Attributed to Descartes in the 1600’s, mind-body dualism derived support largely as a model or belief system to explain illness at the time, rather than as a result of robust evidence.^1,2 In a landmark article by Engel (1977), the theory of mind-body dualism was challenged and a new biopsychosocial model was proposed.² However, the integration of physical and mental health has lagged.

Physical brain abnormalities have been observed in patients with mental illness, for example decreased cerebellar mass and neurological soft signs (NSS) in schizophrenia.^3,4 Neurological soft signs are defined as subtle and non-localising neurological deficits in sensory integration, motor coordination, and sequencing of complex motor acts.⁴ Neurological soft signs are more prominent in patients with schizophrenia than the general population, even prior to initiation of treatment.⁴

In patients with schizophrenia specifically, a higher prevalence of human immunodeficiency virus (HIV), hepatitis, osteoporosis, altered pain sensitivity, sexual dysfunction, obstetric complications, cardiovascular diseases, obesity, diabetes, dental problems and polydipsia has been noticed compared with the general population.⁵ Patients with schizophrenia have a life expectancy that is 15–20 years less than the general population, with 60% of this mortality driven by comorbid physical illness.^2,5

The case study that follows uniquely illustrates the clear overlap between mental and physical factors on a systemic and individual level. The patient presented to both general and psychiatric services and displayed a complex interplay of mental and physical issues on clinical presentation and one could not be separated from the other.

Mr S is a 35-year-old single male with no children residing with his mother and siblings. His highest level of education is matric and he is unemployed. On admission he presented with auditory hallucinations and persecutory delusions since 2014 (see Table 1). He had become withdrawn and began wandering away from home for days at a time. A traditional healer was consulted, with no improvement. These symptoms were accompanied by a decline in functioning. Mr S had reportedly been social, friendly, able to sustain employment, manage finances, navigate 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, non-specific 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).

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 well as neuropsychiatrist. Conditions such as early-onset dementia, Huntington’s disease, pellagra, Wilson’s disease, TB meningitis and autoimmune encephalitis were ruled out.

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.

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.^1,7 A systematic review by Elyamani et al. (2020) highlighted the poor mental health literacy of non-psychiatrists in the ‘Arab Gulf countries’.⁸ In one of the studies included in the review, 54.3% had limited recognition of psychosis.⁸ In a study by Albin et al. (2020), 38% of psychotic participants were not diagnosed with psychosis at their initial contact with a clinician.⁹ These health system factors have been shown to contribute to the duration of untreated psychosis (DUP) in people with mental illness (PWMI).¹⁰ Duration of untreated psychosis is defined as the time from onset of overt positive psychotic symptoms to the initiation of antipsychotic medication.¹⁰ In a study by Oosthuizen et al. (2003), the mean DUP in a South African cohort was 229.10 ± 358.97 days.¹¹ Research suggests that longer DUPs are associated with poorer treatment outcomes.¹¹

Mr 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.