Late paraphrenia, past and present

Late paraphrenia which was first described nearly 45 years ago (Roth & Morrissey, 1952) refers to a relatively common form of paranoid psychosis typically manifest in old age. Its leading features resemble those of schizophrenic illness of early adult life but it also has some distinctive features of its own. Schizophrenic features comprise a high prevalence of first rank symptoms of Schneider and in other cases bizarre delusions often dominated by sexual themes. The premorbid personality is schizoid in a substantial proportion (with such features as suspiciousness, hostility, solitary interests, social withdrawal, emotional poverty). The course is chronic in most cases but response to neuroleptics is favorable in the majority. There is also raised prevalence of schizophrenia in first degree relatives and a raised prevalence of those who never married or who are divorced or separated as compared with control subjects. The differences from schizophrenia comprise the absence of both negative symptoms and deterioration of personality and the presence of a significant excess in prevalence of conductive deafness and visual impairment. A minority of about 10% have limited cerebral lesions identified by imaging or at post-mortem. But kinship with dementing disorders claimed by some authors, is excluded by the absence of intellectual deterioration higher in prevalence than in normal controls. Further, late paraphrenics have a normal expectation of life whereas in dements there is a marked abridgement of the life-span. The post-mortem neuropathology shows lesions characteristic of the main dementias to be absent or sub-threshold or present to the limited extent also found in normal controls. The arguments which have developed regarding the appropriate category for classification of late paraphrenia are unprofitable. Further enquiries into similarities with and differences from schizophrenia are more likely to shed light on certain problems of the schizophrenia family of disorders. A number of questions are posed. What factors are associated with the postponement of manifestation of schizophrenia-like psychotic illness until later life? If a comparable late onset could be achieved in all those predisposed, psychiatric hospitals would be emptied of a large proportion of beds. Can any factors be defined as linked with the absence of personality deterioration in late paraphrenia? What is the significance of sensory deficits for aetiology, do they have relevance for the pathophysiology of schizophrenia of early adult life? Light shed on any of these problems would constitute a valuable advance in knowledge.