Kraepelin’s paraphrenia
Kraepelin used Kahlbaum’s term paraphrenia to identify a group of patients who had many similarities to people with dementia praecox but were differentiated because of “the far slighter development of the disorders of emotion and volition” and “the inner harmony of the psychic life is considerably less involved” [4, p. 283]. Kraepelin recognized that in paraphrenia, paranoid delusions were still a prominent feature along with hallucinations and that abnormalities in disposition were seen late in the illness as opposed to the early “dulness and indifference” [4, p. 283] that is seen as an early manifestation in dementia praecox. He also described how in paraphrenia behavioral abnormalities were understandable in terms of the person’s delusional belief system rather than an independent disorder. Kraepelin felt that paraphrenia was a progressive illness that developed over time and caused significant morbidity.
Kraepelin described four subtypes of paraphrenia.
Paraphrenia Systemica: “the extremely insidious development of a continuously progressive delusion of persecution, to which are added later ideas of exaltation without the decay of personality” [4, p. 284].
Kraepelin believed this to be the most common subtype. He described the occurrence of persecutory delusions that developed from simple suspiciousness to complex delusional systems, which ultimately occupied the person’s life totally. The person would go on to develop hallucinations, typically auditory in nature, and passivity phenomena. This group would then develop ideas of exaltation almost as a response to their negative paranoid delusions that were so dominant in their psyche. Apart from misinterpretations secondary to delusions, perception was never affected and patients remained fully orientated. Patients’ moods could be described as anxious and depressed with suspiciousness and hostility later due to the ongoing negative delusional beliefs. Kraepelin described the course of this illness as being slowly progressive with only minimal fluctuations. The main differentiating factor from dementia praecox was the preservation of the psychic personality. Kraepelin found that 60 percent of patients in this group were male.
Paraphrenia Expansiva: “the development of exuberant megalomania with predominantly exalted mood and slight excitement” [4, p. 302].
Kraepelin felt that this subtype affected only women and the clinical picture was dominated by ideas and delusions of exaltation, often erotic, that involved the person being in an affair that was widely talked about in high circles or that people believed them to be saintly or close to God. There was invariably the presence of persecutory delusions; however, they did not dominate the clinical picture and hallucinations were common and were typically visual. Patients would commonly develop delusional memories. Mood was described as self-conscious cheerful and often irresponsible but with the potential for patients to fall into “violent excitement” [4, p. 306]. Again behavioral abnormalities were understandable in the context of the person’s delusions.
Paraphrenia Confabulans: “distinguished by the dominant role of pseudo-memories” [4, p. 309].
This subtype only consisted of a small number of the patients Kraeplin studied and he felt that there was an equal sex distribution. Patients would have delusions of persecution along with delusions of grandeur; however, the prominent feature would be pseudo-memories and so for the patients everything would seem familiar.
Paraphrenia Phantastica: “luxuriant growth of highly extraordinary, disconnected, changing delusions” [4, p. 315].
In this subtype persecutory delusions are prominent. Patients develop auditory hallucinations and rarely visual hallucinations. They may also experience delusions of passivity and impairment of sensation, leading them to believe they are being tortured. The delusions would become ever more extraordinary and sudden in nature. In this subgroup, 60–70 percent of Kraepelin’s cases were male.
Kraepelin was unable to comment on the heritability of paraphrenia; however, he did consider there to be evidence of abnormal premorbid personality traits in some patients. He also felt that this illness was due to internal causes rather than the predominant external causes of mental disorder at that time—alcohol and syphilis—and the majority of patients developed the illness between the ages of 25 and 50.
Kraepelin himself acknowledged that it was often difficult to delineate the paraphrenias that he observed from other, more accepted diagnoses. In particular he highlighted the similarities between paraphrenia confabulans and mania and paraphrenia phantastica and paranoid forms of dementia praecox. However, he maintained that his observations of these patients over many years (often over 10 years or more) indicated that there were subtle differences, particularly the preservation of emotion, volition, and intellect, that justified the separate description of these disorders.
A follow-up study of the 78 patients that Kraepelin had diagnosed as having paraphrenia cast doubt on the validity of paraphrenia as a diagnosis [6]. It was felt that only 28 of the original 78 patients still had a diagnosis of paraphrenia following 10 years of observation and 32 patients had progressed to dementia praecox. Other diagnoses were thought to be mainly affective or organic psychoses. The study also found little evidence that enabled differentiation between the subtypes proposed by Kraepelin [7] or that it was possible to differentiate between those who would go on to develop dementia praecox [8]. Mayer’s findings that the majority of the patients, whom Kraepelin had identified as having paraphrenia, actually progressed to other identifiable psychiatric diagnoses and had a significant and understandably negative impact on the standing of paraphrenia within the psychiatric community. It is interesting to note, however, that a significant minority of the patients did retain a diagnosis of paraphrenia. Clearly there were some understandable reservations about Kraepelin’s proposal particularly with regard to the validity of the four subtypes of paraphrenia and the delineation between paraphrenia and dementia praecox. However, what has not been satisfactorily reconciled in the literature is what should be done with the 36 percent of patients whose clinical condition seemed to retain the features of paraphrenia as proposed by Kraepelin.
The delineation between paraphrenia and dementia praecox at this time seemed questionable although Leonhard published his findings from a study of 530 people with chronic schizophrenia [9] and used the term paraphrenia to describe all paranoid schizophrenia, which was the prevailing wisdom in German psychiatry at the time [10]. Fish then related Leonhard’s findings to his series of 111 female patients with chronic schizophrenia, with an age of onset of illness ranging from 14 to 56 years. He found that it was possible to use this classification system, which also included the diagnoses of catatonia and hebephrenia, to diagnose the patients in his study [10]. Whilst Fish did make use of the diagnosis of paraphrenia to describe a number of patients from his case series it could be concluded that in doing so he was simply using it as a proxy for paranoid schizophrenia. In doing this it would appear that Fish was in agreement with Mayer’s theory that paraphrenia, as a distinct entity from dementia praecox, was not necessarily a valid diagnosis. More recently Leonhard’s category of systematic paraphrenia was found to have only moderate validity and diagnostic stability in comparison to hebephrenia, schizophrenia and no mental illness [11]. Developments in research techniques may also lead to interesting work based on earlier studies. One area could be in molecular genetic research into subtypes of schizophrenia due to previous findings by Fish [12], that Leonhard’s nonsystematic affect laden paraphrenia seemed to be the treatment sensitive subtype of schizophrenia [13].
