Paraphrenia4

As noted earlier, paraphrenia is a diagnosis which has fallen out of favour, but its demise has left an uncomfortable gap in the diagnostic repertoire which psychiatrists either ignore by labelling everything as schizophrenia or else ineffectually try to fill with nondescript diagnoses such as 'atypical psychosis' or 'schizoaffective disorder'. The ICD-10 category of 'other persistent delusional disorder' (F22.8) could be used for cases of paraphrenia and would at least denote an illness with links to delusional disorder, but it must be made clear that paraphrenia is not simply a variant of the latter.

Clinical features

Kraepelin's description of paraphrenia (1!> was of an illness similar to paranoid schizophrenia, with fantastic delusions and hallucinations but having relatively limited thought disorder and well-preserved affect. Compared with schizophrenia, there was less personality deterioration and volition was less impaired. The patient's ability to communicate with others and to demonstrate rapport and emotional warmth remained good. In contrast with paranoia (now delusional disorder), there was not the encapsulated highly organized quality of the delusional system and the delusions lacked the quasi-logical structure of delusional disorder.

There are few recent descriptions of Kraepelinian paraphrenia (95> and virtually no studies have been carried out on it in the past 60 years. However, a recent investigation by Ravindran et al.'(96> appears to confirm that cases of paraphrenia can readily be recognized on predetermined criteria and can be distinguished from schizophrenia. These patients have a disorder which closely fits Kraepelin's original description. In addition, it is noted that agitation and irrational behaviour are prominent in the acute stage, usually an apparent response to vivid delusions and hallucinations. Despite resemblances to paranoid schizophrenia, less than a third had made threats or displayed aggressive behaviour prior to assessment. In fact, nearly half the patients came to notice because of illogical complaints to the authorities, indicating a breakdown in reality testing but some retention of social judgment.

When the immediate psychotic symptoms settle sufficiently to allow better communication, the preservation of emotional warmth and sociability becomes apparent and is in marked contrast to typical schizophrenia, but these individuals still show widespread thought disorder, multiple delusions, and poor insight.

Diagnosis and differential diagnosis

The principal aim is to distinguish paraphrenia from the more deteriorative aspects of schizophrenia on one side and from the encapsulated delusional system characteristic of delusional disorder on the other. Therefore other disorders to be distinguished are:

• paranoid schizophrenia

• delusional disorder

• major mood disorder with delusions

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