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Paraphrenia—Is It Schizophrenia?

It May Depend on Where You Live

Jan 9, 2009 James Cooper

New-onset delusions in an older person: the condition could be labeled "schizophrenia," or, especially in Europe, "paraphrenia."

A 70 year old woman had no history of psychiatric symptoms. Then she began to complain that a man was spying on her. Her concern was overwhelming, and maneuvers she took to protect herself disrupted her daily life. She hired a detective, but neither the detective nor her family could corroborate her suspicion. In fact, they found evidence that what the woman said was impossible. Being spied on was a delusion.

She had no other complaints. Her family said she had “withdrawn” some. She had no other symptoms of depression.

On medical examination, her memory was normal. She did have high blood pressure, controlled on the same medicine she had been taking for five years. Except for high cholesterol, her blood tests were normal. Imaging of her brain was normal.

She had no family history of any psychiatric disorder.

In summary, this was an older woman with a new-onset delusional disorder.

Which Diagnosis Is Best?

In North America, she might be diagnosed as having schizophrenia. American psychiatrists allowed a diagnosis of paraphrenia once—it was listed in the Diagnostic and Statistical Manual of Mental Disorders Manual III-R (DSM III-R). (The DSM is the “bible” of diagnoses for psychiatrists.) But “paraphrenia” disappeared in the next DSM, DSM IV.

In Great Britain and some parts of Europe, the preferred diagnosis might be paraphrenia, because schizophrenia typically becomes apparent in men in their mid-20’s and in women by their late 20’s. European and some American psychiatrists argue that there are other differences, too. Many believe schizophrenia actually begins at birth. If a delusional disorder occurs in late life, it is probably due to a different process.

Diagnostic Labels Over Time

The term "Schizophrenia” was first used in 1911. It was meant to describe the brain’s splitting away from reality. Late-onset schizophrenia was described in 1943, and British psychiatrists began to use “late-onset paraphrenia” interchangeably, according to French psychiatrists (Convert, Vedie, and Paulin, 2006). Among French psychiatrists, schizophrenia is not diagnosed if the process begins after age 40. In France, the patient might be labeled “Psychose Hallucinatatoire Chronique,” which includes chronic delusional disorders.

Differences Between Schizophrenia and Paraphrenia

Paraphrenia is more likely to be delusional, without prominent hallucinations.
Delusions (and hallucinations when they occur) are likely to be limited to the person’s surroundings in paraphrenia, whereas in schizophrenia, they are unlimited.
There is less likelihood of schizophrenia in close relatives in paraphrenia.
Two typical signs of schizophrenia—loose associations in speech, and negative symptoms (absence of emotion, less energy, motivation and activity)—are less likely in paraphrenia.
People with paraphrenia are more likely to have significant visual or hearing deficits. Schizophrenia typically gets worse, while paraphrenia does not and may improve without treatment.

A Different Process?

At least one American neuropathologist believes paraphrenia is different than schizophrenia. Manuel Casanova, Medical College of Georgia, notes that paraphrenia appears to be a disease caused by abnormal brain tau, similar to Alzheimer's. However, hippocampal pyramidal cells are preserved, and there is little brain amyloid, two characteristics that distinguish paraphrenia from Alzheimer's.

So What?

If paraphrenia is a different disease from schizophrenia, it may not have the implications for family risk. There have been suggestions it is easier to treat, with lower doses of medications. Some believe paraphrenia may be the first sign of a progressive brain disorder that may progress to dementia, so it might need different planning for care.

Sources

Convert H, Vedie C, Paulin P. “Late onset schizophrenia or chronic delusion“ Encephale 2006; 32: 957-61

Kerssens CJ, et al. Tijdschr Psychiatry 2006; 48: 717-27

Casanova MF. Schizophrenia Research 2003; 62:141-6.

The copyright of the article Paraphrenia—Is It Schizophrenia? in General Medicine is owned by James Cooper. Permission to republish Paraphrenia—Is It Schizophrenia? in print or online must be granted by the author in writing.

Delusions can be paraphrenia