History
A 24-year-old man’s parents bring him to see you. Up until a few months ago he seemed to be doing well and there were no concerns. He was in the second year of his PhD, but then apparently quite suddenly lost interest in his academic work and also stopped socializing with his friends. He returned to live at home and has been increasingly more withdrawn at home. He is speaking less and less and is becoming apathetic and rarely shows any emotion or engagement with anyone including his family members with whom he had been reasonably close. When asked how he is, the man insists he is fine and he cannot understand his parents’ concern. When asked about what they think is wrong, his parents cannot say what concerns them but they are sure something is not right.
Mental state examination
His eye contact is variable and when he does make eye contact it is fixed but there is no sense of rapport with you. He is a polite and reasonably cooperative man. He does not appear anxious or agitated but appears rather flat in affect. He seems slightly detached from his parents and does not look at them. His speech appears normal but he does at times struggle to answer even quite basic questions and his responses are short. He describes his mood as ‘fine’ and denies any self-harm ideation. He does not look depressed but seems detached and in a world of his own. He denies any hallucinations or delusions. There is no evidence of any thought disorder, although he says very little so this is difficult to elicit. He is orientated in time, place and person. His serial 7 testing is poor, but his parents say he has never been good at mathematics.
You then call his university tutor who reports that a few months prior to him leaving university and returning home, it was brought to the tutor’s attention by his peers that there had been episodes of strange and erratic behaviour. By the time the university health service saw him, the episodes seemed to have settled, but it was suggested he would benefit from a break.
Questions
•What is the differential diagnosis?
ANSWER 30
The man needs to be assessed and he will need to be seen alone. If he has capacity, his consent is required to share information about his care with his parents. You will need to ask about any changes in mood, any experience of perceptual abnormality, any evidence of delusions, any changes in behaviour. A risk assessment is also needed.
The differential diagnosis will include depression, substance misuse, schizophrenia presenting with negative symptoms, autistic spectrum disorder (extremely unlikely as onset appears to be recent and ASD would have had features from before age three) and possible organic causes.
The most likely diagnoses are depression or schizophrenia. This man appears to be presenting with the negative symptoms of schizophrenia, but it is important not to jump too quickly to conclusions as making this diagnosis has a number of weighty implications for this man and his family. Make sure that other possibilities are excluded.
While there are no tests that can diagnose schizophrenia, simple blood and urine tests can rule out other medical causes of symptoms. Brain imaging studies, such as an MRI or a CT scan, can exclude other very rare problems such as space-occupying lesions. A thorough history and blood screen could exclude any missed systemic illness such as anaemia or hypothyroidism.
The management of this man would depend on the final diagnosis. Initial treatment may focus on psychosocial interventions including information, activity scheduling, family therapy, and cognitive behaviour therapy. Other aspects of treatment include the development of coping strategies and helping him function the best he can whatever the symptoms are. Depression would warrant antidepressants and a diagnosis of schizophrenia would involve treatment with antipsychotic medication, although compliance may be an issue as the man does not believe he is unwell. Psychosocial interventions would allow a period of monitoring before deciding on medication. Antipsychotics appear less effective in reducing negative symptoms than positive ones. Educating and supporting the family is also an important component of care. It is very important that patients stay in treatment even after recovery. Four out of five patients who stop taking their medication after a first episode of schizophrenia will have a relapse. Relapse prevention work is therefore a key part of any treatment programme.
• Avolition and low energy – the person tends to sit around and sleep much more than normal, they lack interest in life and have poor motivation.
• Affective flattening – a blank, blunted facial expression or less lively facial movements, flat voice (lack of normal intonations and variance) or physical movements and poverty of emotional expression compared to before.
• Alogia describes poverty of speech.
• Interest in others is reduced.
• Inability to make friends or keep friends.
• Social isolation.
• Poor self-care.
• Catatonia can present in a number of ways with profound effects on movement and activity. There may be an apparent unawareness of the environment, near total absence of motion and speech, aimless body movements and bizarre postures.
Negative symptoms and signs of schizophrenia
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• Antipsychotic medication is less effective for the negative symptoms of schizophrenia; only with clozapine is there good evidence about significant effects on negative symptoms.
• Educating and supporting the family is a key component of care.