The genetics of delusional psychoses

In a genetic study of the first-degree relatives of 77 patients with delusional (paranoid) psychoses, the morbidity risks for schizophrenia, affective disorders, and atypical psychoses were evaluated using ICD-9 criteria. The prevalence of schizophrenia was 3.10 percent (4.12 percent with age correction to 40 years and 4.94 percent with age correction to age 60), which is higher than in investigations of paranoid psychoses, but lower than in studies of paranoid schizophrenia. The prevalence figure for affective disorders (age-corrected 3.04 percent for unipolar plus bipolar patients) is also intermediate to those for relatives of paranoid schizophrenics and paranoid psychotics. When the 77 index delusional patients were subdivided into axial syndromes (endogenomorphic-schizophrenic, endogenomorphic-cyclothymic, and organomorphic axial syndromes), two very homogeneous subgroups emerged. The endogenomorphic-schizophrenic subgroup showed high rates of schizophrenic secondary cases, whereas the endogenomorphic-cyclothymic subgroup showed high rates of affectively disordered secondary cases. The third organomorphic subgroup showed a high prevalence of atypical psychoses among first-degree relatives. Thirty-seven of the 77 index patients could not be assigned to any axial syndrome; their first-degree relatives had an increased prevalence of schizophrenia, but affective disorders were no more frequent than in the normal population. These data suggest that the heterogeneous group of paranoid psychoses can be meaningfully subdivided by use of axial syndromes which are viewed as representing "basic" disturbances underlying delusional symptomatology.     

Aspects of the course of bipolar manic-depressive,schizo-affective,and paranoid schizophrenic psychoses

Summary The study deals with the course of three diagnostic groups, namely 50 bipolar manic-depressive, 50 bipolar and manic schizo-affective, and 50 recurrent paranoid psychoses. The patients course was observed over 14–17 years, at least 5 years prospectively. The study concentrates mainly on the prognosis based on the symptomatology observed during the first episode, the stability of the symptoms over several episodes, the residual symptomatology, and the degree of remission during the intervals.Bipolar and schizo-affective psychoses show a similar periodicity. The study further reveals that the periodicity of schizo-affective disorders is mainly linked with the affective symptoms of this disorder. Qualitatively the residual symptoms of bipolar and schizo-affective psychoses differ.Bipolar and phasic paranoid psychoses are quite different with regard to their periodicity and their symptomatology during the episodes and during the intervals.From the Psycho-Neurological Institute in Warsaw, Poland, at present working at the Psychiatric University Hospital, Research Department (Scholarship holder of the Roche Research Foundation and Sandoz, Basel, Switzerland)     

Classification of functional psychoses with special reference to follow-up studies

The classification of functional psychoses is still a controversial issue, as are also diagnoses in psychiatry. The predictive validity of the diagnosis is of crucial importance. Diagnostic systems are discussed. The author presents the Scandinavian concept of reactive psychoses, schizophreniform psychoses and schizophrenia, and demonstrates from his own material on paranoid psychoses the predictive value of these concepts, with a percentage recovery of 81, 61 and 23% after long-term follow-up. The concepts are discussed in relation to ICD-9 and DSM-III. The concepts of paranoid disorders, affective disorders and borderline conditions are mentioned. The paper also introduces other papers to be presented in this volume.     

The Kraepelinian dichotomy: preliminary results of a 15-year follow-up study on functional psychoses: focus on negative symptoms

In a 15-year follow-up study, we used a comparative approach to assess course and outcome for all functional psychoses. The presented results focus on negative symptoms and refer to a sample of 76 patients with schizophrenia, 38 patients with a schizoaffective disorder and 32 patients with an affective disorder according to ICD-9. These patients were assessed at their first psychiatric hospitalization and 15 years later. In summary, the findings indicate that the course and outcome of schizophrenia is less favorable than that of affective and schizoaffective disorders. Negative symptoms occurred in all functional psychoses, but were more frequent and prominent in the schizophrenic group than in the other two diagnostic groups at any time of assessment. Narrower concepts of negative symptoms, conceptualized as the deficit syndrome, seem to be specific for schizophrenia and appear quite rarely in patients with affective psychoses. Overall, our study supports Kraepelin's original hypothesis that bifurcated the psychoses into the affective psychoses and schizophrenia, whereby the latter have a more deleterious long-term course and outcome.     

Classification of functional psychoses and its implication for prognosis: comparison between ICD-10 and DSM-IV

BACKGROUND: The aim was to examine the agreement and differences between ICD-10 and DSM-IV in the classification of functional psychoses. Sampling and METHODS: In a sample of 218 first-hospitalised patients, ICD-10 diagnoses were compared with DSM-IV diagnoses. Functional psychoses of both diagnostic systems were classified into the four diagnostic groups schizophrenia, transient/episodic psychoses, delusional disorders and affective disorders. Based on information from a 15-year follow-up, it was examined which course is associated with each diagnostic group. RESULTS: Although in ICD-10 there was a higher frequency of schizophrenia and a lower one of affective disorders, a high agreement between ICD-10 and DSM-IV (kappa value of 0.82) was found. In both diagnostic systems, transient/episodic psychoses and affective disorders were mainly associated with a non-chronic course and schizophrenia was mainly associated with a chronic one. Nevertheless, several patients with transient/episodic psychoses showed a chronic course (ICD-10: 10%, DSM-IV: 15%) and more than one third of patients with schizophrenia a non-chronic one (ICD-10: 40%, DSM-IV: 33%). CONCLUSIONS: In the cross-sectional assessment, there is a high diagnostic agreement between ICD-10 and DSM-IV. With respect to the long-term course, the delimitation of transient/episodic psychoses from schizophrenia was neither completely achieved by ICD-10 nor by DSM-IV.     

Position of affective symptomatology in the course of delusional psychoses

The present study investigates the frequency, gender distribution, mode of appearance, and prognostic value of affective symptoms in a group of 90 patients with paranoid disorders of various etiologies (with the exception of marked organicity) who underwent a follow-up control. It appears that affective symptoms manifest more frequently than the brunt of delusional and hallucinatory ones, whereby the pronounced differences in gender (preponderance of females) that appear in acute states disappear in the course of the illnesses. Altogether, the frequency of affective symptoms diminishes just as that of delusions and hallucinations. Paranoic syndromes (simple delusional syndrome with a logically organized structure corresponding to the classical concept of paranoia) are characterized by a particularly frequent occurrence of dysphoric (irritable) mood, systematic and unsystematic paraphrenias by a depressive mood. Delusion subsided in all three delusional entities in about 50% of the cases; however, defect develops in unsystematic paraphrenias more often to a statistically highly significant degree than in the other two forms. Despite the expected low stability of affective symptoms over longer periods of time, the presence of affective syndromes has a high prognostic value, even in a population characterized primarily by the presence of a mood-incongruent delusion. The results of this investigation suggest that Jaspers' hierarchical principle, still important for many diagnostic systems, according to which the presence of delusions and hallucinations is considered to be pathognomonic for schizophrenia and takes priority over any affective ones, be abandoned. The consequence this would have for the theoretical basis of the diagnosis of endogenous psychoses is that apart from affective syndromes only schizophrenic nuclear symptoms would form the basis of nosological diagnosis, and so-called productive symptoms (delusions and hallucinations) would be construed as a superstructure.     

Course and outcome in paranoid disorders.

All consecutively admitted patients suffering from paranoid psychoses and admitted to the Department of Psychiatry, University of Oslo, during two defined periods (1946-1948 and 1958-1961) have been personally followed up by the author after 5-18 years and by Stein Opjordsmoen after 22-39 years. After the first follow-up period 65% were without psychotic symptoms, after the last period 44%. According to Scandinavian diagnostic tradition, there is a gradual shift from very good clinical and social outcome for patients with reactive psychoses to very poor outcome for schizophrenics, patients with schizophreniform psychoses being in between. According to the DSM-III system, patients with affective and schizoaffective psychoses score best, followed by those with paranoid and schizophreniform disorders. Those with schizophrenia score worst. Course and outcome are primarily dependent on the diagnostic category, not the type of delusion. Of the patients with Kraepelin's paranoia, about one-third were without psychotic symptoms at last follow-up.     

Dysphoria from a transnosological perspective

The objective of our psychopathological analyses is to shed light on the position of irritable mood (dysphoria) in psychiatric diagnostics and nosology. In today's most commonly applied classification systems, the ICD-10 and the DSM-IV, dysphoria is mentioned mostly in the context of diagnostic criteria of personality and affective disorders. Other authors have emphasized the importance of dysphoric states in organic psychoses and delusional disorders. Summarizing the various publications on the nosological position, dysphoria is a nosological nonspecific syndrome which may occur in the course of all psychiatric disorders and illnesses. According to the results of our psychopathological analyses, the pathogenesis of dysphoria has to be considered as a multidimensional circular process in which various mental, physical and social factors act as predisposing, triggering and disorder-maintaining factors. Stressors induced by particular experiences and perceptions and by impaired health may lead to a dysphoric state if adequate coping mechanisms are missing. Dysphoria itself usually leads to a deterioration in the mental and physical state of the patient, and shows a clear impact on the patient's social network. The reactions of people close to the patient combined with the impaired mental and physical conditions of the patient cause the circle to restart. As contemporary diagnostic entities do not refer to pathogenesis, classical categorical diagnostics cannot provide the basis for effective pathogenesis-oriented therapy. A change of paradigm in diagnostics from a categorical to a dimensional approach thus becomes necessary. Following a dimensional diagnostic approach based on a dynamic model of vulnerability, a precise differential diagnosis of the complex constellation of conditions and their interactions becomes necessary in order to develop effective treatment strategies. Disorder-maintaining factors determine the treatment of the acute symptomatology, whereas predisposing and triggering factors serve as the basis for the prophylactic treatment.     

The pathology of deafness in the paranoid and affective psychoses of later life.

Using enlarged samples, this study investigates the results of a previous enquiry which indicated that, compared with a control group of affectives, a higher proportion of patients suffering from paranoid psychoses had bilateral conductive deafness. In the original sample 21 paranoid and 8 affective patients were judged to have been hard of hearing prior to the onset of their psychosis (Group ‘A’). Six additional deaf paranoid and 10 deaf affective patients (Group ‘B’) were identified by the same method as before, providing a total of 27 deaf paranoid and 18 deaf affective patients who were available for audiometry and otological examination.The results confirm that there is a significant association between paranoid illness and bilateral conductive deafness which has an earlier age of onset, longer duration and greater severity than the forms of sensorineural deafness found in the affective group. It is suggested that factors related to long duration and severity of deafness are of greater importance in the aetiology of paranoid psychosis than the quality of hearing loss; and the implications for treatment and prevention are discussed.     

Hypochondriacal delusions in paranoid psychoses. Course and outcome compared with other types of delusions

From a large series of patients with delusional psychoses, first-time admitted to the Psychiatric Department, University of Oslo, hypochondriacal delusions were coded as the main delusion in 15 patients (0.4% of all admissions). These patients have been personally followed up by one of the authors (N.R.) after 5-18 years, and by the other author (S.O.) after 23-39 years (mean 30 years). The results are presented, also according to the newer diagnostic systems (DSM-III, DSM-III-R), and the course and outcome of hypochondriacal delusions are compared with those of other types of delusions. Course and outcome are mainly dependent on the diagnostic category, not the type of delusion. It is also demonstrated that the course and outcome in major affective disorders are more favourable than in paranoid disorders, with the latter being significantly different from schizophrenia.     

Course of atypical psychoses]

An attempt was made to classify the atypical psychoses according to cross-sectional psychopathological criteria. We were able to separate two groups from a group of benign schizophrenics. The latter served more as a comparison group and were in every way similar to the nuclear group, except for a better social prognosis. Group C (atypical manic depressive illnesses) which was closer to manic depressive illness than the other two groups, differs from it by thought disorders and delusional experiences. In the further course of the illness, after a few schizophrenic symptoms had appeared once or repeatedly during the acute stage, the typical features of manic depressive illness came more and more to the fore. In group A (mixed psychotic syndrome) manic depressive and schizophrenic symptom complexes appeared for quite some time during the acute stage with approximately equal clarity and significance. In the further course, during which manic depressive phases as well as schizophrenic thrusts can make their appearances, one can often see the development of a 'hypomanic defect'. Systematised delusions, as well as grimacing and circumstantiality, can also persist frequently. On the whole, however, it is difficult to recognize the defect states from their original state once the illness has settled down. A classification of the atypical psychoses and their differentiation from typical manic depressive illness or nuclear schizophrenia is necessary, at least, because of the worse, respectively better, social prognosis of the atypical psychoses. This investigation should be continued further by using as control groups bi- and unipolar affective psychoses and nuclear schizophrenics with a severe course. The subgroups of the atypical psychoses will be used to evaluate different long-term therapies in a further study.     

Fatherhood, impending or newly established, precipitating delusional disorders. Long-term course and outcome.

Psychopathological reactions to fatherhood are probably not so infrequent as they would seem from psychiatric literature. In a material of paranoid psychoses, impending or newly established fatherhood was considered the main precipitating factor in 4 patients (i.e. 2.4%), compared with 7% of the female psychoses precipitated by pregnancy, childbirth or nursing. Two of the men were bachelors, insecure and inhibited, feeling compromised or helpless in the new situation. Two men were married, passive, avoidant in their personality, strongly dependent on their wives. The course and outcome varied according to the diagnoses; 2 cases having a favorable and 2 an unfavorable course and outcome. Physicians, including psychiatrists, should bear in mind that fatherhood is a possible precipitating factor for paranoid psychoses in male patients.     

Treatment of the interictal psychoses

BACKGROUND: The interictal "schizophrenia-like" psychoses of epilepsy conventionally are treated with antipsychotic medication with uncertain results. In patients with these psychoses, a preceding and concomitant dysphoric disorder usually can be documented. Effectiveness of the pharmacologic treatment by the combination of drugs that is effective for severe interictal dysphoric disorders is demonstrated in a series of patients with interictal psychosis. METHOD: Patients were treated with the combination of a tricyclic antidepressant and a selective serotonin reuptake inhibitor, enhanced if necessary by a small amount of the atypical neuroleptic risperidone. The series consisted of 8 consecutive patients with interictal psychosis seen over a 20-month period. Two additional patients seen over the past 10 years who required a different therapeutic intervention were also included. RESULTS: Five of the 8 consecutive patients achieved full remission of their psychosis; 3 patients could not be reached for the full treatment effort. One patient with a malignant psychosis had been treated successfully (prior to the series reported) by surgical removal of a left frontal epileptogenic zone; a second patient (treated after the series) recovered only upon elimination of the antiepileptic drug that had suppressed clinical seizures but had resulted in an alternating psychosis. CONCLUSION: Interictal psychoses can be viewed as severe interictal dysphoric disorders with psychotic features. The same combination of psychotropic medication that is effective for severe interictal dysphoric disorders serves as the primary therapy for interictal psychoses. The interictal psychiatric disorders presumably result from seizure-suppressing mechanisms that are the targets of the proconvulsant drugs. Upon suppression of seizures, some patients with interictal psychosis may require modification of the antiepileptic medication responsible for excessive inhibition. Complete surgical removal of the epileptogenic zone can eliminate a chronic interictal psychosis upon postoperative fading of inhibitory mechanisms.     

The Relationship Between Bipolar Disorder,Seasonality, and Premenstrual Symptoms

Cyclical mood disorders characterized by shifting affective states include bipolar disorder, seasonal affective disorder, and premenstrual syndrome/premenstrual dysphoric disorder. In this article, we explore the relationship between these disorders and bring the reader up to date on the advances made in the past year in understanding the relationship between bipolar disorder, seasonality, and premenstrual symptoms.     

The concepts of axis syndromes 1965-1983

The first purpose of the paper is to sketch the development of the concept of axial syndromes, starting with the generation of the hypotheses in Berner's monograph on 'The paranoiac syndrome' published in 1965 and leading to the last formulation of the Viennese Research Criteria in 1983. The second purpose is to draw the attention on a series of empirical studies which have been undertaken in order to evaluate the classificatory validity of the concept, studies dealing with the long-term course of paranoid psychoses (both in a retrospective and a prospective design) and secondary cases of different diagnostic classes in the families of the same patients (first-degree relatives).     

Depressive states occurring during the neuroleptic treatment of schizophrenia

Depressive states are often observed during the hospitalizations of acutely schizophrenic patients. But only a few studies have examined the frequency and course pattern of these depressions. In our investigation of 81 patients suffering from schizophrenic or paranoid psychoses and undergoing neuroleptic treatment, we found that the frequency and intensity of depression decreased from admission to discharge. On admission, 63 percent of patients showed a marked depressive apathetic syndrome, as compared to only 23 percent on discharge. Patients' self-rating data from the Actual Mood Scale (filled out every other day) showed that only a small proportion of the patients developed a depression during hospitalization without having also been depressed on admission. An analysis of psychiatrists' admission and discharge ratings produced similar results. Our findings suggest tht neuroleptics are unlikely to be the major cause of depressions in patients suffering from acute schizophrenic or paranoid psychoses.     

Follow-up and family study of postpartum psychoses Part I: Overview

A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2–35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower-morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.     

Epidemiologie und Psychopathologie des Amoklaufes

In order to clarify psychosocial and psychopathological components that may contribute to causes of running amok, judgements and forensic-psychiatric certificates of 27 amok runners were examined. While in the last 20 years there was no increase of amok events in general, a remarkable increase in so-called school shootings occurred; 74% of the culprits had a history of psychiatric disorder, most importantly schizophrenic psychoses, affective disorder or alcoholism. According to the forensic psychiatric certificates, 70% were not or not fully responsible for the crime. Three prototypes of amok runners were found: (1) adolescents with long-term difficulties at school or apprenticeship and suicidal ideas; (2) persons suffering from paranoid psychoses; and (3) adults with personality disorders after breakdowns of close social relationships. Despite these predisposing factors it remains unknown which pathological conditions of brain function finally cause this most deleterious form of violence.     

Long-term course of acute reactive paranoid psychosis. A follow-up study

ABSTRACT The study comprises a retrospective evaluation of the case records of 49 first-admission patients with acute reactive paranoid psychosis and of the subsequent follow-up almost 10 years later, with special reference to clinical and social course and outcome. Ten of the 41 followed-up patients were diagnosed schizophrenic in the observation period and a further five fulfilled the Catego Class S⁺ at a PSE interview. Three patients were diagnosed affective psychosis and one fulfilled Class MT. Three patients were diagnosed paranoid psychosis and four more fulfilled Class P7PT while six patients had reactive psychosis relapses but were non-psychotic at follow-up. During the observation period the number of disabled pensioners increased from three to 21, and at follow-up only seven patients were well-adjusted in their family and work. The need is stressed for valid predictors in the prognosis of acute paranoid psychoses with or without associated stressful life events.