Late onset simple schizophrenia

Abstract

Simple schizophrenia is a rarely used and controversial diagnosis. Here we report the case of a 54-year-old man with insidious changes in personality and behaviour, lacking perceptual abnormalities and delusions. He showed progressive inability in general functioning and self-care. He was diagnosed with simple schizophrenia and treated with antipsychotics, making a rapid and maintained recovery. We use this case to illustrate the continued relevance of the diagnosis, and highlight the risks of overlooking these patients, with significant consequences for their ability to function adequately in society.

Keywords

Simple schizophrenia late onset negative symptoms

Introduction

Mr. S. is a 54-year-old man initially referred by his GP as a result of his father’s concerns over his behaviour and his ability to function normally. Mr. S. had become increasingly isolated, with marked weight loss and decrease in self-care. He had lost his employment and the ability to manage his finances. There were reports of bizarre behaviour where Mr. S. was seen to be increasingly suspicious and irritable, with episodes of standing motionless staring at buildings for extended periods. He was reported to be dismantling electrical equipment, including his refrigerator and television.

He refused to engage with CMHT staff and due to his profound inability to look after his own health and functioning he was admitted to hospital for assessment on a compulsory basis using the mental health act.

Case presentation

Personal history

Mr. S was born and raised in the West of Scotland. There were no significant early life issues and he met his developmental milestones normally. He had an uneventful childhood, living with both parents and a younger brother. He excelled at school and at 18 left to train at a military training academy. He did not proceed with military training and left to complete teacher training. He married in his early 20 s but divorced several years later. He has no children. He spent time working in the airline industry, including air traffic control and spent several years teaching in the Middle East. He completed a psychology degree in his 40 s and has a private pilot’s license.

Most recently, he worked as a supply teacher until being laid off due to bizarre behaviour. He lives alone in a rented rural cottage.

There was no significant medical history. He did not use alcohol or drugs.

Psychiatric history

Mr. S. first came to the attention of psychiatric services in 2006 when he was admitted with what was diagnosed at the time as ‘acute psychotic episode, stress induced’. He made a rapid recovery on trifluoperazine and was discharged after 5 weeks and subsequently discharged from services in 2009.

Mental state examination

On examination, Mr. S. appeared as a middle-aged caucasian male. He was thin and self-care appeared reasonable. Rapport was difficult to establish and eye-contact was intermittent. He appeared guarded and suspicious and did not engage with assessment. Speech was circumstantial but normal in rate, rhythm and intonation. He did not describe any mood problems and objectively he was euthymic and reactive. There was no evidence of any formal thought disorder or evidence of delusions or perceptual abnormalities. He appeared grossly cognitively intact. He displayed no insight into his circumstances and refused to accept any medication.

Investigations

Physical investigation and routine blood tests were unremarkable. CT brain was normal. He achieved 88/100 in an Addenbrooke’s assessment.

Mr. S. refused to cooperate with occupational therapy and thus an assessment could not be carried out.

Diagnosis and treatment

In summary, Mr. S., a previously high-functioning man, presented with progressive changes in personality and odd behaviour. He developed a pervasive decline in social, occupational and general functioning, with pronounced apathy and self-isolation.

Mr. S. continued to display eccentric and solitary behaviour on the ward. His self-care was poor and he required prompting to attend to personal hygiene. He displayed a preoccupation with electrical equipment and occasional odd, paranoid thoughts but these were fleeting and resolved when challenged. There was never any evidence of perceptual abnormalities, and he was diagnosed with simple schizophrenia (according to ICD-10 classification).

Mr. S. refused to accept treatment and a compulsory treatment order was sought and granted. A flupentixol depot was commenced.

Outcome, prognosis and follow-up

Mr. S. displayed a rapid and marked improvement. He started to interact with staff and other patients. His behaviour became less bizarre and his self-care improved. He began to cooperate with occupational therapy and was able to function well at home and organise his finances. He was discharged after three months with community psychiatric nurse input and outpatient clinic reviews.

A year later he remains well in the community on his depot and is actively seeking employment. His cognitive functioning has improved, scoring 97 on the Addenbrooke’s cognitive assessment. He lost points on verbal fluency only.

The prognosis for simple schizophrenia is poor due to the inconspicuous nature of the illness and failure to detect and treat these patients. Literature on treatment outcomes is scare.

Discussion

Simple schizophrenia is described in ICD-10 as:

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. The characteristic ‘negative’ features of residual schizophrenia 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.

The concept of simple schizophrenia was introduced by Diem in 1903 who saw it as a disease that progressed insidiously with ‘no hallucinations or delusional ideas’.¹ It was included in ICD in 1948 and DSM in 1952.

Others argued ‘it was no longer a viable psychiatric diagnosis’.² They felt the criteria were indistinct and inconsistent and it was rarely used, with only one published paper in 40 years. The diagnosis was not included in DSM III.³

The removal of simple schizophrenia left diagnostic space. One study looked at the histories of over 50 individuals diagnosed with simple schizophrenia.⁴ Many of these individuals did not easily fall into pre-existing diagnoses and they proposed a ‘simple deteriorative state’. DSM IV included the term simple schizophrenia as a ‘future contender’ for re-inclusion.

Lifetime prevalence of simple schizophrenia is estimated at 5.3 per 10,000.⁵ Studies on people diagnosed with schizophrenia estimate a simple subtype in 4–10% of cases.^6–9

Conclusion

This previously high-functioning man presented with progressive changes in personality and odd behaviour.

He declined in social, occupational and general functioning, with pronounced apathy and isolation.

There was no evidence of psychosis, and he was diagnosed with simple schizophrenia.

This illustrates a subset of patients who present with vague and heterogeneous negative symptoms, lacking insight and initiative, risk vagrancy and are overlooked by services.

Consent

Verbal consent was obtained from patient before submission.

Footnotes

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors’ contributions

D. O’Brien prepared this manuscript under the supervision of Dr. Macklin.

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