These patients appear to have a greater base and are better oriented to time and space compared to patients with schizophrenia.
Paraphrenia is a late-onset mental disorder similar to schizophrenia in that it presents the positive symptoms of the disease, such as delusions and / or hallucinations, but lacks the negative symptoms, such as impaired intellect or personality.
Compared to schizophrenia, paraphrenia is less inherited, has a slower rate of progression, and does not manifest until the patient is much older, with most patients developing the disorder around 60 years or older.
Paraphrenia affects 2-4% of older people. Although it occurs in both sexes, it is more common in women.
Those who develop the disease in later life are often described as eccentric and / or lonely before the disease. Many are described as argumentative, overly sensitive, overly religious, suspicious, or cold.
It is very common for patients with paraphrenia to experience delusions around the idea of persecution. Feelings of grandiose, hypochondriacal, and erotic delusions have also been reported .
The International Classification of Diseases (ICD-10) and the late paraphrase of the Diagnostic and Statistical Manual of Mental Disorders includes paranoid schizophrenia or persistent delusional disorder.
Patients with late paraphrenia present for the first time in old age with persecutory delusions, auditory and / or visual hallucinations, and first-rank Schneiderian symptoms.
Delusions of reference, hypochondria and grandeur, misidentification syndromes, and hallucinations in other modalities can also occur. Affective symptoms are present concurrently in up to 60% of cases.
Patients with late paraphrenia do not show obvious marked cognitive decline, but their performance on some cognitive test batteries is worse than normal aging.
They have sensory deficits, including hearing and vision problems. The personality characteristics of distrust, sensitivity, contention, and unsociability are also associated with this disorder.
There are no controlled trials of the use of neuroleptics in late paraphrenia, but neuroleptics are anecdotally accepted as the treatment of choice. Correcting sensory deficits can also help. All this must be accompanied by social, psychological and work support.
History of paraphrenia
Paraphrenia does not have a very long history and it faces imminent extinction. During its short life, the diagnosis has been the subject of a degree of dispute and uncertainty unprecedented in the field of old-age psychiatry.
It started out as a simple and useful descriptive category, but has become a confusing no-man’s-land outside of schizophrenia. Paraphrenia is a clinical entity described by Kraepelin in the eighth edition of his textbook in 1913.
Paranoia and paraphrenia are controversial entities that were separated from dementia precocious by Kraepelin, who described paraphrenia as a syndrome identical to paranoia but with hallucinations.
In 1863, Kahlbaum used the term ‘paraphrenia’ to refer to the life-related follies of the transitional periods (there were adolescent and senile forms).
Kraepelin used paraphrenia to refer to a form of paranoid psychosis with attenuated hallucinatory disturbances; and Leonhard named with at least seven kinds of crazy things.
The four subtypes of paraphrenia classified by Kraepelin and Mayer’s prognostic research, which studied the patient outcomes reported by Kraepelin, are described here.
After the publication of Mayer’s study in 1921, the vision to differentiate paraphrenia from schizophrenia was considered unfounded in Germany.
In the 1950s, Roth at the Newcastle school examined patients over 60 years of age with delusions and / with hallucinations, and introduced ‘late paraphrenia’ as a clinical entity.
He formed this concept to define a group of patients who presented symptoms characteristic of early dementia, but with minimal disturbances of emotion and will, and marked delusions with or without hallucinations.
The International Classification of Diseases classifies paraphrenia (late) and Der Beziehungswahn as a persistent delusional disorder that requires symptoms of at least 3 months duration for diagnosis.
Although the term (late) paraphrenia present in the International Classification of Diseases, 9th edition, Clinical Modification, is not included in the recent diagnostic criteria.
Many researchers acknowledge that the concept of (late) paraphrenia has not lost its usefulness for diagnosing psychotic disorders in old age.
As in the days of Kraepelin, problems related to paraphrenia cannot be neglected when considering the classification of psychotic disorders.
The problem of how to classify the follies of old age remains parasitic on beliefs about the follies that affect people.
Historians see science and medicine as examples of narrative and social practice; Doctors see science and medicine as providers of absolute truth and as the only way to understand follies.
This lack of convergence is hampering the understanding and management of older people with dementia and must be addressed.
Symptoms of paraphrenia
The main symptoms of paraphrenia are paranoid delusions and hallucinations. Delusions often involve the individual as the subject of persecution, although they can also be erotic, hypochondriacal, or grandiose in nature.
Paraphrenia is not included in the DSM-5 “Diagnostic and Statistical Manual of Mental Disorders”. More recently, doctors have classified it as a late-onset schizophrenia-like psychosis.
In fact, patients exhibiting these particular symptoms have been diagnosed with a variety of other illnesses, including atypical psychosis, schizoaffective disorder, delusional disorder, or persistent persecutory state.
Hallucinations in paraphrenia are often auditory, with approximately 75% of patients reporting such an experience. Visual, olfactory, and tactile hallucinations have also been reported.
For example, a patient with this disease may believe that the police are stationed in his hedge at night waiting for him to come out, or that he is convinced that a neighbor is connected to his telephone line, listening to everything he says.
What Causes Paraphrenia?
Since the beginning of the 20th century, the population affected by “old age” has grown and cases of “late-onset” insanity appear to be on the rise.
Some of these insanities have different clinical characteristics and respond differently to treatment and it is not clear whether this is due to pathogenic effects, organic factors, or social expectations.
Paraphrenia, like other psychotic disorders, is likely to have genetic origins.
Although a late age at onset (> 60 years) has been proposed in the literature, the evidence for this claim remains debatable. The decline in cognitive functions occurs very slowly, but can lead to mild dementia over a period of years.
Pathological studies indicate the presence of neurofibrillary tangles (NFTs), mainly within the entorhinal cortex. Compared to the severity of neuritic changes, amyloid deposition remains sparse.
Pyramidal cells affected by neurofibrillary tangles appear to be preserved. Both the clinical history and the neuropathology of paraphrenia are similar to those described for the predominantly senile dementia of neurofibrillary entanglement.
Risk factors, including organic lesions, can precipitate an earlier onset of symptoms in patients with this pathology. Many of the symptoms in paraphrenia can be explained by the involvement of the entorhinal cortex.
However, brain injuries caused by strokes, traumatic brain injuries, or drug and alcohol use can also induce psychotic symptoms. Some practitioners believe that paraphrenia is related to dementia.
Diagnosis of paraphrenia
Paraphrenia is a disorder similar to paranoid schizophrenia but with better preserved affect and relationship and much less personality impairment.
It is now diagnosed relatively infrequently and is not listed in the Current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or the International Classification of Diseases.
Psychiatrists often diagnose patients with paraphrenia as atypical psychoses, delusional disorder, psychoses not otherwise specified, schizoaffective disorders, and persistent persecution states of older adults.
Recently, mental health professionals have also been classifying paraphrenia as a very late-onset psychosis such as schizophrenia.
However, it seems that some psychiatrists recognize the disease but qualify it as “atypical psychosis”, “schizoaffective disorder” or “delusional disorder” for lack of a better diagnostic category.
In Russian psychiatric manuals, paraphrenia (or paraphrenic syndrome) is the last stage in the development of paranoid schizophrenia.
The “systematized paraphrenia” (with systematized delusions, that is, delusions with complex logical structure) and the “paranoid expansive paraphrenia” (with expansive / grandiose delusions and persecutory delusions):
They are the variants of paranoid schizophrenia. Sometimes “systematized paraphrenia” with delusional disorder is seen. A delusional disorder of at least 6 months duration characterized by the following:
Preoccupation with one or more semi-systematic delusions, often accompanied by auditory hallucinations.
Affect remarkably well preserved and appropriate. Ability to maintain a good relationship with others. Only partially meets criterion A for schizophrenia. No significant organic brain disorder.
Intellectual impairment. Visual hallucinations Incoherence. Extremely disorganized behavior at times other than during the acute episode. Understandable behavioral disturbance in relation to the content of delusions and hallucinations.
Studies conducted on paraphrenia
Some studies have examined the characteristics of paraphrenia (ie, late-onset delusional disorder) and compared it to schizophrenia.
Parsons reported a prevalence of “late paraphrenia” of 0.17 to 0.24 cases per 100 elderly people living in the community.
Christenson and Blazer reported a 4% prevalence of paranoid delusions in elderly living in the community. Flint, Rifat, and Eastwood found a high incidence of ‘organicity’ in paraphrenia cases compared to late-onset schizophrenia patients.
Yassa and Suranyi-Cadotte compared 20 patients with late-onset schizophrenia with 20 patients with late-onset paraphrenia.
The incidence of paraphrenia was 4% of total admissions over a 7-year period to a geriatric service, which was the same prevalence as for the first episode of schizophrenia.
Patients with paraphrenia were more likely to have had a concomitant physical illness and were less likely to have a premorbid image of personality abnormalities.
These patients were also less likely to have a relapse after successful neuroleptic treatment.
Thus, many cases of schizophrenia appear to develop late in life, with several distinct epidemiologic features that separate them from early-onset cases and from disorders related to late-onset life.
The prevalence of late-onset paraphrenia is more difficult to estimate, but is probably much lower than that of schizophrenia.
Given that one third of all cases of schizophrenia may appear after the age of 50, the expected population prevalence of late-onset schizophrenia may be 0.33%, which is at least twice the prevalence estimates for paraphrenia.
How is paraphrenia treated?
Paraphrenia generally has a much better prognosis than other psychotic disorders. Antipsychotic medication can be helpful, and many people with paraphrenia also benefit from therapy.
Paraphrenia sometimes occurs along with depression and anxiety, and medication to treat these conditions can help improve overall functioning.
Family interventions, including education and family counseling, can also be helpful, especially when the onset is very late and the person with paraphrenia is cared for by family or friends.
Caring for a person with paraphrenia
People with late-onset psychosis often develop strange ideas and delusions. For example, the person may believe that their neighbors are chasing them and that they can hear neighbors talking about them through the walls.
The ideas can be quite strange, p. an elderly woman may believe that there are people living in her loft and that they are sending messages on her phone line.
The symptoms of late-onset psychosis can be particularly distressing for both the older person and the caregiver. It is important, first of all, to verify if there is any truth in what the person says.
Very often it will be very obvious that what they think is happening could not be happening. However, it may be that they are misinterpreting something or, in fact, the situation is true.
It is not unheard of for an older person to live in a flat with very thin walls where they can listen to music played by neighbors at all hours of the day and night.
Assure the person that they are not going crazy and that you believe them. However, try not to get caught up in your beliefs and not collude with them.
Encourage them to visit their GP and, if possible, accompany them to explain the situation. If they are unaware of your illness and refuse to visit the GP, it may be necessary to arrange a home visit.
People with this condition are often referred to the Senior Community Mental Health Team. Medication will likely be prescribed and a community psychiatric nurse will visit to monitor this and to support the person and yourself.
The person may not believe they are sick and may refuse to take the medicine. If possible try to persuade them to try the drug. However, if they flatly refuse, do not enter a battle with them.
They can be socially isolated. You can help encourage them to hang out with you, eg. have a cup of coffee at a local café and may benefit from attending a day hospital or daycare.
People with this type of illness may believe that their problems will disappear if they move, especially if their delusions are related to their neighbors. This rarely works and very often problems carry over with them.
If the person is very distressed by his delusions, he may put himself at risk at home by trying to do something to make the delusions disappear, eg. refusing to have the heat on in the depth of winter.
If this happens, the person may need to be admitted to the hospital for treatment and careful supervision. The person may be very relieved at the suggestion of a hospital admission.
However, in some cases it is necessary for them to be admitted to the hospital under a Section of the Mental Health Law for their own safety.
This condition can be successfully treated with medications. However, what sometimes happens is that the person begins to feel fine and stops taking their medications and then the symptoms return.
It is very helpful if caregivers can monitor whether medications are being taken as prescribed and encourage the person to continue taking their medications.
Seeing the person so distressed by their delusions can be very stressful for the caregiver. It can also be very difficult for the caregiver when the person who is clearly very ill refuses to accept that something is wrong with them and instead accuses the caregiver of turning against them.
It is important that you step away from care and you should speak with the visiting community team member to discuss what support is available, for example, there may be some type of home care or the person is attending child care .
It can also be helpful to attend a group of caregivers or have one-on-one support, either face-to-face or over the phone.