‘White handkerchief’: a patient of attenuated psychosis syndrome

Abstract

The case history of a patient with attenuated psychosis syndrome is discussed under the backdrop of controversies. On one hand, there is apprehension regarding diagnostic validity, associated stigma, unnecessary treatment, and ethical dilemmas. On the other hand, there is possibility of primary prevention.

Introduction

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), evidence is not enough at present to identify attenuated psychosis syndrome (APS) as mental disorder.^[1] Research for a quarter century on early psychosis resulted in APS. Reduction in duration of untreated psychosis (DUP) is the aim. While DUP is well accepted, there is progress in the area of at risk mental state (ARMS) as well, with regard to schizophrenia. Here, the goal is primary prevention. Researchers, especially McGorry and colleagues, for long are working in this context. “I would hate to see the last 25 years of work on high-risk syndrome thrown out of the window”, says McGorry.^[2] “The clinical validity of the syndrome, concern about stigma and unnecessary treatment, and need for responding to patients’ distress in addition to the ethical dilemma” are the main issues.^[3]

Under the circumstances, we present a case report.

Case report

Twenty nine years old Hindu unmarried man from lower socioeconomic status of rural semi-urban background was symptomatic with low mood, increased anger and irritability, quarrelsome with family members, suspiciousness towards his girlfriend for five months, repetitive thoughts coming in his mind, forgetfulness, feeling that office people make fun of him, less interest in family matters, gradually decreasing communication and interaction for two months, refusal to do his duties (job), withdrawn behaviour, decreased sleep and oral intake for four days.

The patient’s symptoms were observed first by his family members as gradually increasing anger; he used to get irritated on family members and started frequent quarrels. He had a relationship with his girlfriend for last one year, which got strained over past five months. They started having frequent altercations between them because of patient being very possessive and suspicious towards his girlfriend. He used to suspect her of having relationship with many other boys, and most strongly, with one boy who was their common friend. According to the patient, suspiciousness started after he was suggested by his close friends and family relatives regarding the character of that girl. The frequent misunderstandings got further accentuated around two months back, when the common friend with whom the patient used to suspect his girlfriend of having a relation gave him a ‘white handkerchief’. The patient interpreted that white handkerchief as a sign of departure, meaning that, by giving white handkerchief, that common friend wanted to symbolise that the patient’s girlfriend is no more meant for the patient and relationship has come to an end. This made the patient very much distressed and he started to remain preoccupied with these thoughts. Then, another incident happened when he was talking via his office landline number to his girlfriend. He called her by some funny nick name, which he gave to her personally. After the call, according to the patient, the office colleagues’ started to humiliate him by calling him by that name. This made him all the more distressed. Then, another incident happened one month ago at Bihu (cultural) function; he was having drinks with his childhood friends when few friends came to know about his childhood secret event of having sexual intercourse with cow. And since that day, according to the patient, they (friends) started calling him by a particular name “gou” which means cow in their regional language. This made the patient very distressed and for last one month he was withdrawn to self, with preoccupation with thoughts of:

1. Guilt feeling regarding his childhood act, and people coming to know about it

2. Thoughts of his girlfriend, with whom he was not in talking terms for last one month

3. Unable to attend office because office people came to know about his girlfriend’s nick name and they made fun of it.

On mental status examination, he had preoccupations with girlfriend’s thoughts, and guilt feeling regarding his childhood deeds, with episodic pattern of depressed mood whenever those things came into his mind. There was no other thought or perceptual disturbances, and cognitive functions were intact with level four insight. On psychodiagnostic evaluation, Object Sorting Test scores indicated “thought disorder” with fused and impoverished responses; and “two” adequate responses. On Rorschach’s test, he gave total “nine” responses with “two” cards (fourth and seventh) rejected and “four” popular responses. One colour response with absent shading or human response. Empathy was lacking and emotional reactivity was impaired with a high need for impulse gratification. Findings indicated “underlying psychotic process” with impaired reality contact.

Patient was started on olanzapine 7.5 mg daily dosage, which was subsequently increased to 10 mg daily dose. He improved drastically from fourth day, and started to communicate well and take care of himself. Gradually, olanzapine was tapered down and finally stopped after 2 weeks. His condition remained stable, and he was maintained on omega 3-fatty acid for a follow up period of 3 months.

Discussion

The proposed diagnostic criteria for APS in DSM-5:^[2]

1. At least one of the following symptoms is present in attenuated form, with relatively intact reality testing and is of sufficient severity or frequency to warrant clinical attention:

   • Delusions
   • Hallucinations
   • Disorganised speech

2. Symptom(s) must have been present at least once per week in the last one month

3. Symptoms(s) must have begun or worsened in the past year

4. Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention

   Symptom(s) is not better explained by another mental disorder, including: Depression or bipolar disorder with psychotic features and is not attributable to physiological effects of a substance or another medical condition.

5. Criteria for any psychotic disorder have never been met.

APS is differentiated from at risk syndrome. It is included under clinical entity demanding attention. Thus, APS is better visualised as early/mild psychosis. Then, why is it not an official mental disorder?^[2] From the 19th century, prodrome is a recognised phase of schizophrenia. Patients suffer from attenuated symptoms that cause distress, before development of full psychosis. Early identification and intervention can achieve prevention.^[3]

Resurgent interest came to a halt from the backward step of DSM-5 by not including APS.