disorders with the most similar
symptoms.

Malingering and Factitious Disorders

For a patient who imitates the symptoms of schizophrenia but

does not actually have the disorder, either malingering or
factitious disorder may be an appropriate diagnosis.

Treatment

Although antipsychotic medications are the mainstay of the

treatment for schizophrenia, research has found that
psychosocial interventions, including psychotherapy, can augment
the clinical improvement. Just as pharmacological agents are used
to treat presumed chemical imbalances, nonpharmacological
strategies must treat nonbiological issues. The complexity of
schizophrenia usually renders any single therapeutic approach
inadequate to deal with the multifaceted disorder. Psychosocial
modalities should be integrated into the drug treatment regimen
and should support it. Patients with schizophrenia benefit more
from the combined use of antipsychotic drugs and psychosocial
treatment than from either treatment used alone.

Hospitalization

Hospitalization is indicated for diagnostic purposes, for

stabilization of medications, for patients' safety because of
suicidal or homicidal ideation, and for grossly disorganized or
inappropriate behavior, including the inability to take care of
basic needs such as food, clothing, and shelter. Establishing an
effective association between patients and community support
systems is also a primary goal of hospitalization.
Short stays of 4 to 6 weeks are just as effective as long-term
hospitalizations and those hospital settings with active behavioral
approaches produce better results than do custodial institutions.
Hospital treatment plans should be oriented toward practical
issues of self-care, quality of life, employment, and social
relationships. During hospitalization, patients should be
coordinated with aftercare facilities, including their family
homes, foster families, board-and-care homes, and halfway
houses. Day care centers and home visits by therapists or nurses
can help patients remain out of the hospital for long periods and
can improve the quality of their daily lives.

Pharmacotherapy

The introduction of chlorpromazine (Largactil; Thorazine) in 1952

may be the most important single contribution to the treatment
of a psychiatric illness. Henri Laborit, a surgeon in Paris, noticed
that administering chlorpromazine to patients before surgery
resulted in an unusual state in which they seemed less anxious
regarding the procedure. Chlorpromazine was subsequently shown
to be effective at reducing hallucinations and delusions, as well as
excitement. It was also noted that it caused side effects that
appeared similar to Parkinsonism.
Antipsychotics diminish psychotic symptom expression and
reduce relapse rates. Approximately 70 percent of patients
treated with any antipsychotic achieve remission.
The drugs used to treat schizophrenia have a wide variety of
pharmacological properties, but all share the capacity to
antagonize postsynaptic dopamine receptors in the brain.
Antipsychotics can be categorized into two main groups: the
older conventional antipsychotics, which have also been called
first-generation antipsychotics or dopamine receptor
antagonists, and the newer drugs, which have been called second-
generation antipsychotics or serotonin dopamine antagonists
(SDAs).
Clozapine (Leponex; Clozaril), the first effective antipsychotic
with negligible extrapyramidal side effects, was discovered in
1958 and first studied during the 1960s. However, in 1976, it was
noted that clozapine was associated with a substantial risk of
agranulocytosis. This property resulted in delays in the
introduction of clozapine. In 1990, clozapine finally became
available in the United States, but its use was restricted to
patients who responded poorly to other agents.

Other Biological Therapies

ECT has been studied in both acute and chronic schizophrenia.

Studies in recent-onset patients indicate that ECT is about as
effective as antipsychotic medications and more effective than
psychotherapy. Other studies suggest that supplementing
antipsychotic medications with ECT is more effective than
antipsychotic medications alone. Antipsychotic medications
should be administered during and after ECT treatment.
Although psychosurgery is no longer considered an appropriate
treatment, it is practiced on a limited experimental basis for
severe, intractable cases.

Psychosocial Therapies

Psychosocial therapies include a variety of methods to increase

social abilities, self-sufficiency, practical skills, and interpersonal
communication in schizophrenia patients. The goal is to enable
persons who are severely ill to develop social and vocational skills
for independent living. Such treatment is carried out at many
sites: hospitals, outpatient clinics, mental health centers, day
hospitals, and home or social clubs.

Social Skills Training

Social skill training is sometimes referred to as behavioral skills

therapy. Along with pharmacological therapy, this therapy can be
directly supportive and useful to the patient. In addition to the
psychotic symptoms seen in patients with schizophrenia, other
noticeable symptoms involve the way the person relates to
others, including poor eye contact, unusual delays in response,
odd facial expressions, lack of spontaneity in social situations,
and inaccurate perception or lack of perception of emotions in
other people. Behavioral skills training addresses these behaviors
through the use of videotapes of others and of the patient, role
playing in therapy, and homework assignments for the specific
skills being practiced. Social skills training has been shown to
reduce relapse rates as measured by the need for hospitalization.

We initiated the treatment with benzodiazepines only (Diazepam

– Valium 10 mg ampoules, three times a day, i.m.). Immediately
after hospitalization, the patient was very distressed; he said
that his father’s claims were untrue, that he needs no psychiatric
treatment. He looked very scared, but manifested not any sign of
perceptual or marked thought disturbances. Immediately after
the first interview, the patient escaped from the psychiatric
ward. He returned three days later, always accompanied by his
father (which, by the way, was very suggestible, had no education
and no permanently job). Now, the patient was less distressed,
and declared that is ready and willing to begin with the
treatment.
We initiated the treatment with benzodiazepines only (Diazepam
– Valium 10 mg ampoules, three times a day, i.m.). The major
patient’s complaints, after the hospitalization, were about fear
from death, strange feelings in the stomach, ambivalence about
his health. We learned that in the last year, the patient had a
marked deterioration in school, and that he stays no more with
his former friends, with the explanation that he doesn’t speak
lot, and that’s why, the friends doesn’t stay with him anymore.
After three days from the hospitalization, we began with low
doses of Risperidone (Risperdal) 1 mg, p.o.: ½ + 0 + ½, and
continued with ½ + 0 + 1, and, after a week, with Risperidone
(Risperdal) 2 mg ½ + 0 + 1. During this time, we saw initially a
moderate, and later a marked improvement. The patient wasn’t
anxious anymore, he had fewer complaints about his health, his
affect was improved, he smiled more often and began to
interfere in the every days patients activities in the ward.
He was dismissed from the hospital and was said to take the
medicines regularly and to come every month for examination.
We didn’t see him, or hear for him for over two months. After
that, his father came and told us that the patient isn’t feeling
well, that he didn’t take medicines regularly, because they had no
money to buy it. In the mean time, he took his son to different
doctors. One of them, because of patient’s complaints for back
and head pain, ordered lumbar puncture, which resulted normal.
We counseled him to bring the patient to the hospital, what he
did a day after. This time, the patient moved with difficulties
(because of lumbar puncture), didn’t speak much, and seemed
very preoccupied about his health. Once, he told us that he is
going to die, because has AIDS. He told us that, even he never
had sex, he is convinced that has AIDS, because he masturbated
very often. The HIV test resulted negative, and the
dermatologic-venereologist examination was with no pathological
findings. We continued with Risperidone (3 mg a day, p.o.) and
Diazepam (20 mg a day, p.o.), and, after 10 days (May 2008),
dismissed the patient from the hospital. He was released in
relatively good shape. Until now, we never saw him or his father
again.

References:

1. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral

Sciences /Clinical Psychiatry, 10th edition. Copyright ©2007
Lippincott Williams & Wilkins.
2. International Statistical Classification of Diseases and Related
Health Problems
10th Revision - Version for 2007
3. Oxford Handbook of Psychiatry, 2005

Section 6: CME Questions

1. Simple schizophrenia is characterized with:

a. Bizarre delusions and marked auditory hallucinations

b. Mood cyclic variations
c. Occupational deterioration
d. Catatonic behavior
e. Sexual promiscuity

Correct answer, c: Simple schizophrenia usually is

characterized with, so called, negative symptoms of
schizophrenia, including the occupational deterioration.
The A criterion of schizophrenia is never meet.

2. The typical age for simple schizophrenia is:

a. Every age equally

b. Adolescence
c. Early childhood
d. Old age
e. Middle age

Correct answer, b: The disorder usually begins before

age 25, persists throughout life, and affects persons of
all social classes