1) Paranoid Schizophrenia: Introduction & Epidemiology

A Schizophrenic's Artwork
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The artwork here can be considered as an approximate representation of the patient's disjointed mental functions.
Image Source: http://commons.wikimedia.org/wiki/File:Cloth_embroidered_by_a_schizophrenia_sufferer_edit.jpg

Coined by Eugen Bleuler in 1950, the term ‘Schizophrenia’ refers to a group of mental disorders with heterogeneous outcomes. The most prevalent subtype of schizophrenia is the paranoid subtype. Typically, this disorder is characterized by psychosis, in which the patient suffers from altered perceptions of reality. According to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM – 5), the typical subtypes – paranoid, catatonic and disorganized, among others have been eliminated, although the general definition of the disorder remains unchanged. These changes were made due to the clinically diverse prognosis, pathophysiology and etiology of the disorder, which add to its heterogeneity[1][2].

In addition, sex of the patient and age of onset of the disorder also contribute to schizophrenia’s diverse effects. The age of onset and sex of the patient heavily influence the demographics and course of paranoid schizophrenia, and in turn are also affected by the patients ethnicity and any premorbid conditions the patient may have suffered[1][3].

Premorbid conditions include major depressive disorder, drug abuse including cannabis and certain anxiety disorders. Paranoid schizophrenics face social and personal problems such as unemployment and failed relationships. This factors result in an increased suicide risk of such people[1].

Paranoid schizophrenia is prevalent in ~0.5% of the general population, affecting males more commonly than females. However, there are widespread differences occurring within countries and communities, right up to the level of individual neighborhoods[1][3].

Introduction

History and Definition

Emil Kraepelin [8]
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Emil Kraepelin defined a set of mental states and
termed it dementia praecox.

Psychosis or a psychotic disorder is a mental condition in which the patient loses touch with reality. Prior to the 19th century, psychosis, in general, had been around since the time of the ancient Egyptians to the era of the ancient Roman and Greek civilizations. But none of these cases had a direct link to schizophrenia, much less paranoid schizophrenia. The first documented case of paranoid schizophrenia was that of an English tea trader named James Tilly Matthews[4]. This account was documented by Phileppe Pinel and was published in 1809. Before the term ‘schizophrenia’ came into existence, a set of mental conditions was defined by the German psychiatrist Emil Kraepelin, and he termed it dementia praecox. Dementia praecox is a psychotic disorder in which the patient presents with progressively deteriorating loss of cognitive function. In 1899, Kraepelin broadly distinguished between the major psychotic disorders at the time and classified them into manic depression and dementia praecox. Dementia praecox was popularized by Kraeplin in his books between 1893 and 1899. These descriptions in his textbooks were ultimately classified as a different disorder altogether and renamed as ‘schizophrenia’.

Eugen Bleuler [9]
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Eugen Bleuler first coined the term 'Schizophrenia' in 1908.

Schizophrenia as a word itself, originates from two Greek words – schizein, which means “to split” and phrēn which translates into “the mind”. The term ‘schizophrenia’ was coined by Eugen Bleuler in the year 1908 and roughly translates into: “the splitting of mental functions (or the mind)”. Bleuler’s intention was to use this term to describe the estrangement or discontinuity of mental functions. These mental functions included perception, memory, cognitive processes, emotions and personality. Bleuler described four primary symptoms of schizophrenia. According to him, the ‘4A’s’ of schizophrenia were – Ambivalence, Autism, reduced Association (or disassociation) of ideas and flat Affect. In addition to this, Bleuler also observed that this disorder was different from dementia praecox, as some individuals recovered partially instead of progressively worsening[5][6].

Kurt Schneider [10]
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Kurt Schneider described Schizophrenia's first-rank symptoms
in the early 20th century.

The German psychiatrist Kurt Schneider, during the earlier half of the 20th century, described the first-rank symptoms or Schneider’s first-rank symptoms. Schneider formulated this list of first-rank symptoms in order to classify and separate schizophrenia from other psychotic disorders. The major first-rank symptoms include – hallucinations (auditory and somatic), thought insertion, thought broadcasting and delusional perception. Schneider’s first-rank symptoms have been instrumental in designing the diagnostic criteria for schizophrenia, however, the exact nature of these symptoms is not very thorough and they have been questioned[7].

DSM-5 Classification

Louis Wain's Cats
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The cats in this image have been drawn by the English artist Louis Wain. The cat in the left panel was drawn when
Wain was not diagnosed with Schizophrenia. The middle and right panels are drawings of a cat by the same artist during
early and advanced stages of the disorder respectively.
Image Source: http://endofthegame.net/2011/11/26/schizophrenic-cats/

After an evolving through six editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the exact definition of schizophrenia still remains elusive. Initially, diagnosing schizophrenia was focused on the Kraepelinian concepts of the disorders poor outcome, chronicity and patients avolition. A broader definition of the disorder was reflected in DSM – I and DSM – II. These two editions used Bleuler’s symptoms as a reference and focused mainly on the interpersonal pathology and negative symptoms. The DSM – III and subsequently the DSM – III R and DSM – IV, adopted Kurt Schneider’s first-rank symptoms and highlighted them in addition to the chronic nature and lack of functioning seen in the disorder. The primary construct of the DSM – IV was seen to be reliable, had a fair amount of validity, but more importantly, was clinically relevant. Therefore the primary definition of schizophrenia remains unchanged in the DSM – 5[2].
However, it is to be noted here that the heterogeneity of the disorder is inadequately described by the various subtypes of schizophrenia listed in the DSM – IV. In addition to this, the diagnostic effectiveness of Schneider’s first-rank symptoms have been scrutinized even more, as its focus on special hallucinations and bizarre delusions further obscure the diagnosis of schizophrenia. According to the DSM – 5, the five characteristic symptoms of schizophrenia of which, at least two are to be present for a period of one month, will remain unchanged. These include – hallucinations, delusions, disorganized speech, catatonic behavior and negative symptoms[2].
Prior to the elimination of its subtypes, schizophrenia had the following distinct clinical subtypes – paranoid, undifferentiated, disorganized and catatonic, with the paranoid subtype being the most commonly diagnosed among patients. However, studies have shown that these subtypes are not reliable, are not stable over a period of time and have little or no prognostic value. In addition, these subtypes do not tend to occur together in families and many a time, patients present with more than one subtype. Finally, the subtypes mentioned above do not respond to any particular pattern of treatment and they cannot be inherited from parent to offspring. As a result, these subtypes of schizophrenia have now been eliminated. The DSM – 5 focuses on the psychopathological aspects of the disorder in order to more effectively address its heterogeneity which can have a higher validity, better use clinically and encourage measurement-based treatment. Along with these new approaches and with the help of the DSM – 5 in combining the neurobiological and genetic aspects of schizophrenia, it might be possible to unravel the true nature behind this mysterious disorder[2].

Epidemiology

Schizophrenia is a conglomerate of mental disorders with distinctly heterogeneous outcomes. Its heterogeneity is affected by the sex and age of the onset in the patient, along with certain premorbid conditions.

Onset Age, Sex and Number of Episodes

In a study conducted by Skokou and Gourzis (2014), it was that the average age of onset is 30.7 ± 8.7 years in males and 36.5 ± 10.6 years in females. It is to be noted that young women are affected by an average of 3 years later than their male counterparts. There is however, no significant difference in the age of onset in older males and females. The young (early) onset group was under the age of 30 years, while the late onset group of patients was 35 years or older. The number of psychotic episodes there was no particular difference between the age and sex of the patient. It was observed that in more than half the cases presented, in both young and late onset males, the patients were suffered from their first episode of psychosis. In females, the majority of young and late onset patients were affected their first psychotic episode, but there was a greater variation in females between the young and late onset patients, when compared to males[1].

Demographic Features

This study showed that older patients who were affected by paranoid schizophrenia had an increased likelihood of being born in rural areas as opposed to younger patients. There were 88 schizophrenic patients in this study, 66% of whom had a preference to urban areas without significant variations amongst the groups (males vs. females/young vs. old). As opposed to the young onset group, the late onset group of patients, particularly females, had a tendency to be married[1].

Effect of Premorbid Conditions

It was seen that patients with an earlier onset of paranoid schizophrenia had a tendency to exhibit avoidant personality disorder characteristics when compared to the late onset group. However, it was seen that late onset patients showed signs of passive-aggressive behavior than younger patients. Additionally, it was noted that males in the late onset group displayed egotistical, exaggerated and antisocial premorbid traits traits than women. Young onset males presented with different premorbid traits – these patients showed signs of paranoia and were not as depressed as young onset females. They also presented with schizotypal symptoms including altered perceptional experiences, suspiciousness, delusions of reference and social anxiety. It is to be noted here that these premorbid schizotypal traits are similar to the psychopathology associated with schizophrenia, in its active phase and are also similar to its positive symptoms. With respect to personality disorders in general, in most cases, patients presented with either paranoid personality disorder (PPD) or obsessive compulsive disorder (OCD). However, borderline, antisocial, schizotypal, avoidant and narcissistic personality traits were also seen but were less common compared to OCD or PPD[1].

Concluding Remarks

Based on the study by Skokou and Gourzis (2014), it can be said that the age of onset and sex of the patient seem to have a regulating effect on the phenotype of the disorder. In other words, the natures in which the symptoms of paranoid schizophrenia seem to present themselves are partially dictated by the age of onset and the gender of the individual. Patients with a younger age of onset for both sexes and the female group in particular develop schizophrenia related to social isolation and social avoidance disorder. This in turn may stem from an anxious-depressive state of mind. Individuals with a later of onset and the male subset of patients seem to affected by hostile, impulsive behavior and paranoia based delusions[1][3].

Bibliography
1. Skokou M, Gourzis P. Demographic features and premorbid personality disorder traits in relation to age of onset and sex in paranoid schizophrenia. Psychiatry Res. 2014; 215(3): 554-559.
2. Tandon R, Gaebel W, Barch DM, Bustillo J, Gur RE, Heckers S, Malaspina D, Owen MJ, Schultz S, Tsuang M, Van Os J, Carpenter W. Definition and description of schizophrenia in the DSM-5. Schizophr Res. 2013; 150(1): 3-10.
3. Kirkbride JB, Fearon P, Morgan C, Dazzan P, Morgan K, Tarrant J, Lloyd T, Holloway J, Hutchinson G, Leff JP, Mallett RM, Harrison GL, Murray RM, Jones PB. Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study. Arch Gen Psychiatry. 2006; 63(3): 250-258.
4. Heinrichs RW. Historical origins of schizophrenia: two early madmen and their illness. J Hist Behav Sci. 2003; 39(4): 349–363
5. Stotz-Ingenlath G. Epistemological aspects of Eugen Bleuler's conception of schizophrenia in 1911. Med Health Care Philos. 2000; 3(2): 153-159.
6. Impact of the term Schizophrenia on the culture of ideograph: The Japanese experience By Kim, Yoshiharu; Berrios, German E. Schizophrenia Bulletin. 2001; 27(2): 181-185.
7. Nordgaard J, Arnfred SM, Handest P, Parnas J. The diagnostic status of first-rank symptoms. Schizophrenia Bulletin. 2008; 34(1): 137–154.

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