Delusional psychosis. Hospital incidence, symptoms and classification

The study comprises a consecutive evaluation of 88 first-admission patients from a well-defined catchment area. All patients disclosed functional delusional psychosis at PSE interview. Sex distribution was equal and the patients' mean age in the thirties. Symptomatology and diagnostic classification are presented and, for the latter, related to the Catego Class of PSE. Forty-five patients fulfilled Catego Class S+, the majority being diagnosed reactive psychosis while only 13 patients were diagnosed schizophrenia. At discharge, 44 patients were fully remitted. A follow-up will be made of social and clinical course and outcome.     

Paranoid psychosis in the elderly. A follow-up study

Hospital records comprising 106 first admissions of patients aged 60 years or more diagnosed paranoid disorder were studied. Affective psychosis and dementia were excluded. The female/male ratio was 2:1. Symptomatology, treatment and diagnostic classification are presented. Seventy-five per cent revealed persecutory delusions, and nearly half were hallucinated. Almost all patients received neuroleptics. The majority were diagnosed paranoid psychosis or reactive psychosis. After 5-15 years of observation a full remission was seen in 27% according to the judgement of general practitioners as well as hospital records. Delusions such as megalomania and delusions with ideas of sex and jealousy showed a significantly poor outcome. The diagnosis reactive psychosis predicts a course of illness characterized by few relapses.     

Clinical course and outcome of delusional psychosis

The purpose of the study was to examine first-admitted patients with delusional psychosis meaning functional psychosis with paranoid symptoms with respect to clinical course and outcome. The index population comprised 88 patients. At discharge from first admission the patients were classified according to ICD-8 and DSM-III. According to both diagnostic classifications the majority of the patients did not belong to either of the two major psychotic groups, schizophrenia or affective psychosis. During the 2-year observation period half of the patients took psychotropic drugs continuously, and almost half of the patients experienced one or more relapses. One third of the patients were readmitted, and in average the patients stayed in the hospital for 4 months during the observation period including the time of index admission. At follow-up half of the patients revealed positive psychotic symptoms, while two thirds were moderately or severely impaired because of psychotic illness or personality dysfunction. It is concluded that the present aftercare treatment is insufficient to prevent relapse and psychotic symptoms. In consequence of this the existence of delusions at first admission to hospital because of functional psychosis seems for many to predict an unfavourable course and outcome. Further study will search for clinical and social predictors of course and outcome in patients with delusional psychosis.     

Time trends in first admissions for schizophrenia and paranoid psychosis in Stockholm County, Sweden

Several studies have reported decreasing time trends in first diagnosed schizophrenia patients. The aim of this study was to analyze time trends for first admissions with a diagnosis of schizophrenia or a diagnosis of either schizophrenia or paranoid psychosis during 1978-1994 in Stockholm County, Sweden, with a population of around 1.8million. Information about first psychiatric admission with the diagnosis schizophrenia or paranoid psychosis for residents of Stockholm County was obtained from the Swedish population-based psychiatric inpatient register. Age-adjusted average yearly changes in first hospitalization rates were estimated in a Poisson regression model. Time trends in first admission rates were calculated from 1978 to 1994, while admissions during 1971 to 1977 were observed only to eliminate later re-admissions. First admissions for schizophrenia declined by 1.9% annually for females and by 1.3% for males, while first admissions for schizophrenia and paranoid psychosis together were unchanged over the study period for both genders. Our results indicate that the incidence of schizophrenia and paranoid psychosis taken together was essentially the same over the studied time period in Stockholm County, and that the apparent decline in first admission rates for schizophrenia may be an effect of changes in clinical diagnosis over time.     

Follow-up study of hysterical psychosis, reactive/psychogenic psychosis, and schizophrenia

The present study was undertaken to learn more about the longer-term course of nonaffective functional psychoses, including hysterical psychosis. A group of 48 female patients diagnosed with hysterical psychosis, nonhysterical reactive/psychogenic psychosis, and schizophrenia at their first admission were reassessed after an average follow-up period of 11.6 years. Seventy-five percent were receiving outpatient treatment; less than half were on neuroleptics, and only 35% were rehospitalized. The patients suffered from a few, mostly unspecific, symptoms and were relatively well adjusted socially. No differences were found between original diagnostic categories regarding all variables studied. Hysterical psychosis does not appear to be a special clinical entity, distinguishable from other reactive/psychogenic psychoses in the short term and from other nonaffective functional psychoses in the longer term. The symptomatology and clinical presentation of nonaffective functional psychoses at first admission do not allow any prognostic longer-term forecast, and the initial differences between individual psychoses tend to disappear over time.     

偏执性精神障碍71例临床分析

本文报导偏执性精神障碍共71例,其中偏执狂13例,偏执状态58例,与CCMD-2相对照,符合诊断标准者偏执狂为6例,偏执状态为45例,经再次住院或随访1～10年,维持原诊断者分别为3例和38例。并发现近40年来无1例诊断为急性妄想发作(妄想阵发)。另对CCMD-2略作评价和建议。     

Clinical and serotonergic predictors of non-affective acute remitting psychosis in patients with a first-episode psychosis

Objective: The study aimed to establish clinical predictors of non‐affective acute remitting psychosis (NARP) and assess whether these patients showed a distinct serotonergic profile. Method: First‐episode never treated psychotic patients diagnosed of paranoid schizophrenia (n = 35; 21 men and 14 women) or NARP (n = 28; 15 men and 13 women) were included. Results: NARP patients showed significantly lower negative symptomatology, better premorbid adjustment, shorter duration of untreated psychosis, more depressive symptomatology and a lower number of 5‐HT2A receptors than the paranoid schizophrenia patients. In the logistic regression, the four variables associated with the presence of NARP were: low number of 5‐HT2A receptors; good premorbid adjustment; low score in the item ‘hallucinatory behaviour’ and reduced duration of untreated psychosis. Conclusion: Our findings support the view that NARP is a highly distinctive condition different from either affective psychosis or other non‐affective psychosis such as schizophrenia, and highlight the need for its validation.     

Manic-depressive patients with delusions. Clinical and diagnostic course

A study was made of the hospital records of 114 first admission patients under 60 years with a diagnosis of manic-depressive psychosis and coexisting paranoid symptoms. The male/female ratio was 1/1.4, and the females were significantly older. Symptomatology and treatment are presented. Seventy per cent disclosed delusions of reference and misinterpretation and 50% had synthymic delusions. During 11-15 years of admission 75% of the patients were re-admitted. The diagnostic concept was changed in 33%. Significantly more females were diagnosed unipolar manic-depressive. According to the general practitioners and hospital records psychotic traits were still present in 50% of the patients at follow-up. Significantly more patients diagnosed as unipolar manic-depressive had no relapse and no remaining psychotic traits. And significantly more patients with changed diagnosis had remaining psychotic traits. The need for prospective studies of patients with coexisting affective and paranoid symptomatology is stressed.     

Organic factors and the clinical features of late paranoid psychosis: a comparison with Alzheimer's disease and normal ageing

The diagnostic allocation and aetiological basis of paranoid psychoses with late onset is controversial. We examined the clinical features of patients with a diagnosis of paranoid psychosis and we compared their cranial computed tomography (CT) scans and electroencephalographic (EEG) recordings with findings from matched samples of patients with Alzheimer's disease and non-demented elderly controls. During a 5-year period, 81 patients (15 men and 66 women) with a diagnosis of paranoid psychosis and onset after age 50 were referred to our Institute. They represent 5.4% of the patients older than 50 admitted during the same period. More than half of these patients had first-rank symptoms. The ventricles, anterior and sylvian fissures of the paranoid group were larger than in non-demented controls but smaller than in Alzheimer's disease. The posterior dominant alpha EEG rhythm was slower than in normal ageing and faster than in Alzheimer's dementia. If paranoid patients with first-rank symptoms were distinguished from the ones without, the former had less severe brain atrophy and faster posterior dominant rhythm, although they received higher doses of neuroleptics. This could be explained by the existence of at least 2 subgroups of late paranoid psychosis: late-onset schizophrenia and organic paranoid syndrome, the former characterized by first-rank symptoms and less severe brain atrophy, the latter by more severe EEG and CT scan changes with a closer resemblance to degenerative brain disease.     

Toward an operationalization of reactive paranoid psychoses (reactive delusional disorder)

Reactive psychoses are relatively often diagnosed in Norway, although they are not operationalized in any classificatory system and the reliability may be questioned. The aim of this study was to define a group of reactive paranoid psychoses and compare its long-term outcome to the group of nonreactive paranoid psychoses and to paranoid schizophrenia. Approximately 200 out of 301 delusional subjects earlier studied by Retterst?l have recently been interviewed semistructurally, making a total follow-up period of 22-38 years. Diagnoses at discharge have been assessed retrospectively before the present interview, with a polydiagnostic approach. Based upon Kendler's criteria of delusional disorder and influenced by Jaspers, the concept of reactive delusional disorder has been operationalized. Results from the first 125 interviews show 31 cases of Kendler's delusional disorder, of which 16 are diagnosed as reactive delusional disorder. Outcome in this group is most favorable, and especially good outcome is found in acute reactive delusional disorder.     

T- and B-lymphocytes in patients with schizophrenia in acute psychotic episode and the course of the treatment

Schizophrenia is associated with alterations of the immune system. There are, however, only limited data dealing with immune parameters in unmedicated schizophrenic patients and the course of these parameters during treatment. In this study, we monitored CD19+ (B)- and CD3+ (T)-lymphocytes in the course of antipsychotic treatment. Forty patients diagnosed with an acute exacerbation of schizophrenia were tested before and after 3 days, 2 weeks, 4 weeks and 3 months of treatment with antipsychotics. The percentages of CD19+- and CD3+ -lymphocytes were analysed by flow cytometry using fluorescence conjugated anti-CD19 and anti-CD3 antibodies. Twenty healthy volunteers served as controls. In the acute state of psychosis, a significant reduction of the CD3+ -lymphocyte subpopulation was observed, while the percentage of CD19(+)-lymphocytes was increased. Both subpopulations levelled to those of the control group in the course of treatment. As expected, the levels of the immune parameters did not change in the healthy controls during the course of the study. The observed alterations of the CD19+ - and CD3+ -lymphocytes in the acute state of psychosis especially in patients with the paranoid subtype of schizophrenia, and the "normalization" during the observation period are discussed under the aspect of the immune hypothesis of schizophrenia, in particular of the type-1/type-2 imbalance hypothesis.     

Reactive psychoses and schizophrenia with good prognosis.

Cross-national studies have indicated that American psychiatrists diagnose schizophrenia more often than others. Clinical, genetic, and follow-up studies suggest that many patients diagnosed as having acute schizophrenia might be more appropriately diagnosed as having affective disorder. Forty probands diagnosed in Aarhus, Denmark, as having reactive psychoses are compared with 28 probands diagnosed in St Louis as having schizophrenia with good prognosis. Clinical differences largely reflect diagnostic criteria, with the patients from the St Louis group frequently having diagnosable affective disorder. A smaller proportion, 39% of the patients from St Louis, could be considered for the diagnosis of reactive psychosis. This is additional evidence supporting the use of the diagnostic category, reactive psychoses. Patients ordinarily given the diagnoses acute schizophrenic episode and/or schizo-affective schizophrenia may be more appropriately diagnosed as having (1) affective disorder and (2) reactive psychoses.     

Prediction of psychosis onset in Alzheimer disease: The role of cognitive impairment, depressive symptoms, and further evidence for psychosis subtypes.

BACKGROUND: Psychotic symptoms in Alzheimer disease (AD+P) identify a heritable phenotype associated with more rapid cognitive decline. The authors have proposed that AD+P is itself a composite of a misidentification and a paranoid subtype with increased cognitive impairment restricted to the misidentification type. Most prior studies of the clinical correlates of AD+P have been limited, however, by the inclusion of prevalent cases. METHODS: Subjects with possible or probable AD or mild cognitive impairment (MCI) without psychosis at study entry were assessed at the time of initial presentation and then annually. Psychotic symptoms were assessed using the CERAD Behavioral Rating Scale. Survival analyses used Cox proportional hazard models with time-dependent covariates to examine the predictors of psychosis onset. RESULTS: A total of 288 subjects completed at least one follow-up examination. Mean duration of follow-up was 22.1 months. The incidence of psychosis was 0.19 per person-year. Cognitive impairment was associated with onset of psychosis, largely as a result of its association with onset of the misidentification, but not the paranoid, subtype. Including psychotropic medication use in the model revealed an association of antidepressant use with the onset of psychosis. This latter association appeared to arise from an underlying association between depression and the risk of psychosis onset rather than from antidepressant treatment. CONCLUSION: These findings are consistent with the hypothesis that the misidentification and the paranoid subtypes each define a more biologically homogeneous group than AD+P as a whole. Further exploration of the relationship between depressive symptoms and psychosis in patients with AD is warranted.     

Psychogenic (reactive) and hysterical psychoses: a cross-system reliability study

The aim of this study was to investigate the concepts of reactive and hysterical psychoses and how they are classified in standardized diagnostic Systems. To this end we identified all of the patients who had been admitted to a psychiatric in-patient unit and diagnosed as suffering from psychogenic psychosis, reactive psychosis, hysterical psychosis or hysteria, using ICD-9 criteria. The case notes of these patients were then re-examined and diagnoses reached using DSM-III-R, DSM-IV and ICD-10 criteria and the Present State Examination (PSE)/catego computer program. The objective of this study was to evaluate the agreement between the diagnoses of reactive and hysterical psychosis obtained using ICD-9 criteria with those obtained using the DSM-III-R, DSM-IV, ICD-10 and PSE diagnostic Systems. A total of 67 case notes were identified in which the above diagnoses had been made: 27 cases with ICD-9 ‘hysteria’ and 26 cases with ‘other reactive and not otherwise specified psychoses’. Using the DSM-III-R criteria, 27 cases were diagnosed as psychotic disorder NOS, 12 as brief reactive psychosis and 11 as bipolar disorder. Using the DSM-IV criteria, 21 cases were diagnosed as psychotic disorder NOS, 11 as mood disorder, 7 as brief disorder without stressor, and 12 as brief disorder with stressor. Using the ICD-10 criteria, 18 cases were diagnosed as unspecified non-organic psychosis, 12 as mood disorder, 10 as acute and transient psychotic disorder without stressor and 13 as acute and transient psychotic disorder with stressor. Using the PSE/catego program, the most common diagnoses were class ‘S’ schizophrenia (17), class ‘P?’ uncertain psychosis (16) and class ‘M+’ mixed and manic affective disorder (11). Using the kappa coefficient a very low level of agreement was found between ICD-9 ‘hysteria’ and ‘other reactive and non-specified psychoses’ and the corresponding categories of DSM-III-R and the PSE/catego program. We concluded that, although DSM-III-R provides operational criteria for brief reactive psychosis, and DSM-IV and ICD-10 provide such criteria for brief or acute psychotic disorder, these bear little relationship to the original concept of the disorder. The PSE/catego program provides a very systematic approach to symptomatology, but the diagnostic classes have little clinical usefulness.     

Thyrotrophin-releasing hormone (TRH) stimulation test in manic-depressive illness.

The thyrotrophin (TSH) response to thyrotrophin-releasing hormone (TRH 200 microgram intravenously was studied in 19 patients with unipolar depression, 12 with bipolar depression, 14 with mania, and 5 with mixed manic-depressive illness. The TSH responses were decreased in all of these affective disorders compared to those found in 10 patients with reactive depression, 5 with reactive paranoid psychosis, 14 with neurotic depression, and 60 controls. The decrease of the TSH response in manics could not be accounted for by the effects of neuroleptic drugs. The TSH response in the groups with reactive depression, reactive paranoid psychosis, and neurotic depression, respectively, did not differ significantly from that found in controls. With the exception of a decrease in serum T3 level and free T3 index in the manics, no significant differences in serum T3 level or in free T3 and T4 indexes were found between the groups. Changes found in serum T4 level were due to changes in the thyroxine-binding proteins.     

Psychoses in drug-resistant temporal lobe epilepsy.

In the survey of 74 Danish patients with temporal lobe epilepsy who underwent temporal lobectomy, a total of 20 patients were psychotic. Nine of these became psychotic during the follow-up period, six of them after cessation of their epileptic seizures. There were 13 schizophrenia-like psychoses, six paranoid delusional and depressive psychoses, and one childhood psychosis. Operation was on the right side in 39 and on the left side in 35 patients. When the various psychotic groups were compared with each other or with the nonpsychotic patients, the side of operation was not found to be statistically important. The patients with psychoses were older at operation and showed a higher rate of focal lesions in the resected specimens. Although more psychotic patients were bright or normally gifted, and had achieved a higher standard of schooling than nonpsychotic patients, their social status after operation was inferior. Surgery had no effect on psychosis present preoperatively nor on its possible postoperative onset. The diagnosis of psychosis was not considered to be contraindication to temporal lobectomy.     

Delusions induced by procaine penicillin: case report and review of the syndrome

A patient manifesting an acute psychosis after receiving an injection of procaine penicillin is reported. The psychosis began immediately after drug administration and gradually abated over a forty-eight-hour period. The clinical presentation was dominated by paranoid delusions and a Capgras-like syndrome. Sixty-six previously reported cases were identified and reviewed. Patients manifested combinations of fear, auditory hallucinations, somatic hallucinations, visual hallucinations, and paranoid or religious delusions. The syndrome may occur with inadvertent intravenous injection of procaine and most likely reflects the action of procaine on limbic system structures.     

Subtype stability in schizophrenia

The authors examine the long-term stability of the subtypes of schizophrenia defined by four diagnostic systems. When all patients were considered, agreement between subtype assigned at index and follow-up was modest. This agreement increased considerably when only patients diagnosed as paranoid, hebephrenic, or catatonic at both index and follow-up were considered. As for individual subtypes, stability was highest for paranoid schizophrenia, intermediate for hebephrenia, and virtually absent for undifferentiated schizophrenia. The stability of paranoid schizophrenia was greatest when onset occurred after age 30. As length of follow-up increased, a larger proportion of patients were diagnosed as undifferentiated or residual.     

Selenium concentrations in blood and serum from patients with mental diseases

Blood and serum concentrations of selenium have been determined in a group of psychiatric patients and in 35 healthy controls. The psychiatric group consisted of 14 schizophrenics, seven paranoid disorders, six affective psychosis (manic-depressive), four reactive psychosis, 11 dementia senilis, 17 with a diagnosis of neurosis and two with delirium tremens. Normal values were found in all groups except for delirium tremens where decreased blood and serum values were found.     

Elderly schizophrenic inpatients in the wake of deinstitutionalization

The authors investigated the factors relating to the observation that in a large state hospital, there is an age-related increase in the ratio of patients with a DSM-II diagnosis of paranoid schizophrenia to those with a diagnosis of nonparanoid schizophrenia. Elderly inpatients (N = 1,518) treated over a 5-year period were studied and the hypotheses of proportionately greater numbers with late onset of paranoid conditions, longer lengths of stay for recently admitted paranoid patients, and changing diagnosis over time were tested and rejected. The data suggest that the buildup among the elderly of those diagnosed under DSM-II to have paranoid conditions is due to patients admitted well before age 54. The authors discuss the reasons for the poor prognosis of this group.