Paraphrenia

Paraphrenia, also known as very late-onset schizophrenia-like psychosis, is a mental illness. Mental delusions and hallucinations that develop late in life are common symptoms of the disorder. However, the disorder is a diagnostically controversial issue since there is no standardized criteria. This disorder has never been and continues to be absent from the DSM (Diagnostic and Statistical Manual of Mental Disorders) nor the ICD (International Classification of Diseases). 

There is also ongoing debate over the relation of paraphrenia to schizophrenia. Two significant differences between the two diseases are age of onset, and the notable absence of personality, emotional, and volitional disruptions in late life paraphrenia.

Psychiatrists often diagnose patients possessing symptoms of paraphrenia as having one of the following:

• atypical psychosis,
• delusional disorder,
• psychosis not otherwise specified,
• schizoaffective disorders,
• persistent persecutory states of older adults 

Recently, mental health professionals prefer classifying the disease previously known as paraphrenia as very late-onset schizophrenia-like psychosis.

​Symptoms

The main symptoms of the disorder are paranoid delusions and hallucinations. The delusions often center around the inflicted person suffering from undeserved persecution. However, delusions may also be erotic, hypochondriacal, or grandiose in nature.

Most hallucinations experienced are auditory. However, hallucinations may occur in any sensory experience. A person may have hallucinations of illness, leading to psychosomatic experiences of pain.

Paraphrenia is notably different from schizophrenia, while the disorder shares the positive symptomology of delusions, However, this late life disorder does not include the negative symptomology of personality and emotional deterioration.  Individuals with schizophrenia personalities, deteriorating as the disease progresses. Individuals with this disorder often maintain a well-preserved personality and affective response, continuing to function in the community.

History of Paraphrenia​

Early Mentions

The term paraphrenia originated in the 17th century from the word paraphrenitis—a term used to describe a from of madness caused by inflammation to the diaphragm (Casanova, 2010).

​Karl Ludwig Kahlbaum ​​

The term paraphrenia was popularized by Karl Ludwig Kahlbaum in 1863, describing the tendency of certain psychiatric disorders to occur during certain transitional periods in life. Kahlbaum categorized paraphrenia with two subgroups:

• Paraphrenia Hebetica (insanity of adolescence)
• Paraphrenia Senilis (insanity of older adults)

​​Emil Kraepelin

​During the early twentieth century (1912-1913), Emil Kraepelin further developed the term paraphrenia. His research and writings introduced the term paraphrenia similar to our current use and understanding of the term today. He describe the disorder as a disease containing many of the symptoms of schizophrenia but lacking a deterioration and thought.

Kraepelin divided his concept of paraphrenia into four large forms:

1. Systemized
2. Expansive
3. Confabulatory
4. Fantastic (Kappas, 1914)

​​Systemized:

The systematica type is characterized by gradual development of persecutory delusions with grandiose ideas appearing in the latter stages of the disease. The personality remains largely intact.

Expansive:

Expansive paraphrenia is marked by ‘exalted ideas of grandeur with a preponderant elevated mood.’ In this form hallucinations are almost always present, often religious or erotic in nature.

Confabulatory:

The confabulatory type is marked by falsification of memories. The delusions of persecution go back to the patient’s childhood.

Fantastic:

Disorders categorized as fantastic are ‘dominated by exalted productions of marked fantastic, loosely connected, changeable ideas’. Delusions of persecution gradually develop as the disease progresses  (1914).​​

Questions and Debates

​A few years after Kraepelin published his findings. However, W. Mayer challenged Kraepelin’s conclusions. Many of Kraepelin’s subjects diagnosed with paraphrenia systematica eventually developed schizophrenia. While Mayer’s findings were later disputed and his methods of study not reproducible, he created lingering doubt over Kraepelin’s studies.

​​Alternate Names

​Schizophrenia disorders arising in old age may be called by several different names or diagnosed as other diseases on the schizophrenia spectrum. Often paraphrenia is diagnosed as very late-onset schizophrenia-like psychosis. Martin Roth, an influential contributor to these studies, referred to it as late paraphrenia.

Diagnosis

​Since paraphrenia is not included in any edition of the DSM or ICD there is no standard format for diagnosing the disorder. Many studies rely on Martin Roth’s 1955 criteria for diagnosis. In 1999, Arun V. Ravindran et al. redefined the disorder and published a more detailed standard for identifying the diorder in patients.

Causes

Pathological Correlates

Modern research has discovered a prevalence of neurofibrillary tangles in older patients diagnosed with late-onset schizophrenia. Neurofibrillary tangles are also pathologically associated with Alzheimer’s disease. However, in late life schizophrenia, the presence of neurofibrillary tangles occurs without the patent cell loss associated with Alzheimer’s disease (Casanova, 2010).

Trauma

Some research suggests that neurological trauma may increase the risk of developing this disorder. Divya Bharat wrote on his medical blog that “when the brain undergoes significant physical modifications, due to a tumour, stroke, grave injury, nerve or blood vessel damage, other neurodegenerative conditions, it affects its normal functioning and response to external stimuli. These abnormal instances could give rise to paraphrenia” (2020).

Several studies over the last 30 years have suggested a structural basis for late onset psychosis. For example, one study discovered that several patients previously diagnosis with paraphrenia had a subtle structural brain injury present that could only be detected by CT or MRI scanning and neuropsychological testing (Haslett, et al. 1992).

Risk Factors for Paraphrenia

Paraphrenia patients tend to be women with onset of the disease occurring after 30 years of age. Studies suggest that social isolation, physical handicaps, and maladaptive personalities, may increase risk of the disease.

Currently, there is insufficient criteria to predictably identify those who will later suffer from this disease. Some modern authors, pointing to the reduced genetic load of these older patients compared to schizophrenia patients, suggest a larger environmental influence is required before the manifestations of the disorder (Casanova, 2010).

Haslett et al. citing their findings wrote “most authors concluded that the mode of inheritances of the late-onset disorder, like schizophrenia, is probably polygenic with many nongenetic factors being influential” (2016). 

This is in line with the diathesis stress theory. “The diathesis–stress model explores how biological or genetic traits (diatheses) interact with environmental influences (stressors) to produce disorders such as depression, anxiety, or schizophrenia.” According to the Diathesis-stress model “Predispositions interact with stressful experiences. When life stresses disrupt our psychological equilibrium (or homeostasis), the stressful event may catalyze development of predispositioned   disorders” (Murphy, 2021).

Prognosis

​Individuals who develop paraphrenia have a life expectancy similar to the normal population. However, recovery from the  psychotic symptoms is rare. These patients suffer a slow deterioration of cognitive functions. In some cases, the disorder leads to dementia.

Treatment

​Physicians typically treat paraphrenia with psychotropic drugs. Often pharmaceutical intervention can alleviate many of the symptoms. Some forms of cognitive behavior therapy has had positive results in helping patients live with their disease. Arata Sato and Shin Ihda report in a 2002 article that “as for the treatments, including pharmaceutical responsiveness of late paraphrenia, we may tentatively say that a consensus has not been reached in any way.”

References:

Bridge, T., & Wyatt, R. (1980). Paraphrenia: Paranoid States of Late Life. II. American Research. Journal of American Geriatrics Society, 28(5), 201-205.

Bharat, Divya (2020). ​​Paraphrenia: Causes, Symptoms And Treatment. netmeds.com. Published 7-27-2020. Accessed 5-27-2022.

Casanova, M. (2010). The pathology of paraphrenia. Current Psychiatry Reports, 12(3), 196-201.

​Hassett, D., Keks, N., Jackson, H., & Copolov, D. (2016). The Diagnostic Validity of Paraphrenia: . Australian and New Zealand Journal of Psychiatry, 26(1), 18-29.

Howard, R., Almeida, O., & Levy, R. (1993). Schizophrenic symptoms in Late paraphrenia. Psychopathology, 26(2), 95-101.

Karpas, M. (1914). Kraepelin’s conception of paraphrenia. JAMA, LXIII (9), 766-769.

Murphy, T. Franklin (2021). Diathesis-Stress Model. Psychology Fanatic. Published 9-7-2021. Accessed 6-1-2022.

Ravindran, A., Yatham, L., & Munro, A. (1999). Paraphrenia Redefined. Canadian Journal of Psychiatry, 44(2), 133-137.

Sato, A., & Ihda, S. (2002). Paraphrenia and late paraphrenia. Psychogeriatrics, 2(1).

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