Paraphrenia (A complete guide)

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In this article, we will talk about the diagnosis of paraphrenia, the clinical forms of paraphrenia, differential diagnosis and treatment. We will also talk about other persistent delusional disorders – paranoia. 

What is Paraphrenia?

Paraphrenia is characterized by a hallucinatory systematized chronic delirium, unlike paranoia, where the delirium, although systematized, is non-hallucinatory.

Historical aspects

Kraepelin delineated paraphrenia in 1909, defining it as “endogenous psychosis characterized by a hallucinatory systemic chronic delirium, with a fantastic character, whose imaginative richness, going as far as the creation of a fantastic world, contrasts with the long-lived life of emotional behaviour relatively corresponding to reality.

The French school calls this disease delirium of imagination (Dupre, Logre) or chronic hallucinatory psychosis (G. Ballet).

H. Ey describes 3 forms of paraphrenia:

  • Schizophrenic;
  • Melancholic;
  • Manic.
Paraphrenia (A complete guide)

The clinical picture

The general appearance of the patient is sometimes extravagant, he may be wearing original clothing, thus externalizing his fantastic personality.

Perceptions are parasitized by hallucinations, in most cases auditory, less often olfactory, gustatory or kinesthetic, the visual ones appearing exceptionally.

Memory is generally preserved. Sometimes paramnesia (memory hallucinations) may occur.

The thoughts are invaded by the imagination, becoming delusional and leading to the creation of a fantastic, unreal world. Delusional ideas fall into three categories:

  • influence (spiritism, telepathy, hypnosis, electromagnetic waves, etc.);
  • persecution (conspiracies, conspiracies);
  • of magnification, with a fantastic character (prophets, deities, etc.).

Affectivity varies depending on the stage of evolution and the content of delirium.

The activity can be kept at a normal level for a long time, in contrast to the fantastic delirium. Sometimes, under the rule of hallucinations or delirium, patients may commit violent, forensic acts.

Awareness of the disease is lacking in all cases.

The stages of paraphrenia

The onset of the disease occurs insidiously, rarely acutely or subacutely, after the age of 35-40 years, by changing the patient’s mood. He becomes irascible, restless, suspicious, anxious, reserved, thus shaping a delirium of persecution. The appearance of hallucinations, especially auditory, strengthens this delirium.

The disease unfolds in 4 phases (after Magnan):

  1. the incubation phase (subjective analysis), extends over several years, the patient presents with agitation, chrestomathic, etc .;
  1. hallucinatory phase, the occurrence of hallucinations, especially auditory;
  1. the phase of the megalomaniac delirium, the paraphrase becoming convinced that he is a special, very important person (from a political, military, social, scientific, religious point of view);
  1. dementia phase, progressive amnesia.
Paraphrenia (A complete guide)

Clinical forms of paraphrenia

Kraepelin describes four forms of paraphrenia: systematic, expansive, confabulatory, and fantastic. Roth adds late paraphrenia.

Systematic paraphrenia is established by the slow and insidious change of the patient’s nature, the delusion of persecution predominating. Delirium is systematized, but hallucinations are present, especially auditory ones.

Expansive paraphrenia (pseudo maniacal), characterized by the establishment of a delusional system of magnification, megalomania, erotomania, against the background of an exalted, euphoric mood, with psychomotor arousal. It is more common in women.

Confabulatory paraphrenia is less common. The characteristic element is memory hallucinations (confabulations). The sick express strange, bizarre, imaginary, mysterious-looking states. The predominant delusion is that of persecution and megalomaniac. Delusional ideas of filiation predominate.

Fantastic paraphrenia is characterized by the appearance of fantastic, unsystematic delusional ideas, but with the preservation of a relatively harmonious personality.

Late paraphrenia (involution) occurs in the 7th and 8th decades, without signs of psychogenic deficiency, in the form of a rich hallucinatory delirium. Women are especially affected.

Positive diagnosis

A diagnosis of paraphrenia is hampered by the patient’s lack of cooperation. The diagnosis is established on the basis of the presence of hallucinatory systemic delirium, with the predominance of fables, imaginative phenomena, fantastic elements.

Differential diagnosis

Paranoid schizophrenia – schizophrenia delirium is limited, incoherent, associated with personality destructuring.

Delusional disorder (paranoia) – is characterized by lack of hallucinations, more active systematization of delirium, the predominant role of interpretation.

Mystical delirium in epilepsy – there is an acute psychogenic syndrome (disturbance of consciousness) or chronic (dementia), in addition to seizures.

Delusional melancholy – delirium is fantastic, but it has a content of humiliation, self-accusation, uselessness, in contrast to the feeling of victory that appears in paraphrenic.

Paraphrenia (A complete guide)

Treatment of paraphrenia

Patients are generally seen as difficult to treat, the disease is basically incurable.

The use of incisive antipsychotics of generation I is indicated (Haloperidol, Flupentixol, Fluphenazine) or atypical antipsychotics (Olanzapine, quetiapine, risperidone, ziprasidone). In extremely severe cases, electroconvulsive therapy is indicated.

A complex treatment includes:

  • drugs – sedative, antipsychotic, hallucinogenic;
  • Sociotherapy;
  • psychotherapy.

Forensic aspects

The delirium in paraphrenia is fictitious, imaginative, with delusional, fantastic themes, a richly imagined delirium, with the advancement of desire in the imaginary, often with a good adaptation to reality. The more the imaginative delirium gains in fiction, the more it loses its danger.

Paraphrenics, compared to paranoids, are not violent, their megalomaniacal plans being so great that they look at the world of real conflicts from above, above, and “do not defile themselves for petty bones”

In many cases, the patient retains his skills, has an attitude to the limit of normal, thus maintaining his position in the profession, society, family, while maintaining a quasi-abnormal activity in the long run.

Sometimes the antisocial behaviour given by paraphrenic psychosis can be manifested by aggression (hitting, outrage, homicide), bizarre, unmotivated. After committing the deed, the behaviour is strange, incomprehensible.

Like the paranoid, paraphrenic tends to disguise forensic psychiatric expertise.

Paraphrenia (A complete guide)

Persistent delusional disorders

Persistent delusional disorders are a group of diseases in which the clinical picture is constituted or dominated by a delirium with a unique theme, systematized and characterized by long persistence over time.

Currently represented by:

1. Delusional disorder, which corresponds to paranoia.

2. Other persistent delusional disorders, corresponding to paraphrenia.

Paranoia

Paranoia is a chronic endogenous psychosis, which consists of the evolution of a delusional system that is sustainable and impenetrable to criticism, developing insidiously against the background of complete preservation of order and clarity of thought, will and action.

Diagnostic

  • Non-bizarre delusions, systematized, lasting at least one month.
  • Delusions occur in the absence of other symptoms that characterize schizophrenia (bizarre behaviour, affective flattening, dissociation).
  • Absence of hallucinations, except for tactile and olfactory ones related to the delusional theme.
  • Except for the impact of delirium, the operation is not impaired marked and the behaviour is obviously not strange or bizarre.

Clinical picture

The main clinical forms of paranoia – depending on the delusional theme – are represented by interpretive delirium, passionate delirium, sensitive relationship delirium.

Interpretive delirium – installs slowly, difficult to specify, in the period of the state becomes obvious and relatively plausible. The theme is persecutory nature (pursuit, poisoning, killing, persecution), of grandeur (political roles, divine missions, parentage).  Heteroaggressive reactions may occur less frequently and are self-aggressive.

Passionate delirium – the relatively sudden emergence of a prevalent idea that

imposed in thinking, acquiring an obsessive character, it develops in a chain by adding new elements, it orients in a pathological sense activity and behaviour.

Passionate deliriums are classified into claim delirium, erotomania delirium, jealousy delirium.

  • The delusion of claim – triggered by a cause more or less which causes dissatisfaction with the subject. The idea of ​​harm it becomes dominant, prevalent, obsessive, the need to obtain justice it is imperative (progressive virulent, passionate idealists, inventors delusional, hypochondriac delirium)
  • Erotomania delirium – the patient is firmly convinced that he is loved by a person with higher status, who wants to marry him. Including phases of hope, disappointment and high-intensity hatred.
  • Delusion of jealousy – consists of the delusional belief of the patient that is received by the partner. In the first stage the patient feels ridiculed and mocked, he gradually gains certainty and seeks evidence later the persecutor becomes the persecutor.

Sensitive relationship delirium – relationship delirium suddenly triggered by the conflict between the patient and the immediate entourage. Debut marked by humiliating circumstances, sentimental failures that hurt the pride of the subject. 

Paraphrenia (A complete guide)

Conclusions

In this article, we talked about the diagnosis of paraphrenia, the clinical forms of paraphrenia, differential diagnosis and treatment. We also talked about another persistent delusional disorder – paranoia. 

Paraphrenia is characterized by a hallucinatory systematized chronic delirium, unlike paranoia, where the delirium, although systematized, is non-hallucinatory.

A diagnosis of paraphrenia is hampered by the patient’s lack of cooperation. The diagnosis is established on the basis of the presence of hallucinatory systemic delirium, with the predominance of fables, imaginative phenomena, fantastic elements.

If you have any questions, comments or recommendations, please let us know in the comments section below. 

Further reading

Dementia Præcox and Paraphrenia, by Emil Kraepelin

Paraphrenia, by Ronald Cohn Jesse Russell 

Tales of Paraphrenia, by b. levy 

The Theory of Schizophrenic Negativism, by Eugen Bleuler 

Psychosis in the Elderly, by Anne M. Hassett 

References

Ebert, A., & Bär, K. J. (2010). Emil Kraepelin: A pioneer of scientific understanding of psychiatry and psychopharmacology. Indian journal of psychiatry, 52(2), 191–192. 

Freitas, C., Figueiredo, A. R., Abreu, T., & Queirós, S. (2016). Paraphrenia: Evolution of the concept. European Psychiatry, 33, S529.

Ravindran AV, Yatham LN, Munro A. Paraphrenia redefined. Can J Psychiatry. 1999;44(2):133-137.

Paraphrenia (A complete guide)

Nadejda Romanciuc

Nadejda Romanciuc holds a Bachelor’s degree in psychology and a diploma in Addiction studies. She is part of the Romanian Association of Integrative Psychotherapy as a psychotherapist under supervision. She's practicing online counselling for over two years and is a strong advocate for mental health.