Which factors affect treatment response in late paraphrenia?

Sixty-four patients with late paraphrenia who had been prescribed neuroleptic treatment for at least three months in the previous year were clinically reviewed in order to asses their treatment response. At the time of assessment, 42.2% of the patients showed no response, 31.3% a partial response and 26.6% a full response to treatment. Compliance with medication, receiving depot rather than oral medication, and use of a community psychiatric nurse if the patient was an outpatient all had a positive effect on treatment response. Despite their better treatment response rate, patients prescribed depot medication received on average a lower daily dose in chlorpromazine equivalents than those prescribed oral medication. Improved compliance, greater clinical efficacy and a reduction in the dose of neuroleptic medication administered are all good reasons to commence treatment of late paraphrenia with a depot antipsychotic medication.     

Late paraphrenia and ICD 10

As part of a field study of the latest draft of WHO'S ICD 10 classification, two clinicians, one familiar with ICD 9 and one with DSM-111, rated 36 cases previously diagnosed as ‘late paraphrenia’ using ICD 9. When raters adhered closely to the diagnostic guidelines issued with the new classification, complete agreement was achieved and most cases received a diagnosis of paranoid schizophrenia. However, both raters were uncomfortable with the low threshold for this diagnosis and when freed from the need to give primacy to schizophrenia preferred a much wider range of diagnoses which included a number of subcategories of delusional disorder. ‘Persistent delusional disorder’ and ‘other persistent delusional disorder’ produced the best fit but up to eight cases were given two diagnoses. Levels of confidence in the diagnosis and ease of achieving this are also given. There was an acceptable level of agreement (kappa = 0.756) when this procedure was employed. It is argued that retrieval of such cases would be facilitated either by providing a code for age of onset or by restoring a separate category for late onset schizophrenia or late paraphrenia.     

Concept actuel de paraphrénie et lien avec les troubles thymiques

Objectives

From a clinical observation, firstly we will discuss the clinical value of such diagnosis of paraphrenia. Secondly, we will describe possible associations between paraphrenia and affective disorder.

Observation

We present the clinical observation of M. B., 42 years, hospitalized in psychiatric department against his will for behavioral troubles and delusional ideas. He previously suffered twice from depression that needed hospitalizations (in 1995 and 2010). After the last hospitalization, a treatment by escitalopram was prescribed but the patient didn’t follow this treatment. When he was rehospitalised, he showed a psychomotor excitation, a depressive mood and insomnia without fatigue. He also had systematized delusions centered on his family, with imagination and interpretation mechanisms and megalomania and persecution thematics. The patient was not desorganised. A treatment by risperidone and valproic acid was prescribed and resulted in a good regression of the different symptoms within two months.

Discussion

If we apply the international classification like the ICM 10, this patient could be diagnosed: “persistent delirium and bipolar disorder”. But if we apply other criteriae such as those of Ravidran and al., M. B. could be considered as presenting a paraphrenia. If we consider the euphoria and the psychomotor excitation as being a part of confabulatory paraphrenia, the affective disorder could be considered as a recurrent depressive disorder rather than a bipolar disorder. Thus, this clinical observation may link paraphrenia to affectives disorders and this link could be supported by four hypotheses. First, paraphrenia can be an affective disorder. Two observations support this hypothesis: the cyclic evolution and some symptoms, like the psychomotrice excitation, which are common between paraphrenia and mania. Second, paraphrenia may be considered as a kind of evolution of affectives disorders as a delusional reconstruction scarring. Nodet even described the paraphrenia post-mania and the paraphrenia post-depression. Third, patient with a paraphrenia may be more prone to develop an affective disorder and the delusional disorder mixing reality and imaginary elements may result in difficulties for the adaptation to environmental stress. Fourth, same risks factors such as genetic or epigenetic factors, emotional deprivation and/or social isolation are common to paraphrenia and affective disorder. However, paraphrenia is frequently associated with cluster A personality disorder (paranoiac and schizoid) while affective disorder are more linked to cluster B personality disorder (borderline).

Conclusion

The efficacy of a treatment combining neuroleptic and mood stabilizers and the preservation of social insertion are important and indicate a therapeutic strategy that is different from schizophrenia. Thus, the determination of a link between paraphrenia and affective disorders could allow better therapeutic strategy and better follow-up on the long run.     

Late paraphrenia,advanced schizophrenic deterioration and dementia

This is a report of a clinical case presentation from the Neuropsychiatry Conference held at Fulbourn Hospital, Cambridge on March 13, 1992. The conference, chaired by Dr Nigel Hymas, was asked to comment on the diagnosis of a case first referred during September 1990. A 60-year-old man with no previous history of psychiatric illness presented with persecutory ideation, delusions and hallucinations in the absence of cognitive impairment. At the time, the initial tentative psychiatric diagnosis was one of late paraphrenia, but it later became clear that the patient was dementing. Were the paraphrenia and dementia related? If so, how? What was the nature of the dementing illness? Could life-long personality abnormalities have been the earliest expression of cerebral abnormalities predisposing him to his current illness? Incompatible evidence from clinical features, functional brain scanning and comprehensive neuropsychological testing demonstrates the inadequacy of current diagnostic criteria.     

Interviewing skills and the detection of psychiatric problems

Recent research from the University Department of Pychiatry at Manchester is reviewed. Doctors who are skilled in the detection of psychiatric problems elicit twice as many cues from their emotionally distressed patients as doctors who are poor at recognizing psychiatric disorder. Less able doctors prevent their patients from giving them verbal and non-verbal cues to the correct diagnosis. The interviewing styles of these doctors differ in that the more skilled doctors conduct a ‘patient-led’ interview, clarifying the patient's problem and facilitating discussion rather than a hurried ‘theory-led’ interview. Doctors who are good at detecting psychiatric disorders also give better information, advice and prescribe more effectively to all their patients than other doctors. Improved interview skills can be taught individually or in groups to general practitioners by video recording and feedback. An outline for teaching relevant skills is described.     

Paraphrenia and Late Paraphrenia

Abstract: Paraphrenia is a clinical entity described by Kraepelin in the eighth edition of his textbook in 1913. He formed this concept to define a group of patients who exhibited symptoms characteristic of dementia praecox, but with minimal disturbances of emotion and volition, and marked delusions with or without hallucinations. Herein the four subtypes of paraphrenia classified by Kraepelin and the prognostic research of Mayer, who studied the outcomes of patients reported by Kraepelin are described. After the publication of Mayer's study in 1921, the view to differentiate paraphrenia from schizophrenia was considered to be unfounded in Germany. In the 1950s, Roth in the U. K. examined patients over age 60 with delusional states and with/without hallucinations, and introduced late paraphrenia as a clinical entity. Although the term (late) paraphrenia present in the ICD-9 is not included in the recent diagnostic criteria, many researchers recognize that the concept of (late) paraphrenia has not lost its usefulness for the diagnosis of psychotic disorders in old age. As in the days of Kraepelin, the problems concerning paraphrenia cannot be neglected when considering the classification of psychotic disorders.     

Impact of biopsychosocial factors on psychiatric training in Japan and overseas: Are psychiatrists oriented to mind,brain, or sociocultural issues?

Aim: To clarify the impact of biopsychosocial factors on psychiatric training under the new and traditional postgraduate medical education system in Japan and to compare them with young psychiatrists from other countries. Methods: Psychiatric residents and early‐career psychiatrists were recruited in Japan and other countries. Using mail‐based and web‐based self‐administered questionnaires, we evaluated participants' demographic information, motivation to become psychiatrists, interest and commitment to various aspects of psychiatry, and reactions to a case vignette, focusing on biopsychosocial factors. Results: A total of 137 responses, 81 from Japan and 56 from other countries, were collected. Before starting psychiatric training, Japanese participants showed a strong interest in ‘mind’ and less interest in ‘brain’ and ‘environmental factors’, while the interest in ‘brain’ and ‘environmental factors’ is presently as high as that in ‘mind.’ Japanese participants reported less commitment to their training toward ICD/DSM‐based diagnosis, interview, pharmacotherapy, psychosocial treatment and epidemiology, compared with participants from other countries. In particular, Japanese participants showed less commitment to their training in suicide prevention, despite their perception of its high importance due to a high suicide rate in Japan. Suicide risk of a case vignette proved to be differently assessed according to participants' commitment levels to each aspect of psychiatry. Conclusion: Our results suggest that young psychiatrists' attitudes concerning the biopsychosocial model generally become well‐balanced with psychiatric training, however sociocultural factors do not seem to be well represented in the Japanese psychiatric training system. Additional training on sociocultural issues, such as suicide in Japan, should be considered.     

Late paraphrenia: Neuropsychological impairment and structural brain abnormalities on computed tomography

Forty-three patients with ‘late paraphrenia’ were subjected to detailed clinical and psychological assessment and computed tomography (CT). The paraphrenics had significantly larger lateral cerebral ventricles and greater cognitive deficits than a group of 40 age-matched normal volunteers. Group comparisons within the patients, between those with particularly large ventricular brain ratio (VBR) (equal or more than two standard deviations above the control mean) and the rest of the group, showed that the extent of ventricular enlargement had no direct bearing on the clinical presentation of the paraphrenic syndrome. The results suggest that ventricular enlargement may have preceded the onset of overt symptoms by a period of years and probably served as a non-specific risk factor for the development of the disorder. The unimodal distribution of VBR values suggests that paraphrenia, at least at a brain structural level, is a unitary condition. It also indicates the presence of subcortical pathology which might be in part responsible for the cognitive dysfunction elicited.     

Psychotropic medication and ethnicity: an inpatient survey

Summary A survey of the catchment area psychiatric inpatient population of the Bethlem and Maudsley Hospitals showed that more black (Afro Caribbean) than non-black (white British) patients received anti-psychotic medication. This finding ceased to be significant after adjustment for diagnosis because a larger proportion of black than non black patients received a diagnosis of schizophrenia. However, after adjustment for diagnosis, black patients were significantly more likely to be receiving depot anti-psychotic medication, to be detained under a section and to have been involved in a violent incident during the present admission. There were no significant ethnic differences in total dose equivalents of anti-psychotic medication but doses of the depot form were significantly higher for black patients.     

Comparison of diagnostic names of mental illnesses in medical documents before and after the adoption of a new Japanese translation of 'schizophrenia'

Aim: The name of a disease entered in medical documents often differs from the true diagnosis in psychiatric practice. We examined the effects of different translations of ‘schizophrenia’ into Japanese on the usage of disease names in documents. Methods: We conducted a retrospective survey of the names of diseases used in the medical documents of 250 outpatients with schizophrenia or depression. These patients had attended our department of psychiatry between 1998 and 2000. We also investigated the names of the diseases of 226 outpatients who had first visited our department between 2003 and 2007. We defined the diagnosis (based on ICD‐10) as the ‘ICD‐10 disease name’ and the name of the disease written in medical documents as the ‘disease name in documents’. We classified the documents that were used to apply for national psychiatric care and welfare services as ‘official documents’ and those submitted to others as ‘private documents’. Results: Prior to 2000, the term ‘seishin‐bunretsu‐byo’ (‘split‐mind disease’; old translation of ‘schizophrenia’) was used in 72.3% of official documents and 3.6% of private documents. In 2003 and later, the term ‘togo‐shitcho‐sho’ (‘integration disorder’; new translation of ‘schizophrenia’) was used in 98.0% of official documents and 21.7% of private documents. Conclusion: The use of ‘togo‐shitcho‐sho’ in official documents has become established. On the other hand, terms such as ‘nervous breakdown’ and ‘depressive state’ are still commonly used in private documents after the adoption of the new Japanese translation of schizophrenia.     

Utilization of psychiatric in-patient care among new patients in a comprehensive community-care system: a 3-year follow-up study

Utilization of psychiatric in-patient care among 537 new patients was studied in the Department of Psychiatry in Oulu, Finland, during a 3-year follow-up period. Hospitalization during the second and third years of the follow-up was predicted by hospitalization and number of emergency out-patient contacts during the first year of the study, diagnosis of functional psychosis or personality disorder, and previous in-patient care. In total, 5% of the cohort fulfilled our criteria for ‘revolving-door’ patients. The ‘revolving-door’ phenomenon was associated with in-patient care at the first contact with the psychiatric services and diagnosis of psychosis or personality disorder. In total, 2% of the cohort became long-stay hospital patients, and this was predicted by psychosis diagnosis. The clinical implications of these findings are that increased attention should be paid to the first assessment of new patients and to the interaction between psychiatric services and patients during the first year of care.     

The concept of mental disorder in Greek cinema

Mental patients in Greek society have never been considered as ‘sacred’, but on the contrary as handicapped, and cinema largely reflects these concepts. A total of 30 films that appeared to deal with mental disorder in a direct or indirect way have been reviewed. The identification of each mental disorder was made according to DSM-IV criteria. Five of these cases were presented as having a factitious disorder, seven were psychotic and two had dissociative (hysterical) disorders. The remaining eight cases related to personality disorder or character deviance. In two cases diagnosis was impossible. The image of mental disorder is consistent with psychiatric nosology, and disorders with‘dramatic’ or‘impressive’ manifestation of symptomatology are chosen. No real solutions, proposals or ideology on mental illness emerge.     

The taps project. 21: Functional and organic comorbidity and the effect of cognitive and behavioural disability on the placement of elderly psychiatric inpatients—a whole-hospital survey

This article reports a survey by the Team for the Assessment of Psychiatric Services (TAPS)

1 TheTeam for the assessment of Psychiatric Services (TAPS) is a research team established in 1985 to study the proposed closures of Friern and Claybury Hospitals in North London.

of all inpatients aged 70 years or more resident in Claybury Hospital, London, for more than 12 months. Age, sex, total length of inpatient stay and type of care received were recorded for each subject, and assessments using the Mini-Mental State Examination (MMSE) and Modified Crighton Royal Behavioural Rating Scale (MCRBRS) were performed. Of 189 inpatients who completed the assessments, 142 (75%) showed unequivocal, severe cognitive disability (MMSE ≤ 17). Patients were assigned to ‘functional’, ‘organic’ or ‘mixed’ diagnosis groups by staff report and case note review. A staff report of ‘mixed’ diagnosis missed a large number of patients who had an original diagnosis of functional psychiatric disorder plus severe measured cognitive disability. Sixty-five per cent of patients with an original diagnosis of functional psychiatric disorder fell into this category. AFter controlling for age, sex and total length of inpatient stay, patients with a severe degree of reported behavioural problems (MCRBRS ≥ 17) were almost 23 times (95% CI 6.6–79.4) more likely to receive specialized psychogeriatric care than other patients. Severe cognitive disability was not associated with type of care received. Issues related to measurement of cognitive disability across disparate diagnostic groups are discussed.     

DUAL DIAGNOSIS IN ELDERS DISCHARGED FROM A PSYCHIATRIC HOSPITAL

Recent evidence indicates persons 60 years and over experience significant alcohol and substance abuse problems. Since a combination of alcoholism and depression is likely to increase the relative rsk of suicide, it is important to examine the prevalence of dual diagnosis in older adults. The purpose of this study is to examine the prevalence and correlates of dual diagnosis in older psychiatric inpatient populations and compare our results with findings from studies of younger hospitalized dually diagnosed patients. A retrospective chart audit was performed on 101 elders who were discharged from three psychiatric hospitals. Clinical variables that were examined included length of hospital stay, psychiatric and medical diagnoses, medications and history of suicidal ideation or intent. The leading psychiatric disorder diagnosis for our sample of hospitalized psychiatric elders was depression. Over one-third (37.6%) had a substance abuse disorder in addition to a psychiatric disorder, and almost three-fourths (71%) of this ‘dual diagnosis’ group abused alcohol and 29% abused both alcohol and other substances. In addition, significantly more elders in the ‘dual diagnosis’ group (17.7%) than in the group with only a mental disorder diagnosis (3.3%) made a suicide attempt prior to admission to the hospital. Because affective disorders in conjunction with alcohol abuse are the most frequently found disorders in completed suicides, our findings have important relevance for the advocating of routine use of diagnostic assessment and screening for both substance abuse and mental disorders in this population. © 1997 by John Wiley & Sons, Ltd.     

Late-life paraphrenia: an organic delusional syndrome

Five patients with late-life onset of schizophrenic symptomatology (late-life paraphrenia) were found to have occult organic disorders. Although it was not possible to prove that the organic disorders were causal in these patients, none had any psychiatric illness until late in life and none had any significant risk factors for developing schizophrenia. This study demonstrates the need to investigate the medical and neurologic condition of any elderly patient presenting with a new onset of delusions. Modern investigative techniques may permit more accurate classification (and therapy) of some patients with late-life paraphrenia.     

Psychological climate and countertransference in psychiatric treatment homes

Holmqvist R, Fogelstam H. Psychological climate and countertransference in psychiatric treatment homes. Scand 1996: 93: 288–295. © Munksgaard 1996. The associations between milieu therapists' feelings towards patients and the unit's psychological climate were studied at 21 small treatment homes for severely disturbed psychiatric patients. The milieu therapists filled out self-report instruments where they rated their feelings towards patients on a feeling-word checklist and their opinion about the psychological climate on a Bion-based scale. Scores on the climate scale were used as independent variables in a series of regression analyses, with scores on the feelings as the dependent variables. It was found that a substantial component of the average differences between units with regard to feelings towards patients could be attributed to the unit's climate. Correlations showed that units characterized by ‘Work’ and ‘Pairing’ had high scores for helpful and autonomous feelings, while unhelpful feelings were evoked in units characterized by ‘Dependency’ and ‘Fight’. Close feelings were evoked in units characterized by ‘Dependency’.     

Study of understanding the internalized stigma of schizophrenia in psychiatric nurses in Japan

Aim: ‘Internalized stigma’ is a construct that reflects the degree to which a person accepts beliefs endorsed by society about mental illness. Among people with schizophrenia spectrum disorders, internalized stigma has been found to moderate the associations between insight and social function, hope, and self‐esteem. Among families of patients with schizophrenia, internalized stigma may not only hinder help‐seeking but also result in the families attempting to provide care themselves, without assistance from mental health services. Little is known about internalized stigma among service providers, especially psychiatric nurses in Japan. Therefore, we investigated the correlation between internalized stigma and ‘beliefs about the most appropriate form of hospitalization’ among psychiatric nurses. Methods: The subjects were 215 psychiatric nurses employed in psychiatric hospitals who completed the personal stigma scale, perceived stigma scales, and Difficulty of Community Living Scale (DCLS) with respect to a chronic schizophrenia case vignette. Results: Internalized stigma was positively correlated with greater ‘beliefs about the most appropriate form of hospitalization’ among psychiatric nurses. We also showed that stronger ‘beliefs about the social disadvantages of schizophrenia patients in the community’ was positively correlated with stronger ‘beliefs about the most appropriate form of hospitalization’. Conclusion: The present findings suggest that the psychiatric nurses employed at Japanese psychiatric hospitals have a pessimistic view of the community living of people with schizophrenia and their families. And these psychiatric nurses' beliefs were related to their understanding of the deeply dependent relationship between patients and families, and was related to the Confucian ideal.     

Beyond specialist programmes: a study of the needs of offenders with intellectual disability requiring psychiatric attention

Background Despite the increased prevalence of psychiatric disorder amongst offenders with an intellectual disability (ID), there is very little known about the characteristics and needs of those with dual disability. Method A study of admissions to a new community forensic dual disability clinic during the first 10 months of its operation. Results Typically, the offenders are male, are older than other offenders, exhibit long‐standing and continuing serious behavioural disturbance (independent of their psychiatric diagnosis or level of involvement with the criminal justice system) and require supported or custodial accommodation, despite only mild or borderline levels of ID. Although only one‐third have a diagnosable major nonparaphilic psychiatric disorder, three‐quarters have had prior or current contact with psychiatric services and two‐thirds suffer chronic medical illness. Conclusions These offenders suffer psychosocial disadvantages far more extensive than those implied by the ‘psychiatric’ or ‘disability’ label. The multiple services provided to this group have been ad hoc, poorly co‐ordinated and sometimes dangerously inappropriate. A service provision model is required which must be integrative and consistent. We suggest the use of multiskilled key workers, who maintain close contact with individual clients. Their role will be to implement management plans from the various specialist agencies who become involved with this group and provide long‐term follow‐up of their recommendations.