Paraphrenia

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Paraphrenia
Other namesParaphrenic syndrome
Specialty Psychiatry

Paraphrenia is a mental disorder characterized by an organized system of paranoid delusions with or without hallucinations (the positive symptoms of schizophrenia) and without deterioration of intellect or personality (its negative symptom). [1] [2] [3]

Contents

This disorder is also distinguished from schizophrenia by a lower hereditary occurrence, less premorbid maladjustment, and a slower rate of progression. [4] Onset of symptoms generally occurs later in life, near the age of 60. [2] [5] The prevalence of the disorder among the elderly is between 0.1% and 4%. [1]

Paraphrenia is not included in the DSM-5; psychiatrists often diagnose patients presenting with paraphrenia as having atypical psychosis, delusional disorder, psychosis not otherwise specified, schizoaffective disorders, and persistent persecutory states of older adults. [4] Recently, mental health professionals have also been classifying paraphrenia as very late-onset schizophrenia-like psychosis. [4]

In the Russian psychiatric manuals, paraphrenia (or paraphrenic syndrome) is the last stage of development of paranoid schizophrenia. "Systematized paraphrenia" (with systematized delusions i. e. delusions with complex logical structure) and "expansive-paranoid paraphrenia" (with expansive/grandiose delusions and persecutory delusions) are the variants of paranoid schizophrenia (F20.0). [6] Sometimes systematized paraphrenia can be seen with delusional disorder (F22.0). [6] The word is from Ancient Greek : παρά – beside, near + φρήν – intellect, mind.

Signs and symptoms

The main symptoms of paraphrenia are paranoid delusions and hallucinations. [1] [7] The delusions often involve the individual being the subject of persecution, although they can also be erotic, hypochondriacal, or grandiose in nature. The majority of hallucinations associated with paraphrenia are auditory, with 75% of patients reporting such an experience; however, visual, tactile, and olfactory hallucinations have also been reported. [1] [7] The paranoia and hallucinations can combine in the form of “threatening or accusatory voices coming from neighbouring houses [and] are frequently reported by the patients as disturbing and undeserved". [1] Patients also present with a lack of symptoms commonly found in other mental disorders similar to paraphrenia. There is no significant deterioration of intellect, personality, or habits and patients often remain clean and mostly self-sufficient. [7] Patients also remain oriented well in time and space. [1]

Paraphrenia is different from schizophrenia because, while both disorders result in delusions and hallucinations, individuals with schizophrenia exhibit changes and deterioration of personality whereas individuals with paraphrenia maintain a well-preserved personality and affective response. [2] [7]

Causes

Neurological

Paraphrenia is often associated with a physical change in the brain, such as a tumor, stroke, ventricular enlargement, or neurodegenerative process. [4] Research that reviewed the relationship between organic brain lesions and the development of delusions suggested that "brain lesions which lead to subcortical dysfunction could produce delusions when elaborated by an intact cortex". [8]

Predisposing factors

Many patients who present with paraphrenia have significant auditory or visual loss, are socially isolated with a lack of social contact, do not have a permanent home, are unmarried and without children, and have maladaptive personality traits. [4] [9] [10] While these factors do not cause paraphrenia, they do make individuals more likely to develop the disorder later in life.

Diagnosis

While the diagnosis of paraphrenia is absent from recent revisions of the DSM and the ICD, many studies have recognized the condition as "a viable diagnostic entity that is distinct from schizophrenia, with organic factors playing a role in a significant portion of patients." [4] As such, paraphrenia is seen as being distinct from both schizophrenia and progressive dementia in old age. [2] Ravindran (1999) developed a list of criteria for the diagnosis of paraphrenia, which agrees with much of the research done up to the time it was published.

1. A delusional disorder of at least six months duration characterized by the following:
a. Preoccupation with one or more semisystematized delusions, often accompanied by auditory hallucinations.
b. Affect notably well-preserved and appropriate. Ability to maintain rapport with others.
c. None of
i. Intellectual deterioration
ii. Visual hallucinations
iii. Incoherence
iv. Flat or grossly inappropriate affect
v. Grossly disorganized behavior at times other than during the acute episode.
d. Disturbance of behavior understandable in relation to the content of the delusions and hallucinations.
e. Only partly meets criterion A for schizophrenia. No significant organic brain disorder. [10]

Management

Research suggests that paraphrenics respond well to antipsychotic drug therapy if doctors can successfully achieve sufficient compliance. [1] [10] Herbert found that Stelazine combined with Disipal was an effective treatment. It promoted the discharging of patients and kept discharged patients from being readmitted later. [9] While behavior therapy may help patients reduce their preoccupation with delusions, psychotherapy is not currently of primary value. [10]

Prognosis

Individuals who develop paraphrenia have a life expectancy similar to the normal population. [1] [2] [4] [11] Recovery from the psychotic symptoms seems to be rare, and in most cases paraphrenia results in in-patient status for the remainder of the life of the patient. [1] [2] [9] Patients experience a slow deterioration of cognitive functions and the disorder can lead to dementia in some cases, but this development is no greater than the normal population. [2] [4] [7]

Epidemiology

Studies suggest that the prevalence of paraphrenia in the elderly population is around 2–4%. [1]

Sex differences

While paraphrenia can occur in both men and women, it is more common in women, even after the difference has been adjusted for life expectancies. [1] The ratio of women with paraphrenia to men with paraphrenia is anywhere from 3:1 to 45:2. [5]

Age

It is seen mainly in patients over the age of 60, but has been known to occur in patients in their 40s and 50s. [2] [5]

Personality type and living situation

It is suggested that individuals who develop paraphrenia later in life have premorbid personalities, and can be described as “quarrelsome, religious, suspicious or sensitive, unsociable and cold-hearted.” [1] Many patients were also described as being solitary, eccentric, isolated and difficult individuals; these characteristics were also long-standing rather than introduced by the disorder. [7] Most of the traits recognized prior to the onset of paraphrenia in individuals can be grouped as either paranoid or schizoid. [9] Patients presenting with paraphrenia were most often found to be living by themselves (either single, widowed, or divorced). [9] There have also been reports of low marriage rate among paraphrenics and these individuals also have few or no children (possibly because of this premorbid personality). [1] [5] [9]

Physical factors

The development of paranoia and hallucinations in old age have been related to both auditory and visual impairment, and individuals with paraphrenia often present with one or both of these impairments. [1] [5] [9] Hearing loss in paraphrenics is associated with early age of onset, long duration, and profound auditory loss. [5]

History

The term paraphrenia was originally popularized by Karl Ludwig Kahlbaum in 1863 to describe the tendency of certain psychiatric disorders to occur during certain transitional periods in life (describing paraphrenia hebetica as the insanity of the adolescence and paraphrenia senilis as the insanity of the elders. [4] [12] [13]

The term was also used by Sigmund Freud for a short time starting in 1911 as an alternative to the terms schizophrenia and dementia praecox, which in his estimation did not correctly identify the underlying condition, [14] [15] [16] and by Emil Kraepelin in 1912/3, [17] [18] who changed its meaning to describe paraphrenia as it is understood today, as a small group of individuals that have many of the symptoms of schizophrenia with a lack of deterioration and thought disorder. [4] [13] Kraepelin's study was discredited by Wilhelm Mayer in 1921 when he conducted a follow-up study using Kraepelin's data. His study suggested that there was little to no discrimination between schizophrenia and paraphrenia; given enough time, patients presenting with paraphrenia will merge into the schizophrenic pool. [4] [13] However, Meyer's data are open to various interpretations. [12] In 1952, Roth and Morrissey conducted a large study in which they surveyed the mental hospital admissions of older patients. They characterized patients as having "paraphrenic delusions which… occurred in each case in the setting of a well-preserved intellect and personality, were often ‘primary’ in character, and were usually associated with the passivity failings or other volitional disturbances and hallucinations in clear consciousness pathognomonic of schizophrenia". [4] [19]

In recent medicine, the term paraphrenia has been replaced by the diagnosis of "very late-onset schizophrenia-like psychosis" and has also been called "atypical psychoses, delusional disorder, psychoses not otherwise specified, schizoaffective disorders, and persistent persecutory states of older adults" by psychotherapists. [4] Current studies, however, recognize the condition as "a viable diagnostic entity that is distinct from schizophrenia, with organic factors playing a role in a significant portion of patients." [4]

Related Research Articles

<span class="mw-page-title-main">Dementia praecox</span> Obsolete medical term for the schizophrenia and autism spectrums

Dementia praecox is a disused psychiatric diagnosis that originally designated a chronic, deteriorating psychotic disorder characterized by rapid cognitive disintegration, usually beginning in the late teens or early adulthood. Over the years, the term dementia praecox was gradually replaced by the term schizophrenia, which initially had a meaning that included what is today considered the autism spectrum.

Psychosis is a condition of the mind or psyche that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are disorganized thinking and incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.

Paranoia is an instinct or thought process that is believed to be heavily influenced by anxiety, suspicion, or fear, often to the point of delusion and irrationality. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself. Paranoia is distinct from phobias, which also involve irrational fear, but usually no blame.

A delusion is a false fixed belief that is not amenable to change in light of conflicting evidence. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, hallucination, or some other misleading effects of perception, as individuals with those beliefs are able to change or readjust their beliefs upon reviewing the evidence. However:

<span class="mw-page-title-main">Delusional disorder</span> Mental illness featuring beliefs with inadequate grounding

Delusional disorder, traditionally synonymous with paranoia, is a mental illness in which a person has delusions, but with no accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect. Delusions are a specific symptom of psychosis. Delusions can be bizarre or non-bizarre in content; non-bizarre delusions are fixed false beliefs that involve situations that could occur in real life, such as being harmed or poisoned. Apart from their delusion or delusions, people with delusional disorder may continue to socialize and function in a normal manner and their behavior does not necessarily seem odd. However, the preoccupation with delusional ideas can be disruptive to their overall lives.

<span class="mw-page-title-main">Thought disorder</span> Disorder of thought form, content or stream

A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."

<span class="mw-page-title-main">Eugen Bleuler</span> Swiss psychiatrist (1857–1939)

Paul Eugen Bleuler was a Swiss psychiatrist and humanist most notable for his contributions to the understanding of mental illness. He coined several psychiatric terms including "schizophrenia", "schizoid", "autism", depth psychology and what Sigmund Freud called "Bleuler's happily chosen term ambivalence".

Kurt Schneider was a German psychiatrist known largely for his writing on the diagnosis and understanding of schizophrenia, as well as personality disorders then known as psychopathic personalities.

Paranoid personality disorder (PPD) is a mental disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this personality disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they often think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.

The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

Disorganized schizophrenia, or hebephrenia, was a subtype of schizophrenia prior to 2013. Subtypes of schizophrenia were no longer recognized as separate conditions in the DSM 5, published in 2013. The disorder is no longer listed in the 11th revision of the International Classification of Diseases (ICD-11).

Intermetamorphosis is a delusional misidentification syndrome, related to agnosia. The main symptoms consist of patients believing that they can see others change into someone else in both external appearance and internal personality. The disorder is usually comorbid with neurological disorders or mental disorders. The disorder was first described in 1932 by Paul Courbon (1879–1958), a French psychiatrist. Intermetamorphosis is rare, although issues with diagnostics and comorbidity may lead to under-reporting.

Thought broadcasting is a type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence. The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet. Different people can experience thought broadcasting in different ways. Thought broadcasting is most commonly found among people who have a psychotic disorder, specifically schizophrenia.

An auditory hallucination, or paracusia, is a form of hallucination that involves perceiving sounds without auditory stimulus. While experiencing an auditory hallucination, the affected person hears a sound or sounds that did not come from the natural environment.

<span class="mw-page-title-main">Grandiose delusions</span> Subtype of delusion

Grandiose delusions (GDs), also known as delusions of grandeur or expansive delusions, are a subtype of delusion characterized by extraordinary belief that one is famous, omnipotent, wealthy, or otherwise very powerful. Grandiose delusions often have a religious, science fictional, or supernatural theme. Examples include the extraordinary belief that one is a deity or celebrity, or that one possesses extraordinary talents, accomplishments, or superpowers.

Brief psychotic disorder—according to the classifications of mental disorders DSM-IV-TR and DSM-5—is a psychotic condition involving the sudden onset of at least one psychotic symptom lasting 1 day to 1 month, often accompanied by emotional turmoil. Remission of all symptoms is complete with patients returning to the previous level of functioning. It may follow a period of extreme stress including the loss of a loved one. Most patients with this condition under DSM-5 would be classified as having acute and transient psychotic disorders under ICD-10. Prior to DSM-IV, this condition was called "brief reactive psychosis." This condition may or may not be recurrent, and it should not be caused by another condition.

<span class="mw-page-title-main">Persecutory delusion</span> Delusion involving perception of persecution

A persecutory delusion is a type of delusional condition in which the affected person believes that harm is going to occur to oneself by a persecutor, despite a clear lack of evidence. The person may believe that they are being targeted by an individual or a group of people. Persecution delusions are very diverse in terms of content and vary from the possible, although improbable, to the completely bizarre. The delusion can be found in various disorders, being more usual in psychotic disorders.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

Unitary psychosis (Einheitspsychose) refers to the 19th-century belief prevalent in German psychiatry until the era of Emil Kraepelin that all forms of psychosis were surface variations of a single underlying disease process. According to this model, there were no distinct disease entities in psychiatry but only varieties of a single universal madness and the boundaries between these variants were fluid. The prevalence of the concept in Germany during the mid-19th century can be understood in terms of a general resistance to Cartesian dualism and faculty psychology as expressed in Naturphilosophie and other Romantic doctrines that emphasised the unity of body, mind and spirit.

Simple-type schizophrenia is a sub-type of schizophrenia included in the International Classification of Diseases (ICD-10), in which it is classified as a mental and behaviour disorder. It is not included in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the upcoming ICD-11, effective 1 January 2022. Simple-type schizophrenia is characterized by negative ("deficit") symptoms, such as avolition, apathy, anhedonia, reduced affect display, lack of initiative, lack of motivation, low activity; with absence of hallucinations or delusions of any kind.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Almeida, O. P., Howard, H. F., & Levy, R. (1992). Late paraphrenia: a review. International Journal of Geriatric Psychiatry, 7, 543-548.
  2. 1 2 3 4 5 6 7 8 Roth, M. (1955). The natural history of mental disorder in old age. The British Journal of Psychiatry, 101, 281-301
  3. ↑ Roth, M. & Kay, D. W. K. (1998). Late paraphrenia: A variant of schizophrenia manifest in late life or an organic clinical syndrome? A review of recent evidence. International Journal of Geriatric Psychiatry, 13, 775-784
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Casanova, M. F. (2010). The pathology of paraphrenia. Current Psychiatry Reports, 12, 196-201.
  5. 1 2 3 4 5 6 Almeida, O. P., Howard, R. J., Levy, R., & David, A. S. (1995). Psychotic states arising in late life (late paraphrenia): The role of risk factors. British Journal of Psychiatry, 166, 215-228
  6. 1 2 Сметанников, П. Г. (2002). Психиатрия: Краткое руководство для врачей [Psychiatry: A Brief Guide for Physicians] (in Russian). Rostov-on-Don: Phoenix (Феникс). pp. 157, 165. ISBN   5-222-02133-5.
  7. 1 2 3 4 5 6 Kay, D. W., & Roth, M. (1961). Environmental and hereditary factors in schizophrenias of old-age (late paraphrenia) and their bearing on general problem of causation in schizophrenia. Journal of Mental Science, 107, 649.
  8. ↑ Cummings, J. L. (1985). Organic delusions: Phenomenology, anatomical correlations, and review. British Journal of Psychiatry, 146, 184-197.
  9. 1 2 3 4 5 6 7 Herbert, M. E., & Jacobson, S. (1967). Late paraphrenia. British Journal of Psychiatry, 113, 461.
  10. 1 2 3 4 Ravindran, A. V., Yatham, L. N., & Munro, A. (1999). Paraphrenia redefined. Canadian Journal of Psychiatry-Revue Canadienne De Psychiatrie, 44, 133-137.
  11. ↑ Roth, M., & Kay, D. W. K. (1998). Late paraphrenia: A variant of schizophrenia manifest in late life or an organic clinical syndrome? A review of recent evidence. International Journal of Geriatric Psychiatry, 13, 775-784
  12. 1 2 Berrios G E (2003) A Conceptual History of Paraphrenia. Journal of Nutrition, Health and Aging 7: 394-399
  13. 1 2 3 McKenna, P.J. (1997). Schizophrenia and related syndromes . Psychology Press. pp.  239–242. ISBN   978-0-86377-790-5.
  14. ↑ Sigmund Freud. Psychoanalytische Bemerkungen über einen autobiographisch beschriebenen Fall von Paranoia (Dementia paranoides) (in German).
  15. ↑ Sigmund Freud. Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides).
  16. ↑ Peter Widmer (2007). Widmer, Peter; Schmid, Michael (eds.). Psychosen: Eine Herausforderung für die Psychoanalyse (in German). Bielefeld: transcript Verlag. p. 75-102 Paraphrenie - ein vergessenes Konzept Freuds
  17. ↑ Kraepelin, Emil. "Über paranoide Erkrankungen." Zeitschrift für die gesamte Neurologie und Psychiatrie 11 (1912): 617-638, here 623-626.
  18. ↑ Kraepelin, E. (1913). Psychiatrie: ein Lehrbuch für Studierende und Ärzte. Vol. 3 (8. Auflage ed.). Verlag Johann von Ambrosius Barth. pp. 668, 973–974.
  19. ↑ Roth, M. & Morrissey, J. D. (1952) Problems in the diagnosis and classification of mental disorders in old age. The Journal of Mental Science, 98, 66–80.
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