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.     

Delusional disorders. I. Comparative long-term outcome

ABSTRACT— Of 301 first-admitted patients with delusional psychoses, 94 met DSM-III criteria of schizophrenia (S), 53 paranoid disorder (PD), 47 schizophreniform disorder (SFD), 35 schizoaffective disorder (SAD), 54 major affective disorder (AD), and 18 other disorders (OD). Retterstol selected the patients and personally interviewed them after 5–18 years, and later the author interviewed them after 22–39 (mean 30) years. At last follow-up good functioning was noticed in 42%, moderate symptoms in 22%, severe defect in 20%, and very severe defect in 16%; 40% were still delusional. On average S patients did poorest, and OD patients slightly better. AD patients had superior outcome, while PD, SFD and SAD patients showed an intermediate position, but a little closer to AD than to S. However, heterogeneous course and outcome was noticed in all diagnostic groups.     

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.     

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.     

Delusional psychoses associated with unpatriotic conduct during World War II: a long-term follow-up study.

Of a large sample of patients with paranoid psychoses consecutively admitted to the Psychiatric Department, University of Oslo, during a period after World War II, 10 patients (6.3%, 9 women and 1 man) became ill through accusations of unpatriotic conduct during the war. The psychosis seemed precipitated in connection with legal procedures against the patient in 3 cases, and against close relatives in 2 patients. In 2 cases mixed precipitating events were present, while the psychosis in 3 cases had a connection with the woman being intimate with occupation soldiers. Discharge diagnosis according to DSM-III was schizophrenia (n = 2), schizophreniform disorder (n = 4), schizoaffective disorder (n = 1), major depressive disorder (n = 1), mania (n = 1), and atypical psychosis (n = 1). The patients have been followed up twice, with a mean 31 years of observation. Course and outcome varied, mostly according to the diagnosis. Most patients had a favorable global outcome, although they had a tendency to keep up their social isolation. None of the patients felt they had done anything wrong or regretted their behavior during the war.     

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.     

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.     

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.     

A Longitudinal Study of Schizophrenia in Adolescence: I. The One- to Three-Year Outcome

Abstract: In an attempt to evaluate retrospectively the three-year course and outcome of treated adolescent schizophrenics, the medical data of 19 patients were collected from the first admissions over a period of 10 years (1971-1981). According to the DSM-III criteria, 17 were diagnosed as having schizophrenic disorders and the remaining 2 were schizophreniform disorders. The outcome at the time of first- to third-year follow-up was assessed on the outcome rating scale. The three-year outcome was favorable with respect to both the length of hospitalization and the presence of psychotic symptoms. However, there was a sustained impairment in occupational (or scholastic) functioning throughout the three-year follow-up period. The female sex and the initial diagnosis of schizophreniform disorder might be factors affecting the good third-year clinical (or symptomatic) outcome. The younger age at onset, the longer duration of the prodromal phase, and the longer period of time between the onset and the first presentation appeared to predict the poor third-year occupational outcome.     

Long-term clinical outcome of schizophrenia with special reference to gender differences

A sample of 94 first-admitted schizophrenics and 47 patients with schizophreniform disorder (DSM-III) was personally re-examined after a mean of 10 years (by Retterstöl), and 110 of the patients after a mean of 31 years (by the author). Nearly half of the patients were admitted in 1946-1948 (long-term) and the remaining in 1958-1961 (short-term). Average outcome was significantly more favourable for short-term than for long-term patients. Single marital status and no, minimal or mild psychosocial stressor at onset (Axis IV) predicted poor long-term outcome. At 10-year follow-up there was no difference between men and women in clinical outcome. No substantial change was revealed in men at last follow-up, whereas on average women had clearly deteriorated.     

A longitudinal study of schizophrenia in adolescence. I. The one- to three-year outcome

In an attempt to evaluate retrospectively the three-year course and outcome of treated adolescent schizophrenics, the medical data of 19 patients were collected from the first admissions over a period of 10 years (1971-1981). According to the DSM-III criteria, 17 were diagnosed as having schizophrenic disorders and the remaining 2 were schizophreniform disorders. The outcome at the time of first- to third-year follow-up was assessed on the outcome rating scale. The three-year outcome was favorable with respect to both the length of hospitalization and the presence of psychotic symptoms. However, there was a sustained impairment in occupational (or scholastic) functioning throughout the three-year follow-up period. The female sex and the initial diagnosis of schizophreniform disorder might be factors affecting the good third-year clinical (or symptomatic) outcome. The younger age at onset, the longer duration of the prodromal phase, and the longer period of time between the onset and the first presentation appeared to predict the poor third-year occupational outcome.     

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.     

Erotomania--erotic self-reference psychosis in old maids. A long-term follow-up.

The concept of erotomania is discussed and the literature surveyed. The aim of the study is to present a long-term personal follow-up evaluation of cases with erotomania-like symptoms. In a material of 1,802 consecutively admitted patients, 6 (0.3%) presented symptoms suggestive of erotomania. They have been personally followed up 2 or 3 times by the authors over a period of 22-35 years. Our sample was characterized by avoidant and/or paranoid premorbid personality traits with difficulties in establishing relationships, and life-long social isolation. However, the overall clinical outcome was not hopeless. Neuroleptics may be of benefit, and our findings indicate the need for psychosocial treatment to increase the life quality in these patients.     

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.     

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。     

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.     

Psychiatric disorders of old age in Enugu, Nigeria. Sociodemographic and clinical characteristics

A retrospective study of the demographic and clinical characteristics of 73 consecutive patients aged 60 years and over admitted for the first time into a psychiatric hospital in Nigeria shows that they constituted about 5% of all admissions over a 2-year period. While the majority (58%) were aged below 70 years, 8% were aged over 80 years, with more females than males living to the older age groups. Single status, separation and divorce were more common among males; widowhood was more common among the females. A high illiteracy rate of 86% was recorded, with more males than females being literate. More than 84% belonged to the 2 lowest socioeconomic classes. There was a significant difference in the distribution of diagnostic categories, with senile dementia, affective psychosis, neurotic disorders and paranoid states more common among the females, while arteriosclerotic dementia and schizophrenia were diagnosed more often among the males. Functional psychosis (49%) was the largest diagnostic category, followed by organic psychosis (30%), while neurotic disorders (10%) ranked third. Within the functional psychoses, paranoid states (30%) predominated, followed by affective disorders (14%) consisting mainly of depressive symptoms; 6% presented with schizophrenic illness; and 11% presented with physical illness with associated psychiatric manifestations. There was a long delay before referral to hospital, associated with use of alternative medical facilities (traditional and spiritual healers). The probable sociocultural antecedents and medical and social 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.     

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)