SCHIZOPHRENIA AND SCHIZOPHRENIFORM DISORDERS
Posted by recep on June 25th, 2009SCHIZOPHRENIA AND SCHIZOPHRENIFORM DISORDERS
Suspiciousness, persecutory ideation, and paranoid delusions are frequently seen in cognitively impaired or emotionally distressed older adults. Between 2% and 5% of elderly persons in the community exhibit excessive suspiciousness and persecutory ideations. As many as 4% to 5% have delusions and hallucinations, and these symptoms are often disabling. Nevertheless, the prevalence of schizophrenia, as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), is < 1% in later life.
Although current nomenclature does not help in the differential diagnosis of schizophrenia-like symptoms in the elderly, investigators and clinicians who have worked with older adults generally agree upon five relatively distinct syndromes: (1) abnormal suspiciousness, (2) transitional paranoid reactions, (3) late-life paraphrenia (severe paranoid illness without deterioration of other cognitive or affective processes) or paranoia associated with late-onset schizophrenia, (4) persistence of early-onset schizophrenia, and (5) acute paranoid reactions secondary to affective illness.
Symptoms, Signs, and Diagnosis
Most older adults who exhibit abnormal suspiciousness do not have contact with mental health professionals. However, they frequently have medical problems and are often seen by a primary care physician or geriatrician. These patients may have vague complaints of external forces controlling their lives. Occasionally, these beliefs become focal, often directed at their children; eg, they believe that their children have deserted them or have plotted to obtain control of their finances or property. Perception of a loss of control, coupled with an inability to evaluate the social milieu, favors the development of such suspiciousness.
Physicians also encounter suspiciousness associated with memory loss and attention deficits. Institutionalized persons suffering from dementia are often suspicious of both family and staff. Their accusations are usually disjointed, unfocused, and unaccompanied by sustained emotional distress. Common complaints concern objects being stolen, medicines being swapped, and attendants misbehaving. Symptoms derive from the patient’s inability to organize environmental stimuli and comprehend the often confusing activities of the hospital or long-term care facility. It is unknown whether an underlying paranoid personality contributes to excessive paranoid behavior in persons with dementia. Physicians must remember, however, that older persons at times are mistreated in long-term care facilities, and suspiciousness may be grounded in fact.
Transitional paranoid reactions are narrow, focal, and situational. They are usually manifested in women who live alone and believe in plots against them. The focus of hallucinations and delusional thinking usually moves gradually from outside the home to inside it, from complaints of noises in the basement and attic to reports of physical abuse or molestation. Hence, a transition can be observed from external threats to violations of property and person. Social isolation and perceptional difficulties contribute to transitional paranoia.
Paraphrenia is not universally accepted as a distinct syndrome. Those who distinguish the syndrome emphasize that the condition is primary and not secondary to an affective illness or to an organic mental disorder. In addition, the gross disturbances of affect, volition, and function characterizing schizophrenia are not prominent. Nevertheless, paranoid delusions and hallucinations are almost invariably present. Late-life paraphrenia may be chronic, but deterioration to the extent observed in schizophrenia or Alzheimer’s disease is not characteristic. The boundaries blur not only between late-life paraphrenia and classic paranoid schizophrenia but also between the transitional paranoid state and paraphrenia.
Persons suffering from late-onset paraphrenia often report plots against them, focusing once again on family members. In contrast to mild suspiciousness, these plots are persistent, extreme, and elaborate. No cognitive impairment is noted. Although the paraphrenic patient is physically independent (diet and hygiene are rarely compromised), social functioning and cooperation with health care staff members are greatly impaired. Such persons rarely speak for long without referring to the symptoms of concern.
No clear association has been established between late-onset paraphrenia and the female sex, social isolation, or a distinct personality type. Nevertheless, paraphrenic patients usually are female, live alone, and have shown evidence of difficult social interactions earlier in life. In contrast to schizophrenic patients, however, these persons are warm, friendly, and trusting, especially when interviewed in their own homes and not threatened with the diagnosis of a psychiatric disorder. Paraphrenic patients tend to have hearing problems, but the relationship between hearing impairment and paraphrenia is not nearly as strong as some authorities contend.
Early-onset schizophrenia may persist into late life. Typically the symptoms become less acute, yet social functioning continues to deteriorate gradually over time. Acute paranoid thinking may accompany a severe major depression or an acute manic episode. Treating the mood disorder usually eliminates the paranoid thinking in these patients.
Treatment
The physician caring for the paranoid older adult must establish a trusting and supportive relationship. Displays of respect, a willingness to listen to complaints and fears, and availability by telephone are essential. Most elderly persons do not abuse telephone privileges and are generally willing to wait for the physician to return a call.
The physician should not—at least initially—confront the patient with the lack of reason and false assumptions inherent in paranoid ideation. Such a confrontation is of no value and may disrupt the therapeutic relationship. On the other hand, the physician must not deceive the patient by pretending to agree with the paranoid beliefs. Rather, an interest should be expressed in wanting to understand what is troubling the patient and in working together despite any disagreement over the source of the problem. A desirable goal is to develop a level of confidence that permits an examination of the patient’s beliefs.
The physician must also establish a relationship with key persons in the patient’s social environment. Family members are often the first to notice a deterioration in the patient’s condition and, therefore, the first to contact the physician when a problem arises. Police officers, neighbors, and pharmacists also can serve as valuable allies. By understanding the paranoid behavior, they can contact the physician or family when appropriate and not overreact. However, physicians clearly must maintain standards of privilege and confidentiality when talking to family, neighbors, and friends.
Pharmacotherapy: Effective management also requires antipsychotic drug therapy. Initial dosages may range from 10 to 25 mg/day of thioridazine, 2 to 4 mg/day of thiothixene, or 1 to 3 mg/day of haloperidol.
Daily doses may be increased significantly (eg, thioridazine 50 to 100 mg), but the lower doses usually suffice except in the most acute cases. The drugs may be given once daily (at bedtime) in less severe cases.
The choice of agent is determined by the side effects the physician wishes to avoid. Thioridazine is especially troublesome in patients with postural hypotension, whereas haloperidol may create significant problems in those inclined to develop parkinsonian symptoms. Agents that are less likely to produce parkinsonian side effects are thought to also be less provocative of tardive dyskinesia. In treatment-resistant and severely psychotic persons, clozapine is a possible choice. To date, there has been little cumulative experience with clozapine in older persons, although there is evidence that the incidence of agranulocytosis is higher in older patients.
Most elderly persons are willing to take an antipsychotic drug if told that the drug will help to improve sleep and alleviate anxiety. Compliance is often problematic but less so in later life than earlier. Even paranoid persons usually trust their physicians and are willing to adhere to therapy. If objections occur, the family may be able to help. A strong objection to medication or other interventions may suggest the need for hospitalization if symptoms are severe.
