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Simple schizophrenia or disorganisation syndrome? A case report and review of the literature

  • Susannah Whitwell, Jessica Bramham and John Moriarty
Abstract

Simple schizophrenia is a sometimes controversial diagnosis. Here we review the concept with particular reference to its history in diagnostic systems. Using an illustrative real case of a 25-year-old man, we show that there is a need to retain this diagnostic category, which may fit better within proposed dimensional (psychomotor poverty, disorganisation and reality distortion) rather than categorical classifications of schizophrenia. Symptoms of the disorder may be better revealed by functional assessment than by relying on descriptive psychopathology.

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References
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BJPsych Advances
  • ISSN: 1355-5146
  • EISSN: 1472-1481
  • URL: /core/journals/bjpsych-advances
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Simple schizophrenia or disorganisation syndrome? A case report and review of the literature

  • Susannah Whitwell, Jessica Bramham and John Moriarty
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eLetters

Simple schizophrenia- rising incidence owing to academic pressures

Thanjavur R Suresh, Consultant Psychiatrist
19 July 2006

This article considering simple schizophrenia (Whitwell et al 2005) raises important issues. In our country, India, scoring high marks and gaining admission to professional courses is considered almost a matter of life and death, especially by the middle and upper middle classes. The academic pressure exerted on students by parents, schools and evenby the students themselves, is relentless. So much so, that suicides are common after results of the qualifying examinations are released.

An interesting phenomenon in this light is that the presentation of students aged 5 to 20 years with symptoms of poor concentration, deteriorating academic performance and explosive irritability is increasing in frequency in clinical practice. Many of these developments are diagnosed as "stress reactions" or "adolescent disorder" and managed essentially by counselling, with poor results. Some also exhibit a tendency to demand and receive innumerable things like CDs, games, etc. and spend hours playing video games, but not touching books at all. This presentation is frequently diagnosed as "bipolar disorder" and managed accordingly. Careful history-taking and examination reveal littleevidence of formal thought disorder or positive symptoms such as hallucinations and delusions. The condition would certainly fit with simple schizophrenia,though the diagnosis is practically not made of late.

Usually there is a good response to neuroleptic drug treatment and reduction of academic stress. One wonders, though hard dataare lacking, if the condition is increasing in incidence with the changingsociocultural forces?

Reference: Whitwell,S., Bramham,J., and Moriarty,J.(2005) Simple schizophrenia or disorganisation syndrome? A case report and review of the literature. Advances in Psychiatric Treatment,11,398-403
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Conflict of interest: None Declared

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Simple schizophrenia or disorganisation syndrome? A case report and review of the literature

Sameer Jauhar, Senior House Officer
05 February 2006

I read with interest Whitwell et al’s engrossing case report and comprehensive review of the literature relating to the psychiatric enigma of simpleschizophrenia. While I wholeheartedly agree with their assertion that a dimensional approach be taken to diagnosis, I was slightly perturbed by the conclusions drawn in the article that “psychological batteries and occupational therapy assessment may be more revealing” (than descriptive psychopathology), and that “Cognitive symptoms, including disorders of thought, may be overlooked owing to overreliance on the symptoms and signsof descriptive psychopathology”.

The case report illustrates itself the need for sound history taking,mental state examination and the judicious skills used in descriptive psychopathology (which is not merely a “symptoms list” of objective facts.) Although hindsight is a luxury, when reading through the history given prior to initial assessment I was curious how one could have arrived at a diagnosis of dysmorphophobia, epecially having seen no clinical response to intervention? Furthermore, how was a patient with quite telling social decline and “difficulty planning decisions” left at home for 5 months with no clear follow up? This point is further illustrated by the telling quality of the mental state examination given by the authors:“…he appearedperplexed..struggled to describe his experience of feeling different to other people…sometimes difficult to follow his train of thought and he used stock phrases” This clear use of descriptive psychopathology conveys not only symptoms but empathic understanding (as called for in classical texts of psychopathology (Jaspers, 1959) making it clearly apparent to the reader that something is amiss There then follows mention of fairly thorough neuropsychological testing, though the telling points are the gross impairment of executive function and observation of behavioural disinhibition during testing; both of which should be picked up on cursorymental state examination by any psychiatrist or trainee .

From the history given here, although the thorough nature of the assessment by a specialist unit should not be overlooked, it appears that accurate delineation of the patient’s narrative, corroborative history from family and clinical judgement provoked further investigation, and though investigative tools such as neuropsychological testing and other functional assessments undoubtedly have a role to play, the art of “observation of behaviour and the empathic assessment of the subjective experience” of the patient (the tenets of descriptive psychopathology, as detailed by Sims (2003) should not be discounted readily.

References

Jaspers K. General Psychopathology Vol 1 (Translated)Johns Hopkins Edition, 1997.

Sims A. Symptoms in the Mind, 3rd Edition 2003.

Whitwell S et al.Simple schizophrenia or disorganisation syndrome? A case report and review of the literature. Advances in Psychiatric Treatment Vol 11:6:398-404
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Conflict of interest: None Declared

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