Paraphrenia

   Karl Kahlbaum coined the term in his Classification of Psychiatric Diseases (Die Gruppirung der psychischen Krankheiten, 1863), to mean both hebephrenia in the young (see Schizophrenia: Emergence) and the dementia of the elderly; his idea was that people undergoing physiological change at both ends of the life cycle are subject to mental illness, hence "para-" (p. 129). Kraepelin took up the term "paraphrenia" in the eighth edition of his Psychiatry (die Psychiatrie) textbook, in the volume published in 1913, to mean a downhill form of paranoia close to dementia praecox. Yet, paraphrenia vanished from the next, posthumous edition in 1927.

   In 1954, Martin Roth, (1917–), then director of research at Graylingwell Hospital in Chichester, revived the Kraepelinian concept of late paraphrenia. Paranoia in the elderly had first surfaced as an independent disease in the sixth edition (1899) of the Kraepelin textbook as presenile delusional insanity (praeseniler Beeinträchtigungswahn). It remained in the Kraepelinian system as part of "presenile and senile insanity." But did this category have subdivisions?

   As early as 1952, in an effort to differentiate separate illnesses in the elderly aside from dementia, Roth called attention to "paraphrenia"; yet the emphasis in his article in the Journal of Mental Science was on depression in the elderly. It was only in the 1954 textbook of psychiatry, which Roth cowrote with Eliot Slater and Willi Mayer-Gross, that he gave a full description of the disorder: "There is . . . a group of cases with firmly systematized paranoid delusions occurring in the setting of a well-preserved personality which are likewise sharply defined from the organic diseases." The presentation: "The patient usually becomes quieter and more solitary, and avoids her friends. Her suspicions may fasten on one of them or a neighbour or relative, and she may then pester the police with complaints, or bombard others with anonymous letters. She sees her enemies communicating with one another by shining lights from the windows. . . .

   Finally, her behaviour becomes so bizarre, noisy or aggressive, that the attention of public authorities is attracted, and she is removed to hospital" (pp. 474, 501). As the treatment of choice, the authors recommended leukotomy (see Lobotomy). Paraphrenia in the elderly surfaced in the DSM series only once: in DSM-II in 1968 as "involutional paranoid state (involutional paraphrenia)," evolving from "involutional psychotic reaction" in DSM-I (1952). (See also Wernicke–Kleist–Leonhard Pathway.) Roth’s concept of paraphrenia in the elderly was officially abandoned after a consensus conference led by Robert Howard (1961–) of the Institute of Psychiatry in London on Late Onset Schizophrenia [LOS], the results of which were published in the American Journal of Psychiatry in 2000. It is interesting that once again the Kraepelinian urge to swallow up rivals with the diagnosis dementia praecox had prevailed. (See Schizophrenia: Recent Concepts: late onset schizophrenia [1997].)