Descriptive Psychopathology: The Signs and Symptoms of ...

284 Section 3: Examination domainsParanoiaIn its original usage, the term paranoid included delusions of grandeur. Kahlbaumintroduced it in 1863 to replace the older term Verrucktheit. Paranoia referred toan “insanity essentially affecting intellectual activity”.Paranoia and delusions of persecution are synonymous in modern usage.In lay terms it has also come to mean suspiciousness or prone to seeing conspiraciesin everyday human affairs. Originally, paranoia referred to a disorder ofintellect leading to a fixed false belief, the patient normal in other respects. Therewere no associated “negative” symptoms or hallucinations, and personality wasspared. Kraepelin conflated the syndrome into his dementia praecox construct,but many writers continued to recognize a circumscribed delusional disordertending to occur in early mid-life without deterioration in other behavioraldomains. This view is reflected in the terms: paranoid reaction and paranoidpersonality (DSM-I), paranoid states and involutional paranoid state or paraphrenia(DSM-II), paranoid disorders, folie à deux (DSM-III) and delusionaldisorder (DSM-IV). 50ParaphreniaThe paraphrenias are syndromes no longer recognized in classification and aresubsumed in the delusional disorders category. Their presence suggests definableneurologic disease. If they differ from delusional disorder, it is only in their lessstructured delusional story. Paraphrenias are of acute onset, occur in late adultlife, and are typically associated with intense emotional expression. Prognosisrelative to schizophrenia is good, and sufferers continue their daily activities andemployment as long as the intensity of the symptoms remains low.Paraphrenias were classified by the predominating psychopathology (affectladenwith rapid intense mood swings, hypochondriacal with delusions of organdisease, incoherent with a delirious picture, expansive with grandiose delusions,and fantastic with confabulatory delusions of experiences outside physical possibility).The validity of these designations has not been adequately studied, andthey likely represent several different illnesses. 51Two forms, however, are usefully separated from delusional disorder. Phonemicparaphrenia with continuous voices that gradually wax and wane is discussed inChapter 10. 52 Late paraphrenia (“paranoid states of the elderly”) is a delusionalsyndrome occurring after age 60. Deafness, visual impairment and general medicaldisability are common co-occurring conditions. It is often a harbinger ofdementia. It is also seen in older men, previously abusers of alcohol, who becomeincreasingly suspicious and irritable, accusing wives of infidelity, family membersof stealing, and neighbors and local government of various infringements. 53