A case of schizophrenia refuting mind-body dualism

Introduction The case report depicts the complex interplay between mental and physical illness and contests the notion of mind-body dualism in medicine. It emphasises the importance of holistic management of patients and the misnomer of schizophrenia as a purely mental illness. Patient presentation Mr S is a 35-year-old male who presented to a South African specialist psychiatric hospital via the forensic system. He had multiple physical symptoms involving the abdominal, haematological, dermatological and neurological systems, in addition to an eight year duration of untreated psychosis with a marked decline in cognition and functioning. Management and outcome An extensive medical examination during his admission excluded conditions such as early onset dementia, Huntington’s disease, pellagra, Wilson’s disease, autoimmune encephalitis and substance-related complications. A definitive diagnosis of schizophrenia was made, and both physical and psychiatric symptoms responded well to the administration of an antipsychotic resulting in an eventual discharge from the hospital. Conclusion Mind-body dualism can result in a delayed diagnosis of schizophrenia and subsequent increased duration of untreated psychosis and other complications. Contribution This case emphasises the flaws of mind-body dualism, and the interplay of mental and physical illness.


Read online:
Scan this QR code with your smart phone or mobile device to read online.
to and from places by himself and had a good relationship with his brother prior to the onset of symptoms.
Mr S was arrested in 2019 for a charge of trespassing and had no other forensic history.He was subsequently referred by court for a psychiatric forensic observation in October 2021.The assumption for the delay in his referral for forensic observation, is the long waiting list for observandi at state psychiatric facilities in South Africa.In October 2021, he underwent observation and was found unfit to stand trial and not criminally responsible.The differential diagnosis at the time was a major neurocognitive disorder and psychotic disorder.No psychotropics were initiated at the time and he was sent back to prison with the suggestion to be readmitted as an involuntary mental health care user for treatment.From prison, he was admitted to a psychiatric hospital for treatment in March 2022, after being on the waiting list for admission.This was his index presentation to psychiatry and he was antipsychotic naïve.
Mr S occasionally consumed alcohol.He did not meet the criteria for a substance use disorder on interview and this was confirmed by collateral.He had previously been diagnosed with pulmonary tuberculosis (TB) while in prison and completed six months of treatment (in February 2020).There is no family history of psychiatric or neurological illness.
Upon admission to the psychiatric hospital, Mr S was observed to be physically unwell.He presented with neurological signs (specifically cerebellar signs -ataxia, dysmetria dysdiadochokinesia), anaemia, a maculopapular rash, nonspecific gastrointestinal symptoms (nausea, vomiting, abdominal pain and diarrhoea) and cachexia (body mass index 17.78).He scored 18 on the Scale for Assessment and Rating of Ataxia (SARA).
Upon a mental status examination, Mr S displayed a speech fluency disorder (stutter), psychomotor slowing, marked cognitive impairment, anosognosia and persecutory delusions.His mood was euthymic with a restricted affect and he displayed poor insight and impaired judgement.He scored 111 on the Positive and Negative Syndrome Scale (PANNS) and 12/30 on the Montreal Cognitive Assessment Test (MoCA).

Investigations and differential diagnoses
An extensive medical work-up including infective markers, HIV, enzyme-linked immunoassay (ELISA) test, syphilis serology, thyroid function test, Vitamin B12, autoimmune markers, heavy metal studies, tumour markers, ceruloplasmin levels, lumbar puncture, a skin biopsy and electroencephalogram all came back normal.His computed tomography brain scan showed prominent sulci and gyri and cerebellar atrophy.His magnetic resonance imaging brain scan revealed age-inappropriate cortical and cerebellar atrophy.Mr S was consulted by a neurologist as as neuropsychiatrist.Conditions such as early-onset dementia, Huntington's disease, pellagra, Wilson's disease, TB meningitis and autoimmune encephalitis were ruled out.

Case management
A definitive diagnosis of schizophrenia was made.Mr S was initiated on risperidone 2 mg orally at night after a discussion with him as per National Institute of Clinical Excellence Guidelines, 6 which was uptitrated to 4 mg during his admission.He was initiated on flupentixol decanoate 20 mg intramuscularly, monthly.He responded to antipsychotics and his PANNS score changed from 111 to 79 at discharge and a repeat MoCA had improved to 21/30.His cerebellar symptoms, cognitive symptoms and physical symptoms also improved on antipsychotics, with a SARA score of 5 at discharge.Mr S was discharged in August 2022.

Discussion
Another consideration is the initiation of psychotropics indicated on observation of those who are found not fit and/ or not responsible due to mental illness. 1,7A systematic review by Elyamani et al. (2020) highlighted the poor mental health literacy of non-psychiatrists in the 'Arab Gulf countries'. 8In one of the studies included in the review, 54.3% had limited recognition of psychosis. 8In a study by Albin et al. (2020), 38% of psychotic participants were not diagnosed with psychosis at their initial contact with a clinician. 9These health system factors have been shown to contribute to the duration of untreated psychosis (DUP) in people with mental illness (PWMI). 10Duration of untreated psychosis is defined as the time from onset of overt positive psychotic symptoms to the initiation of antipsychotic medication. 10In a study by Oosthuizen et al. (2003), the mean DUP in a South African cohort was 229.10 ± 358.97 days. 11Research suggests that longer DUPs are associated with poorer treatment outcomes. 11Mr S had an approximately eight year DUP.During this time, he consulted a traditional healer and various medical doctors in prison and a tertiary medical hospital for physical complaints.Despite this, he was neither diagnosed with schizophrenia nor initiated on an antipsychotic.When he presented to a psychiatric hospital via the forensic system, he was physically ill.He had developed anaemia, cachexia and pulmonary TB likely secondary to the negative symptoms of schizophrenia.Had Mr S's physical and mental health been treated holistically, he would have likely had a reduced DUP and subsequent improved outcome.Another consideration is the initiation of psychotropics on observandi that are found not fit and/or not responsible due to mental illness.Prompt initiation may reduce DUPs and improve outcomes for patients.
The case of Mr S illustrates the integration of physical and mental health.This case study emphasises the flaws of mind-body dualism and the misnomer of schizophrenia as a purely mental illness.The case also highlights the treatment of people with mental illness within the forensic system.Long waiting lists for observation, waiting lists for admission into psychiatric facilities and inadequate medical services in prison are all serious concerns, which need to be addressed.

TABLE 1 :
Timeline of patient presentation.