Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Four-Dimensional Classification

Delusional Psychoses

Paranoia and Paraphrenia

It might be argued that delusional development shares some common characteristics with psychogenic paranoid reactions, but the same does not apply to "paranoia," a term adapted from the Greek by Heinroth in 1818. By describing delusional states as "disorders of intellect" (Verruckheit) that virtually do not affect other faculties of the mind, Heinroth opened the path for Kahlbaum (1874) and Kraepelin (1919) to develop their concepts of paranoia and paraphrenia respectively.

Kahlbaum used the term "paranoia" for chronic fixed delusions of persecution and/or grandeur and distinguished the disorder from those "endogenous" disorders characterized by a deteriorating course (e.g., schizophrenias). Kahlbaum's formulation was further elaborated by Kraepelin's contribution. He characterized "paranoia" as a disorder with a "permanent and unshakable delusional system, which is accompanied by perfect preservation of clear and orderly thinking, will power and action"; and separated paraphrenia, another content-disorder of thinking with a logically contents derived systematized delusional system. While in paraphrenia perceptual psychopathology (hallucinations) is interwoven with the systematized delusional system, in contradistinction to paranoid schizophrenia deterioration does not occur in the course of the illness. In the 8th edition of his textbook, Kraepelin (1913) separated paraphrenia from dementia praecox on the basis of the absence of emotional and volitional pathologies in the clinical picture (Ban, 1973). Late paraphrenia, first described by Roth (1955), is a special form of paraphrenia, which can only be distinguished from "paraphrenia" by its time of onset in the late middle age or even later (Hamilton, 1976).

Kraepelin's concepts of both paranoia and paraphrenia have been questioned by Koelle (1931) who followed 66 patients diagnosed paranoia, including the 19 on whom Kraepelin's definition was based. Because he found a higher incidence of schizophrenia among the relatives of these patients than in the general population but a lower incidence than among the relatives of schizophrenics, he contended "that paranoia must be regarded as a variety of schizophrenia" (Hamilton, 1976).

Similarly, Meyer (1921) followed the 78 patients on whom Kraepelin's definition of paraphrenia was based. Because he found that 40 percent of these patients showed obvious signs of "dementia praecox" within a few years, he concluded "that paraphrenia was not a disease entity, which could be sharply distinguished from schizophrenia."

The inference that neither paranoia nor paraphrenia are valid concepts and should be merged with the schizophrenias brings to attention the limitations of the empiricistic-statistical approach to psychopathological research. These studies actually show that both are valid diagnostic concepts. Within a two-dimensional model of psychiatric classification it is difficult to distinguish the 60% truly paraphrenic patients from the 40% schizophrenic patients, and impossible to identify the patients with the diagnosis of paranoia responsible for the lower genetic loading for schizophrenia in the experimental cohort. The importance of Meyer's (1921) and Kolle's (1931) findings is in the recognition that delusional psychoses exist but their forms (paranoia and paraphrenia) are ill-defined within the frame of reference of Kraepelin. If Meyer and Kolle would have employed a different frame of reference in the interpretation of their findings they probably would have provided support for the diagnostic concepts of acute and chronic delusional psychoses.