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.     

Dysphoric mood in paranoid psychoses

Many authors have stressed the particular affective behavior in paranoid psychoses, mainly its dysphoric pattern. In 1983, Berner formulated the dysphoric axial syndrome as a third type of the endogenomorphous cyclothymic axial syndrome. In this paper two points are examined: (1) The interrelation between dysphoric and depressive and/or manic affective disorders in paranoid psychoses, cross-sectionally and longitudinally, in order to test the hypothesis of their independence, and (2) the relation of dysphoric mood disorders in paranoid psychoses to their course, again in comparison with other types of affective symptoms. The paper is based on an empirical study by Gabriel in 1978 on the phenomenology and the course of paranoid psychoses.     

Problems concerning the concept of reactive psychoses

The problems of reactive psychoses are discussed from the following perspectives: terminology, prevalence, psychogenesis and trauma, predisposition and vulnerability, as well as outcome. Four definitions of reactive psychoses, which are used in Scandinavia, are presented and discussed. Each of them is beset with problems. The authors argues that the term 'reactive psychoses' should be limited to those functional psychoses which are not typically schizophrenic, manic-depressive or paranoid.     

Psychiatric disorders following and preceding temporal lobectomy]

We analysed pre- as well as post-operative psychiatric disorders in thirty eight patients with temporal lobe epilepsy. While postoperative paranoid disorders were closely correlated with preoperative acute interictal psychoses, episodes of postictal psychoses prior to surgery were associated with postoperative mood disorders. A good prognosis of postoperative mood disorders was stressed. The literature search supported the predominance of right-sided lobectomy in patients with de novo psychoses after surgery. The relationship between left-sided lobectomy and postoperative mood disorders needs further amplification and remains tentative. We stressed the need for a prophylactic psychotherapy to surgical candidates to cope with unrealistic wishes to get relieved from all the difficulties in their lives after temporal lobectomy.     

Paranoid disorders following war brain damage. Preliminary report.

Roughly 3,000 war veterans with moderate or severe brain injury have suffered from a psychiatric disturbance. Psychotic disorders are found in approximately 750 cases. The material of this preliminary report consists of the first 100 veterans with paranoid disorders. Delusional psychosis is the most common main diagnosis (28% of veterans), followed by major depression (21%), delirium (18%) and paranoid schizophrenia (14%). Paranoid schizophrenia and paranoid schizophreniform psychosis develop earlier (in 23% of cases within 1 year) than delusional psychosis (4%). Delusional psychosis lasted less than a year in 28% of the cases and more than 5 years in 40% of cases. The corresponding figures for paranoid schizophrenia and paranoid schizophreniform psychoses are 26 and 63%. Jealousy or fear of being sexually betrayed constitutes the most prominent individual content of delusions.     

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.     

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。     

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)     

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.     

The epidemiology of functional psychoses of late onset

For the functional psychoses of late life, epidemiological information comes from two sources: studies of persons who have reached psychiatric services; and surveys of elderly persons sampled from the general population. A conspectus of published data from both sources leads to the following conclusions: States phenomenologically similar to those found in clinics do occur in the community in non-trivial numbers. There is no notable divergence in the information obtained from clinical series and from population-based surveys. These states are more common in women, they become more common with increasing age and are sometimes associated with decline in cognitive performance or with degenerative changes in the brain revealed by neuroimaging. Genetic factors appear to be less important than in early-onset psychoses but remain ill-defined, and the roles of social isolation and disorders of personality have not yet been sufficiently elucidated. Both clinical and community-based studies have found an association with sensory impairment. The community-based data suggest that paranoid symptoms may be detectable at subclinical level, and an association between them and cognitive impairment is demonstrable in individuals who are not diagnosable cases either of psychosis or of dementia. Differences exist between late-onset paranoid psychoses and affective psychoses in symptomatology and response to treatment. These observations confirm the importance of the late-onset psychoses for research directed towards uncovering the origins of psychotic symptoms in any age group.     

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.     

Validity of the family history method for diagnosing schizophrenia, schizophrenia-related psychoses, and schizophrenia-spectrum personality disorders in first-degree relatives of schizophrenia probands

This study examined the validity of the family history method for diagnosing schizophrenia, schizophrenia-related psychoses, and schizophrenia-spectrum personality disorders in first-degree relatives of schizophrenia probands. This is the first large-scale study that examined the validity of the family history method for diagnosing DSM-III-R personality disorders. The best estimate DSM-III-R diagnoses of 264 first-degree relatives of 117 adult-onset schizophrenia probands based on direct structured diagnostic interviews, family history interview, and medical records were compared to Family History Research Diagnostic Criteria (FH-RDC) diagnoses based on the NIMH Relative Psychiatric History Interview and to family history Structured Clinical Interview for DSM-III-R: Personality Disorders (SCID-II) diagnoses based on the SCID-II adapted to a third person format. Diagnoses of relatives were made blind to proband diagnostic status. The median sensitivity for schizophrenia and the related psychoses was 29% (range 0-50%), the median specificity 99% (range 98-100%), and the median positive predictive value (PPV) 67% (range 20-80%). The median sensitivity for the personality diagnoses was 25% (range 14-71%), the median specificity 100% (range 99-100%), and the median PPV 100% (range 67-100%). The family history method has low sensitivity but has excellent specificity and PPV for schizophrenia, schizophrenia-related psychoses, and schizophrenia-spectrum personality disorders. The kappa coefficient for the family history method was moderately good for the psychoses (0.598) and for paranoid and schizotypal personality disorder (0.576). Using the family history method, the validity of making schizophrenia-related personality disorder diagnoses was comparable to that of making psychotic disorder diagnoses.     

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.     

Diagnostic shifts of functional psychoses in the transition from ICD-9 to ICD-10

In order to identify diagnostic changes caused by the transition from ICD-9 to ICD-10, in a sample of 218 first hospitalised patients from the years 1980 and 1981, ICD-9 diagnoses were compared with ICD-10 diagnoses. For this comparison, functional psychoses were classified into five main diagnostic groups. Results showed a decreased frequency of the diagnostic groups schizophrenia, schizoaffective psychoses, and paranoid psychoses and an increased frequency of the diagnostic groups acute psychoses and affective psychoses. With the exception of acute psychoses and schizoaffective psychoses, a high agreement between ICD-9 and ICD-10 diagnoses was found, and the Kappa value was 0.70. With regard to the homogeneity of psychopathological symptoms, ICD-10 diagnoses showed no improvement over ICD-9 diagnoses. Nevertheless, ICD-10 diagnoses have gained in predictive validity because schizophrenia was further narrowed to cases with a more unfavourable outcome.     

Visual acuity and ocular pathology in the paranoid and affective psychoses of later life.

The visual acuity and ocular pathology occurring in association with functional psychoses in later life is examined in two groups of elderly patients (54 paranoid and 57 affective) in whom the prevalence of social deafness and hearing loss has already been studied.Visual acuity for distant vision is found to be considerably worse in the paranoid group but significantly so only in the eyes with less good vision. No difference between the groups is noted with respect to near vision.On the basis of a screening test, significant ocular pathology is found in the eyes of 30 paranoid and 21 affective patients. Significantly more cataract is detected among the paranoid patients than the affectives; and within the paranoid group, an association between deafness and cataract is found which is not due to age. The implications of these findings are discussed.     

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.     

Disorders of premorbid social adaptation as a predictor of the 5-year prognosis of schizophrenic psychoses

The prognostic validity of three scales concerning premorbid adjustment (Gittelman-Klein-Scale, Goldstein-Scale, Phillips-Scale) was tested in a 5-year follow-up study on 81 patients with schizophrenic or paranoid psychoses. The scales showed relatively high correlation with various outcome criteria. In general, however the total scores were of no greater predictive value than the prognostically most relevant single items of each scale. As compared to the shorter and more practicable Phillips-Scale, the longer scales (Gittelman-Klein- and Goldstein-Scale) did not show higher predictive power.     

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.     

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.     

What can genetics contribute to reduce the problems of schizo-affective psychoses?

The biological base of psychoses is controlled by multifactorial genotype compounds using sometimes the same gene locus or DNA information section for diverse diseases, but always in different and repeatable combinations. These compounds can be formed by special regulatory or junction genes. With the help of inherited serum markers of the haptoglobin and the Gc system including quantitative studies of the ceruloplasmin and transferrin serum level, the combinations of diverse biological factors have been presented especially for cycloid psychoses, unsystematic schizophrenias, and paranoid psychoses with late onset and a cyclic axis syndrome. Considering the specifications of genetic control and clinical course no indefinite mixtures in the sense of schizo-affective psychoses should be discussed furthermore.