Kinesthetic Hallucination, a Rare Presentation of Schizophrenia

Schizophrenia is a complex mental disorder, with typical onset in late adolescence or early adulthood. Incidence and prevalence of schizophrenia is on the decline, estimated to be 0.28%. An estimated 70.8% (or 14.8 million) of these incidents occurred among individuals aged 25 to 54. Schizophrenia is associated with a considerable loss of daily life functioning and a high illness burden [1]. Delusions and hallucinations are core components in the diagnosis of schizophrenia [2]. About 70% of schizophrenia patients experienced hallucinations [3]. The most common hallucinations in schizophrenia are auditory, followed by visual. Tactile, olfactory, and gustatory are reported less frequently [4]. Sims (2003) divides tactile hallucinations into three categories: superficial, kinesthetic, and visceral, the last of which is most typically organic in nature. Kinesthetic hallucinations affect the muscles and joints, and the patient feels that their limbs are being twisted, pulled, or moved [5]. Since their use in 1880 by the British neurologist Henry Charlton Bastian, few cases have been reported, and presentation varies among different patients. These hallucinations can be diagnostic of a special variety of rare schizophrenia [6]. Moreover, somatic/tactile hallucination in general can be presented with unique expressions and experiences by people from various religious, cultural, and educational backgrounds [7]. Delusion, another component of schizophrenia, is a belief that is firmly held on inadequate ground, that is not affected by rational argument or evidence to the contrary, and that is not a conventional belief given their educational, cultural, and religious background [8]. Paranoid, grandiose, nihilistic, hypochondriacal, jealous, and bizarre are some of the delusions. Although delusions are not exclusive to schizophrenia, atypical presentation and the presence of another psychopathology are strong indicators. Although most of the cases are comparatively simple to diagnose due to the clarity of diagnostic criteria and expertise in the relevant field, atypical presentations may make both diagnosis and subsequent treatment problematic.

A 45-year-old female hailing from Sunamganj, Sylhet, was admitted into this hospital with the complaints of twisting pain in joints & limbs, firm belief of not having any joints and muscles, poor self-care, and trouble sleeping for 1 year. She was admitted to the Internal Medicine department on 18th November 2022 and was transferred into the psychiatry department on 22nd November 2022. Prior to transfer, consultation with neurology and rheumatology yielded no positive organic findings. For the last year, she was suffering from a constant twisting sensation in various joints, which caused severe and pervasive pain all over her body. She believed her whole body was ulcerated; bones and all the muscles had been rotten. Moreover, she saw and felt little worms coming out of her body and felt a nibbling sensation of eating worms by an unseen wood parrot. At times she tore down her clothes and ran amok when pain became unbearable. She didn’t take a bath or take care of herself as she believed death was imminent, so there was no point in doing so. She felt trouble falling asleep as her sensations kept her awake, and for the last 2 months, while awake, she pondered how to end her miserable life. For the last two months, she felt low, found doing anything extremely difficult, ate little, and thought about dying. She was normotensive, non-diabetic, did not receive any formal education, was a homemaker with 2 children, and had no family history of psychiatric illness. There was no manic-like feature, and she did not have forgetfulness, any stereotyped or disinhibited behavior, or specific joint pain or morning stiffness. She was previously treated with various pain medications by local physicians and also took Tab Amitriptyline 25 mg, Tab Risperidone 2 mg, and Tab Lamotrigine 50 mg, which were prescribed by a psychiatrist during the course of her illness, but she did not continue any of these drugs for long. On physical examination, her blood pressure was 90/60 mmHg, pulse 68 b/min, and she was dehydrated and mildly anemic; all other physical and systemic examinations revealed no abnormality. On mental state examination, it was found that she was unkempt and uncombed with the angle of the mouth turned downward with a downward gaze; mood and affect were depressed, suicidal thoughts, nihilistic delusions, and bizarre delusions were present, kinesthetic and superficial tactile hallucinations were present, and she did not contemplate having a psychiatric illness. Attention, concentration, and orientation were normal. On CBC, her Hb was 10 mg/dl. All other parameters of CBC along with FT4, TSH, S. creatinine, S. electrolytes, ANA, HbA1C, USG of the whole abdomen, and ECG were normal. A CT scan of the head revealed mild atrophy in the parieto-temporal region with no other remarkable findings. According to the DSM-5TR, a diagnosis of schizophrenia and major depressive episode superimposed on schizophrenia was made. Initially, she was treated with tab Risperidone 2mg, tab Quetiapine 25 mg, and tab Clonazepam 1mg with little to no improvement. The patient started showing signs of improvement when 8 mg of risperidone was reached. As improvement stalled, it was amped up to 12 mg. To elevate mood and ensure sleep, Tab Mirtazapine 15 mg was added. After 25 days of her hospital stay, she was scheduled for discharge. During the time of discharge, her kinesthetic and superficial tactile hallucination resolved; bizarre delusion was not present, although nihilistic delusion was still present in attenuated form, but as her pain was no more, she was feeling relieved. After 1 month, her improvement was stationary, and she started doing household chores. Since her last visit on February 5th, all her active symptoms abated; mood was improved, but some somatic complaints and occasional sleep difficulty were present. The treatment regimen was unaltered.

Despite the availability of criteria allowing reliable diagnostic identification, schizophrenia essentially remains a broad clinical syndrome defined by reported subjective experiences (symptoms), loss of function (behavioral impairments), and variable patterns of course. As a result, many of the cases are atypical in their presentation and may even go unnoticed. Kinesthetic hallucination may sometimes be misdiagnosed as somatic symptom disorder, so therefore, it needs careful evaluation. Moreover, depression may act as a pathoplastic factor, making things more difficult. The prevalence of depression is 7-75%, and it results in frequent relapse and hospitalization, increased risk of suicide, poor medication adherence, worse psychosis symptoms, and poor physical health compared to schizophrenic patients without depression [9]. A case report of similar nature described a patient with bizarre delusion and somatic hallucination. Moreover, patients reported a sensation of her wrist being twisted. Although the patient improved a bit, the overall improvement was disappointing [10]. Developing a therapeutic alliance with the patient and having them accept psychiatric treatment is by far one of the biggest initial challenges.

Dr. Mostofa Hossain, Associate Professor, Department of Neurology, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh.

No conflict of interest.

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