Abstract
Before the age of 12, the patient was a boy with acceptable academic results. He was interested in soccer, had a limited group of friends and was a videogames enthusiast. At age 12 he began to experience some unspecific somatic complaints and developed a progressive blunting of affect, loss of interest, and self-absorbed behavior. As time went by, he lost interest in his soccer team, his game console, and his mobile phone, and he stopped reacting to his best friend's calls. His academic performance began to decline and some facial motor tics appeared, which disappeared 6 months later without any treatment. No other neurological symptoms were noticed, and the beginning of the medical profile did not coincide with any infectious disease.
Two years later, the patient refused to attend school and his personal hygiene became poor. Additionally, at this time, the patient also displayed no eye contact and no spontaneous speech. He spent all the day closed in his room, lying on the bed, sometimes reading comics and without any other interests. After unsuccessful treatment by his psychiatrist with paroxetine (up to 20 mg/day), venlafaxine (up to 150 mg/day), and olanzapine (up to 5 mg/day), he was admitted to our department at age 16.
The patient displayed isolated behavior. Psychopathological evaluations (the Diagnostic Interview Kiddie Schedule for Affective Disorders & Schizophrenia, Spanish Version) did not reveal any positive symptomatology, such as delusions or hallucinations. Hypoprosexia, apathy, and anhedonia were detected, but no other depressive symptoms like irritability, low frustration tolerance, anger, sadness, hopeless feelings, and depressive cognitions were found. We also detected blunting of affect, no eye contact, and no spontaneous speech during the interview.
The neurological exploration was strictly normal, and no disturbances in motor behavior were found. He had no remarkable history of familial mental illness, drug-taking behaviors, or evidence of developmental disorders. His intelligence quotient (IQ) was assessed to be in the medium range of normality, but neuropsychological evaluation showed him to have mild difficulties in working memory, selected attention, and verbal memory. A magnetic resonance imaging scan showed both lateral ventricles to be enlarged and the callous body to be narrowed. His Positive and Negative Syndrome Scale (PANSS) total score the day after being admitted to our department was 67 (P, 7; N, 34; G, 26).
We decided to move to clozapine for the effects on the negative dimension of the illness, prominent in this case, and the treatment was begun (up to 150 mg/day (Llorca et al. 2000; Kerwin 2007). Three weeks later, the patient agreed to attend a computer course, showed some interest in hospital activities and in his roommate, and demonstrated affection when he received familial visits. He was then discharged and continued treatment as an outpatient.
Four months later, sertraline was also prescribed (up to 100 mg/day) (Silver 2004) due to the persistence of somatic complaints. After the introduction of the antidepressant, his complaints decreased, he showed interest in his favorite soccer team and watching matches on television, and he complied with requests from others, such as his mother's suggestion to do housework and to attend a daily workshop-school. His PANSS total score at this time was 45 (P, 7; N, 20; G, 18). This improvement continues until today, 2 years after the introduction of clozapine and sertraline.
This case illustrates that the ICD-10 subcategory of simple schizophrenia is a useful although uncommon diagnosis despite having no equivalent in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association 1994). The combination of antipsychotics and antidepressants could be partially effective in its treatment.
Footnotes
Disclosures
The authors have no financial ties or conflicts of interest to disclose.