Beware of the misleading of family history: a classic case of brain organic disease misdiagnosed as schizophrenia

It is rare to have schizophrenia for the first time over the age of 55
.

In fact, most of the psychotic symptoms in this age group are secondary to physical illness, alcohol and drug abuse, dementia, delirium, and affective disorders
.

However, in actual clinical work, it is not uncommon for middle-aged and elderly patients to be misdiagnosed as schizophrenia
.

In a case report published in J Clin Psychiatry[1], a 59-year-old female patient was once misdiagnosed as schizophrenia due to a series of negative symptoms and a misleading "positive family history"; Olfactory groove meningioma, healed after surgical resection
.

Case A, 59 years old, was admitted to the hospital due to a change in mental state
.

The family members found that the patient was confused and behaved erratic, and said something about "making magic potions" inexplicably
.

Before these manifestations, the patient had complained of blurred vision and visual disturbances, including seeing some "creatures" at home
.

The patient was physically fit
.

Due to a series of negative symptoms such as lack of emotion, loss of will, decreased self-care, and lack of social interest, and a positive family history of schizophrenia, according to DSM-IV, the patient was diagnosed with schizophrenia and has received 3 Years of outpatient psychiatric treatment
.

However, despite the patient's injection of fluphenazine 50 mg long-acting injection every 14 days, the above symptoms persisted
.

Mental examination showed that the patient was thin, untidy, and no urgent pain; his speech was clearly organized, but hesitated, and there was no voice change; thinking was digressive; emotions were flat; lack of concentration, and it takes a while after being questioned.
Answer, and the waiting time varies
.

The patient denied the existence of delusions, but displayed weird, non-systematic digressions, such as making magic potions
.

The patient admitted to visual hallucinations, but lacked any typical hallucinations in the senses
.

Cognitive tests showed that the patient's location and time orientation was impaired, short-term recall and series of attention tasks were impaired, and structural disuse related to visual space impairment could be investigated
.

The patient's abstract thinking tends to be concrete, and his response to the judgment of hypothetical scenes is not good
.

Information from family members and the patient’s outpatient clinician showed that the patient’s cognitive disorder has deviated from the patient’s baseline level
.

A 5 cm tumor can be seen on the sphenoid platform, and laboratory examination with extensive frontal edema failed to find sufficient results to explain the above abnormal results
.

Head CT revealed that there was a 5 cm mass on the sphenoid platform in the front of the sella, and extensive edema in the frontal lobe, as shown in Figure 1
.

Magnetic resonance imaging further confirmed the presence of the mass, which is large and highly vascularized, and is considered to be an olfactory groove meningioma
.

So he asked for a neurosurgery consultation to perform double-frontal craniotomy to remove the mass
.

After the operation, the patient's delirium disappeared, and the symptoms caused by the previous "schizophrenia" did not reappear during the 1-year follow-up; antipsychotic drugs have also been stopped
.

Discussion Olfactory groove meningioma is a relatively rare, slow-growing tumor that can cause insidious progressive symptoms
.

Patients often present with personality changes and cognitive disorders
.

Unless the tumor grows to a considerable size, the above changes may not be obvious; however, other factors, including edema around the tumor and secondary brain tissue compression, may have an impact on clinical manifestations
.

Patients may also experience neurological symptoms, such as headaches and visual/olfactory changes, but they are not irreversible
.

Twenty percent of patients complained of psychiatric symptoms, including affective disorders and mental illness
.

In any case, misdiagnosing an organic disease that can be treated by neurosurgery as a "functional disease" may result in the former being unable to be identified and treated
.

In this case, until the patient's performance was "chaotic", the organic etiology was revealed
.

The patient's clinician was too affected by the patient's positive family history, and ignored brain imaging, an examination method that could help discover the underlying cause
.

However, looking back, the patient’s mental condition a few years ago suggested the need for neurological evaluation: 1.
Psychotic symptoms appeared to have exceeded the common age of vulnerability; 2.
Symptoms were atypical, such as flat emotions, apathy, and decreased will Etc.
, consistent with the abnormal frontal lobe function; 3.
Poor response to antipsychotic treatment
.

Conclusion: Slow-growing tumors, such as meningiomas, can cause isolated psychiatric symptoms; cognitive changes may not be significant until the tumor volume reaches a certain level; the content of delusions related to such tumors is relatively simple, complex and systemic than mental Schizophrenia patients
.

In addition, before giving an immature psychiatric diagnosis, clinicians must be careful not to be "carried away" by a positive family history
.

When clinically suggesting that elderly patients have psychotic symptoms, the diagnosis must consider 6 D[2] The following manifestations suggest that psychotic symptoms may be secondary [2] Literature index: 1.
Leo RJ, A Case of Olfactory Groove Meningioma Misdiagnosed as Schizophrenia .
J Clin Psychiatry 2016;77(1):67–682.
Reinhardt MM, Cohen CI.
Late-life psychosis: diagnosis and treatment.
Curr Psychiatry Rep.
2015 Feb;17(2):1.
doi: 10.
1007/s11920- 014-0542-0.
Click "Read Original" to view and retrieve historical articles
.