Paraphrenia as a Side of the Schizophrenia – Week 4 Solution

This article discusses Paraphrenia as a Side of the Schizophrenia.

Paraphrenia as a Side of the Schizophrenia

Paraphrenia is not diagnosed as a disorder on its own but is currently subsumed under schizophrenia. The tyerm orginated from Kraepelin, who used the term paraphrenia to describe a particular and uncertain group between dementia praecox and paranoia (Freitas 529). Paraphrenia is excluded in the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM) series (Jesus 99). This uncertain group continues to be an issue during diagnosis. Currently, the term paraphrenia should be somewhere between delusional disorder and paranoid schizophrenia. This paper discusses paraphrenia and how it relates to other mental illnesses.

Psychiatric disorders naming began with Hippocrates in 460-377 BC. Pinel and Esquirol proposed new concepts in the eighteenth century to classify different psychiatric illnesses according to the observations and systemizing data. Kraepelin modified this classification system in the nineteenth century and considered observations and symptoms organizations.

Earlier dementia originated from this classification, later changed to Schizophrenia because of a not negative prognosis (Freitas 529). Psychiatrists in this period used hallucinations, delusions, and paranoid disorders to describe and classify patients’ behavior in clinics and hospitals. The concept of psychosis and thought alterations among older adults originated from Emil Kraepelin, Kahlbaum, and Felix Post, which gave birth to the term paraphrenia.

Kahlbaum used the term paraphrenia in 1863 to describe insanities associated with transitional life periods, including adolescence and senile forms. Kahlbaum used it to explain and differentiate various mental disorders such as paraphrenia hebetica among adolescents and paraphrenia senilis affecting older adults (Freitas 529). Kraepelin used this concept in 1913 to describe a form of paranoid psychosis with features like attenuated hallucinatory disturbances.

Leonhard named paraphrenia along with the other seven insanity types. Kraepelin believed it is related to paranoid schizophrenia, is characterized by delusions and hallucinations, does not indicate the full delusional disorder characteristics or schizophrenia deterioration characteristics, minimal personality decay well maintained emotional rapport, and relatively benign features.

According to Kraepelin, Paraphrenia is as chronic as schizophrenia and currently diagnosed as atypical psychosis or schizoaffective disorder. In the 20th century, there was an increase in the population hit by old age and a high number of reported cases of late-onset insanity (Kirkby 29-38). The insanities presented with various differing clinical features and responded differently to treatments.

The cause was unclear, and experts speculated between pathoplastic effects, organic factors, or social factors. This increase in unknown insanities led to the development of late-paraphrenia. Austrian neurologist Sigmund Freud developed between 1913 and 1917 a theory of paranoia that comprised delusions with and without grandeur which provided that the disorder should be treated differently from schizophrenia.

Initially using the concept in 1913, Kraepelin was able to define a collection of psychotic patients with typical symptoms of dementia praecox, but with slight emotional and volition disturbances and marked delusions. The term was well recognized in the early 20th century, but in 1921, it began to decline in its clinical use and diagnoses because the majority of the Kraepelin personal cases had worsened to schizophrenia and the remaining cases did not maintain their initial features (Freitas 530).

Late-onset-paraphrenia was used in the diagnoses in the United Kingdom, but it grew challenging to distinguish it from late-onset-schizophrenia. There was also no research evidence that paraphrenia affects the elderly exclusively as many authors perceived paraphrenia as an illness of middle and old-age adults, with little credible information about the onset age. Mayer-Gross’ 1921 report provided that the evidence or information for differentiating between paraphrenia and schizophrenia was unfounded.

Paraphrenia diagnostic criterion is not included in the ICP or DSM series, but it includes a delusional disorder occurring for a period of at least six months with features like preoccupation with one or more semisystematized delusions along with auditory hallucinations. The delusions are not abridged from the rest of an individual’s personality like in the case of delusional disorder (Freitas 529).

Paraphrenia affect is well-preserved and appropriate, and even in severe or acute situations, patients can still maintain their rapport. Paraphrenia does not include intellectual deterioration, visual hallucinations, inconsistent grossly disorganized behavior, incoherence, and flat or grossly inappropriate affect. It includes understandable behavior disturbance and partially satisfies schizophrenia Criterion A partially. Paraphrenia is also characterized by a not significant brain disorder.      

Relation with Other Mental Illnesses

Neuropsychology, psychiatry, and neurology diagnose paraphrenia as a pathology located on the frontier that can bring the patient great suffering if not identified (Escelsior and Murri 947). Paraphrenia is associated with distress, agitation, irrational behavior, which appear when delusions become more vivid, and judgment weakens. Patients tend to accuse other people of persecution, report to authorities, or sometimes charge at imagined pursuers.

Paraphrenia onset is in middle adulthood or old age. It is a chronic illness that can be ameliorated but not cured using any treatment. An individual’s intellectual functioning is unimpaired. However, daily living, occupation functions, socialization, marriage quality can deteriorate as the symptoms exacerbate (Pelizza and Bonazzi 130-140).

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Paraphrenia complications include dementia and can deteriorate to schizophrenia. Paraphrenia predisposing factors include migrant status, deafness, social isolation, and different stressors. Premorbid paranoid and schizoid occur mostly along with paraphrenia. Paraphrenia can also possibly affect personality traits indicated by patients presenting celibacy, lower-than-normal marital rates, and low fertility.

It is more common in females, and there are low incidences of schizophrenia in families affected by paraphrenia, indicating little to no genetic link between the two disorders. Differential diagnoses for paraphrenia include schizophrenia, delusional disorder, major mood disorder with delusions, dementia, schizoaffective disorder, schizotypal, severe schizoid, and severe obsessive-compulsive disorder.    

Paraphrenia is deemed similar to schizophrenia and other psychotic disorders regarding its symptoms and progression. People suffering from paraphrenia can experience strange or unusual thoughts, delusions, and eccentric behavior. Unlike schizophrenia, an individual’s personality is not disturbed significantly, and people present with almost normal affect.

The patients can have a normal level of comfort and maintain normal connections with other people (Goudie 22-30). It occurs later in life than schizophrenia, which appears earlier, including the teen years and during the 20s. Paraphrenia is also different from schizophrenia that persists and deteriorates late in someone’s life.

Paraphrenia originates from genetics, brain injuries due to stroke, traumatic brain injuries, risky drug, and alcohol use. Paraphrenia is different from classic schizophrenia syndrome because its symptoms are not present in early adulthoods. It is also rare, unlike schizophrenia, and affects about 0.1% and 4% of the older adults and presents a better prognosis than schizophrenia. 

Some people also associate paraphrenia with dementia, but the diagnoses criteria show that it differs from dementia syndrome because it does not lead to cognitive and daily life functions decline. Initially, paraphrenia was developed in the process of defining dementia praecox.

Kraepelin later worked to differentiate the two and define dementia praecox as a different entity from paraphrenia. He described the basic symptoms of dementia praecox as including disturbances of emotion and volition, which is different from paraphrenia that defines a group of disorders without emotional or volition disturbances.

In paraphrenia, cognitive function deterioration occurs very slowly, but over time it can cause mild dementia. There is a presence of neurofibrillary tangles (NFT) in paraphrenia patients, especially with the entorhinal cortex (Van Assche et al. 604-621). The amyloid deposition is scant, and the pyramidal cells impacted by the NFTs are preserved.

The paraphrenia clinical history and neuropathology are similar to the aspects provided for NFT-predominant senile dementia. Many of the paraphrenia symptoms involve the entorhinal cortex, and risk factors include organic lesions.

There are different subtypes of paraphrenia, with some proposed by Kraepelin that include paraphrenia systematic, paraphrenia expansiva, paraphrenia confabulans, and paraphrenia phantastica. Paraphrenia systematica is the main one, and the onset is insidious, occurring over several years with patients manifesting delusions of reference and persecution. Paraphrenia expansiva presents with grandeur delusions, exalted feelings, and mild excitement. Paraphrenia confabulation is distinctively characterized by pseudo-memories and/or performance delusions.

Paraphrenia phantastica presents with immensely fanciful, loose, and modifiable delusions (Mata et al. 793-794). There is another type, late paraphrenia Roth proposed in 1955 after realizing that most of the Kraepelin cases later deteriorated to late-onset schizophrenia. The ICD-10 and DSM-5 include late paraphrenia in their diagnostic criteria, but it is subsumed under paranoid schizophrenia or persistent delusional disorder. Patients affected by late paraphrenia initially during old age have persecutory delusions, visual and/ or auditory hallucinations, and Schneiderian symptoms.

Patients can also present with delusions of reference, grandeur and hypochondriasis, misidentification syndromes, and hallucinations in other modalities. About 60 percent of patients with late paraphrenia have affective symptoms. Patients score less than healthy people in cognitive test batteries. Personality features presenting in these patients include sensitivity, unsociability, quarrelsomeness, and suspiciousness.    

Today, many practitioners refer to the late paraphrenia as schizophrenia arising late in life. However, there are distinct features that differentiate the two disorders. The clinical features of late paraphrenia differ somehow from those of schizophrenia appearing early in life. Late paraphrenia (LP) patients present with multiple symptoms similar to those of schizophrenia.

However, LP patients experience a lesser degree of personality deterioration (Marinho 55). LP is prevalent among women, and hearing loss as a diagnoses criteria is used more in LP than schizophrenia. Also, more LP patients are socially isolated compared to patients suffering from the affective disorder, highly attributed to the paranoid-schizoid type personality before the onset of the disease. Patients with LP differ from those presenting with dementia of the Alzheimer type (DAT) regarding the relatively better preservation of former intellect and memory.

Research shows that various factors induce LP, such as personality, hereditary, organic, and social factors, others associated with senility. The study of organic factors contributing to LP shows that individuals suffering from LP have a reduced cognitive performance than healthy individuals of similar age. However, their cognitive performance is fundamentally better than those with DAT. Neurological studies indicate that LP is related to organic brain changes, including cortical atrophy, enlargement of the ventricles, and the brain’s frontal or temporal hypoperfusion.     

The primary differentiating factors between the late onset of schizophrenia and paraphrenia is a criterion that includes the presence of delusions, preserved personality, cognitive and functional decline, understanding behavioral changes, organize brain disorder absence (Goudie 22-32).

Schizophrenia appearing late in life has a decrease in positive and negative symptoms, mild cognitive decline, and patients respond after a few antipsychotic doses. Paraphrenia patients’ personality, functionality, and cognitive functions preservation are associated with the entorhinal cortex involvement, adjacent to the hippocampal region. Patients with late-onset schizophrenia have their personality, functionality, and cognitive function highly affected.

There is increased longevity, and the number of patients with schizophrenia is growing. There is a growing diagnosis of multiple schizophrenia, and practitioners are not able to diagnose some unknown conditions not described in DSM-5 due to the non-inclusion of paraphrenia. The initial criteria considered the symptoms’ onset age to differentiate early-onset schizophrenia’s late manifestations and late-onset schizophrenia.

Today, ICD-10 and DSM-IV series cannot differentiate clearly between earl- and late-onset schizophrenia. There has been an extended period of failure to offer distinguishing neuropathological explanations, prompting narrower definition criteria. Psychotic or schizophreniform symptoms in late life can be Alzheimer’s disease manifestations, and therefore, degenerative changes can be used to distinguish between early-onset schizophrenia and late-onset schizophrenia.

A study conducted to differentiate the two disorders found neuronal cytoskeletal disruption, altering information flow through the hippocampus among late-onset schizophrenia, a typical feature of a disorder, paraphrenia, that has until recently been diagnosed as schizophrenia.

The conclusion that paraphrenia is the same as late-onset schizophrenia created some gaps that have affected the correct diagnosis of schizophrenic patients that present with preserved intellectual, functioning, personality (Marinho et al. 55). A growing group of scientists is advising that paraphrenia is still useful in the diagnosis and should be included in the series to close the gaps.  

A relationship exists between patients that develop late paraphrenia and those developing dementia syndrome. Dementia tends to present with memory impairment and can raise clinical concern or attention through personality change, mood disturbance, delusions, and hallucinations before the detection of any cognitive deficit.

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Therefore, some elderly patients suffering from hallucinations and delusions are diagnosed with dementia. Research shows that a small number of those patients indicating late paraphrenia have been primarily diagnosed with dementia.

Paraphrenia patients’ personality, functionality, and cognitive functions preservation is also primary differentiating aspect between paraphrenia and dementia (Goudie 22-32). Dementia patients that experience delusions experience a significant cognitive and functional decline.

Conclusion

Despite researches showing the diagnostic gaps after the exclusions of paraphrenia in ICD-10 and DSM-5 criteria, some practitioners still see some relationship between some current psychosis symptoms and the classical paraphrenia. Late paraphrenia continues to be the primary differential diagnosis within the schizophrenic spectrum. This implies that paraphrenia is still vital, especially with the growing aging population.

Paraphrenia, especially late paraphrenia, does not lose its usefulness, particularly with an increasing observation of psychotic symptoms beginning from age 60 years in persons without a history of any psychiatric illness. This trend has become a vital and credible hypothesis for late paraphrenia and the need to make it independent of schizophrenia.

Currently, people presenting with late paraphrenia receive a differentiated diagnosis of disorders like atypical psychosis, psychotic disorder not otherwise specified, delusional disorder, schizoaffective disorder, and persistent persecutory states of older adults.

Today, many older patients diagnosed with late-onset schizophrenia indicate premorbid paranoid and schizoid traits, but present factors typical to late paraphrenia such as quick response to medication, short duration of the disorder, and perseveration of intellect, functionality, and personality. Paraphrenia is undoubtedly related to other mental illnesses like dementia and Alzheimer’s disease, but there is an increasing diagnosis for late paraphrenia a new among the aging population. 

Work Cited

Escelsior, Andrea, and Martino Belvederi Murri. “Modulation of Cerebellar Activity in Schizophrenia: Is It the Time for Clinical Trials?.” Schizophrenia bulletin 45.5 (2019): 947.

Freitas, C., et al. “Paraphrenia: Evolution of the concept.” European Psychiatry 33.S1 (2016): S529-S529.

Goudie, Fiona. Physical and emotional problems in later life. In The Essential Dementia Care Handbook (2017): (pp. 22-32).

Jesus, M. “Paraphrenia in modern times? Revisiting an elder concept.” European Psychiatry 64.S1 (2021): S799-S800.

Kirkby, Kenneth C. “Conceptual Histories in Psychiatry: Perspectives Across Time, Language and Culture in the Work of German Berrios.” Rethinking Psychopathology. Springer, Cham, 2020. 29-38.

Marinho, Mariana Lemos Brochado Cunha, João Marques, and Miguel Braganca. “Late paraphrenia, a revisited diagnosis: case report and literature review.” Actas Esp Psiquiatr 45.5 (2017): 248-55.           

Mata, A. Hernández, et al. “Paraphrenia phantastica. A case report.” European Psychiatry 64.S1 (2021): S793-S794.

Pelizza, Lorenzo, and Federica Bonazzi. “What’s happened to paraphrenia? A case-report and review of the literature.” Acta bio-medica : Atenei Parmensis vol. 81,2 (2010): 130-140.

Van Assche, Lies, et al. “The neuropsychology and neurobiology of late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: a critical review.” Neuroscience & Biobehavioral Reviews 83 (2017): 604-621.

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