Dementia

• severe schizoid, schizotypal, or paranoid personality disorder

• schizoaffective disorder.

Epidemiology

By inference it appears that cases of paraphrenia are about one-tenth as common as all other cases of schizophrenia in an inpatient psychiatric population, but this tells us nothing about its frequency in a general population. Since personality deterioration is less marked, one might expect cases of paraphrenia to survive better in the community than cases of schizophrenia and to be relatively more common there, but we have no statistics on this.

The illness occurs in both males and females, but the sex ratio is undetermined. Despite their retention of some positive social attributes, many of these patients live alone and experience considerable social isolation. Contrary to the traditional belief that this is an illness of older people, the age of onset can be at any time from early adult life to extreme old age. It is possible that paraphrenia may occur more often in immigrant groups. Schizophrenia is said to be uncommon in the family history, although psychiatric illness in general is frequent in families.

Aetiology

The possible association with immigration has been noted above. Many texts have declared that deafness, and to a lesser extent blindness, are potentially isolative and provocative factors, but evidence for this is uncertain. A family history of psychiatric illness occurs in perhaps half of the cases of paraphrenia and its presence seems to be associated with an earlier onset of the disorder. A prior history of substance abuse and head injury are presumed to have significance in some cases but no statistics are extant.

Course and prognosis

The illness is chronic and is progressive in many cases. Fluctuations in severity occur, but nowadays this may be related to intermittent periods of treatment alternating with non-compliance. Despite their good rapport with staff and fellow patients, paraphrenics often have poor insight and judgement about their illness. As inpatients they co-operate with treatment and usually respond well to neuroleptics, so that superficially they appear remarkably normal at the time of discharge. However, delusional thinking remains covertly active in many cases and a high proportion repeatedly relapse after discharge because they stop their medications. Fortunately many patients remain fairly undeteriorated even after several exacerbations, but in the longer term possibly as many as half will gradually deteriorate towards schizophrenia, particularly of the paranoid type. Consistent compliance with medication is likely to lead to a much more optimistic outcome.

Treatment

In an acute phase the patient usually needs to be admitted for inpatient observation until stabilized on medication. The little evidence that exists suggests that paraphrenics in general respond well to all standard neuroleptics. If relapse occurs, non-compliance is a likely cause. Since the illness is potentially lifelong, the choice of neuroleptic should be influenced by the need to avoid long-term side-effects. Following discharge from hospital it is extremely important to maintain permanent supervision, even when the patient appears appear well, and to remember that these patients can utilize their retained social skills to hide their delusions and their lack of co-operation, at least for a time. The uncooperativeness is often delusionally motivated.

Case Study Paraphrenia A 38-year-old woman was admitted to a psychiatric inpatient unit for the sixth time in 5 years with an initial diagnosis of paranoid schizophrenia. On admission she was restless, disruptive, and grandiose, and she appeared to have severe auditory hallucinations. She had been brought to hospital because she had been virtually camping in the police station demanding action against allegedly persecutory neighbours. This hospital admission was typical of several previous ones. Each time, after some initial resistance, she accepts treatment and rapidly improves. Despite the severity and pervasiveness of her delusions, she always becomes pleasant and shows remarkable appropriateness and range of mood and a good deal of depth of affect. Rapport with others is good. At discharge she always insists she will comply with treatment, but her insight is poor and she never completely loses her delusional beliefs. Relapse is always the result of stopping her medications. Despite frequent exacerbations and chronicity of the illness, her personality remains remarkably preserved when she takes her treatment, but long-term prognosis is thought to be poor.

Break Free From Passive Aggression

Break Free From Passive Aggression

This guide is meant to be of use for anyone who is keen on developing a better understanding of PAB, to help/support concerned people to discover various methods for helping others, also, to serve passive aggressive people as a tool for self-help.

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