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Journal of Postgraduate Medicine, Vol. 53, No. 1, January-March, 2007, pp. 75-76 Letters Clozapine-resistant mutism in noncatatonic schizophrenia Basanth KK, Gopalakrishnan R, Jacob KS Department of Psychiatry, Christian Medical College, Vellore - 632 002, Tamil Nadu Code Number: jp07025 Sir, Mutism is defined as functional inhibition of speech and vocalization. Mutism has been reported in various types of schizophrenia.[1],[2] There are reports of mutism in catatonic schizophrenia lasting for years.[3] Cognitive dysfunction in schizophrenia and duration of untreated psychosis have also been implicated in the development of mutism.[3] Mutism can occur as a severe form of poverty of speech. The largest report on mutism associated with noncatatonic schizophrenia is from the Kosraean population, where it is described as a specific cultural variant of psychopathology.[3] Mutism has lasted from a few days to 20 years in this community and is noted in the initial part of the illness, predicting relapse. Most of these patients use nonverbal methods of communication. To our knowledge, only one case associated with paranoid schizophrenia has been reported.[1] Mutism is now rare in developed countries. Mutism in catatonic schizophrenia responds well to benzodiazepines, electroconvulsive therapy and antipsychotics, including clozapine.[4] The response to treatment in the Kosraean population has been good.[3] We report a case of mutism in noncatatonic schizophrenia. A 32-year-old single male presented with a 17-year history of illness. The initial five years were characterized by vague somatic complaints, insomnia and anger outbursts. Persecutory and referential delusions along with auditory hallucinations appeared following the death of his mother 11 years ago. There was a decline in socio-occupational functioning and deterioration in personal hygiene. Mutism had developed over a period of the last four years. There was no history to suggest seizures, substance use, dementia, confusion or a mood disorder. On examination, he was mute but would indicate his needs by gesturing and limited writing. The reason for being mute and other psychopathology could not be explored. Clozapine was started, as he had not responded to risperidone, olanzapine and three courses of electroconvulsive therapy. The dose of clozapine was gradually increased to 450 mg/day. After several months on clozapine, his eye contact improved. He was less defensive and was willing to communicate. He consented to video record an interview where he communicated in writing. The reason for his silence he wrote, "I am not speaking on my own accord. I do not enjoy talking". He wrote about fear, hearing voices and wanting to work in his father's grocery shop but was reluctant to elaborate. He became defensive and stopped writing on detailed questioning. He has been on a daily dose of over 300 mg for eight months. He continues to be mute and unemployed, although there is some improvement in negative symptoms. However, he is able to meet his day-to-day needs. In our patient, we considered a diagnosis of paranoid schizophrenia, where mutism had occurred later in the course of illness and did not respond to treatment. Catatonic schizophrenia was not considered due to prominent delusions and hallucinations. Mutism, which was secondary to delusional beliefs, was the only catatonic symptom present among the list in ICD-10.[5] We infer that the psychotic symptoms are resistant to clozapine and hence the patient continues to be mute. Dismissing mutism as an old phenomenon, which occurs only with catatonic schizophrenia, may be too simplistic. It could occur in other types of schizophrenia and at varying times during the course of illness. Mutism while being a rare phenomenon can be resistant to treatment and requires further study. References
Copyright 2007 - Journal of Postgraduate Medicine |
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