A Case of Schizophrenia with Multiple Unusual Symptoms : A Case Report from Iran

We intend to report a case of Schizophrenia whom was presented with multiple rare and interesting symptoms. He showed perseveration, autoscopic hallucination and confabulation. The patient is a 23 years old man that his problems started about five years ago with bizarre behavior; self-talking, autoscopic hallucination, seeing himself at past. In this exacerbation; had poverty of content of thought, commanding auditory hallucination and elementary visual hallucination. About Autoscopic hallucination, our current data mentions this fact that several brain mechanisms are involved in Autoscopic Hallucination, hence we suggest that since Schizophrenia accompanies with several brain changes, these changes led to Autoscopic Hallucination in this patient. Our patient's confabulation is Schizophrenic confabulation that is due to his poverty of content of thought and is not related to any neurological disorder.


INTRODUCTION
Schizophrenia is a chronic, debilitating psychotic disorder that affects only nearly 1 % of general population.It is now believed that there is combination between multiple genetic basis and environmental agents (1).Its symptoms generally begin in late adolescence or early adulthood and usually continue as life-long (2).Diagnostic features include; auditory hallucinations (generally voices that converse with or about the patient) and delusions (often the paranoid belief that external forces are conspiring against the patient).Patients may have partial insight that the voices are internal thoughts and that the delusions cannot probably be really, but these phenomena remain persistent and troubling.In addition to these overt psychotic, or "positive " symptoms, various deficits, or "negative" symptoms, occur, including an inability to pay attention, the loss of a sense of pleasure, the loss of will or drive, disorganization or impoverishment of thoughts and speech, flattening or silly affect, and social isolation.Positive and negative symptoms vary in intensity over time; patients may have predominantly one type at any particular time.Cognitive impairment, including a decreased ability to focus attention and deficiencies in short-term verbal and nonverbal memory, is also a core feature of disorder, which predicts vocational and social disabilities for patients (3,4).It has a remarkable debilitating influence effect on the patient's functions and quality of life (QoL) and despite significant developments in medications, neuropathology, brain imaging, molecular genetics and greater understanding of the pathophysiology of schizophrenia and improved treatment, it remains a debilitating disorder that inflict a burden on patients, their families, and society.
Autoscopic hallucination is a kind of Autoscopic Phenomenon.Autoscopic Phenomena are visual illusory reduplication of the patient's own body that belong to a group of disorders of somatognosia that include a variety of usually short lasting, illusory experiences about the seen and felt location and position of one's body or body parts in an atmosphere and generally happen in patients with posterior brain damage and is called "autoscopic phenomena" when it affects the whole body (5).The person see's an exact copy of him or herself out of body without any sense of leaving body and awareness center remains in patient's physical body.
Perseveration is a common deficit in schizophrenia and other psychiatric disorders .t is the measure for evaluation of cognitive flexibility impairment and an item of executive function, is recognized by involuntary behaviors that aren't intentionally repeated and are false or inappropriate responses to situations which need novel feedbacks (6).Confabulation or false claim is common with delusions at this aspect (7, 8).The patient says false and erroneous memories which could be incorrect basically or a mixture of real memories with incorrect and temporal context.It might be spontaneous or reaction to a memory conflict (9).
We intend report a case of Schizophrenia presenting multiple rare and interesting symptoms which include autoscopic hallucination, perseveration and confabulation.

Case Presentation
The patient is a 24 years-old single and unemployed man suffering from chronic undifferentiated type schizophrenia with autoscopic hallucination and kleptomania manifestations.The patient is the fourth child among five children in an Iranian Eastern South family.His birth was in a normal vaginal delivery and had the history of four times fever and seizure in his childhood.
He grew up in an aggressive family that children were fighting with each other most of the time.Based on patient's words, his father has delusion of grandiosity, angry and irritability behaviors.His problems started about five years ago with bizarre behavior; speak with himself, autoscopic hallucination, seeing himself at past and kleptomania.In this exacerbation had poverty of content of thought, commanding auditory hallucination and elementary visual hallucination.Now he is seeing three persons persistently: A young man who tells patient about future, a little girl who summons spirits such as Abdol -Malik Rigi (an eastern south Iranian terrorist who was arrested and executed about one year ago) and Ali Sayyad Shirazi (a famous Iranian Army commandant who was killed at a terrorist attack about 12 years ago), and an old man who tells patient about afterlife (limbo).He stares at one point from time to time and says that there are these three persons at that point.The patient says that he saw Imam Zaman (Grandchild of Muslims' prophet, Muhammad, who is promised to rise up one day and make justice in the world based on beliefs of a group of Muslims that called shia) in his dreams and he told patient that you must suffer to find merit to see me at your awakening and you don't have this merit right now (It can mention grandiosity).
The patient has good eye contact and answers to our questions very clearly.His appearance seems older than his actual age.He has a silly affect.He talks Spontaneous.
He seems to have poverty of content of thought but he has coherence of ideas and answers questions goal directed.He has sometimes perseveration; for example, when he is asked about his childhood he starts talking about those three persons.He has good concentration, memory and abstract thinking, insight and judgment.
He says that he was working in a paneling workshop but since there was so noisy, he experienced summoning the spirit and had too much stress, his body became rigid and he got unconscious; hence he had to quit his job.But when we asked his older sister about it she said this is not true and he was never employed anywhere and he made these things by himself which may mention spontaneous type Confabulation.
He had gone to school until grade 8 and left school after that.He explains that although he has no interest at women and decided to be single for rest of his life but he feels terrible and guilty about his masturbations.The patient says he was always alone and likes loneliness.He is interested in historical books and horror movies and documentaries containing scenes which show murdering people.He had kleptomania at the beginning of his problem.He has a good viewpoint about others and does not have persecutory and reference delusion and thoughts broadcasting or thought insertion and suicide thinking.He also has no depersonalization or derealization.

Treatment:
The patient has been under treatment in four time periods: At the first period he was treated by Tab.Haloperidol 10 mg daily, Tab Biperidon 4 mg daily and Tab.Imipramine 50 mg at night.
At the second period he was treated by Tab.Perphenazine 24 mg daily, Tab.Biperidon 4 mg daily and Tab Imipramine 50 mg at night.At the third period of time he was treated by Tab sertraline 100 mg daily and Tab clozapine 150 mg daily (that was dropped due to somnolence and overweighting).
And now he is treating by Tab.Risperidone 2 mg at night, Tab Biperidene 2 mg at night, Amp.Fluphenazine monthly and Tab.Citalopram 20 mg at night.He had never been asymptomatic and he has not had favorable function.

DISCUSSION
We wish to discuss about perseveration, autoscopic hallucination and confabulation in this patient and their probable etiologies.
Perseveration and sensor motor gating deficits can be basic core features of Obsessive-compulsive disorder (OCD) (10).As Shanahan et al., findings mentioned orbitofrontal 5-HT1BRs are both necessary and sufficient for the expression of OCD-like behavior in mice as mentioned in the last phrase, its core features include repetitive behaviors and sensor motor gating impairments (10).On the other hand, Perseveration may be related to lesions and changes in brain (11,12).In Waford study, it was mentioned, it appears that perseveration is not pathgnomonic to any disorder and may be more of a genetic deficit that is not diagnostically useful.Examination of clinical variables in the sample of patient with schizophrenia showed that perseveration is associated with negative symptoms and depressive symptoms in young adults (6).Our patient showed that perseveration when asked about his childhood that may insinuate to us that there is something about his childhood that he does not want us to know about.But as Shanahan et al., findings mentioned orbitofrontal 5-HT1BRs are effective in perseverative behavior and as Rutledge et al,.mentioned perseveration in choice, independent of reward history, increases with Parkinson's disease and decline with prescription of dopamine ( 12) and as it was mentioned before about reduction in 5-HT2 receptors and 5-HT reuptake sites in the prefrontal cortex of patients with schizophrenia (13) that might be related to changes in brain accompanying with Schizophrenia.
At this section, we discuss about relationship and its possibility between Autoscopic Hallucination and Schizophrenia in this patient.Autoscopic Hallucination belongs to group of autoscopic phenomena.Authors suggest different systems in autoscopic phenomena that most of the opinions are on Visual System, proprioception and kinesthesia, Proprioceptive and Tactile Processing System and Vestibular System (5).There is a case report of patient with possibility of "flash back," due to his long history of abuse of psychotomimetic amphetamines and LSD.The complete psychiatric history and evaluation made it clear that the diagnosis should be that of schizophrenia (14).There is also a case report about autoscopic hallucination with Seizure that in most of them (86%) temporal lobe ( TLE) was involved (15).There is another similar case of autoscopic phenomena of Heautoscoopic (Autoscopy that patient can not decide which body he or she is in) with seizure with right parietal epileptic focus (16).These data mention this fact that several brain mechanisms are involved in Autoscopic Hallucination, hence we suggest that since Schizophrenia accompanies with several brain changes, these changes led to a type of autoscopic phenomena known as autoscopic hallucination in this patient.
Finally, we discuss about relationship between Confabulation and Schizophrenia in this patient.Confabulation looks like delusion due to having false claims (7, 8).One of the most features of Schizophrenia is delusion (3, 4) and as we mentioned above, this patient seems to have delusion of grandiosity at some degrees.In other hand, existence of confabulation has been demonstrated in schizophrenia (17)(18)(19).The patients with schizophrenia showed significantly more confabulations than the others (17,19).It is showed Lorente-Rovira and colleagues that this higher amounts of confabulation in Schizophrenic patients was not significantly associated with memory impairment but Confabulation scores were associated with impairment on two semantic memory tests (17).It is demonstrated that schizophrenic patients mostly present spontaneous confabulation (18).In another study by Lorente-Rovira and et al, Confabulation in Schizophrenic patients was predominated in those with thought disorder and differs from its neurological form neuro-psychologically (19).To summarize all the data, since our patient has poverty of content of thought and spontaneous confabulation, it seems that his confabulation is Schizophrenic confabulation and is not related to any neurological disorder.

CONCLUSION
This article supports bio psychosocial theory about Schizophrenia.The next result is that Schizophrenia may cause progressive and chronic changes in brain that we could see their outcomes as symptoms that we see in presented patient.At the end, these patients like ours need a full family and social and governmental support to achieve appropriate quality of life.