The quiet end of the spectrum: A case report and review of “simple schizophrenia”

BackgroundSchizophrenia is increasingly understood as a neurodevelopmental disorder in which cognitive and negative symptoms may precede or overshadow florid psychosis. Such neuropsychiatric presentations can be difficult to recognise within current diagnostic frameworks that privilege positive symptoms.ObjectiveTo illustrate a schizophrenia presentation without hallucinations and delusions and to contextualise it within contemporary and historical nosology.MethodsSingle case report with a focussed narrative review of the literature on simple schizophrenia subtypes.Casea 24-year-old woman experienced a two-year insidious decline in motivation, social engagement, and cognition, with prominent affective flattening, avolition, bradyphrenia, poverty of speech, and psychomotor slowing. There were no delusions or hallucinations, and thought form was linear. Extensive investigations including MRI, EEG, FDG-PET, and CSF studies were unremarkable. Neuropsychological testing showed deficits in new learning, processing speed, and executive functioning consistent with schizophrenia-spectrum illness. The illness was refractory to multiple antidepressants, antipsychotics, and a course of electroconvulsive therapy. Following exclusion of organic pathology, multidisciplinary assessment, and longitudinal review, a diagnosis of schizophrenia was formulated.ConclusionCurrent diagnostic systems may overlook individuals with schizophrenia without hallucinations or delusions. Incorporating neuropsychiatric markers and establishing cognitive trajectories into diagnostic thinking may enable earlier identification and more targeted interventions.