Original Paper Psychopathology 1999;32:60–69
Life Events in Late Paraphrenia and Depression Thomas Fuchs Psychiatric Clinic, University of Heidelberg, Germany
Abstract 38 patients with late paraphrenia and 38 with endogenous depression of late onset were examined and various premorbid characteristics and biographical data compared. The main objective of the study was to look for differential risk factors and for biographical experiences that suggested a specific premorbid vulnerability in paranoid and depressive patients. In the paranoid group, a significantly higher frequency of discriminating, humiliating or threatening experiences during earlier life was found. These included expulsion from home in the years 1944–46 (53%), somatic handicaps such as amputations (13%), illegitimate birth (11%) or illegitimate children (13%), and others. In the depressed group, severe early loss prevailed (29%). The significance of these results for the etiology of late-life mental disorder is discussed.
Introduction
Paranoid and depressive functional psychoses of late life and their etiology are commonly considered from the viewpoint of risk factors such as genetic predisposition, triggering life events and organic cerebral dysfunction. Biographical and personality aspects have only played a minor role for research in the origin and understanding of late life disorder. However, these aspects may well be part of a premorbid vulnerability that manifests for the first time under the influence of additional adversities arising in old age. The main intention of the present study on late paraphrenia and depression was therefore to contribute to a biographical research in late life psychosis. Paranoid psychoses of this age are at present variably classified as late-onset schizophrenia, late paraphrenia, involutional paranoid states or delusional disorders [1, 2]. DSM-IV as well as ICD-10 demand a splitting of the well established diagnosis of late paraphrenia into paranoid schizophrenia of late onset on the one hand and delusional disorder on the other. However, this transfer of the nosology from younger age to late life has not stood the test of clinical validation so far; neither demographic nor prognos-
Fax + 41 61 306 12 34 E-Mail
[email protected] www.karger.com
© 1999 S. Karger AG, Basel 0254–4962/99/0322–0060$17.50/0
Accessible online at: http://BioMedNet.com/karger
Thomas Fuchs, MD Psychiatric Clinic University of Heidelberg Voss-Str. 4, D–69115 Heidelberg (Germany) Tel. +49 6221 56 4422, Fax +49 6221 56 5477
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
ABC
tic nor risk factors could be consistently correlated with those distinctions or with other subtypes [2, 3]. Late paraphrenic patients form a markedly homogeneous clinical picture, and their possible subgroups do not differ much from one another. For the purpose of our study we followed most other investigators in this field [1, 3–5] treating paranoid disorders of late life as a uniform type of illness. Apart from problems of classification, several risk factors and conditions have repeatedly shown up in the literature on late paraphrenia: hereditary disposition (though weaker than in schizophrenia of early onset), paranoid or schizoid premorbid personality traits, female sex, social isolation, hearing impairment, subtle cognitive dysfunction and brain abnormalities [6]. Until now, however, neither personality, biographical history nor life events have been investigated systematically. – The same holds true for involutional melancholia or late life depression. Although the precipitating role of life events in the onset of illness has been repeatedly demonstrated, there is a lack of data on the role of personality and biographical experiences in its etiology [7]. Personality disorders or traits have rarely been assessed by structured interviews, and the question whether early biographical experiences may act as vulnerability factors cannot be answered yet. In a previous retrospective study [8] of patients with late-life paranoid psychosis, we found evidence of a connection between the origin of this disorder and a past history of uprooting, flight or expulsion caused by war events. The present prospective study on late paraphrenia and depression was designed to further substantiate the role of biographical history and personality in the predisposition to paranoid or depressive illness in later life. The literature comparing both patient groups is scarce and mainly related to single issues such as premorbid personality, sensory impairment and sociodemographic variables; late paraphrenic patients appear to be more often single, to have fewer children, more frequent hearing impairment and more paranoid or schizoid personality traits than involutional depressives [1, 5, 9]. The present study addresses two questions: (1) Which risk factors are specific for late paraphrenia versus depression? and (2) Are there biographical experiences which could contribute to a specific vulnerability of elderly paranoid and depressed patients?
Sample and Method Our sample consisted of 76 elderly psychiatric patients, 38 with a diagnosis of paranoid psychosis and 38 with endogenous depression, admitted consecutively to the Psychiatric Clinic of the Technical University, Munich, between 1992 and 1997. All depressives were inpatients; of the paranoid sample 24 were inpatients and 14 outpatients who were referred to the psychiatric clinic by their general practitioner or sought help at the University’s toxicological department for fear of poisoning. Inclusion criteria were: (1) schizophrenic, delusional or schizoaffective disorder (ICD-10, F 20.0, 22.0, 22.8 or 25.1) or major depression, melancholic type, with or without psychotic symptoms (ICD10, F 32.11, 32.2 or 32.3); (2) onset of first symptoms after the age of 55. Exclusion criteria were: (1) drug or alcohol abuse; (2) degenerative, vascular or tumorous brain disease, as manifested by clinical signs or CT/MR scan; (3) history of bipolar affective disorder; (4) Mini-Mental State Examination (MMSE) score ! 25. All patients were assessed by the author who administered a semistructured clinical interview designed to cover a wide range of biographical, sociodemographic and illness-related information, the MMSE and a structured interview for personality disorders.1 Clinical records were searched for the presence of somatic illness; practitioners’ reports were used if no records were available. All patients The results of the personality assessment are presented in a separate report.
Life Events in Late Paraphrenia and Depression
Psychopathology 1999;32:60–69
61
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
1
underwent a clinical examination and received CT or MR scans in order to exclude brain lesions. In addition, auditory and visual impairment were assessed by grading each into 3 categories, respectively, according to clinical impression or examination. Hearing: 1 = normal hearing, no difficulty in verbal communication; 2 = moderate hearing impairment, patient uses hearing aid or needs to have material repeated or presented at greater volume; 3 = severe impairment, shouting or written communication required. Vision: 1 = normal vision (with or without spectacles); 2 = moderate visual impairment, patient unable to read normal newspaper print but only headlines; 3 = severe impairment, patient cannot read any print. Data Analysis For analysis of group differences, the ¯2 test and the t test were used.
Results
In total, 76 patients met the requirements for being enrolled in the study. 9 further patients with paranoid or depressive disorder were not included because of alcohol abuse, history of stroke and metabolic CNS disease. In accordance with the diagnostic guidelines in ICD-10 the patients were categorized as follows (tables 1, 2): of the depressive patients, 14 had only one, 24 a recurrent episode; the mean number of episodes was 2.5. Delusions were present in all of the paranoid and in 18 of the depressive patients. Table 3 shows general sociodemographic and clinical variables of the study sample. Female sex was overrepresented in the paranoid group which is in accordance with the findings in most other studies on late paraphrenia [3–5, 10]; the difference, however, was not significant. The level of education2 was significantly higher in the depressive group. – Somatic illness was considered present, if a chronically impairing and continuously treated condition had been diagnosed before. The prevalence was also significantly higher in the depressed group; nearly half of the patients suffered from chronic somatic diseases, whereas most of the paranoid patients were not only free from serious illness but even in an exceptionally healthy and vital state.3 – There was also a highly significant, yet inverse difference in hearing impairment, with the paranoid patients having more moderate or severe deafness, whereas visual impairment did not distinguish the two groups. Family history of paranoid or affective disorder was different as expected in accordance with the index illness. – In all other variables the two groups were similar; as can be noted, all patients were born before World War II, which is of importance for the comparison of their biography. A major purpose of our study was to record information on biographical conditions or events which patients experienced as severe strain or distress and which in retrospect were meaningful for their life. Table 4 compares the prevalence of such conditions in both groups during patients’ life-span up to 5 years before illness onset.4 All items were asked for separately in the course of the biographical interview. These results can be summarized as follows: In the paranoid group we find an increased frequency of (a) discriminating or stigmatizing conditions (illegitimate birth 2 Low = primary school, apprenticeship or no occupational training; high = secondary or grammar school, higher occupational training. 3 The diagnoses referred mainly to cardiovascular, gastrointestinal, respiratory diseases as well as neoplasms or Parkinson’s disease. Since the paranoid patients were on average 2 years older (cf. table 3), this could not be due to age differences. 4 Other, in most cases more recent events such as bereavement, retirement, physical illness, will be examined in a separate report.
Psychopathology 1999;32:60–69
Fuchs
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
62
Table 1. Diagnoses of 38 paranoid patients (ICD-10)
Diagnosis
n
%
F 20.0 (paranoid schizophrenia) F 22.0 (delusional disorder) F 22.8 (other delusional disorder) F 25.1 (schizoaffective disorder, depressive)
9 12 15 2
24 32 40 5
Table 2. Diagnoses of 38 depressive patients (ICD-10)
Diagnosis
n
%
F 32.11 (moderate depressive episode with somatic syndrome) F 32.2 (severe depressive episode without psychotic symptoms) F 32.3 (severe depressive episode with psychotic symptoms)
11 9 18
29 24 47
Table 3. Sociodemographic and clinical variables
Gender Men Women Mean (BSD) age, years Year of birth Level of school education Low High Chronically impairing somatic illness Hearing impairment 1 = None 2 = Moderate 3 = Severe Visual impairment 1 = None 2 = Moderate 3 = Severe Mean (BSD) age of first onset of illness, years Mean (BSD) duration of illness, years Family history of paranoid or schizophrenic disorder Family history of affective disorder or suicide Mean (BSD) MMSE score
Paranoid (n = 38)
Depressive (n = 38)
5 (13) 33 (87) 73.3B7.6 1902–1938
12 (32) 26 (68) 71.1B7.6 1906–1935
27 (72) 16 (42) 5 (13)
11 (29)* 22 (58)* 18 (47)*
21 (55) 11 (29) 6 (16)
32 (84)** 4 (11)* 2 (5)
31 (82) 5 (13) 2 (5) 68.4B8.9 4.7B4.5 6 (15) – 27.0B1.0
34 (89) 4 (11) – 66.5B6.8 4.1B4.8 –* 12 (29)*** 28.1B1.2
* p ! 0.05; ** p ! 0.01; *** p ! 0.001. Values in parentheses are percentages.
Psychopathology 1999;32:60–69
63
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
Life Events in Late Paraphrenia and Depression
Table 4. Severe life events (up to 5 years before onset of illness)
Life events
Illegitimate birth Divorce of parents before age 14 Death of parent before age 14 Illegitimate child Death of a child before age 18 Rape Expulsion/flight Amputation or handicap Divorce or separation
Paranoid
Depressive
n
%
n
%
4 4 1 5 2 3 20 5 12
11 11 3 13 5 8 53 13 32
1 2 7 3 4 – 7 1 4
3 5 18* 8 11 – 18** 3 11*
* p ! 0.05; ** p ! 0.01.
or child, amputation, handicap): 14 cases (vs. 5 in the depressive group which is significant, p ! 0.01); (b) experiences of persecution or threat from others (expulsion from home, rape)5: 23 cases (vs. 7 in the depressive group, significant, p ! 0.01); (c) experiences of fragility of relationships (divorce of parents, own divorce): 16 cases (vs. 6 in the depressive group, significant, p ! 0.05). In the depressive group, on the other hand, we find a history of serious losses (early death of a parent in 7 cases, 3 of these by suicide; death of a child before age 18 in 4 cases) in altogether 11 cases (vs. 3 in the paranoid group, significant, p ! 0.01).
Discussion Diagnostic Classification of Late Paraphrenia In our paranoid sample we found a comparatively high rate (72%) of delusional disorder (with or without hallucinations) as compared to paranoid schizophrenia (24%). In a larger sample of 100 late paraphrenics Howard et al. [3] found ICD-10 schizophrenia in 61.4%, delusional disorder in 30.7%, and schizoaffective disorder in 7.9%; Quintal et al. [5], in their diagnostic study on late paraphrenia, obtained similar results. In these studies, however, the diagnosis ‘other delusional disorder’ (ICD-10, F 22.8), including among others ‘involutional paranoid states’, was not applied; patients with ‘persistent hallucinations’ were therefore assigned to paranoid schizophrenia generally, though this symptom can also be present in category F 22.8. If the 15 patients classified as ‘other delusional disorder’ in our study because of persistent hallucinations were assigned to paranoid schizophrenia, the frequency of this diagnosis would be comparable to the studies mentioned (i.e. 64%). However, a high rate of late paraphrenic patients have prevailing hallucinations without any first-rank or negative symptoms of schizophrenia [3, 5, 10]; in view of their clear phenomenological differences, it would 5 All these were independent life events, i.e. not due to paranoid premorbid personality or delusional perception.
Psychopathology 1999;32:60–69
Fuchs
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
64
seem inappropriate to lump all these forms of paranoid disorder together under the heading of ‘schizophrenia’. Risk Factors for Late Paraphrenia and Depression A number of risk factors named in the literature on late paraphrenia [3, 6] were confirmed by the present study in comparison to a group of elderly melancholic patients: Female sex, low grade of education, family history of paranoid or schizophrenic disorder and hearing impairment. Also in accordance with other studies visual impairment, though present in moderate or severe form through cataract and macula degeneration in 7 paranoid patients, was not significantly different in both groups. At present there is no consistent explanation of the preponderance of females in late paraphrenia. The theory of protective estrogen activity in women put forward by Häfner et al. [11] may be applicable to schizophrenia of later onset, but rather not for late paraphrenia, which usually manifests for the first time 20–30 years after the menopause. As to sensory impairment, a higher proportion of deafness (30–40%) in late paraphrenics compared to patients with other diagnoses has been repeatedly confirmed. Auditory impairment is about 3 times more frequent than in the normal population, usually longstanding, bilateral and conductive [12]. Kraepelin [13] already described delusional disorders in the deaf and pointed to a connection of humiliation, suspiciousness and paranoid thinking caused by this handicap. An etiological model based on distorted perception, self-centered interpretation of other’s verbal or nonverbal behavior, and loss of correcting feedback was suggested by the author [14]. The specific importance of impaired sensory functions for paranoid psychosis is emphasized by the inverse frequency of impairing or disabling somatic illness which in our study was significantly more prevalent in the depressive group. Accompanying physical illness was also more frequent in depressed than in paranoid elderly patients in a study of Wigdor and Morris [15]. Somatic illness acts as a precipitating factor for depression [16] and has a detrimental effect on prognosis as well [17]. Biographical Vulnerability As we expected from the results of our pilot study [8], the majority of paranoid patients had experienced events or conditions during earlier life which could have fostered a reserved and suspicious stance towards their environment; experiences of discrimination or stigmatization, expulsion or threat, and fragility of interpersonal relations. Discriminating conditions (14 in total, vs. 5 in the depressive group) consisted first in illegitimate birth in 4 cases and illegitimate children in 5 cases. These conditions may not appear so stressful nowadays as they were then; the patients themselves mostly described the resulting conflict with current sexual morals as a lasting ‘disgrace’, followed by feelings of shame and inferiority. A 76-year-old patient with delusions of poisoning had born a child when she was 22; the boy’s father died early in the war, before they could marry. The illegitimate birth was considered as unforgivable ‘indiscretion’ by her strictly catholic parents; she was turned out of the house and cut dead ever since. She found a job as a domestic help in the house of a higher civil servant who adopted the child on condition that she disavowed her motherhood even to her son for whom she had to be ‘aunt Emmy’. This humiliating situation ended by her expulsion and flight with the son to Western Germany after the war, where she hardly earned her living by cleaning or carrying letters. She could not find a new partner, and preferred her autonomy at last. The patient was described by her son as bearing deep
Psychopathology 1999;32:60–69
65
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
Life Events in Late Paraphrenia and Depression
grudges and not being able to get free from the past. Since her repudiation from her family she had thought of herself as ‘being condemned to suffer’ and had actually ‘gathered all that could have been directed against her’. He had never seen her carefree or cheerful. Delusions of reference and poisoning developed when she had to move into an old people’s home.
As a second cause of discrimination, handicaps were present in the form of limb amputation in 2 cases, in a conspicious limping gait caused by a childhood accident in 1 case, and in deafness since childhood in 2 cases. These patients had felt as ‘outsiders’ most of their lives, even if they had successfully coped with their setback by strenuous work, tenacity, and ‘relying on oneself only’. Tölle [18] also pointed to delusional developments in handicapped persons, usually in connection with a sensitive structure of personality; even early acquired handicaps may predispose to later paranoid psychosis, especially when additional experiences of shame, humiliation and lack of self-confidence occur. A 74-year-old patient, admitted with delusions of self-reference and persecution, had sustained a complicated thigh fracture in a bicycle accident at the age of 8, resulting in a limping gait. She had always suffered from her handicap and used to be called ‘limping cripple’ by her sister as well as her class-mates. She had to leave school at last and could not start a higher vocational training which also hurt her deeply. Later on she felt as an ‘outcast’ in society: ‘I was only half human, and people would let me notice it.’ She had no lasting relations with men, whom she suspected not to be really interested in her, and led a withdrawn life, mainly engaged in her work in a post office. When she retired, she gradually developed the delusional idea that former collegues were spying her house in order to drive her out.
Experiences of fragility of relations were found in 16 cases (vs. 6 in the depressive group). In 4 cases, the patients’ parents had divorced before their children were 15; these patients later had no enduring relationship themselves. Two of them explicitly stated that they did not want to run the risk of marrying which only seemed a ‘lottery’ to them. 12 patients were divorced or separated themselves; 3 were left by their partner, 9 had initiated the divorce, in 6 cases for reasons of supposed or actual infidelity (not due to delusional jealousy). As it could not always be decided whether a preexisting suspicious or schizoid attitude had contributed to the separations, these life events are not independent of personality structure. However, they still meant an experience of untrustworthiness and unreliability of significant others, which led to feelings of disappointment and bitterness. Experiences of persecution or threat from others were present in 23 cases (vs. 7 in the depressive group), mainly due to expulsion at the end of World War II; of the 3 reported rape traumas 2 occurred during these events. 20 (53%) of the paranoid patients had been expelled from previous German territories in the East during the years 1944– 1946; they were then between 7 and 38, on average 25 years of age. The percentage of expellees in the depressive group (18%) was significantly different and is in accordance with the proportion in the normal population, amounting to about 20%. Possible connections between expulsion and paranoid psychosis manifesting decades after have been discussed by the author in an earlier study [8]. Several transcultural investigations have shown that forced migration and uprooting can favor a disposition to later paranoid illness even with an onset years or decades after the migration; the period of delay was especially high in women [19–21]. Further evidence of an aftereffect of early trauma is gained from the impairment of holocaust survivors in old age [22, 23]. The conspicuous aggravation of symptoms in these patients, including an increase in suspicion and paranoid ideation, may be interpreted as a stepwise breakdown of previous defense mechanisms and coping strategies in late life.
Psychopathology 1999;32:60–69
Fuchs
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
66
These considerations could be supported to a large extent by the autobiographical interviews. Almost all of the former expellees regarded the expulsion as a severe interruption of their lives and rated it in the first, second or third position on a list of their worst life reminiscences. As particular distresses they named the loss of their home, property and social rank which they thought upon as injust and undeserved; the hostilities they had been exposed to during expulsion (e.g. 2 of the women were raped on their flight, 2 others were imprisoned for several weeks before their expulsion); the time they had to stay in camps for ‘displaced persons’, and finally the humiliating experiences as refugees in their new environment. Many of them, in spite of seemingly successful reintegration, had never wholly stopped feeling as strangers or outsiders. In at least 10 of the paranoid patients those events had obviously left lasting feelings of offence, bitterness and resentment which could still be elicited during exploration. A 67-year-old patient who suspected her neighbors of tormenting her with poisonous gases had pleasant recollections of her childhood in the country of Eastern Prussia. In 1945, however, when she was 10 years old, she and her family had to leave behind her farm and flee from the Russians. She remembered to have been anxious and frightened all the time, but also furious about all that happened. In Bavaria they had to start anew from the beginning, and she often heard her parents lament and complain bitterly. She herself had suffered having to live as a stranger or refugee in the village, and later had always felt discriminated in the family she married into. Some years ago, her sister-in-law once had said to her that she had really got a lot of things now and was doing quite well; which she understood as meaning to say ‘you know you came here without a penny and only got wealthy by marrying my brother’.
Apart from such difficulties, the effect of uprooting may also have exerted an adverse impact on patients’ marriages and birth rates, with the result of more frequent loneliness in old age. The 20 expellees married later in life than the 18 nonexpellees (average age of marriage 30.2 B 4.1 vs. 25.7 B 3.4 years, p ! 0.01); they had a lower birth rate (average 1.2 vs. 1.5 children) and were more often childless (11 = 55% vs. 7 = 39%). Several of the patients described the difficulties of integration and the obligation to support their parents or families in the new environment as obstacles for starting a family themselves. The fate of expulsion may thus have diminished the patients’ experience of close attachment and intimacy, and could have had an indirect effect on their paranoid stance in later life. In the depressive group, severe life events or conditions apart from the onset of illness were less conspicuous. However, it was found that 9 depressed patients had lost a parent before age 15 (in 3 cases by suicide); moreover, 4 female patients experienced the death of a child before he was grown up (in the paranoid group such losses were found in only 3 cases). Especially the suicides and the losses of a child were described as deeply distressing and traumatic events. It seems possible that they increased the patients’ effort to avoid further severe losses through even closer attachment to their loved ones. However, in contrast to the well established role of life events in the triggering of depressive episodes, it is unknown whether stressful conditions in earlier life can predispose a person to depressive illness in old age. The literature relating to depression in earlier adult life is inconsistent on this point. Brown et al. [24], Forrest et al. [25] and Roy [26] found that depressed patients had experienced the loss of a parent during childhood between 3 and 5 times more often than healthy controls, which could have influenced later reactions to separation or bereavement detrimentally. However, Abrahams and Whitlock [27] as well as Matussek and May [28], could not confirm a correlation between early loss and frequency
Psychopathology 1999;32:60–69
67
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
Life Events in Late Paraphrenia and Depression
of depression. This question remains as yet unsettled; especially the biography of late life depressives would certainly deserve further investigation. Because most of the above data were based on self-report, there is no conclusive way to rule out either report or recall bias, even though all patients were asked about the same type of events separately. However, as all events or conditions taken into account were of considerable severity, it seems improbable that there should be a major difference between our data and the actual distribution of these biographical adversities.
Conclusions
Several risk factors for late paraphrenia known from previous research, such as low grade of education, hearing impairment or family history of paranoid disorder, could be confirmed by comparison to a similarly impaired group of endogenous, partly psychotic elderly depressives. On the other hand, in the depressive group the prevalence of physical illness was significantly higher. Moreover, biographical anamnesis exhibited several conditions which could have contributed to a differential vulnerability of both groups. In the majority of the paranoid patients, experiences of uprooting, humiliation, outside social position, disappointment and fragility of relations were found; as could be gathered from patients’ self-reports, these experiences fostered a reserved and distrustful stance towards the environment during most of their lives. They may thus be regarded as possible vulnerability factors for late life paranoid disorder. On the contrary, in the life histories of the depressive patients severe early loss experiences appeared in a high proportion of cases. They may have contributed to a vulnerability quite different in kind from the paranoid patients’, consisting mainly in the dependence on intimacy with significant others and in the latent, yet constant threat of anticipated separation. To explain the delay between traumata in earlier life and onset of psychotic illness in old age, we may further hypothesize that the patients compensated a latent vulnerability during their adult life by specific defense mechanisms rooted in their personality, e.g. striving for autonomy and refraining from intimacy in the paranoid patients, versus intensive attachments to others and avoidance of conflict in the depressives. The changes and stresses of later life such as the ending of occupational or family engagement, bereavement, somatic illness, hearing impairment or beginning cognitive dysfunction might then have led to a decompensation, and thus to a late effect of traumatic experience that occurred early in life. These issues will be further investigated.
Acknowledgements The present study was supported by a grant from the Deutsche Forschungsgemeinschaft (DFG).
References
2 3
68
Kay DWK, Roth M: Environmental and hereditary factors in the schizophrenias of old age (‘late paraphrenia’) and their bearing on the general problem of causation in schizophrenia. J Ment Sci 1961;107:649–686. Quintal M, Day-Cody D, Levy R: Late paraphrenia and ICD-10. Int J Geriatr Psychiatry 1991;6:111–116. Howard R, Almeida O, Levy R: Phenomenology, demography and diagnosis in late paraphrenia. Psychol Med 1994;24:397–410.
Psychopathology 1999;32:60–69
Fuchs
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
1
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Naguib M, Levy R: Late paraphrenia: neuropsychological impairment and structural brain abnormalities on computed tomography. Int J Geriat Psychiatry 1987;2:83–90. Post F: Persistent Persecutory States of the Elderly. Oxford, Pergamon, 1966. Almeida OP, Howard R, et al: Psychotic states arising in late life (late paraphrenia). The role of risk factors. Br J Psychiatry 1995;166:215–228. Ruegg RG, Zisook S, Swerdlow NR: Depression in the aged. An overview. Psychiat Clin North Am 1988;11: 85–99. Fuchs T: Uprooting and late life psychosis. Eur Arch Psychiatry Clin Neurosci 1994;244:126–130. Kay DWK, Cooper AF, Garside RF, Roth M: The differentiation of paranoid from affective psychoses by patients’ premorbid characteristics. Br J Psychiatry 1976;129:207–215. Herbert M, Jacobson S: Late paraphrenia. Br J Psychiatry 1967;113:461–469. Häfner H, Maurer K, Löffler W, et al: The influence of age and sex on the onset and early course of schizophrenia. Br J Psychiatry 1993;162:80–86. Cooper AF, Kay DWK, Curry AR, Garside RF, Roth M: Hearing loss in paranoid and affective psychoses of the elderly. Lancet 1974;ii:851–854. Kraepelin E: Psychiatrie. Leipzig, Barth, 1913. Fuchs T: Wahnsyndrome bei sensorischer Beeinträchtigung – Überblick und Modellvorstellungen. Fortschr Neurol Psychiat 1993;61:257–266. Wigdor BT, Morris G: A comparison of 20-year medical histories of individuals with depressive and paranoid states. Gerontology 1977;32:160. Kukull WA, Koepsell TD, Inui TS, et al: Depression and physical illness among elderly general medical patients. J Affect Disord 1986;10:153–162. Murphy E: The prognosis of depression in old age. Br J Psychiatry 1983;142:111–119. Tölle R: Somatopsychic aspects of paranoia. Psychopathology 1993;26:127–137. Eitinger L: Schizophrenia and persecution. Acta Psychiatr Scand 1965;180(suppl):141–145. Hitch PJ, Rack PH: Mental illness among Polish and Russian refugees in Bradford. Br J Psychiatry 1980;137: 206–211. Krupinski J: Sociological aspects of mental ill-health in migrants. Soc Sci Med 1967;1:267–281. Dasberg H: Psychological stress of holocaust survivors and offspring in Israel, forty years later. A review. Isr J Psychiatry Relat Sci 1987;24:243–256. Freudenberg N: Alterswandel psychischer Verfolgungsschäden. Eine Studie an Entschädigungsgutachten; in Stoffels H (ed): Schicksale der Verfolgten. Berlin, Springer, 1991, pp 44–61. Brown GW, Harris T, Copeland JR: Depression and loss. Br J Psychiatry 1977;130:1–18. Forrest AD, Fraser RH, Priest RG: Environmental factors in depressive illness. Br J Psychiatry 1965;111: 243–253. Roy A: Vulnerability factors and depression in men. Br J Psychiatry 1981;138:75–77. Abrahams MJ, Whitlock FA: Childhood experience and depression. Br J Psychiatry 1969;115:883–888. Matussek PA, May U: Verlustereignisse in der Kindheit als prädisponierende Faktoren für neurotische und psychotische Depressionen. Arch Psychiatr Nervenkr 1981;229:189–204.
Life Events in Late Paraphrenia and Depression
Psychopathology 1999;32:60–69
69
Downloaded by: Universitätsbibliothek Heidelberg 149.126.78.1 - 10/18/2015 7:08:27 AM
4
