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.     

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.     

The French concept of “psychose hallucinatoire chronique” -a preliminary form of schizophrenia? The role of late-life psychosis in the anticipation hypothesis of schizophrenia

The distinction between schizophrenia and chronic delusional syndromes (including the French concept of "psychose hallucinatoire chronique" [PHC] or chronic psychotic hallucinations, paraphrenia, and late paraphrenia) is currently used in various European countries, although there are no international criteria for chronic and bizarre delusions. The French concept of PHC is characterized by late-onset psychosis, predominantly in females, with rich and frequent hallucinations, but almost no dissociative features or negative symptoms. PHC and late-onset schizophrenia may have risk factors in common, which may help differentiate these disorders from young-onset schizophrenia, especially with regard to the potential role of (i) the estradiol hypothesis; (ii) the impact of sensory deficit; (Hi) putative specific brain abnormalities; or (iv) specific genetic mutations. In accordance with this hypothesis, and taking into account the familial aggregation analyses of PHC, here we evaluate the possibility that PHC represents a less severe form of schizophrenia, which would partly explain the "Sherman paradox" also observed in schizophrenia. The Sherman paradox describes the fact that multiplex families frequently have only one affected ascendant, meaning that an isolated sporadic case is at the origin of a highly loaded family. We thus propose that if unstable mutations are involved in the risk for schizophrenia, then PHC might represent a moderate disorder belonging to the schizophrenia spectrum phenotype.     

Apolipoprotein e genotype and late paraphrenia

Patients with late paraphrenia or late onset schizophrenia frequently have associated cognitive impairment which may in some cases progress to a recognized dementia. The frequency of the apoE ?4 allele is high in individuals who develop Alzheimer's disease. Twenty-three patients with late paraphrenia were genotyped for ApoE. The frequency of the ?4 allele was comparable with that found in a large group of centenarians, but lower than previously reported from populations of normal controls and Alzheimer's disease patients. Two out of three male patients tested had the rare ?2/?2 genotype, which was not found in any of the females.     

Phantom boarders as a symptom of late paraphrenia

Three elderly women believed that people were living in their homes. These delusions and congruent hallucinations occurred without other evidence of thought disorder, affective disturbance, or organicity and may be a subset of late paraphrenia, one of the atypical psychoses.     

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.     

Trouble de l’humeur unipolaire dépressif. À propos d’un cas

The authors aimed to show how difficult the nosography seems to be between unipolar depression and paraphrenia, especially when treatments (even with ECT) were poorly effective. Mrs A. presented megalomania and persecution delusions and for years lived in a chronic delusional state. She suffered from delusions after three depressive relapses but she did not show any dissociation or cognitive impairment. The mechanisms were imaginative, intuitive, without hallucinations, but with little coherence, and delusions were constantly stable. This case brings to mind paraphrenia as an evolutionary state of a persistent major depressive period. It is as if a continuum exists between different kinds of psychosis. The report concerns paraphrenia as a secondary process with thymic disorders, discusses the place of chronic delusion in the nosography, and questions the concept of single psychosis.     

Computer-assisted CT measurements in late paraphrenics with and without Schneiderian first-rank symptoms: A preliminary report

Computer-assisted measurements were made on the computed tomography (CT) scans of 14 patients meeting ICD-9 diagnostic criteria for late paraphrenia, seven of whom had exhibited one or more first-rank symptoms during their illness. When the CT scans of all 14 late paraphrenics were compared with those of an age-matched healthy control group, there were no significant differences with regard to planimetric measurements of brain and ventricle areas. Comparison of the scans of late paraphrenics with first-rank symptoms and those without them demonstrated that late paraphrenics without first-rank symptoms had a greater degree of cerebral atrophy, which was significantly so for the left frontal lobe. The findings support the observation that late paraphrenia is a heterogeneous condition which is comprised of a group with first-rank symptoms who probably represent late-onset schizophrenia and a group without first-rank symptoms who have structural brain abnormalities and a presumed organic substrate for their symptoms that is impossible to exclude through clinical evaluation.     

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.     

Delusions in individuals with schizophrenia: factor structure, clinical correlates, and putative neurobiology

BACKGROUND: Delusions are a central feature of schizophrenia, yet our understanding of their neurobiology is limited. Attempt to link dimensions of psychopathology to putative neurobiological mechanisms depends on careful delineation of symptoms. Previous factor analytic studies of delusions in schizophrenia were limited by several methodological problems, including the use of patients medicated with antipsychotics, inclusion of nondelusion symptoms in the analyses, and/or inclusion of patients with psychotic disorders other than schizophrenia. These problems may have possibly biased the resulting factor structure and contributed to the inconclusive findings regarding the neurobiology of positive symptoms. Our goal is to examine the factor structure of delusions in antipsychotic-free individuals with diagnoses of schizophrenia/schizoaffective disorder. SAMPLING AND METHODS: We assessed 83 antipsychotic-free individuals with DSM-IV diagnoses of schizophrenia/schizoaffective disorder. A principal component analysis was conducted on the delusions symptoms of the SAPS. RESULTS: The principal component analysis resulted in three distinct and interpretable factors explaining 58.3% of the variance. The Delusions of Influence factor was comprised by delusions of being controlled, thought withdrawal, thought broadcasting, thought insertion, and mind reading. The Self-Significance Delusions factor was comprised by delusions of grandeur, reference, religious, and delusions of guilt/sin. The Delusions of Persecution factor was comprised solely by persecutory delusions. The three factors displayed distinct associations with hallucinations, bizarre behavior, attention, positive formal thought disorder, and avolition/apathy. CONCLUSIONS: The results indicate that delusions are best described by three distinct subtypes. The authors propose a novel model linking the three delusion subtypes, attributions to self/other, and putative neurobiological mechanisms. Implications for future research are discussed, as well as links to cognitive-behavioral conceptualizations of delusions.     

Paraphrenia in the elderly. Psychopathologic and computer tomography indications of two subtypes

Psychopathological and cranial computed tomography findings in 48 patients with late paraphrenia were compared with the findings in 40 normal controls. 19 patients with late paraphrenia and first rank symptoms showed significantly less cortical atrophy than 29 patients without first rank symptoms (p less than 0.01). There were no significant differences of ventricular enlargement, cerebellar atrophy, the presence of leukoaraiosis or basal ganglia mineralisation between the late paraphrenic and control groups. In contrast to the controls, cortical atrophy, ventricular enlargement and the presence of leukoaraiosis were not age-related. These results may indicate different origins of late paraphrenia with or without first rank symptoms.     

The psychopathology of 'late schizophrenia'

We investigated the clinical features of schizophrenic syndromes first manifested after the age of 50. By comparison with the schizophrenic syndromes first manifested before the 50th year of life we found: late schizophrenia is characterized by rich psychotic productive syndromes (delusions and hallucinations); disturbances of thought are rare; depression, euphoria and anxiety show no difference between the two groups; females are much more represented than males; social isolation is not more common in late schizophrenia than in non-late schizophrenia.     

Religious delusions in patients admitted to hospital with schizophrenia

Background Religious delusions are clinically important because they may be associated with selfharm and poorer outcomes from treatment. They have not been extensively researched. This study sought to investigate the prevalence of religious delusions in a sample of patients admitted to hospital with schizophrenia, to describe these delusions and to compare the characteristics of the patients with religious delusions with schizophrenia patients with all other types of delusion. Method A cross-sectional investigation was carried out. The prevalence of religious delusions was assessed and comparisons were made between religiously deluded patients and a control group on demographic, symptom, functioning and religious variables. One hundred and ninety-three subjects were examined of whom 24% had religious delusions. Results Patients with religious delusions had higher symptom scores (as measured by the PANSS), they were functioning less well (as measured by the GAF) and they were prescribed more medication than those patients with schizophrenia who had other types of delusion. Conclusion It is concluded that religious delusions are commonly found in schizophrenia and that by comparison with other patients who have schizophrenia, those patients with religious delusions appear to be more severely ill. This warrants further investigation. Accepted: 15 November 2001     

A new look at delusions of grandeur

Delusions of grandeur were explored by chart review. Seventy-six percent of manics and 40% of schizophrenics studied demonstrated these delusions. Male patients with schizophrenia and delusions of grandeur were ill an average of 0.86 years longer than patients without grandiose delusions. The author suggests that in male schizophrenics these delusions may indicate advanced illness. The author proposes a subtyping of delusions of grandeur into ability. role, and identity. Grandiose ability was the most common, found in all manics and 74% of schizophrenics. The author explores the relation of subtypes to duration of illness, birth order, and sex in mania and schizophrenia.     

The cerebral cortical appearance in late paraphrenia

The cortical appearance on CT scan in patients suffering from late paraphrenia was assessed compared to that of age-matched normal controls. There was no difference in overall cortical appearance between the two groups. However, a correlation existed between ventricular size and cortical size and between ventricular size and age in normal controls but this was not present in paraphrenia. The implications of these findings are discussed in relation to a possible structural abnormality in late paraphrenia.     

Delusions in first-admitted patients: gender, themes and diagnoses

Whether there is a specific link between certain delusional symptoms and particular etiologies has not yet been completely clarified. In this study, 639 first ever admitted deluded patients were investigated in order to find out whether age and gender are associated with certain delusional contents, whether age at first admission may be linked to certain etiologies and whether it is possible to detect indicators particularly related to basic dysfunctions. At first admission, delusional female patients were older than men with a significant predomination of delusions of persecution, while men presented significantly more frequently delusions of jealousy and grandiosity. Within delusions of persecution, of religious or metaphysical content and of grandiosity, women were even significantly older than men. Religious or metaphysical and grandiosity contents occurred significantly more frequently in ICD-8 schizophrenia, indicating that these themes seem to be particularly linked to ICD-8 schizophrenia. Additionally, some target symptoms not included in the delusional symptomatology were investigated to test the relationship between delusions and schizophrenia. Overall, the results of the present investigation indicate that delusions are not specific for schizophrenia, and therefore, other symptomatological criteria should be applied for the nosographic attribution.     

先天性和成年发作性精神分裂症的临床特征

目的 为了比较先天性和成年发作性精神分裂症的临床特征。方法 对１２０例次发病的精神分裂症病人进行了比较。结果 显示先天性组更多见情感淡漠、病前适应差;成年发作性组更多见幼觉、被害亡想。结论 提示精神分裂症划无天性和成年发作性有一定的临床意义。     

The psychosis of schizophrenia: prevalence, response to atypical antipsychotics, and prediction of outcome.

BACKGROUND: Psychosis is a defining feature of schizophrenia consisting of formal thought disorder, delusions, and hallucinations. Although psychosis is present in the majority of patients with schizophrenia, the prevalence, responsiveness to atypical antipsychotic drug therapy, and prediction of outcome of individual psychotic symptoms in a population of well-diagnosed patients with schizophrenia have not been conclusively established. METHODS: This paper examined the prevalence, responsiveness to the atypical antipsychotic olanzapine, and relationship to outcome of individual psychotic symptoms using data from a previously reported large multicenter, double-blind clinical trial of olanzapine (mean daily dose at endpoint = 13.6 +/- 6.9 mg/day). RESULTS: The most frequently reported psychotic symptoms at baseline were delusions (65%), conceptual disorganization (50%), and hallucinations (52%), and the majority of patients (68%) experienced from one to three symptoms. Additionally, with olanzapine treatment there were significant improvements (p < .001) in baseline to endpoint Positive and Negative Symptom Scale (PANSS) psychotic item scores, with the largest effect sizes observed for hallucinatory behavior, unusual thought content, suspiciousness/persecution, and delusions. During the acute phase of the trial, quality of life was correlated significantly with baseline conceptual disorganization (p = .038) and unusual thought content (p = .023), and time spent in the hospital was correlated with unusual thought content (p = .005). CONCLUSIONS: The implications of these for the clinical management of schizophrenia are discussed.