PROGNOSIS OF PARANOID STATES IN RELATION TO THE CLINICAL FEATURES

Scandinavian psychiatrists acknowledge endogenous psychoses which are neither schizophrenic nor manic-depressive, i.e., above all the “reactive psychoses” and the “schizophreniform psychoses”, both of which differ from schizophrenia in their features as well as in their good prognoses. These Scandinavian diagnoses bear relationships to psychoses, which I separate from schizophrenia. In the present paper, paranoid states are discussed with regard to their clinical pictures and their good prognoses. Among these are the “cycloid psychoses”. Patients suffering from these diseases recover from every phase, though most of the German psychiatrists consider them schizophrenic. Among the cycloid psychoses, the “anxiety happiness psychosis” shows ideas of reference on the one hand and ecstatic ideas on the other. In “inhibited confusion psychosis”, the patients are suffering from ideas of reference and ideas of significance; in “excited confusion psychosis”, from misidentifications of persons. The other symptoms which occur - anxiety, happiness, stupor, incoherent pressure of speech - confirm the cycloid psychoses and disprove schizophrenias. Besides the already mentioned psychoses, there is a monopolar psychosis, “suspicious depression”, in which ideas of reference and ideas of guilt mix. It is extremely important, not only for theoretical but also practical reasons, to separate from schizophrenia paranoid states which terminate in complete recovery from every phase.     

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.     

Empirical study on an inpatient psychogeriatric unit: diagnostic complexities

Retrospective analysis of the phenomenology and the diagnostic process of 112 consecutive psychogeriatric admissions revealed the majority (61%) were suffering from affective illness. In 53 percent, the reason for admission was depression and 8 percent were in the manic phase of a bipolar disorder. Dementia was diagnosed in 32 percent, with a third of these patients having an associated depression. The remaining 7 percent had a schizophrenic or paranoid disorder. Ninety-two patients (82%) were found to have at least one coexisting medical and/or neurological disorder(s) requiring early intervention. Associated acute organic brain syndromes were common (18%) and often difficult to diagnose. The AOBS was at times the only sign of an underlying active medical condition. The diagnosis of this condition often required serial observations for fluctuations in mental status accompanied by appropriate laboratory investigations. These findings underscore the complexity of the diagnostic process in psychogeriatric patients suffering from concomitant medical and psychiatric disorders. High index of awareness is recommended for the need to search for coexisting delirium, which may be masked at times by the major psychiatric disorder.     

Pathological lability of venous fasting blood sugar regulation in psychotic disease]

The lability of peripheral venous postabsorptive blood sugar regulation was investigated in 98 patients suffering from floridly psychotic diseases (45 somatically based psychoses, 27 endogenous/involutional depressions, and 26 schizophrenic psychoses). In total, 259 times, in 30-sec intervals, 10 fasting blood sugar values each were determined (so-called 'Anderson curves'). The maximal normal range of 36 mg% of spontaneous blood sugar oscillations in normal probands was exceeded in 17% of depressive, in 15% of schizophrenic, and in 12% of somatically based psychoses. The frequency and probability of appearance of pathological Anderson curves proved independently of any clinical-psychiatric diagnosis, and only significantly correlated with the criterion 'psychotically ill'. Discussed are primary central deviations from nominal gluco-sensitive regulatory 'tone' as postulated cause of pathological lability of venous blood sugar homeostasis resulting. Besides additional, pre-known glucose-metabolic derangements accompanying certain neuropsychiatric syndromes, pathological Anderson curves in psychotic illness are looked at as unspecific functional deviations involving bipolar-adrenergic dysbalances.     

Role of carbamazepine in the treatment of endogenous psychoses. Results of an open study

The authors report the results of an open trial which aims at specifying the clinical profile of responders to carbamazepine among a population of twenty patients aged from fifteen to seventy, suffering from endogenous, schizophrenic, affective psychoses and paranoid states according to the criteria of the ICD 9. The trial points out a proof of Kishimoto's criteria and a preferential acting of the molecule on schizo-affective psychoses and mixed affective states. The results are interpreted according to psychopathological concepts from the Vienna school that highlight the clinical profile of the responders.     

Postpsychotic depression in schizophrenics

Seventeen patients suffering acute schizophrenic decompensations were followed longitudinally for up to six months in order to study the incidence and quality of postpsychotic depression. Only two of these patients developed a moderately severe and prolonged depression following a relatively symptom free period. Six other patients evidenced mild to moderate depression for short periods of time either during or immediately following their acute psychoses.     

精神分裂症伴发抑郁症状及其临床特征

目的 了解急性期住院精神分裂症患者伴发抑郁症状的发生率、临床特征及其相关因素。方法 对符合CCMD-3诊断标准的精神分裂症患者75例，分别于入院3天内评定PA．NSS、HAMD、TESS量表。结果 急性期抑郁发生率为30．7％，抑郁组与非抑郁组性别、婚姻、文化、年龄无显著性差异，抑郁组平均住院次数、偏执型精神分裂症所占比例多于非抑郁组。治疗前汉密顿抑郁量表总分与阴性量表、思维障碍症状群、反应缺乏症状群负相关，与一般精神病理量表、抑郁症状群正相关。结论 精神分裂症抑郁症状急性期较常见、较严重，偏执型精神分裂症更易出现抑郁症状。     

Long-term follow-up of paranoid psychoses

Approximately 200 out of 301 first-admitted hospitalized patients with paranoid psychoses earlier studied by Retterst?l are still alive. These subjects are at present being interviewed semistructurally by the author, making a total follow-up period of 22-37 years after index admission. Before the interviews, diagnoses at discharge and at previous follow-ups based upon the records are established. Different diagnostic procedures are used. Preliminary results from the first 125 interviews indicate a small change to the worse as to psychopathology during the last 20 years. Outcome in DSM-III schizophreniform disorder, RDC schizoaffective disorders, Kendler's delusional disorders and ICD-9 reactive psychoses differs distinctly from the less favorable outcome in DSM-III schizophrenia.     

Cerebrospinal fluid filtration as experimental therapy in therapy refractory psychoses in Borna disease virus seropositive patients. Therapeutic effects, findings

According to previous investigations, mild Borna disease virus encephalitis may underlie a subgroup of affective or schizophrenic type psychoses. And virus-induced immune pathology may underlie even a larger subgroup of psychoses. We treated BDV seropositive patients suffering from therapy resistant schizophrenic or affective spectrum psychoses by cerebrospinal fluid filtration (CSFF) in an experimental add-on treatment. CSFF was shown previously to be an effective immune modulatory treatment in autoimmune neurological disease, Guillain-Barré syndrome. CSFF appears to be an effective treatment in therapy resistant psychosis also, but only 4 patients were treated yet.     

Why has the incidence of schizophrenia in Danish psychiatric institutions decreased since 1970?

From The Danish Psychiatric Register five cohorts of all first-admitted patients to Danish psychiatric institutions from the years 1970, 1973, 1976, 1979, and 1980 have been followed, and trends in age-standardized rates of schizophrenia investigated. The first-admission rates have decreased in both sexes, significantly in males. In addition, the cumulated schizophrenia rates for the cohorts, including those of patients diagnosed as schizophrenics only at a later admission within periods of 2 and 5 years, decreased. This decrease is significant at 2 years of observation in both sexes and at 5 years in females. The decreasing first-admission rates might be explained partly by changes in diagnostic habits. The differential diagnoses of schizophrenia (paranoid states (ICD-8:297), paranoid reactive psychoses (298.3), unspecified psychoses (298.9 and 299), and borderline states (ICD-8 Danish version: 301.83] are increasingly used as first-admission diagnosis for patients later to be diagnosed as schizophrenic, possibly owing to a tendency to avoid the diagnosis of schizophrenia, when treatment of a patient is possible. A method of calculating the hospital incidence of schizophrenia approaching the real incidence better than the incidence of first-admission diagnoses is suggested.     

First admissions for psychosis in Turku. A time trend study.

Patients over 15 years of age from Turku hospitalized for psychosis for the first time during the years 1949-50, 1959-60 or 1969-70 were investigated. The incidence of hospitalized psychoses (per 100,000 inhabitants) was 115, 136 and 160, respectively. The increase in incidence was greater in women than in men. The incidence remained approximately the same in patients aged 30 to 59, but increased in the younger and older groups. The incidence of functional psychoses increased; in schizophrenia, however, it declined, while in paranoid and effective psychoses it increased. In organic psychoses, the admission frequency of psychoses of old age rose in the 1950's, but declined in some measure in the 1960's. The incidence of psychosis increased for single persons. The ratio of the incidence between single and married persons rose in men, whereas in women it fell. This was particularly pronounced in schizophrenics. The incidence of psychosis was highest in unskilled laborers. The overrepresentation of schizophrenia and paranoid psychoses seemed to have become more pronounced in this occupational group.     

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.     

Expectation of life and liberty in patients suffering from functional psychoses

Summary From data obtained in a follow-up study over a period of 18 years of 632 patients suffering from functional psychoses, tables have been prepared to show percentages discharged from the hospital and dying in successive years, and the percentages of readmissions of discharged patients. The factors investigated were diagnosis at onset, age and sex; and of these, diagnosis proved to be the most useful prognostic guide. The chance of discharge was high for patients in the first year of hospital life, but, thereafter, discharge was not a frequent event. The presence of an unmistakable schizophrenic picture on first admission made the outlook poor, and such patients over the age of 20 had only a 2 in 5 chance of discharge. Sex appeared to influence only the readmission rates, and these were higher in males than in females; male readmissions on the average spent less time than females outside the hospital between their first and second admissions.The findings of previous authors concerning the high mortality rates among psychotics hospitalized for long periods, and the particular importance of tuberculosis as a cause of death in them were confirmed.From The Institute of Psychiatry, the Bethlem Royal Hospital, and the Maudsley Hospital, University of London, London, England.     

Psychosis in epilepsy patients

Summary   Epileptic psychoses reflect a fundamental disruption in the fidelity of mind and occur during seizure freedom or during or after seizures. The psychotic symptoms in epilepsy share some qualities with schizophrenic psychosis, such as positive symptoms of paranoid delusions and hallucinations. Psychotic syndromes in epilepsy are most common but not exclusively associated with temporal lobe epilepsy. De Novo psychosis following epilepsy surgery is rare. Forced normalization—psychosis associated with dramatic reduction of epileptiform activity or seizures is described in small series only. Ictal and postictal psychosis can be prevented with seizure control, but postictal and chronic interictal psychoses require multidisciplinary and psychopharmacologic management.     

Validation of Danish case register diagnosis for schizophrenia

The ABC schizophrenia study aims at investigating sex differences in age of onset, symptoms and course of schizophrenic and paranoid disorders. For this purpose, we used case register data from Denmark and Mannheim and a directly examined sample of first admissions (ABC sample). The Danish case register sample included less clinical diagnoses of schizophrenia and more schizophrenia-related disorders (acute paranoid reaction, paranoid states and borderline schizophrenia) than the Mannheim data (case register and ABC sample). The problem therefore was whether the two datasets are comparable and the results are valid. For this reason a randomized, stratified sample of 116 patients was drawn from the Danish case register sample. The case notes of these 116 patients were requested from the hospitals where the patients had been treated and analyzed by means of a scoring sheet based on the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). The use of operationalized diagnoses of the CATEGO program, based on PSE items, which are integrated in IRAOS, demonstrated that the samples of the Danish and the Mannheim case registers and the directly investigated ABC sample have comparable diagnostic distributions. Possible explanations for the differences between the clinical and the CATEGO diagnoses in the Danish case register may be the frequent use of diagnoses of borderline schizophrenia and reactive psychoses (previously called psychogenic psychoses), and above all a more narrow concept of schizophrenia; in Denmark, schizophrenia is diagnosed relatively late, i.e., after the presence of enduring negative symptoms, and thus mostly after the appearance of residual state. These diagnostic preferences may help to explain the fall in first admission rates for schizophrenia – above all in women – in Denmark and the low incidence rates of schizophrenia by first contact within the WHO determinants of outcome study. The earlier hospitalization of men could be replicated as well as the course of treatment (readmissions and discharges) of schizophrenic men and women over 10 years after first admission.     

Outcome studies on schizophrenic psychoses in Helsinki

This paper deals with the prognosis of schizophrenic psychoses in Helsinki in 1950-1955, 1960-1965, 1965-1970, 1970-1975, and 1975-1980. The first 4 cohorts each include a sample of 100 patients taken in 1950, 1960, 1965, and 1970. The patients were admitted for the first time to a psychiatric hospital because of schizophrenic and paranoid psychoses. The 1975 material includes all (n = 94) first admissions for schizophrenia, fulfilling the DSM-III criteria of schizophrenia or schizophreniform psychosis.     

A study of genetic factors, childhood bereavement, and premorbid personality traits in patients with anancastic endogenous depression.

From a sample of 1,005 patients admitted to the State Hospital in Aarhus for the first time during the period 1950-1959 and who had been diagnosed as suffering from manic-depressive psychosis or endogenous depression (affective psychoses), a subsample of 104 manic-depressive aptients with anancastic symptoms in the history were selected. The 104 probands were individually matched with 104 non-anancastic probands with affective psychoses. The anancastic probands and the controls who were still living were seen personally at the follow-up. Information concerning the psychiatric history of 945 first degree relatives of the anancastic probands and 1,000 first degree relatives of the controls were obtained. During the search for factors which could be used to distinguish affective psychoses with anancastic symptoms from affective psychoses without these traits, a positive correlation was found between the presence of anancasma and the following factors: (a) premorbid obsessive personality traits; (b) traumatic environmental factors in childhood; (c) a tendency to monopolarity; (d) a preponderance of monopolar depressions in the family; (e) the presence of secondary cases of anancastic endogenous depression. The findings are compatible with a theory which attributes a pathoplastic effect to the obsessive personality giving rise to anancastic symptomatology in the form of affective psychoses which tend to a unipolar course.     

Onset of acute psychotic states in India: a study of sociodemographic,seasonal and biological factors

This is a comparative study of patients with acute-onset, non-affective, non-organic, remitting psychoses and with non-remitting or schizophrenic psychoses in India. Two groups of patients with acute remitting and non-remitting or schizophrenic psychoses were compared with regard to the following variables: month of onset of psychosis; presence of stress, particularly fever, within 4 weeks preceding the onset of psychosis; childbirth within 12 weeks preceding the onset of psychosis; gender differences. It was found that the acute remitting psychoses showed an overrepresentation of females, a higher frequency of associated stress preceding the onset of psychosis, more often had onset during the summer months, i.e. between May and September, and had fever and childbirth preceding the onset of psychosis in a significantly higher proportion of patients, compared to acute non-remitting psychoses or schizophrenia. The implications of the findings which point towards biological factors in the aetiology of acute remitting psychoses are discussed.