ORIGINAL ARTICLES

TRANSITION FROM SCHIZOPHRENIA TO PERSISTENT DELUSIONAL DISORDERS

1 2 3 4Ion Papava , Ana-Cristina Bredicean , Sorana Raluca Papava , Mircea Lãzãrescu

111

Abstract: B a c k g r o u n d : C u r re n t n o s o l o g i e s a c c e p t nonschizophrenic and inorganic psychotic disorders, besides schizophrenia and mood disorders. Today's researchers and clinicians focus more on the interference and transitions between schizophrenia and periodical affective disorders, rather than predominantly delusional psychosis. As is the case of the transition between schizophrenia and periodical affective disorders, which is assessed by episodes and schizo-affective disorder, the combination and transition between persistent delusional disorder and schizophrenia can also be discussed.Aim: This paper aims to focus on schizophrenia and persistent delusional disorder, as two distinct nosological entities, between which we expect to find an intermediate area populated by mental entities neglected by current nosologies and psychiatric approaches.Method: There have been three specific batches of endogenous psychoses (schizophrenic patients, patients with persistent delusion and psychotic patients with intermediate symptoms to the first and second batches of patients) with a long evolution (over 15 years of cathamnesis), from a Case Register from the Timisoara Psychiatric Clinic. Each batch is comprised of 25 cases, which have been actively and prospectively studied by a team of specialists in terms of demographic, social and evolutionary perspective. Results: A comparison of these three batches has revealed significant differences in the age of onset of the mental entities, employment, marital and evolutional status and, in particular, between the batches of patients with schizophrenia and persistent delusion. The batch comprising patients with intermediate symptoms is occupying an equidistant position between the two afore-mentioned batches, in terms of the track parameters value.Conclusions : Schizophrenia and persistent delusional disorder are not identical and need to be studied separately. There is the possibility of intermediate nosological entities that need current psychiatric attention and further research studies.Key words : continuum, distinction, boundaries, similarities.interval prolongation.

Rezumat: Context: Nosologiile actuale acceptã pe lângã schizofrenie ºi tulburãri afective, tulburãrile psihotice neschizofrene ºi neorganice. Cercetãtorii ºi clinicienii actuali discutã mult interferenþa ºi tranziþiile dintre schizofrenie ºi tulburãrile afective periodice, dar foarte puþin cu psihozele predominant delirante. La fel ca în cazul tranziþiei dintre schizofrenie ºi tulburãrile afective periodice care e comentatã prin episoadele ºi tulburarea schizo-afectivã, se poate pune problema combinãrii ºi tranziþiei dintre tulburarea delirantã persistentã ºi schizofrenie . Obiectiv: În cadrul acestei lucrãri se încearcã o focusare pe schizofrenie ºi tulburarea delirantã persistentã ca douã entitãþi nosologice distincte, între care ne aºteptãm sã gãsim o zonã intermediarã populatã de entitãþi psihice neglijate de nosologiile ºi abordãrile psihiatriei actuale. Metoda: S-au evidenþiat trei loturi de psihoze endogene (un lot de schizofreni, un lot de deliranþi persistenþi ºi un lot de psihotici cu simptomatologie intermediarã între cea a celor douã loturi anterioare) cu evoluþie îndelungatã (peste 15 ani de catamnezã), dintr-un registru de cazuri al Clinicii de Psihiatrie Timisoara. Fiecare lot cuprinde un numãr de 25 de cazuri ce au fost urmãrite activ, prospectiv de cãtre o echipã de specialiºti în perspectivã demograficã, socialã ºi evolutivã. Rezultate: Compararea celor trei loturi au relevat diferenþe semnificative privind vârsta de debut a entitãþilor psihice, statutul profesional, marital ºi evolutiv, în special între loturile de schizofreni ºi deliranþi persistenþi, lotul cu simptomatologie intermediarã ocupând o poziþie echidistantã între cele douã loturi mai sus menþionate, în ceea ce priveºte valoarea parametrilor urmãriþi. Concluzii: Schizofrenia si tulburãrile delirante persistente nu se identificã si se cer studiate separat. Existã posibilitatea unei (unor) entitãþi nosologice intermediare ce necesitã atenþia psihiatriei actuale prin studii ºi cercetãri ulterioare.Cuvinte cheie: continuum, graniþe, asemãnãri, distincþie. prelungirea intervalului QT.

1,2 University Lecturer, Department of Psychiatry, Victor Babeº University of Medicine and Pharmacy, Timisoara and Mara Institute, Timisoara3 Fourth year resident Eduard Pamfil Psychiatry Clinic, Timisoara Clinical Emergency City Hospital4 University Professor, Department of Psychiatry, Victor Babeº University of Medicine and Pharmacy , TimisoaraCorrespondence to: Ion Papava, MD, Department of Psychiatry, University of Medicine and Pharmacy, 21 I. Vãcãrescu, Timisoara300128 Romania, e-mail: papavaion@yahoo.com

THEORETICAL ASPECTS

Understanding and defining psychosis has always been a challenge. Over time, conceptualizing psychosis has been impregnated by a number of assumptions: the endogenous assumption, the nosological assumption, the pathogenic assumption, the hierarchy principle assumption; the model of structural-dynamic

cohesion; the hypothesis of biorhythm disturbance for affective disorders and the bipolar-unipolar dichotomy assumption (1).

The history regarding the conceptualization of psychoses has acknowledged several classic nosological entities:

- schizophrenia and schizophrenic-pattern psychosis;

- manic-depressive psychosis;- paranoia;- atypical psychoses.If manic-depressive psychosis, as a nosological

entity, has known a linear trend in accepting the particular forms of emotional pathology from Kraepelin to Leonhard and Keski, the concept of schizophrenia has been subject to numerous controversies. Although schizophrenia (former Dementia Praecox) has been considered along psychiatric evolution as a stable clinical entity, its definition and boundaries have undergone continuous change over time. On this concept, the most important input has been brought by Kraepelin, Bleuler, Jaspers and Kurt Schneider. Kraepelin has not provided specific criteria for definition, but he has stressed the chronic longitudinal evolution by patient deterioration. In contrast, Bleuler and Schneider have been more interested in the cross-cutting issues of disease, developing criteria for defining this disorder, criteria that are different for the two specialists, due to the fact that each has emphasized different aspects of the disease. Jaspers considered that the deterioration in the schizophrenic empathic communication is the basic feature, alongside completely incomprehensive individual experiences. Given this concept, Schneider has later operationalized his first rank criteria (2).

The diagnosis status of Persistent Delusional Disorders has been subject to debate from the moment Kraepelin launched the modern concept of Paranoia (3). Then, at the beginning of the 20th century, there was a period when it became virtually extinct, by being incorporated to schizophrenia; it was only in 1987 that it was reintroduced among the modern psychiatric diagnoses (4). Despite the progress made around delusional disorders nosology, they are still accompanied by a lack of consensus among psychiatrists regarding their definition (3, 5).

A typical psychosis has been used by various authors to define entities that are not found in classical Kraepelin's dichotomy. They have found a more consistent diagnosis in Japanese psychiatry, through their founder, Mitsuda Hisatoshi (6). Today, part of them can be encountered among the acute and transient psychotic disorders. Currently, the basic feature of psychosis is represented by a severe disturbance in the psychotic's relation with reality.

ICD 10 (The International Classification of Diseases) defines the term “psychosis” by the presence of hallucinations, delusional ideas or a limited number of serious behavioral abnormalities, such as rough excitement and hyperactivity, marked motor retardation and catatonic behavior (7).

In DSM IV (The Diagnostic and Statistical Manual of Mental Disorders), the term "psychotic" refers to delusional ideas, notable hallucinations, speech disruption and disorganized or catatonic behavior (8).

Inorganic psychotic disorders or those induced by substance abuse may vary in current nosological classifications (ICD-10, DSM - IV TR) in:

A1. Schizophrenic psychosis2. Schizo-affective psychosis

3. Mood disorders with psychotic symptoms

B1. Short and transient psychosis 2. Persistent delusional psychosis subgroup

-paranoia -induced deliriumPersistent delusional disorders (PDD), potentially hallucinatory and/or accompanied by depression are accepted by the ICD -10 for research at code F22.0. While currently, clinicians and researchers are largely assessing the interference and transitions between schizophrenia and affective mood disorders, their focus is directed, however, only slightly towards persistent delusional psychosis (9, 10).

Nowadays, the definition of schizophrenia (including ICD-10 and DSM IV TR) includes Kraepelin's chronic evolution, Bleuler's negative symptoms and Kurt Schneider's positive symptoms (fig. 1) (11, 12). The current definition of schizophrenia keeps the defining heterogeneity of the clinical picture and its boundaries, aspects that have accompanied its evolution over time, also suggested by the fig. 1 (2).Schizophrenia, even in a very broad and lax sense, cannot be diagnosed only through the presence of hallucinatory delusion. The delusional- hallucinatory symptoms, by themselves, are not specific to schizophrenia. It requires in addition:

negative primary symptomsideoverbal and behavioural disruptionspecial aspects of positive shizophrenia, consisting of Kurt Schneider's first rank symptoms :

- transparence-influence phenomena- commentative auditory hallucinations- relational symptoms and primary

delusion- special supervisory believes

It should be mentioned that Kurt Schneider's first rank symptoms can also be found in other nosological entities.

The delusional psychotic disorder (F22.0 according to ICD -10) is usually not accompanied by the afore-mentioned syndromes or symptoms (sdr + sp). As is the case of transition between schizophrenia and periodical mood disorders, defined by periodic episodes and schizo-affective disorders, it may be a question of combining and transitions between persistent delusional disorder and schizophrenia, especially if it is accepted that there are cases of schizophrenia that express predominantly by positive symptoms.

T.D.P. ----------------- Sx positive -------------Sx complete ( including sdr. + sp. ) sdr. + sdr -

Transition territory sdr disorganized

The transition territory mentioned above would be characterized by T.D.P. symptoms, to which sdr + sp are added, to a small extent. These symptoms are less visible in terms of duration and intensity.

In the international classification system ICD 10,

Ion Papava , Ana-Cristina Bredicean, Sorana Raluca Papava, Mircea Lãzãrescu: Transition Of Schizophrenia – Persistent Delusional Disorders

112

113

one can find these psychoses ranked in the nosological category. Other persistent delusional disorders include the presence of persistent hallucinatory voices or other schizophreniforms symptoms, but at an intensity that would be insufficient for it to qualify as schizophrenia.

Between paranoid schizophrenia and non-

METHOD

There have been many highlighted cases, monitored and analyzed for a long time by the same team of research. Currently, the research has been carried out in the context of the PTTEP (Timisoara Project for the Study of Endogenous Psychoses Typology), which assesses functional psychoses recorded in Timisoara, since 1985 to date. For this paper, we have selected 3 batches (table 1, table 2, table 3), each consisting of 25 subjects. The data listed below has been collected at the onset of the disease and, once again, after 15 years of disease progression for each subject.

The batches have been divided into:A= persistent delusional psychosis (F22.0 according to ICD 10)B= persistent delusional psychosis with partial sdr+sp symptoms (as frequency and intensity)

schizophrenic delusional psychosis, areas of transition and interference might appear, both in terms of episode, as well as disorder. This problem can be studied from various points of view, in case of long-term mental illnesses, when the clinical characteristics of successive episodes (9) can be determined.

C= schizophrenia with clinical features, which allow a full diagnosis

The cases were selected from the Case Register of the Psychiatric Clinic of Timisoara, Romania, having been recorded from 1985-2006, as well as all new cases of endogenous (functional) psychosis. The diagnosis was then formulated after ICD-9, later ICD-10 (including ICD-10 for research). The PSE-9 and later, the PSE-10-SCAN, were both used as semiological manuals. All the cases have been actively and prospectively monitored by a team of supervised specialists. The project initiator, the supervision and administrative team remained unchanged from 1985 to date. All hospitalizations have been recorded with full symptoms; the intervals between various episodes, treatment and course of life, highlighted in separate files. Thus, they have been monitored in terms of demographic, social and clinical evolution.

Romanian Journal of Psychiatry, vol. XII, No.3, 2010

Fig.1. Time line showing the historical evolution of the concept of schizophrenia since the mid-nineteenth century. Prior descriptions of mental illnesses resembling what we now term schizophrenia, which may date back millennia, are not reflected in this scheme. Kraepelin integrated several entities under the umbrella of Dementia Praecox, later termed schizophrenia by Bleuler; the concept of schizophrenia subsequently was revised several times, expanding, narrowing and re-expanding over the past century as a result of prevailing disease models as well as developments in diagnostic and therapeutic approaches. Currently, the concept of schizophrenia as a disease entity is in flux; there is an emerging consensus of a need to deconstruct schizophrenia as we now know it into ethiopathologically meaningful dimensions clinically identifiable, with a view to reconstruct a more valid and useful entity, or more likely, set of entities.

Presentation of batches:

Table 1. Batch A

Table 2. Batch B

Ion Papava , Ana-Cristina Bredicean, Sorana Raluca Papava, Mircea Lãzãrescu: Transition Of Schizophrenia – Persistent Delusional Disorders

114

N r.

Ini tia ls

Sex A ge ( onse t)

Pro fess. sta tu s

(on se t)

M arit sta tus

(onse t)

N o . of re lapse s

Pr ofe ss. sta tu s

(P)

M arit sta tus

( P)

A udit. hal lu cina

t io ns

D epre ssion

1 M .G M 24 E mpl Sing 6 Re ti red Singl + + 2 P .A . F 42 E mpl M ar 3 E mp l W id + + 3 C .A M 24 E mpl Sing 3 Re ti red Sing + + 4 P .A . F 40 E mpl M ar 6 Re ti red W id + + 5 T .A . F 22 E mpl Sing 4 Re ti red Sing + + 6 G .M F 42 E mpl M ar 3 Re ti red M ar + + 7 T .V . F 38 E mpl M ar 3 Re ti red M ar + - 8 V .A F 46 E mpl M ar 3 Re ti red M ar + + 9 H .A F 44 E mpl M ar 3 Re ti red M ar + + 10 R .E . F 24 E mpl M ar 3 E mp l M ar + + 11 V .I. M 32 E mpl M ar 4 E mp l M ar + + 12 H .C. F 56 E mpl D ivor c 4 Re ti red D iv + + 13 J. I M 36 E mpl M ar 3 Re ti red M ar - - 14 P .G . M 47 E mpl M ar 3 E mp l M ar - + 15 O .P. F 41 D om W id 4 Re ti red W id - + 16 M .I. M 31 E mpl M arie 3 E mp l M ar - - 17 B .E . F 50 E mpl M ar 3 Re ti red M ar + + 18 B .D . F 25 E mpl M ar 3 E mp l M ar - + 19 S . A. F 39 E mpl M arie 5 Re ti red W id + + 20 B .M . F 23 E mpl D ivor 5 Re ti red D iv + + 21 M .A M 32 E mpl M ar 5 Re ti red M ar + + 22 S . M . M 34 E mpl M ar 3 Re ti red M ar + - 23 B .M F 36 E mpl M ar 4 E mp l M ar - + 24 T .C M 42 E mpl D ivor 4 Re ti red D iv - - 25 S . H M 40 E mpl M ar 4 E mp l M ar - + Tota l

36.4 3. 76

Nr.

Initia ls

Sex A ge (onset)

Pro fess. sta tu s

(on set)

Marit sta tus

(onset)

No . of re lapses

Profess. sta tu s

(P)

Marit sta tus

(P)

Audit. hallu cina

tio ns

Depression

1 S.D. M 23 Empl Sing 4 Retired Sing 5 0 S.D. 2 G .F. M 31 Empl Mar 5 Pens Div 2 0 G.F. 3 H .I. M 26 Empl Mar 5 Retired Mar 2 0 H.I. 4 C .E . F 39 Empl Mar 9 Retired Div 1 1.1 1 C.E . 5 M .A F 31 Empl Mar 6 Retired Mar 3 3.3 M.A 6 M .E. F 30 Empl Mar 4 Retired Mar 5 0 M.E . 7 A.N. M 37 Empl Mar 6 Retired Mar 1 6.6 6 A.N. 8 L .S. F 49 Unemp l Div 3 Unem pl Div 3 3.3 3 L.S. 9 P .M. F 21 Empl Sing 7 Retired Sing 4 2.5 8 P.M. 10 S.M F 38 Empl Mar 7 Retired Mar 2 8.5 7 S.M 11 B .A. F 30 Empl Mar 5 Retired Mar 6 0 B.A. 12 D .E. F 49 Empl Mar 7 Retired Mar 2 8.5 7 D.E . 13 G .C. F 29 Empl Mar 5 Emp l Mar 4 0 G.C. 14 R .P. M 37 Empl Mar 5 Retired Mar 6 0 R.P. 15 G .R. F 50 Empl Mar 3 Retired Mar 3 3.3 3 G.R. 16 C .D. M 48 Empl Div 3 Retired Div 6 6.6 6 C.D. 17 P .A M 43 Empl Mar 3 Retired Mar 3 3.3 3 P.A 18 B .I. M 28 Empl Sing 6 Retired Sing 5 0 B.I. 19 F.A. M 20 Empl Sing 7 Retired Sing 2 8.5 7 F.A. 20 C .D. M 30 Empl Sing 1 2 Retired Sing 3 3.3 3 C.D. 21 V .F M 24 Empl Sing 4 Retired Sing 5 0 V.F 22 B .E F 45 Empl Mar 7 Retired Mar 2 8.5 7 B.E 23 C .I M 27 Empl Mar 5 Retired Mar 2 0 C.I 24 L .B F 31 Empl Mar 7 Retired Div 2 8.5 7 L.B 25 F.D F 30 Empl Mar 4 Emp l Mar 5 0 F.D Tota l

3 3.84 5.56 3 6. 6 5

115

COMMENTED RESULTS

The sex distribution for the 3 batches was, as follows: for batch A, M / F = 10/15, batch B, M / F = 12/13 and for batch C, M / F = 12/13.

The average age at onset was significantly lower in the batch of schizophrenic patients (25 years, with age limits between 18 and 38 years), when compared with the average age at onset of the other two batches (patients with persistent delusional disorder with an average of 36.5 and age limits ranking between 22 and 56 years, and delusional patients with partial Kurt Schneider symptoms, with an average age of 34 years and age limits between 50 and 21 years).

The largest number of relapses requiring hospitalization was identified in the schizophrenia batch, with an average of approximately 6.5 relapses in 15 years, i.e. the number of relapses was similar to the number of intermediate delusional subjects (5.5), but significantly different from that of simple persistent delusional patients (3.76).

The number of people remaining employed is 32% in the batch with persistent delusional disorder, in comparison with the other two groups, where the percentage is rather insignificant, almost zero, most of them being retired because of their medical condition.

As regards to the marital status, the

schizophrenic batch has succeeded very little, as number of cases, in forming a family, unlike the other two groups. An explanation of the difference from the other two groups could be the early onset of the disorder, at an age when people are not yet usually married. A remarkable fact worth mentioning is that the patients with schizophrenia, who had a later onset of illness, after already being married, have succeeded to stay within their family (there is only one case of divorce).

In the pure persistent delusional disorder batch (without Kurt Schneider's first rank symptoms), one can frequently find associations between auditory hallucinations (16/25) and affective depression (20), entities which correspond to the diagnosis category of Other Persistent Delusional Disorders.

The relapses with Kurt Schneider's first rank symptoms are found to an average of 1/3 of the relapses that have required hospitalization (36.65%).

CONCLUSIONS

As expected, the average age at onset was significantly lower in the schizophrenia batch, compared to the batch with persistent delusional disorder patients (5, 13, 14), however much lower than the batch with intermediate delusion, with an average age at onset close to that of the pure persistent delusional disorder batch,

Romanian Journal of Psychiatry, vol. XII, No.3, 2010

Nr.

I nit ia ls

Sex A ge ( onse t)

Profes. sta tus (onse t)

M ari ta l status (o nset)

No . of r elap ses

Pro fes sta tu s (P)

M arital sta tus ( P )

E pisodes Sx- affec t

1 P .M M 2 2 E mpl Sing 4 Re tired Sin g 1 ( D ) 2 C .L M 3 7 E mpl M ar 6 Re tired M ar 2 ( D ) 3 J.M F 3 6 E mpl M ar 4 Re tired Div 0 4 G .D F 2 2 E mpl Sing 5 Re tired Sin g 0 5 D .C M 2 2 Unemp l Sing 7 Re tired Sin g 2 ( D ) 6 S.D M 2 7 E mpl M ar 4 Re tired M ar 0 7 T .M M 2 0 E mpl Sing 6 Re tired Sin g 1 ( M ) 8 T .A. M 1 8 E mpl Sing 1 7 Re tired Sin g 0 9 B .M M 1 8 Unemp l Sing 9 Re tired Sin g 1 (M )1( D) 10 I .A . F 1 9 E mpl Sing 4 Re tired M ar 0 11 D .A M 3 1 E mpl Sing 9 Re tired M ar 1 ( D ) 12 O .L. F 2 3 E mpl Sing 4 Re tired Sin g 0 13 B .M . F 3 8 E mpl M ar 5 Re tired M ar 1 ( D ) 14 P .M . F 3 0 E mpl M ar 4 E mp l M ar 0 15 B .T F 3 1 E mpl M ar 5 Re tired M ar 0 16 C .S M 1 9 Unemp l Sing 5 Re tired Sin g 0 17 M .M F 2 4 Unemp l Sing 1 3 Re tired Sin g 1 ( D ) 18 D .D F 1 8 Stud en t Sing 6 Re tired Sin g 2 ( D ) 19 G .T M 2 6 E mpl M ar 4 Re tired M ar 0 20 C .R. F 3 2 E mpl Sing 4 Re tired Sin g 1 ( D ) 21 N .N F 2 5 E mpl Sing 1 3 Re tired Sin g 0 22 N .P F 3 0 E mpl Sing 9 Re tired Sin g 0 23 I .N . M 2 0 E mpl Sing 7 Re tired Sin g 1 ( M ) 24 T .O F 2 0 Stud en t Sing 5 Re tired M ar 0 25 M .H M 1 9 Unemp l Sing 5 Re tired Sin g 0 Tota l

2 5.0 8 6 .52

Table 3. Batch C

Legend : Mar = Maried, Empl = Employed,Unempl = Unemployed, Sing = Single , Div = Divorced, Wid = Widow , Div = Divorced, Dom = DomesticFor category variables, such as socio-demographic and clinical characteristics, the descriptive statistics were used as percentages.

with intermediate delusion, with an average age at onset close to that of the pure persistent delusional disorder batch, which approaches them, more, by the latest batch mentioned.

The number of relapses that have required hospitalization is almost equal between schizophrenia and intermediate delusional patients and much higher the in case of simple delusional disorder patients. There is also a similarity between schizophrenia and intermediate delusional subjects, in terms of number of people that have stayed employed after 15 years of evolution, however with a significant difference compared to the batch comprising of simple delusional disorder patients.

With regards to the marital status, differences are visible between the pure persistent delusion and schizophrenia, i.e. the patients with persistent delusion have succeeded to maintain their marital status, as was also the case with intermediate delusion patients (14, 15).

Therefore, with regards to the intermediate delusional batch, certain parameters can situate them closely to the schizophrenia batch (number of relapses and maintenance of the employment status), while other parameters do so to the pure persistent delusional patients (age of onset and marital status). In terms of clinical framework, only a third of the relapses are similar to the schizophrenic relapse. The questions are: What diagnostic category would fit them best? Are they a distinct diagnostic entity?

DISCUSSIONSSchizophrenia, despite the fact that its definition

and boundaries have varied continuously over time, remains one of the most studied psychiatric nosological entities of psychiatry. It has also been a unique entity, although it is characterized by a significant ethio-pathogenic heterogeneity, symptoms and evolution. In various periods of time, the concept of schizophrenia has been influenced by the diagnostic tools of the moment and the existing nosological entities, from which it should have been differentiated (3, 16, 17).

Unlike schizophrenia, persistent delusional disorder, although it represents a valid diagnostic entity, is still neglected, in terms of importance, by many professionals in the field. Its diagnosis status has been subject to debate since the time of Emil Kraepelin, the developer of the modern concept of paranoia. Thus, its partial remnant obscurity can be explained by the fact that this concept has undergone many changes over time and, in addition, the diagnostic criteria are not fully crystallized yet. Most of the time, they have been attributed to schizophrenia, which is also supported by its vast heterogeneity (4, 10, 18). This subsuming of the predominantly delusional psychosis to schizophrenia is achieved due to the fact that Schizophrenia is a rather wide nosological framework, where the diagnosis can be established somewhat easily and, also, a consequence for Kurt Schneider's first rank symptoms being seen as specific symptoms of schizophrenia, although there are current approaches that present these symptoms as a syndrome that surpasses by far the boundaries of schizophrenia (19).

Since the two concepts have undergone many changes over time and boundaries between them have

always been unclear, there were very few works in the field to address and investigate this borderline topic. Clinical practice has often highlighted many nosological entities, that were difficult to classify, according to the current diagnostic criteria (ICD 10 or DSM IV TR), in one of the two categories. The present paper presents such entities in the case of batch B.

A nosological entity which could be ranked in this transition area is that of late-onset schizophrenia (onset after 45 years), which is now subsumed to schizophrenia, as a general rule, but there are also specialists supporting the idea of an entity distinct from current schizophrenia (20, 21).

Returning to the batches presented in this paper, subjects in batches A and C fall under ICD 10 diagnostic criteria of the two valid diagnostic entities of paranoid schizophrenia and persistent delusional disorder; the paranoid schizophrenia, where the negative or disorganized symptoms module is not totally absent, although it is not a relevant diagnosis . With regards to batch B, subjects in this group are totally free of symptoms that could be found in the negative or disorganized module of schizophrenia.

In terms of age at onset of both, batches A and C, the results correspond to previous studies, which showed a later age of onset to delusional disorders, than in the case of schizophrenia. As regards to the intermediate batch, a resemblance to the persistent delusional subjects, is to be noticed. With respect to batches A and C, in terms of professional functionality and marital status, the afore-mentioned results also correspond to previous similar studies. In terms of marital status, the intermediate delusional patients resemble those without Kurt Schneider persistent symptoms, but in terms of maintaining their employment status, they are similar to schizophrenia patients.

Interestingly, the number of relapses is similar between schizophrenia and intermediate delusional patients, which might be correlated, in their case, to the professional functionality.

With regards to the association of depressive dysthimia to persistent delusional patients, previous studies have shown increased co morbidity between delusional psychoses and depressive disorders, which can reach approximately 55%. Another approach in justifying the high rates of depression co morbidity, would be its acceptance as part of the common symptoms of ordinary delusional disorders (Serreti). In this case, the depressive episodes are seen as part of a single nosological entity, namely persistent delusional disorder. Previous studies on batches of persistent delusional disorder with depression /no depression have not shown significant differences in socio-demographic, clinical and prognosis factors (5, 14).

In conclusion, the present research supports the idea that persistent delusional disorder - as circumscribed in the ICD 10 for research - is a valid long term diagnosis. The assessment of several parameters allow it to be differentiated, over long-term, from schizophrenia. The idea of a transition zone between these two clinical entities remains, as well as the necessity for further investigation in the long term analysis of psychoses existent in this area.

Ion Papava , Ana-Cristina Bredicean, Sorana Raluca Papava, Mircea Lãzãrescu: Transition Of Schizophrenia – Persistent Delusional Disorders

116

117

REFERENCES:

1. Berner P. Criteres diagnostiques pour les psychoses schizophreniques et affectives. Paris: Expansion Scientifique Francaise, 1987.

. Schizophrenia

3. Grover S, Gupta N, Kumar S. Delusional Disorders: An overview. German Journal of Psychiatry 2006; 9:62-73.

4. Munro A. Delusional Disorder Paranoia and Related Illnesses. Cambridge: Cambridge University Press , 2006.

5. Grover S, Biswas P, Avasthi A. Delusional disorder: Study from North India. Psychiatry Clin Neurosci 2007; 61:462–470.

6. Hatotani N. The concept of 'atypical psychosis': special reference to its development in Japan. Psychiatry Clin Neurosci 1996; 50:1–10.

7. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization, 1992.

8. Rounsaville BJ, Alarcon RD, Andrews G, et al. Basic nomenclature issues for DSM-V. In: Kupfer DJ, First MB, Regier DE (eds). A research agenda for DSM-IV. Washington DC, American Psychiatric Association, 2002, 1-29.

9. Lãzãrescu M. Psihiatrie, Sociologie, Antropologie. Timiºoara: Editura Brumar, 2002.

10.Lãzãrescu M. Psihopatologie clinicã. Timiºoara: Editura Helicon, 1994.

11.

2. Tandon R, Nasrallah HA, Matcheri SK , just the facts 4 - clinical features and conceptualization. Schizophrenia Research 2009; 110:1–23.

Bleuler M. The Schizophrenic Disorders. NewHaven: Yale University Press, 1972.

12.

13.

14.

15.

Schultze-Lutter F. Subjective symptoms of schizophrenia in research and the clinic: the basic symptom concept. Schizophrenia Bull 2009; 35:5–8.

Mintz AR, Dobson KS, Romney DM. Insight in schizophrenia: a meta-analysis. Schizophr Res 2003; 61:75–88.

Katschnig H. Kurt Schneider's first rank symptoms reconsidered. European Psychiatry 2004; 19(1):56.

Khopra S, Khan RA, Bourgeois JA, Hilty DM. Delusional Disorder. eMedicine Specialties Online 2009. http://emedicine.medscape.com/article/292991-overview.

Hsiao MC, Liu CY, Yang YY, Yeh EK. Delusional disorder: Retrospective analysis of 86 Chinese outpatients. Psychiatry Clinical Neuroscience 1999; 53:673-676.

Kendler KS. Demography of Paranoid Psychosis (delusional disorder). Arch Gen Psychiatry 1982; 39:890-902.

16.

17.

18. Suvisaari J , Perälä J, Saarni SI. The Epidemiology and Descriptive and Predictive Validity of DSM-IV Delusional Disorder and Subtypes of Schizophrenia. Clinical Schizophrenia and Related Psychoses 2009; 2(4):289-297.

19. Kirkpatrick B, Buchanan RW, Ross DE et al. A Separate Disease within the Syndrome of Schizophrenia. Arch Gen Psychiatry 2001; 58:165 - 171.

20. Howard R, Rabins PV, Seeman MV and al. Late-Onset Schizophrenia and Very-Late-Onset Schizophrenia-Like Psychosis: An International Consensus. American Journal of Psychiatry 2000; 157(2):172-178.

21. Harris MJ, Jeste DV. Late-onset schizophrenia: an overview. Schizophrenia Bulletin 1988; 14(1):39-55.

¯̄̄

Romanian Journal of Psychiatry, vol. XII, No.3, 2010