A 70 year old woman who lived in California's central valley, with no history of any psychiatric disorder, began to complain that a man was stealing the ranch's water. Water is in short supply in many parts of the region, and she and her late husband had gone to great expense and trouble to find a deep well supply. The water was critical to their livelihood. She took to staying up nights, sitting near the well with a flash camera on her lap, ready to catch the thief. However, she fell asleep before dawn each night. Her family parked a pickup truck nearby so that she could sit in it and be more comfortable. She just fell asleep earlier in the truck, and never did catch the thief. The family verified that no water had been stolen. It was a delusion in the 70 year old woman.
An 80 year old woman in Tennessee "knew" a man was spying on her and taking items her family knew she had just misplaced. The man entered the house through the ceiling. He was also putting thoughts into her head. Her concern was overwhelming. 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.
Neither woman had other complaints. Their families both said they had “withdrawn” some, but had no other symptoms of depression. Neither woman was taking any prescription or over-the-counter medication (such medications can, rarely, lead to delusions).
On neurobehavioral examination, both women had normal memory. In summary, these older women had new-onset delusional disorders.
Is It Late-Onset Schizophrenia or Paraphrenia?
In North America, these women 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-20s and in women by their late 20s. 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. Paraphrenia is said to occur without most of the signs and symptoms of schizophrenia—the person's thinking is essentially normal otherwise.
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 many 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
Differences suggest these two conditions are entirely distinct.
- Paraphrenia is more likely to be delusional, without prominent hallucinations. (Hallucinations are perceptions not based on reality, such as hearing voices or seeing objects that no one else perceives.)
- Delusions (and hallucinations when they occur) are likely to be limited to the person’s surroundings in paraphrenia, whereas in schizophrenia, they are unlimited.
- In paraphrenia, there is less likelihood of schizophrenia in close relatives.
- 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. Dr. Manuel F. Casanova, neurologist and neuropathologist at the Medical College of Georgia, notes that paraphrenia appears to be a disease caused by abnormal brain tau similar to Alzheimer's. (Tau is a protein in brain cell membranes.) However, hippocampal pyramidal cells are preserved, and there is little brain amyloid, two characteristics that distinguish paraphrenia from Alzheimer's, according to Dr. Casanova.
Is It Alzheimer's Dementia?
Delusions are not uncommon in Alzheimer's dementia. However, before Alzheimer's can be diagnosed, there must be significant loss of memory.
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.
Since delusions in an older person might be due to several different causes, many clinicians now simply label the condition "delusional disorder."
Sources
"Paraphrenia" by Osvaldi Alemeida in Seminars in Old Age Psychiatry. By Rob Butler, Brice Pitt. (1998) American Psychiatric Press
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.
James Cooper - I'm on the faculty of a health science department at a large university. Most of my articles derive from conferences or presentations ...
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