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Diagnostic challenge regarding a clinical case of schizophrenia at onset of the symptoms.

Schizophrenia is a brain disorder included in Schizophrenia spectrum and other psychotic disorders, according to DSM-V. The specific symptoms of schizophrenia are delusions, hallucinations, disorganized thinking and speech, grossly disorganized or abnormal motor behaviour (including catatonia) and negative symptoms. (1)

Neuroimaging studies show differences between the brains of the patients diagnosed with schizophrenia and those without the disorder. For example, the ventricles are somewhat larger, there is a decreased brain volume in medial temporal areas and changes are seen in the hippocampus. (2, 3, 4)

The causes of schizophrenia are not exactly known. Most likely, there are at least two sets of risk factors, genetic factors and perinatal ones. In addition, undefined social and environmental factors may increase the risk of schizophrenia in international migrants or urban population of ethnic minorities. Increased parental age is associated with a greater risk of schizophrenia. (5, 6, 7) By using precise methods in its diagnosis and a large representative population, schizophrenia seems to occur with relative consistency over time during the last half century. (8)

The lifetime prevalence of schizophrenia appears to be approximately 0.3 to 0.7 %, although there is reported variation by race/ethnicity, across countries, and by geographic origin for immigrants and children of immigrants. The sex ratio differs across samples and population: for example, an emphasis on negative symptoms and longer duration of disorder, associated with poorer outcome, shows higher incidence rates for males, whereas definitions allowing for the inclusion of more mood symptoms and brief presentations show equivalent risk for both sexes. (13)

The patient M. I. is a 21 years old woman, with the residence in urban area. She is under psychiatric observation since the age of 19 years old, when she was first admitted in "Socola" Institute of Psychiatry Iasi.

Educational level: student (Anthropology) Marital status and family: unmarried; satisfactory relationship with the family members; Religion: orthodox

She does not declare any addictive behaviours (smoking, drugs or alcohol), but she is set on healthy food. The patient declares that she avoids eating meat and she prefers seeds, nuts, fresh fruits and vegetables. She also started to practice yoga, eight months after the first admission in hospital and she often declare how important it is to meditate.

The first admission in hospital was two years ago, when she presented the following symptoms:

--increased motor activity;

--somatic hallucinations ("something is moving in my belly");

--poisoning delusions ("some friends gave me to drink a tea and I think that they put neuro-stimulating substances in it") and persecutory delusions ("it was a woman who watched me in the bus");

--decreased rhythm of thinking, disturbance of associations of ideas, sudden discontinuation of coherence of the thoughts, derailment, thought blocking, stereotypes in thinking;

--often avoids the answer to questions, increased suspiciousness;

--self guilt and distrustful, diminished emotional expression, anxiety;

--avolition;

--mixed insomnia.

According to these symptoms the patient was diagnosed with "Acute Psychotic Disorder with Schizophrenic Symptoms" ("Brief Psychotic Disorder"). The patient received as treatment Aripiparazol 10 mg/day, Acid Valproic 500 mg/day and Zopiclonum 7.5 mg/day. For six months the patient followed the treatment prescribed, being monitored monthly; meanwhile it was observed that the symptoms decreased. The patient and the family, insisted that her condition is better and contrary to medical advices, stopped the medication. After another six months without any psychotropic treatment, the patient returns with a worse status, than the first admission.

PERSONAL HISTORY

Her birth was natural, after 36 weeks of pregnancy, with a weight of 3300 g, length of 152 cm; APGAR score was eight, without major health issues in the first year of life. First menstruation was at nine years old. At 18 years old she was diagnosed and operated of a breast tumor (fibro adenoma). Also, she was diagnosed with polycystic ovarian syndrome, treated with birth control pills, bilateral kidney micro stones, sinus tachycardia and ventricular preexcitation syndrome.

EXAMINATION OF THE PRESENT CLINICAL STATE reflects:

--Underweight and short stature (152 cm/ 34 kg);

--Postoperative scar on left breast;

--Tachycardia, pulse = 95 bpm;

--Osteotendinous reflexes discreetly increased bilateral.

PSYCHIATRIC INTERVIEW

Appearance and behaviour

--Disoriented and confused;

--Increased motor activity alternating with catatonic episodes;

--Sometimes she take abnormal, repetitive, goal-directed movements and bizarre postures;

--She usually repeats investigator phrases or words and creates neologisms;

--Verbal stereotypy;

--Disorganized speech, echolalia, alogia;

--Often is focusing on her breath and explain how important is some types of respiration;

--Stereotyped movements, staring, grimacing;

--Reduction in the expression of emotions in the face, poor eye contact.

Perception

--Somatic hallucinations, "something is flowing down there", "we should let the things to flow";

--Hallucinatory behaviour, self-talking, staring look.

Thinking

--Delusional thoughts of control, "there are sensors in the radiators which send messages";

--Paranoid and persecutory delusions, "poor people are sexually watching me and middle class are watching me because I have a special mission", "you hold me in hospital because I want to make an anthropological study about the communism";

--Decreased rhythm of thinking with sudden discontinuation of a chain of thoughts or thought blocking;

--Driveling, loosening associations between ideas;

--Stereotyped thinking, she repeats "I eat healthy, I breath conscious";

--Formal thought disorder.

Emotions

--Inappropriate affect expressed by laughing or crying in the absence of an appropriate stimulus;

--Dysphoric mood;

--Anxiety because of paranoid and persecutory delusions;

--Affective inversion and episodic aggressively against mother;

--Apathy and anhedonia.

Attention and memory

--Hypoprosexia;

--Hypomnesia.

Instincts and sleep

--Food refusal;

--Disturbed sleep pattern, decreased need of sleep;

--Lack insight of the disorder.

PSYCHOLOGICAL EXAMINATION

At the first admission in hospital, BPRS (Brief Psychiatric Rating Scale) indicates 47 points. High values were canned on following items:

--Somatic concern--5 pts;

--Anxiety--6 pts;

--Guilt--5 pts;

--Suspiciousness--4 pts;

--Conceptual disorganization--5 pts;

--Tension--6 pts.

After a month of treatment the score of BPRS decreased at 30 points and after two months of treatment, BPRS score was 25 points. When the patient reverts to consultation, half year after she stopped the treatment, the BPRS score indicates 64 points with high values on:

--Somatic concern--6 pts;

--Anxiety--6 pts;

--Guilt--5 pts;

--Suspiciousness--6 pts;

--Conceptual disorganization--6 pts;

--Tension--6 pts;

--Bizarre behaviour--4 pts;

--Uncooperativeness--4 pts;

--Grandiosity--3 pts;

--Disorientation--4 pts;

--Excitement--5 pts;

--Emotional withdrawal--3 pts.

PARA-CLINICAL EXAMINATIONS

--ELCTROENCEPHALOGRAM (EEG) shows dominant alpha rhythm, decreased (8-9 Hz, 30-50 pV) in temporal, parietal and occipital bilateral lobes.

--BRAIN ELECTRICAL SOURCE ANALYSIS (BESA)

The analysis of deep electrical sources shows the presence of an electric center in the left insular lobe.

--COMPUTER TOMOGRAF (CT scan of the brain) shows discreet atrophy of the cortex, predominant in frontal, temporal and insular areas.

--Neurological and endocrinological examinations didn't reveal disturbances.

POSITIVE DIAGNOSTIC

Schizophrenia, multiple episodes, currently in partial remission.

The positive diagnostic is supported based on the DSM-V diagnostic criteria:

--Presence of delusions and hallucinations more than a 1-month period;

--Disorganized speech;

--Disorganized behaviour alternating with catatonic episodes;

--Negative symptoms: diminished emotional expression, avolition, alogia, anhedonia;

--For a year since the onset of the disturbance, the level of self-care, interpersonal and academic functioning was markedly below the level achieved prior to the onset.

--Continuous signs of the disturbance persist for at least six months manifested by negative symptoms and odd beliefs.

--Apparently, the disturbance couldn't be attributed to the physiological effects of a substance or another medical condition.

--Even if the patient has stereotypes, echolalia, agitation not influenced by external stimuli, posturing and other catatonic elements, we can't associate the catatonia diagnostic because this symptoms didn't dominate the clinical picture.

DIFFERENTIAL DIAGNOSIS

--MAJOR DEPRESSIVE OR BIPOLAR DISORDER

During the two psychotic episodes, the patient has a diminished emotional expression and apathy. After the first psychotic episode, she has a disthymic mood, but in that residual period of the illness, delusions and hallucinations were absent.

--SCHIZOAFFECTIVE DISORDER was ruled out because it didn't occurred major depressive or manic episodes concurrently with the active phase symptoms.

--SCHIZOPHRENIFORM DISORDER AND BRIEF PSYCHOTIC DISORDER was ruled out because the patient has the symptoms for more than a year.

--DELUSIONAL DISORDER was ruled out because this patient has many symptoms characteristic for schizophrenia, which we can't find at the persons with delusional disorder (disorganized speech and behaviour, negative symptoms).

--SCHIZOTYPAL DISORDER was ruled out because we can't find bizarre behaviour and hallucinations.

--POSTTRAUMATIC STRESS DISORDER was ruled out because the patient doesn't have flashbacks with a hallucinatory quality.

--OBSESSIVE-COMPULSIVE DISORDER AND BODY DISMORPHIC DISORDER was ruled out because the patient doesn't have prominent obsessions, compulsions or preoccupations with appearance or body odor.

TREATMENT

First psychotic episode was treated with Aripiprazol 10 mg/day, Valproic Acid 500 mg/day and Zopiclonum 7.5 mg/day. It was chose Aripriprazol because it is a third generation antipsychotic with fewer side effects, which reduce positive and negative symptoms. There are also studies which evidence those atypical antipsychotics increased the volumes of the thalamus and cortical grey matter. Valproic Acid was administrated as mood stabilizer and Zopiclonum was used to restore sleep architecture.

At the second psychotic episode, the patient received Risperidonum (oral solution) 6 ml/day as antipsychotic. Even if Aripiprazol improved the clinical picture, the patient was complaining about side effects as akatisia and losing weight. It was associated Trihexyphenidyl 2 mg/day to prevent extrapiramidal side effects and Valproic Acid 600 mg/day, Pentoxifylline 400 mg/day. All the doses were adapted to the patient weight.

DISCUSSIONS

--Para-clinical investigations as EEG, BESA and CT of the brain help us to orientate the diagnosis. There is meta-analysis and reviews which describe the neuroanatomical abnormalities observed in schizophrenia, thus volume reductions of prefrontal, temporal, cingulated cortices are already evident before the first psychotic symptoms emerge, and even at the onset of the disorder, before antipsychotic treatment starts. Among other brain areas, recent meta-analytic evidence, incorporating findings from both structural and functional neuroimaging studies suggests a predominant role for perigenual cingulated and insular cortices (10, 11).

--The second psychotic episode of the patient occurred after she stopped the medication and started to practice meditation techniques. There are disputed opinions according meditation in psychotic diseases (12). Our patient seems to be influenced by that because she has bizarre postures, borrowed from yoga and she is practicing all the time her "conscious breathing".

--Her overprotective mother stops the patient to be independent and to do the things as she wants. This aspect often raises her anxiety and she became aggressive with her mother.

--The patient has an obsession with healthy eating, focusing on the quality of ingested food. She usually became very anxious if we suggest eating something else except fresh fruits, vegetables, nuts and seeds. She also has a low weight, probably due to various deficiencies given by absence of important nutrients. This behaviour makes us think that she could have an eating disorder called orthorexia nervosa (14).

CONCLUSIONS

It is very hard to state the diagnostic of schizophrenia at the onset because you can't know if it is only an isolated acute psychotic episode. To have a diagnostic of schizophrenia is very stigmatizing for a young patient and we don't have to hurry to state this diagnostic. It is recommended to observe the patient in time and to select relevant evidence.

Teodora PARASCHIV--Resident in Psychiatry, "Socola" Institute of Psychiatry, Iasi, Romania

Alexandra BOLOS--Assistant of Professor, Senior Psychiatrist, "Gr. T. Popa" University of Medicine and Pharmacy Iasi, Romania

Vasile CHIRIJA--Professor, M. D., Ph. D., "Socola" Institute of Psychiatry, Iasi, Romania

Cristina Elena NEDELCU--Clinician Psychologist, "Socola" Institute of Psychiatry, Iasi, Romania

Roxana CHIRIJA--Professor, Department of Psychiatry, M. D., Ph. D., "Socola" Institute of Psychiatry, Iasi, Romania

ACKNOWLEDGMENTS AND DISCLOSURE

The authors declare that they have no potential conflicts of interest to disclose.

REFERENCES

(1.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, D. C.: American Psychiatric Press; 2000.

(2.) Wright, I. C., Rabe-Hesketh, S., Woodruff, P. W. et al., Meta-analysis of regional brain volumes in schizophrenia. Am J Psychiatry. 2000 Jan. 157(1):16-25.

(3.) Tamminga, C. A., Stan, A. D., Wagner, A. D. The hippocampal formation in schizophrenia. Am J Psychiatry. 2010 Oct. 167(10):1178-93.

(4.) Mattai, A., Hosanagar, A., Weisinger, B., Greenstein, D., Stidd, R., Clasen, L., Hippocampal volume development in healthy siblings of childhood-onset schizophrenia patients. Am J Psychiatry. 2011 Apr. 168(4):427-35.

(5.) Selten, J. P., Cantor-Graae, E., Kahn, R. S. Migration and schizophrenia. Curr Opin Psychiatry. 2007 Mar. 20(2):111-5.

(6.) Bourque, F., van der Ven, E., Malla, A., A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants. Psychol Med. 2011 May. 41(5):897-910.

(7.) Kirkbride, J., Coid, J. W., Morgan, C. et al., Translating the epidemiology of psychosis into public mental health: evidence, challenges and future prospects. J Public Ment Health. 2010 Jun. 9(2):4-14.

(8.) Hafner, H., an der Heiden, W., Epidemiology of Schizophrenia. The Canadian Journal of Psychiatry. 1997; 42:139-151.

(9.) Schizophrenia. World Health Organization. 2011. Retrieved February 27, 2011.

(10.) Boutro, N. N., Arfken, C., Galderisi, S., Warrick, J., Pratt, G., Iacono, W., The Status of Spectral EEG Abnormality as a Diagnostic Test for Schizophrenia. Schizophrenia research. 2008;99(1-3):225-237.

(11.) Dazzan, P., Arango, C., Fleischacker, W., Galderisi, S., Glenthoj, B., Leucht, S. et al., Magnetic Resonance Imaging and the Prediction of Outcome in First-Episode Schizophrenia: A Review of Current Evidence and Directions for Future Research Schizophr Bull. 2015

(12.) Mark, D., Jonathan, D., Psychiatric complications of meditation practice. The Journal of Transpersonal Psychology, 1981, Vol. 13, No. 2.

(13.) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TM). 5th ed. Washington, D. C.: American Psychiatric Press; 2013.

(14.) Donini, L. M. et al., Orthorexia nervosa: a preliminary study with a proposal for diagnosis and an attempt to measure the dimension of the phenomenon.Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 2004, 9.2: 151-157.

Correspondence:

Alexandra BOLOS "Socola" Institute of Psychiatry No. 36 Str. Bucium, zip code 700282, Iasi, Romania

E-mail: bolalexandra@gmail.com

Submission: June, 10th, 2015

Admittance: August, 2nd, 2015
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Article Details
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Title Annotation:Case Reports
Author:Paraschiv, Teodora; Bolos, Alexandra; Chirita, Vasile; Nedelcu, Cristina Elena; Chirita, Roxana
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Sep 1, 2015
Words:2313
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