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Don’t forget the little people

 

A news story this week about a man who shot his wife in a care home and was diagnosed with a mental illness called paraphrenia (http://www.bbc.co.uk/news/uk-england-essex-36865867) put me in mind of a patient I saw a few months ago.

My patient confidently told me that there were a group of little people (about 3 inches tall) on her garden fence who fire green arrows at her. She feels these arrows prick her skin and she is convinced they are loaded with poison which will kill her. The arrows penetrate brick so wherever she goes she is subject to a constant volley. Furthermore the little men read her thoughts, so she can never evade their clutches; they always know where she is. And they talk about her – commenting on where she is going and what she is doing.

She has had these thoughts for over 10 years. Well, they are not “thoughts” insomuch as they may or may not be true; she believes these things are happening, incontrovertibly. For many years the “little people” were quite benign but more recently they have become malevolent, using stronger poison and saying nasty things. Her fear became so intense she took to sleeping in her car which gave some respite but the clever people have made new arrows that can penetrate metal so she is worse than ever. It was only after going to the Police to complain about the men that she was brought to my attention.

The diagnosis here is “very late onset schizophrenia-like psychosis” which is a bit of a mouthful so many psychiatrists, me included, use the outmoded term “paraphrenia”. Paraphrenia is a disorder of older people. It is characterised by multiple, stable delusions (fixed false beliefs) which, as in this case, are often bizarre and persecutory. Patients often have frequent auditory and tactile hallucinations. People with paraphrenia tend to live socially isolated lives (although they are usually immaculately well groomed) and tend not to be married or have children. Nor are their problems picked up by social services or GPs so the usual conduits to mental health care are lost. The consequence is they live quietly psychotic, often profoundly distressing psychotic, lives for many years without help. This is not always the case and many patients seem to live symbiotically with the psychosis and may value the “relationship” they have with the protagonist. Paraphrenia often responds to medication but I think the trick is not to try to rid the patient of every last vestige of their psychosis, which can require high doses, but take away the distress and anxiety.

No one really knows how common paraphrenia is. It is less common than dementia and depression but may affect up to 1% of older people. What is certain is the recent emphasis on dementia has diverted much needed NHS resources away from helping this very vulnerable and isolated group of people.

 


staffDr James Warner 
Medical Director, Red & Yellow Care
Former Chair, Faculty of Old Age Psychiatry, RCPsych
National Professional Advisor, CQC

 

 

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