Psychomotor Retardation and Vegetative Symptoms as the First Overt Signs of sychosis: A Case Report

A 15-year-old female adolescent presented with her parents and reported a significant reduction in appetite for the past two weeks, along with complaints of having slept only one to two hours at night for the past week. This was her first visit to a child psychiatrist. According to information obtained from her family, she was a successful and outgoing student until a year ago. Over the past year, she has struggled to concentrate and understand her studies and has appeared more withdrawn. The family noted that she had exhibited some suspicious behaviors for about three years but had not paid much attention to them. She has always been a picky eater, but for the last two weeks, she has refused to eat anything unless pressured by her family. Additionally, she has not been sleeping at night for the past week, simply lying in bed and observing her surroundings. Examples of her suspicious behaviors over the last few years include believing that she might be poisoned by cheese, checking her father's phone, and thinking that others have a negative opinion of her.

The patient's birth history and developmental milestone acquisition were reported to be within normal limits. The patient's uncle exhibited signs of suspiciousness during young adulthood. The patient's family members were unaware of the uncle's diagnosis, but as far as they knew, he had received outpatient psychiatric follow-up and had never been hospitalized.

In the first psychiatric interview with the adolescent, she reported having no appetite, could not sleep at night, saw shadows and felt scared, and that despite studying for her classes recently, she was unable to understand the material. She stated that there had been no problems at school or home recently. When auditory, visual, and other hallucinations were assessed, she reported that she did not experience these symptoms. Inquiries about paranoia, grandiosity, and delusions related to being harmed revealed that she did not have these complaints. She mentioned feeling sad because she could not understand her studies as before, but asserted she did not feel unusually happy, angry, or depressed. During the interview, the patient's responses were consistently brief; however, she provided meaningful responses, indicating a lack of detail and spontaneous conversation.In the mental status examination, she was noted to be of slight build, with normal self-care and a slight tremor in her hands. She maintained eye contact and provided meaningful responses; however, her answers were brief. She took a long time to respond and appeared to think for an extended period, suggesting that her associations were slow. Her speech and movement, as well as her reactions, were slow, and her mood was flat with a slightly anxious affect. It was determined that her thought content included concerns about her difficulties understanding the material.

In the patient’s neurological examination, it was noted that she had mild bilateral tremors, her movements were slightly slowed, her gait was normal, she exhibited no difficulties with balance, and her muscle strength in both upper and lower extremities was rated 5/5. When assessed for symptoms of catatonia according to the DSM-5 criteria, it was determined that none of the following symptoms were present: stupor, waxy flexibility, catalepsy, mutism, posturing, negativism, stereotypies, agitation, echopraxia, echolalia, mannerisms, or grimacing.

Given the patient’s history of mild suspiciousness over several years, a decline in executive functions in the past year, worsening mood, psychomotor retardation, and vegetative symptoms such as decreased appetite and insomnia, early-onset psychosis developing after the prodromal phase was considered the primary diagnosis. Consequently, treatment with olanzapine at a dose of 5 mg/day was started.

At the one-week follow-up, it was observed that her flat mood had improved, the sluggishness of her thought processes had resolved, and her psychomotor speed had returned to normal. Additionally, she reported being able to eat and sleep, and that the shadows she had seen at night had ceased. However, she still had concerns that others were speaking negatively about her and calling her 'crazy,' stating that her primary concern was her inability to study as she used to. The family noted that while their daughter had not returned to her previous level of functioning from a year ago, her complaints had significantly diminished. It was recommended that she continue the olanzapine 5 mg/day treatment. She was also referred to the child neurology department and scheduled for a follow-up appointment in one month. However, the patient did not attend the follow-up, so no information regarding her subsequent clinical management could be obtained.