CASE REPORT

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A MENTALLY RETARDED PATIENT WITH SCHIZOPHRENIA

Rabia K, MMed(FamMed)
EM Khoo, MRCGP, FAMM, FAFP (Hon), University of Malaya

Address for correspondence: Dr Rabia Khatoon, P.O. Box 136308; Jeddah 21313, Kingdom of Saudi Arabia

CASE SUMMARY

SNS, a thirteen-year-old girl, was brought to our clinic by her father with a recent onset of a change in behaviour. One month prior to her visit, she became more talkative, irritable, talking to herself, roaming around the school and house aimlessly. She was verbally abusive particularly when her mother told her to be quiet. She disturbed her neighbourhood and was destructive towards their property. She had even broken her neighbour’s glass window. She had poor sleep and appetite, as well as visual hallucinations; however she denied having any auditory hallucinations and delusions.

There was no recent history of seizures, high-grade fever, head injury or fluctuating consciousness suggestive of delirium. There were no stressors at home and school, and she denied having suicidal intentions. She had never taken any traditional medication or illicit drugs.  For the past one month, she had given up her schooling and was not taking care of her personal hygiene and feeding. Prior to her visit to the hospital, her parents sought treatment from a bomoh (traditional healer), but her condition worsened gradually. Her parents found it difficult to take care of her at home due to her queer behaviour. Her father was very worried and suspected that she might have mental problem. He wanted her to be admitted to the hospital for treatment and care.

Her past medical history revealed that she had febrile fits at the age of six years old and was admitted to the hospital. She had investigations that included an electroencephalogram (EEG), which turned out to be normal. She had another episode of seizures at the age of twelve while in school, and the episode was witnessed by her class teacher. She again had another EEG carried out, with an equivocal report. The attending doctor explained to her parents, about the possibility of a false negative result and the need of antiepileptic treatment. However her father was not very keen for her to have long-term medications.

There was no history of physical, emotional and psychological abuse. She had no previous history of psychiatric illness. She was born prematurely at seven months of age and stayed for ten days in hospital for neonatal jaundice. She had delayed developmental milestones and had only started walking after two years of age. She was noted to have delayed speech and started to talk after three years old. Her school performance had always been very poor, and in primary school she was last in her class and recently she had failed her primary school public examination.

She was the only child from his father’s second marriage. It was a non-consanguineous marriage. Her father had separated from his first wife, who had two children, and both of them were healthy. There was no family history of mental illness, mental retardation, febrile fits and epilepsy. She was a much pampered child especially by her father. He described her as an introvert who did not mix much with other children. Her premorbid temperament was very childish; she liked to play with children who were younger than her. She did not have close friends. She also had lack of confidence and because of this her parents never allowed her to go out on her own. Nonetheless premorbidly she could manage her daily living needs and at times helped her mother in daily chores. Her mother was a housewife and her father worked as a clerk in a government office. Their financial status was satisfactory.

On examination she was alert and her vital signs were stable. There was no neck stiffness but she had a syndromic facies. Her systemic examinations were unremarkable. She had disorganized behavior, poor eye contact and talked irrelevantly and continuously. She was agitated and non-cooperative and had poor insight. Her mood was elated and she grinned inappropriately. There was no abnormal movement. She had pressure of speech, her affect was inappropriate and there was looseness of associations. She was oriented to place and person but not to time. Her attention and concentration were poor. Registration and recall were difficult to obtain.

A provisional diagnosis of mental retardation with schizophrenia and a differential diagnosis of bipolar affective disorder with manic phase were considered. She was urgently referred to a psychiatrist and subsequently admitted to the psychiatric ward with a diagnosis of schizophrenia. In the ward she was referred to a psychologist and had an intelligent quotient (IQ) test, which showed that she had mild mental retardation. Her electroencephalogram (EEG) and thyroid function test were normal. She was commenced on antipsychotics drugs: risperidone and chlorpromazine. Subsequently, due to poor early response to oral medications, she was given electroconvulsive therapy (ECT).

Psycho-education was given to the patient and her family members. Her parents were counselled and educated with regards to schizophrenia and its treatment, the importance of compliance and good family relationship and support, as well as the importance of regular follow up. She was discharged when her condition was stable and her parents assured the doctors that they could manage her at home. She was regularly followed up in the psychiatric clinic by psychiatrist and psychologist. After two months she was well and was responding to treatment. She had no side effects to treatment. She slept well and had good appetite. She was not disturbing nor had any aggressive behaviour. She was able to help her mother in simple daily chores. She was also referred to the social worker for consideration of welfare benefits of mentally disabled. She was advised to attend classes at special school where she can obtain vocational training.

SNS illness has a major impact on her parents’ physical, social, emotional, psychological health as well as financial burden. Her parents initially thought that their daughter were charmed by black magic and had sought treatment from bomoh (traditional healer). When they found no improvement in her condition, they turned to Western treatment. Her parents were very concerned and worried about her mental retardation and her future.

Her parents were informed that she would get vocational training at the special school, which could help her financially in future. She would also be entitled to get free health care.

However there are still other issues to consider in this patient and her family such as her future placement and who would take care of her socially and financially after her parents die. There is also issue of sexuality, and marriage. She would also be at risk of sexual abuse as people may take advantage of her mental retardation and the issue of contraception will need to be dealt with. All these issues would need to be discussed and plan in the medium and long-term with her carers.

DISCUSSION

SCHIZOPHRENIA

The lifetime prevalence of schizophrenia is about 1%.  According to the WHO, schizophrenia is one of the leading causes of disability worldwide and approximately 10% of patients with schizophrenia may die of suicide.¹

Definition of schizophrenia

Schizophrenia is defined in DSM-IV-TR2 as a psychiatric condition with two or more of the following: delusions, hallucinations, disorganized speech (e.g. incoherence), catatonic behaviour, negative symptoms, i.e. affective flattening, alogia and avolition. These symptoms should be present for a significant portion of time during one-month period or less if successfully treated. One or more major areas of functioning such as work, interpersonal relations, or self-care should be markedly below the level achieved prior to the onset, however when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement need to be considered. These symptoms should persist for at least 6 months (however, in ICD-103, the duration should be at least one month to qualify the diagnosis of schizophrenia). The disturbance should not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia should be made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

In case of SNS she had visual hallucination, disorganized speech and behavior; however she had no delusions and other negative symptoms. SNS has more than one-month duration of symptoms prior to her treatment; though prodromal period was not manifested in her case. Her interpersonal relationships, self care and academic achievement was badly affected and she had no history of substance abuse and abnormality of general medical condition. She also had no history of autistic disorder and pervasive developmental disorder.

Aetiology of schizophrenia

The aetiology of schizophrenia is uncertain, although there is evidence for genetic and environmental risk factors. Among the genetic factors, there is 10-15% increased risk in the siblings of patient with schizophrenia, 15% increased risk among children with one parent with schizophrenia, and 40% increased risk if both parents are affected.⁴ Predisposing factors for schizophrenia include abnormalities of pregnancy and labour, which include premature rupture of membranes, low birth weight and birth events that are linked to infection and hypoxia, low social class and social deprivation. Stressful life events occurring shortly before the disorder are important precipitating factors.⁴

MENTAL RETARDATION

Mental retardation (MR) is present in 2-3%of the population, either as an isolated finding or as part of the syndrome.⁵ It can be defined as a cognitive ability that is markedly below average level and a decreased ability to adapt to one’s environment. The causes of MR are numerous and include genetic and environmental factors. In at least 30-50% of cases, physicians are unable to determine the aetiology despite thorough evaluation. MR is divided into 5 categories, borderline, mild, moderate, severe and profound. Diagnosis of MR is highly dependent on a comprehensive personal and family history, a complete physical examination and a careful developmental assessment of the patient. SNS had delayed developmental milestones.

Physicians should have high index of suspicion to consider the diagnosis of mental retardation in any child. Some helpful clues include the findings in the child of delayed speech, dysmorphic features, generalised hypotonia or of the extremities, general inability to do things for self and expressed concern by parents. Information should be obtained about the family units, parent’s occupations and educational achievements, educational and developmental status of the siblings, and the role of the patient in the family. Child should be examined closely for dysmorphic features or other minor abnormalities. This will guide appropriate evaluations and referrals for genetic counselling, early intervention programmes for the child and offer appropriate resources that may support the family.⁵

Referral can be made to a tertiary level child development unit that can provide interdisciplinary evaluations which include developmental assessment by paediatrician, geneticist, neurologist and ophthalmologist, as well as functional assessment by occupational and physical therapists, speech and language pathologist, audiologist, psychologist, nutritionist and child psychiatrist.⁵ The role of teacher is very imperative in early recognition of MR, especially in children who are slow learners.

However in the case of SNS, the diagnosis of MR was somehow missed and she had been attending normal school despite very poor school performance.