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Clinical characteristics of patients with non-affective, non-organic, late onset psychosis
Asian Journal of Psychiatry 25 (2017) 74–78
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Asian pearls
Clinical characteristics of patients with non-affective, non-organic, late onset psychosis Sureshkumar Ramasamya,* , Srikala Bharathb a b
Department of Psychiatry, PSG Institute of Medical Sciences and Research, Coimbatore, 641004, Tamilnadu, India Department of Psychiatry, National Institute of Mental Health AND Neurosciences (NIMHANS), Bangalore, Karnataka, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 July 2016 Received in revised form 17 October 2016 Accepted 23 October 2016 Available online xxx
Objective: Schizophrenia and related psychotic disorders are predominantly studied in young population. However some individuals do develop psychotic disorder for the first time during their old age. The aim of this study is to look at the clinical characteristics of non-affective, non-organic, late onset psychosis. Participants and methods: Retrospective chart review study, medical records of all patients registered between 1st of January 2006 and 31st May 2011 at geriatric clinic in NIMHANS, Bangalore was screened, 83 files with a diagnosis of late onset psychosis and meeting the study criteria were systematically analyzed. Results: The mean age at onset of illness was 67 10 years; 98.8% were married, females formed 67.5% of the sample, commonest phenomenon was delusions followed by hallucinations, 80.5% of the subjects had delusion of persecution, 38.5% had referential delusion, 51.8% had accusative and derogatory auditory hallucinations, negative symptoms was seen only in 2.4% of subjects, none had formal thought disorder. 3.6% had co-morbid Axis II diagnosis. Conclusion: Despite its rarity non affective, non organic, late onset psychosis forms a distinct group with unique manifestation. Further systematic research is needed for better understanding of this condition. ã 2016 Elsevier B.V. All rights reserved.
Keywords: Psychosis Schizophrenia Late onset Elderly psychosis Geriatric psychosis
1. Introduction Schizophrenia and related Non-Affective psychotic disorders are predominantly studied in adolescence and young adults. However some individuals do develop psychotic disorder for the first time during their old age. Community prevalence estimates for schizophrenia range from 0.1% to 0.5% (Castle and Murray, 1993; Copeland et al., 1992, 1998; Kua, 1992). 1-year prevalence rate of schizophrenia in individuals between ages 45 and 64 is 0.6% (Keith et al., 1991). For individuals over 65 years of age, incidence rate of schizophrenia with first onset after 44 years is 12.6 per 100,000 population per year (Copeland et al., 1998). The Studies on lateonset schizophrenia began with Manfred Bleuler, Late onset schizophrenia constituted 15% of patient whom he examined; 4% of the patients had an onset after 60 (Bleuler, 1943). About 50% of the patients with late-onset schizophrenia had symptoms that were similar to those seen in early onset schizophrenic patients. However he did report certain striking differences; more than 50% of patients had Paraphrenia like symptoms, depressive, anxious,
* Corresponding author. E-mail addresses: [email protected], [email protected] (S. Ramasamy). http://dx.doi.org/10.1016/j.ajp.2016.10.017 1876-2018/ã 2016 Elsevier B.V. All rights reserved.
catatonic or confused agitated symptoms, but with less affective flattening (Harris and Jeste, 1988; Jeste et al., 1988, 1995; Mayer et al., 1993; Pearlson et al., 1989; Rabins et al., 1984). Subsequently there are lot of studies on late onset psychosis (LOP), mostly from developed countries of Europe and America, but the research findings in this area is struck with difficulties because neither ICD 10 nor DSM V contain separate codes of diagnosis for ‘late onset schizophrenia’; different terms being used to describe a similar illness occurring in old age and using different age cut-off to be called late onset psychosis (LOP) (Howard et al., 2000). But other limitations of existing literature in this field are some studies include patients who had early onset psychosis but grown old, including patients with affective disorder and organic psychosis. Some of these confusions were cleared after The International Late Onset Schizophrenia group came up in the year 2000 with consensus on nomenclature defining Late Onset Schizophrenia and Very Late Onset Schizophrenia like Psychosis. For developing countries like India and China with their large population and increasing geriatric population, late onset psychosis is a major concern. Socio cultural factors like globalization, migration, breaking up of joint families, poorer healthcare facilities etc in developing countries in Asia are certainly different to that of developed countries in Europe and America. There are many
S. Ramasamy, S. Bharath / Asian Journal of PsychiatryAJP 25 (2017) 74–78
factors that increase the risk of developing psychiatric disorder in elderly like loss of close relatives, social network, previous status in society, sensory functions, functional ability, and health (Skoog, 2008).These psycho socio cultural factors can influence the presentation of individuals with late onset psychosis. Currently there is a paucity of literature on the clinical manifestation of late onset psychosis in Asia especially from India. So the aim of this study is to study the clinical characteristics of non-affective, nonorganic, late onset psychosis in an Indian set-up. 2. Methods 2.1. Study design & setting This is a retrospective chart review study conducted at the Geriatric clinic & Services in National institute of mental health and neuro sciences (NIMHANS) Bangalore, a tertiary care hospital in India, which caters to individuals with psychiatric, neurology and neurosurgery problems. Geriatric clinic is run by a multi disciplinary team which includes psychiatrists, neurologists, neuro psychologists and social workers. All the patients attending geriatric clinic are assessed using a semi structured workup proforma, thorough physical examination, Hindi Mental State Examination scale (HMSE) which is an Indian adaptation of Mini Mental State Examination, Geriatric Depression Scale (GDS), Clinical Dementia Rating Scale (CDR), Neuro Psychiatric Inventory (NPI) and Everyday Abilities Scale for India (EASI). They also undergo basic investigations like complete haemogram with peripheral smear, random blood sugar test, liver function test, renal function test, serum electrolytes and Computerized tomography of brain. Other investigations are done if necessary. 2.2. Study participants We retrieved and screened medical records of all patients who got registered in the geriatric clinic between 1st of January 2006 and 31st of May 2011. In this study we included medical records of patients diagnosed to have psychosis (Schizophrenia, delusional disorder, acute psychosis, nonspecific psychotic disorder, other psychotic disorder) as per International classification of disease 10th version (ICD-10), who were above 50 years of age at the time of onset of psychosis and those who followed up in geriatric clinic atleast for 3 months. We excluded files of patients whose diagnosis was other than psychosis, who developed psychotic symptoms secondary to affective disorder or substance use or organicity (epilepsy, cerebral tumors etc), dementia, whose age at onset of psychosis was below 50 years, those who had major mental illness in the past and medical records that lacked sufficient data. Finally we selected 83 medical records which satisfied our inclusion and exclusion criteria, these records were analyzed. This study was approved by NIMHANS Institute ethics committee, written informed consent was not taken as it is a retrospective chart review, and anonymity of all patients was maintained. 2.3. Materials 1. Hindi Mental Status Examination (HMSE) – Is an Indian adaptation of Mini Mental Status Examination (MMSE) that is being used in epidemiological studies of dementia in India. It contains 23 items which test different components of intellectual capability. The scale has a total score of 31, a score less than 19 is indicative of dementia and warrants a detailed cognitive assessment (Ganguli et al., 1995). 2. Everyday Abilities Scale for India (EASI) –This is brief, reliable and valid scale to assess activities of daily living, with norms, which
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is appropriate for use in assessing dementia in elderly people in India. This is a 12-item uni-dimensional scale which measures mobility, instrumental and personal care activities, the scale has good internal consistency (Pandav et al., 2002). Each item is scored either 0 or 1, less number of 1 score, in other words lower total scores indicates better functioning. 3. Neuropsychiatric Inventory (NPI) – The purpose of NPI is to obtain information on the presence of psychopathology. The NPI was developed for application to patients with Alzheimer’s disease and other dementias, but it may be useful in the assessment of behavioral changes in other conditions aswell. It assesses ten behavioral symptoms including psychotic and affective symptoms and two neurovegetative symptoms. The NPI has been proven to be sensitive to change with treatment, it is available in many languages, has been shown to be valid and reliable in crosscultural studies (Wood et al., 2000). 4. Geriatric Depression Scale (GDS) – Short version – GDS short version is a 15 item scale.The GDS was found to have a high sensitivity and specificity. The validity and reliability of the tool have been supported through both clinical practice and research. In a validation study comparing the Long and Short Forms of the GDS for self-rating of symptoms of depression, both were successful in differentiating depressed from non-depressed adults with a high correlation (Sheikh and Yesavage, 1986). Scores of 0–4 are considered normal; 5–8 indicate mild depression; 9–11 indicate moderate depression; and 12– 15 indicate severe depression. 2.4. Statistical analysis Descriptive statistics (frequency, ratio, mean, standard deviation) was used to define the socio demographics and clinical characteristics of the patients. Chi square test and Fisher’s exact tests were conducted for to compare the symptomatology between different age groups. Person’s correlation test was used to analyze the association between cognitive functions and different variables, with p value of <0.05 considered as significant. The data was analyzed using SPSS version 19. 3. Results Among the 83 medical records that were reviewed, the mean age of the patient was 69 9 years at the time of initial consultation, and age ranging between 51 and 91 years. The average age at the time of onset of illness was 67 10 years. The mean duration of illness was 2.5 years (SD 2.2 years); 55.4% of the patients were uneducated and 54.2% belonged to low socio economic class. 3.1. Socio demographics and clinical characteristics The socio demographics and clinical characteristics of the patients are depicted in (Table 1). The sample had female preponderance; with number of females being almost double that of males. Except one person all others were married, most of them followed Hindu religion. Psychosis not otherwise specified (psychosis NOS) was the most common diagnosis in these patients, followed by schizophrenia, delusional disorder and acute and transient psychosis. Interestingly all patients diagnosed with acute and transient psychosis developed illness only at 60 years. Only 3/83 (3.6%) patients had Axis II disorder (Anankastic personality disorder – 1; Anxious avoidant personality disorder – 1; and Paranoid personality disorder 1) Precipitating factor was noticed in 12% of these patients, with some developing psychosis following a loss of family member, some following hearing or visual impairment etc. Positive family history was found in more than 20% of patients, with nearly 11% of them had either a first or second
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Table 1 Socio-demographics and Clinical characteristics.
Table 2 Symptomatology.
Variables
Mean
SD
Current age (years) Age at onset of illness (years) Education (years) Duration of illness (years)
69 67 3.4 2.5 N = 83
9 10 4.6 2.2 %
Sex Female Male
56/83 27/83
67.5 32.5
Socioeconomic status Low Middle High
45/83 35/83 3/83
54.2 42.2 3.6
Married
82/83
98.8
Diagnosis Psychosis NOS Schizophrenia Delusional disorder Acute and transient psychosis Schizoaffective disorder
39/83 15/83 15/83 14/83 0/83
46.9 18.0 18.0 16.8 0
Precipitating Factor Entry event Exit event Sensory impairment Other
10/83 3/83 2/83 2/83 5/83
12 3.6 2.4 2.4 6
Positive family history of psychiatric disorders Psychosis Mood disorder Dementia Suicide Other disorders
17/83 9/83 4/83 3/83 1/83 1/83
20.5 10.8 4.8 3.6 1.2 1.2
56/83
67.4
Co-morbid medical illness SD: Standard deviation, N: total number, Psychosis NOS specified.
Psychosis not otherwise
degree relative with psychosis. Co-morbid medical illness was found in 67.46% of patients; with most common being hypertension followed by Type 2 diabetes mellitus. 3.2. Symptomatology Delusions and hallucinations dominated their clinical presentation, with acting out behavior secondary to delusions being the commonest reason for bringing the patient for consultation. Thought alienation phenomenon noted in 15.7%, none of the patients reported delusional perception, made phenomenon or somatic passivity. Affective symptoms (sadness, irritability, fear, anxiety, dysphoria and rarely elation) were seen in nearly half of the patients (Table 2). Only two patients had negative symptoms, one with apathy, anhedonia, and another patient had asocialization, apathy and anhedonia. One third of patients had verbal/ physical aggression and other behavioral disturbance like restlessness, aimless wandering, and disorganization. One third had subjective or objective memory disturbances. No patients had formal thought disorder or expressed any bizarre delusions. Among delusions, delusions of persecution followed by referential delusion were the commonest. 64% of patients had hallucination, out of which half of them had 2nd person auditory hallucination, very few patients had hallucination in other modality (Table 3). There was no significant difference in the symptomatology between those with late onset psychosis and very late onset psychoses (where the onset of psychosis was 60years) (N = 16 & 67 respectively).
Symptoms
N = 83 n/N
%
Delusion Hallucination Thought alienation Made phenomenon Somatic passivity Formal thought disorder Negative symptom Affective symptom Aggression Other behavioral disturbance Sleep disturbance Memory disturbance Suicide attempt
73/83 53/83 13/83 0/83 0/83 0/83 2/83 43/83 29/83 28/83 48/83 27/83 3/83
88 63.9 15.7 0 0 0 2.4 51.8 34.9 33.7 57.8 32.5 3.6
Table 3 Type of Delusion & Hallucination. N = 83 n/N
%
Delusion Persecutory Reference Misinterpretation Infidelity Grandiose Infestation Bizarre Other
67/83 32/83 10/83 3/83 2/83 1/83 0/83 0/83
80.7 38.5 12.0 3.6 2.4 1.2 0 0
Hallucination 2nd person auditory hallucination 3rd person auditory hallucination Running commentary Visual hallucination Tactile hallucination Extracampine hallucination Intracorporeal hallucination Pseudo hallucination
43/83 12/83 0/83 10/83 2/83 1/83 1/83 1/83
51.8 14.4 0 12.0 2.4 1.2 1.2 1.2
3.3. Cognitive function and activities of daily living Although one third of the patients had some memory disturbances, their cognitive functions and their ability to function independently remained largely intact (Table 4), with mean HMSE and EASI scores being 24.5 4.9 & 2.3 2.8 respectively. Most patients had an EASI score of 0 indicating they were functioning independently. Cognitive functions were slightly lower in females Table 4 Cognitive function & Activities of daily living. Mean
SD
HMSE (score out of 31) Female Male
24.50 23.34 26.50
4.9 4.4 3.5
EASI (score out of 15) Female Male
2.3 2.5 2.1
2.8 2.9 2.7
HMSE &
Pearson’s correlation P* value 0.74 0.67 0.83
Current age Age at onset of illness Duration of illness
HMSE: Hindi Mental Status Examination, EASI: Everyday Abilities. Scale for India, Correlation significant at p* value < 0.05.
S. Ramasamy, S. Bharath / Asian Journal of PsychiatryAJP 25 (2017) 74–78
compared to males. There is no significant association between cognitive functions and age, age at onset of illness or duration of illness (P values 0.74; 0.67; 0.83 respectively). 4. Discussion 4.1. Sociodemographics and clinical characteristics This study evaluated the clinical characteristics of nonaffective, non-organic, late onset psychosis in a sample of Indian population seeking care in special clinic. A minimum of 3 month follow up was included as a part of study criteria in order to validate the diagnosis and to allow for any revision after initial consultation. Most participants in this study were above 60 years of age at the time of onset of psychosis, the “age of onset” is defined as a change from a state without psychotic features to a clearly abnormal psychotic state as evidenced by the presence of any of the characteristic symptoms of psychosis according to ICD-10. Female preponderance was noted in overall sample which is comparable to other studies (Castle and Murray, 1993; Harish et al., 1996). Many were uneducated in our sample which could be due to female preponderance and also most of them were from rural background, according to Indian government census in 2001 on literacy rate in India, overall literacy rate works out to be 64.8%, the male literacy rate is 75.3% and that for females is 53.7%, showing a gap of 21.6 percentage points between the sexes at the national level and the gap is more in the rural areas. In our sample almost all were married and had a stable occupation suggesting a good premorbid functioning in these patients, in concurrence with other studies done in western countries (Alici-Evcimen et al., 2003; Lacks et al., 2006), the higher marriage rate and fairly good adjustment in occupation may also merely reflect the late onset of illness in this group, this finding good pre-morbid functioning is in contrast to early onset group, with some researchers speculating early onset patients perhaps represents pernicious form of the illness particularly associated with pre-morbid dysfunction (Castle and Howard, 1992; Pearlson et al., 1989). In our study co-morbid Axis II disorder was found only in 3.6% of participants and with only one patient diagnosed to have paranoid personality disorder, our study contradicts other studies which reported as high as 45% of patient with late onset psychosis having paranoid or schizotypal personality (Jeste et al., 1988; Kay and Roth, 1961; Kay et al., 1976). Family history of psychiatric disorder was noted in just over 20% of patients, among which family history of psychosis and mood disorder are 10.8% and 4.8% respectively, family history studies almost all show a familial risk of late-onset schizophrenia lower than that of early onset patients but greater than that of the general population (Howard et al., 1997). 4.2. Symptomatology In our population delusions and hallucinations are the common symptoms, which are in concordance to other studies (Castle and Howard, 1992; Pearlson et al., 1989) which also reported delusions and hallucinations being common among late onset psychosis. On further analysis of type of delusions we found certain differences when compared to other studies. Though delusion of persecution was the commonest (88%) none of the patients had partition delusion which is in contrast to other studies that reported a high prevalence of this delusion (Howard et al., 1997; Pearlson et al., 1989).In addition only 2.4% had grandiose delusion, whereas other studies reported grandiose delusion in 14%-17% of subjects (Howard et al., 1997; Pearlson et al., 1989).Though accusatory, abusive, 3rd person auditory hallucination and hallucinations in other modalities were noted in our sample, none had running
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commentary type hallucination which is not in accordance with other studies (Harish et al., 1996; Howard et al., 1997). In our study negative symptoms was reported in 2.4% of subjects and none had any formal thought disorder which is consistent with an overall lower prevalence of these symptoms in other published reports (Almeida et al., 1995; Howard et al., 1994, 1997; Pearlson et al., 1989). Some affective symptoms was noted in half of these subjects, but they appeared secondary to psychotic symptoms and were not severe enough or lacked associated symptoms that would warrant a diagnosis of mood disorder or schizoaffective disorder. As we all know well even in core schizophrenia it is not uncommon to have depressive or anxiety symptoms, which could in fact be secondary to psychotic symptoms. It is possible to misdiagnose patients with severe depression with psychotic symptoms as late onset psychosis, but in this study we recruited only those patients who followed up for at least 3 months, and we excluded those patients if diagnosis was revised to affective disorder. 3.6% of patients attempted suicide which is a cause for concern, as the intentionality and lethality of such attempts are very high in geriatric population. There was no difference in Symptomatology between sexes. This perhaps suggests that the clinical presentation of late onset schizophrenia is similar in both sexes. Diagnosis wise most patients would fall under the category of Psychosis Not otherwise Specified (Psychosis NOS) as per ICD-10, as our sample is not restricted to schizophrenia. Memory disturbance either subjective or objective was reported in one third of the subjects despite having a stable cognitive functions and ability to take care of themselves as indicated by HMSE (Mean-24.5) and EASI (Mean-2.3) scores, in our study there was no correlation between cognitive functioning and age, age of onset of illness or duration of illness, this could be because of our strict selection criteria this in turn can validate our initial diagnosis. However it’s worth evaluating the longitudinal course of these patients as two of these patients diagnosis was revised to fronto temporal dementia after nearly 1.5 years of follow-up, and there are many studies that suggest late onset psychosis is a prodrome of dementia (Brodaty et al., 1999). 4.3. Strengths Strengths of this study are it adds to the existing knowledge on late onset psychosis in this part of the world as there is paucity of research in India on this area, relatively large sample size compared to many earlier studies done in west (Jeste et al., 1988, 1995; Pearlson et al., 1989)as well as in India (Harish et al., 1996), stricter diagnostic criteria making the sample more homogenous. We felt compared to late onset psychosis as such (which could be secondary to other cause) non-affective nonorganic late onset psychosis forms a distinct group with unique manifestations which warrants further research for better understanding. 4.4. Limitations Some of the major limitations of this study are its retrospective study design, reliance on medical records to collect details; lack of control groups (like early onset group, late onset group with organic psychosis) that would have helped us to distinguish the clinical features of these groups. One can always question the reliability of determination of symptoms from medical records, as interpretation of psychopathology can vary between individuals, the symptoms which were not mentioned in the medical records were considered as absent, No inter-rater reliability test done, which could have made the data more reliable, and the severity of symptoms could not be assessed. However since we use validated
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scales and follow a standard protocol at geriatric clinic in NIMHANS, Bangalore, we hope some of these limitations were reduced. 5. Conclusion Despite its rarity non affective, non organic, late onset psychosis forms a distinct group and validity of this psychiatry entity is undeniable. Though our study has certain striking similarities with other published research like female preponderance, delusions and hallucinations being the common symptoms, lack of negative symptoms and formal thought disorder, there are subtle variations with respect to the type of delusion and hallucination. Further systematic research is needed for better understanding of phenomenology, epidemiology, biological underpinnings, psychosocial issues, as well as course and outcome of this condition. References Alici-Evcimen, Y., Ertn, T., Eker, E., 2003. Case series with late-onset psychosis hospitalized in geriatric psychiatry unit in Turkey: experience in 9 years. Int. Psychogeriatr. 15, 69–72. Almeida, O., Howard, R., Levy, R., David, A.S., 1995. Psychotic states arising in late life (late paraphrenia): psychopathology and nosology. Br. J. Psychiatry. 166, 205– 214. Bleuler, M., 1943. Die spatschizophrenenKrankheitsbilder. Fortschritte der Neurologie und Psychiatrie 15, 259–290. Brodaty, H., Sachdev, P., Rose, N., Rylands, K., Prenter, L., 1999. Schizophrenia with onset after age 50 years. I: Phenomenology and risk factors. Br. J. Psychiatry 175, 410–415. Castle, D.J., Howard, R., 1992. What do we know about the aetiology of late onset schizophrenia? Eur. Psychiatry 7, 99–108. Castle, D.J., Murray, R.M., 1993. The epidemiology of late-onset schizophrenia. Schizophr. Bull. 19, 691–700. Copeland, J.R.M., Davidson, I.A., Dewey, M.E., Gilmore, C., Larkin, B.A., McWilliam, C., et al., 1992. Alzheimer’s disease, other dementias, depression and pseudodementia: prevalence: incidence and three-year outcome in Liverpool. Br. J. Psychiatry. 161, 230–239. Copeland, J.R.M., Dewey, M.E., Scott, A., Gilmore, C., Larkin, B.A., Cleave, N., et al., 1998. Schizophrenia and delusional disorder in older age: community prevalence incidence, comorbidity and outcome. Schizophr. Bull. 24, 153–161. Ganguli, M., Ratcliff, G., Chandra, V., Sharma, S., Gilby, J., Pandav, R., et al., 1995. A hindi version of the MMSE: The development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int. J. Geriatr. Psychiatry 10, 367–377. Harish, M.G., Suresh, K., Rajan, I., Janardhanreddy, Y.C., Sumant, K., 1996. Phenomenological study of late-onset schizophrenia. Indian J. Psychiatary 38, 231–235.
Harris, M.J., Jeste, D.V., 1988. Late-onset schizophrenia: an overview. Schizophr. Bull. 14, 39–45. Howard, R., Almeida, O.P., Levy, R., 1994. Phenomenology, demography and diagnosis in late paraphrenia. Psychol. Med. 24, 397–410. Howard, R., Graham, C., Sham, P., Dennehey, J., Castle, D.J., Levy, R., et al., 1997. A controlled family study of late-onset nonaffective psychosis (late paraphrenia). Br. J. Psychiatry 170, 511–514. Howard, R., Rabins, P.V., Seeman, M.V., Jeste, D.V., 2000. International Late-Onset Schizophrenia Group: late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. Am. J. Psychiatry 157, 172–178. Jeste, D.V., Harris, M.J., Pearlson, G.D., Rabins, P.V., Lesser, I., Miller, B.L., et al., 1988. Late-onset schizophrenia: studying clinical validity. Psychiatric Clin. N. Am. 11, 1–13. Jeste, D.V., Harris, M.J., Krull, A., Kuck, J., McAdams, L.A., Heaton, R., 1995. Clinical and neuropsychological characteristics of patients with late-onset schizophrenia. Am. J. Psychiatry 152, 722–730. Kay, D.W.K., Roth, M., 1961. Environmental and hereditary factors inthe schizophrenias of old age (late paraphrenia) and theirbearing on the general problem of causation in schizophrenia. J. MentSci. 107, 649–686. Kay, D.W.K., Cooper, A.F., Garside, R.F., Roth, M., 1976. The differentiation of paranoid from affective psychoses by patients’ premorbid characteristics. Br. J. Psychiatry 129, 207–215. Keith, S.J., Regier, D.A., Rae, D.S., 1991. Schizophrenic disorders. In: Robins, L.N., Regier, D.A. (Eds.), Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. Free Press, New York, pp. 33–52. Kua, E.H.A., 1992. Community study of mental disorders in elderly Singaporean Chinese using the GMS-AGECAT package. Aust. N. Z. J. Psychiatry 26, 502–506. Lacks, J., Fontenelle, L.F., Chalita, A., Mendlowicz, M.V., 2006. Absence of dementia in late-onset schizophrenia: a one year follow-up of Brazilian case series. Arquivos de Neuro-Psichiatra 64, 946–949. Mayer, C., Kelterborn, G., Naber, D., 1993. Age of onset in schizophrenia: relations to psychopathology and gender. Br. J. Psychiatry 162, 665–671. Pandav, R., Fillenbaum, G., Ratcliff, G., Dodge, H., Ganguli, M., 2002. Sensitivity and specificity of cognitive and functional screening instruments for dementia: the Indo-U.S. Dementia Epidemiology Study. J. Am. GeriatrSoc. 50 (3), 554–561. Pearlson, G.D., Kreger, L., Rabins, P.V., Chase, G.A., Cohen, B., Wirth, J.B., et al., 1989. A chart review study of late-onset and early-onset schizophrenia. Am. J. Psychiatry 146, 1568–1574. Rabins, P.V., Pauker, S., Thomas, J., 1984. Can schizophrenia begin after age 44? Compr. Psychiatry 25, 290–293. Sheikh, J.I., Yesavage, J.A., 1986. Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In: Brink, T.L. (Ed.), Clinical Gerontology: A Guide to Assessment and Intervention. The Haworth Press, Inc, New York, pp. 165–173. Skoog, I., 2008. Mental Disorders Associated with Aging. In: Heggenhougen, K., Quah, S. (Eds.), International encyclopedia of public health, vol. 6. Academic Press, San Diego (CA), pp. 174–182. Wood, S., Cummings, J.L., Hsu, M.-A., Barclay, T., Wheatley, M.V., Yarema, K.T., et al., 2000. The use of the Neuropsychiatric Inventory in nursing home residents, characterization and measurement. Am. J. Geriatr. Psychiatry 8, 75–83.
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Asian pearls
Clinical characteristics of patients with non-affective, non-organic, late onset psychosis Sureshkumar Ramasamya,* , Srikala Bharathb a b
Department of Psychiatry, PSG Institute of Medical Sciences and Research, Coimbatore, 641004, Tamilnadu, India Department of Psychiatry, National Institute of Mental Health AND Neurosciences (NIMHANS), Bangalore, Karnataka, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 July 2016 Received in revised form 17 October 2016 Accepted 23 October 2016 Available online xxx
Objective: Schizophrenia and related psychotic disorders are predominantly studied in young population. However some individuals do develop psychotic disorder for the first time during their old age. The aim of this study is to look at the clinical characteristics of non-affective, non-organic, late onset psychosis. Participants and methods: Retrospective chart review study, medical records of all patients registered between 1st of January 2006 and 31st May 2011 at geriatric clinic in NIMHANS, Bangalore was screened, 83 files with a diagnosis of late onset psychosis and meeting the study criteria were systematically analyzed. Results: The mean age at onset of illness was 67 10 years; 98.8% were married, females formed 67.5% of the sample, commonest phenomenon was delusions followed by hallucinations, 80.5% of the subjects had delusion of persecution, 38.5% had referential delusion, 51.8% had accusative and derogatory auditory hallucinations, negative symptoms was seen only in 2.4% of subjects, none had formal thought disorder. 3.6% had co-morbid Axis II diagnosis. Conclusion: Despite its rarity non affective, non organic, late onset psychosis forms a distinct group with unique manifestation. Further systematic research is needed for better understanding of this condition. ã 2016 Elsevier B.V. All rights reserved.
Keywords: Psychosis Schizophrenia Late onset Elderly psychosis Geriatric psychosis
1. Introduction Schizophrenia and related Non-Affective psychotic disorders are predominantly studied in adolescence and young adults. However some individuals do develop psychotic disorder for the first time during their old age. Community prevalence estimates for schizophrenia range from 0.1% to 0.5% (Castle and Murray, 1993; Copeland et al., 1992, 1998; Kua, 1992). 1-year prevalence rate of schizophrenia in individuals between ages 45 and 64 is 0.6% (Keith et al., 1991). For individuals over 65 years of age, incidence rate of schizophrenia with first onset after 44 years is 12.6 per 100,000 population per year (Copeland et al., 1998). The Studies on lateonset schizophrenia began with Manfred Bleuler, Late onset schizophrenia constituted 15% of patient whom he examined; 4% of the patients had an onset after 60 (Bleuler, 1943). About 50% of the patients with late-onset schizophrenia had symptoms that were similar to those seen in early onset schizophrenic patients. However he did report certain striking differences; more than 50% of patients had Paraphrenia like symptoms, depressive, anxious,
* Corresponding author. E-mail addresses: [email protected], [email protected] (S. Ramasamy). http://dx.doi.org/10.1016/j.ajp.2016.10.017 1876-2018/ã 2016 Elsevier B.V. All rights reserved.
catatonic or confused agitated symptoms, but with less affective flattening (Harris and Jeste, 1988; Jeste et al., 1988, 1995; Mayer et al., 1993; Pearlson et al., 1989; Rabins et al., 1984). Subsequently there are lot of studies on late onset psychosis (LOP), mostly from developed countries of Europe and America, but the research findings in this area is struck with difficulties because neither ICD 10 nor DSM V contain separate codes of diagnosis for ‘late onset schizophrenia’; different terms being used to describe a similar illness occurring in old age and using different age cut-off to be called late onset psychosis (LOP) (Howard et al., 2000). But other limitations of existing literature in this field are some studies include patients who had early onset psychosis but grown old, including patients with affective disorder and organic psychosis. Some of these confusions were cleared after The International Late Onset Schizophrenia group came up in the year 2000 with consensus on nomenclature defining Late Onset Schizophrenia and Very Late Onset Schizophrenia like Psychosis. For developing countries like India and China with their large population and increasing geriatric population, late onset psychosis is a major concern. Socio cultural factors like globalization, migration, breaking up of joint families, poorer healthcare facilities etc in developing countries in Asia are certainly different to that of developed countries in Europe and America. There are many
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factors that increase the risk of developing psychiatric disorder in elderly like loss of close relatives, social network, previous status in society, sensory functions, functional ability, and health (Skoog, 2008).These psycho socio cultural factors can influence the presentation of individuals with late onset psychosis. Currently there is a paucity of literature on the clinical manifestation of late onset psychosis in Asia especially from India. So the aim of this study is to study the clinical characteristics of non-affective, nonorganic, late onset psychosis in an Indian set-up. 2. Methods 2.1. Study design & setting This is a retrospective chart review study conducted at the Geriatric clinic & Services in National institute of mental health and neuro sciences (NIMHANS) Bangalore, a tertiary care hospital in India, which caters to individuals with psychiatric, neurology and neurosurgery problems. Geriatric clinic is run by a multi disciplinary team which includes psychiatrists, neurologists, neuro psychologists and social workers. All the patients attending geriatric clinic are assessed using a semi structured workup proforma, thorough physical examination, Hindi Mental State Examination scale (HMSE) which is an Indian adaptation of Mini Mental State Examination, Geriatric Depression Scale (GDS), Clinical Dementia Rating Scale (CDR), Neuro Psychiatric Inventory (NPI) and Everyday Abilities Scale for India (EASI). They also undergo basic investigations like complete haemogram with peripheral smear, random blood sugar test, liver function test, renal function test, serum electrolytes and Computerized tomography of brain. Other investigations are done if necessary. 2.2. Study participants We retrieved and screened medical records of all patients who got registered in the geriatric clinic between 1st of January 2006 and 31st of May 2011. In this study we included medical records of patients diagnosed to have psychosis (Schizophrenia, delusional disorder, acute psychosis, nonspecific psychotic disorder, other psychotic disorder) as per International classification of disease 10th version (ICD-10), who were above 50 years of age at the time of onset of psychosis and those who followed up in geriatric clinic atleast for 3 months. We excluded files of patients whose diagnosis was other than psychosis, who developed psychotic symptoms secondary to affective disorder or substance use or organicity (epilepsy, cerebral tumors etc), dementia, whose age at onset of psychosis was below 50 years, those who had major mental illness in the past and medical records that lacked sufficient data. Finally we selected 83 medical records which satisfied our inclusion and exclusion criteria, these records were analyzed. This study was approved by NIMHANS Institute ethics committee, written informed consent was not taken as it is a retrospective chart review, and anonymity of all patients was maintained. 2.3. Materials 1. Hindi Mental Status Examination (HMSE) – Is an Indian adaptation of Mini Mental Status Examination (MMSE) that is being used in epidemiological studies of dementia in India. It contains 23 items which test different components of intellectual capability. The scale has a total score of 31, a score less than 19 is indicative of dementia and warrants a detailed cognitive assessment (Ganguli et al., 1995). 2. Everyday Abilities Scale for India (EASI) –This is brief, reliable and valid scale to assess activities of daily living, with norms, which
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is appropriate for use in assessing dementia in elderly people in India. This is a 12-item uni-dimensional scale which measures mobility, instrumental and personal care activities, the scale has good internal consistency (Pandav et al., 2002). Each item is scored either 0 or 1, less number of 1 score, in other words lower total scores indicates better functioning. 3. Neuropsychiatric Inventory (NPI) – The purpose of NPI is to obtain information on the presence of psychopathology. The NPI was developed for application to patients with Alzheimer’s disease and other dementias, but it may be useful in the assessment of behavioral changes in other conditions aswell. It assesses ten behavioral symptoms including psychotic and affective symptoms and two neurovegetative symptoms. The NPI has been proven to be sensitive to change with treatment, it is available in many languages, has been shown to be valid and reliable in crosscultural studies (Wood et al., 2000). 4. Geriatric Depression Scale (GDS) – Short version – GDS short version is a 15 item scale.The GDS was found to have a high sensitivity and specificity. The validity and reliability of the tool have been supported through both clinical practice and research. In a validation study comparing the Long and Short Forms of the GDS for self-rating of symptoms of depression, both were successful in differentiating depressed from non-depressed adults with a high correlation (Sheikh and Yesavage, 1986). Scores of 0–4 are considered normal; 5–8 indicate mild depression; 9–11 indicate moderate depression; and 12– 15 indicate severe depression. 2.4. Statistical analysis Descriptive statistics (frequency, ratio, mean, standard deviation) was used to define the socio demographics and clinical characteristics of the patients. Chi square test and Fisher’s exact tests were conducted for to compare the symptomatology between different age groups. Person’s correlation test was used to analyze the association between cognitive functions and different variables, with p value of <0.05 considered as significant. The data was analyzed using SPSS version 19. 3. Results Among the 83 medical records that were reviewed, the mean age of the patient was 69 9 years at the time of initial consultation, and age ranging between 51 and 91 years. The average age at the time of onset of illness was 67 10 years. The mean duration of illness was 2.5 years (SD 2.2 years); 55.4% of the patients were uneducated and 54.2% belonged to low socio economic class. 3.1. Socio demographics and clinical characteristics The socio demographics and clinical characteristics of the patients are depicted in (Table 1). The sample had female preponderance; with number of females being almost double that of males. Except one person all others were married, most of them followed Hindu religion. Psychosis not otherwise specified (psychosis NOS) was the most common diagnosis in these patients, followed by schizophrenia, delusional disorder and acute and transient psychosis. Interestingly all patients diagnosed with acute and transient psychosis developed illness only at 60 years. Only 3/83 (3.6%) patients had Axis II disorder (Anankastic personality disorder – 1; Anxious avoidant personality disorder – 1; and Paranoid personality disorder 1) Precipitating factor was noticed in 12% of these patients, with some developing psychosis following a loss of family member, some following hearing or visual impairment etc. Positive family history was found in more than 20% of patients, with nearly 11% of them had either a first or second
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Table 1 Socio-demographics and Clinical characteristics.
Table 2 Symptomatology.
Variables
Mean
SD
Current age (years) Age at onset of illness (years) Education (years) Duration of illness (years)
69 67 3.4 2.5 N = 83
9 10 4.6 2.2 %
Sex Female Male
56/83 27/83
67.5 32.5
Socioeconomic status Low Middle High
45/83 35/83 3/83
54.2 42.2 3.6
Married
82/83
98.8
Diagnosis Psychosis NOS Schizophrenia Delusional disorder Acute and transient psychosis Schizoaffective disorder
39/83 15/83 15/83 14/83 0/83
46.9 18.0 18.0 16.8 0
Precipitating Factor Entry event Exit event Sensory impairment Other
10/83 3/83 2/83 2/83 5/83
12 3.6 2.4 2.4 6
Positive family history of psychiatric disorders Psychosis Mood disorder Dementia Suicide Other disorders
17/83 9/83 4/83 3/83 1/83 1/83
20.5 10.8 4.8 3.6 1.2 1.2
56/83
67.4
Co-morbid medical illness SD: Standard deviation, N: total number, Psychosis NOS specified.
Psychosis not otherwise
degree relative with psychosis. Co-morbid medical illness was found in 67.46% of patients; with most common being hypertension followed by Type 2 diabetes mellitus. 3.2. Symptomatology Delusions and hallucinations dominated their clinical presentation, with acting out behavior secondary to delusions being the commonest reason for bringing the patient for consultation. Thought alienation phenomenon noted in 15.7%, none of the patients reported delusional perception, made phenomenon or somatic passivity. Affective symptoms (sadness, irritability, fear, anxiety, dysphoria and rarely elation) were seen in nearly half of the patients (Table 2). Only two patients had negative symptoms, one with apathy, anhedonia, and another patient had asocialization, apathy and anhedonia. One third of patients had verbal/ physical aggression and other behavioral disturbance like restlessness, aimless wandering, and disorganization. One third had subjective or objective memory disturbances. No patients had formal thought disorder or expressed any bizarre delusions. Among delusions, delusions of persecution followed by referential delusion were the commonest. 64% of patients had hallucination, out of which half of them had 2nd person auditory hallucination, very few patients had hallucination in other modality (Table 3). There was no significant difference in the symptomatology between those with late onset psychosis and very late onset psychoses (where the onset of psychosis was 60years) (N = 16 & 67 respectively).
Symptoms
N = 83 n/N
%
Delusion Hallucination Thought alienation Made phenomenon Somatic passivity Formal thought disorder Negative symptom Affective symptom Aggression Other behavioral disturbance Sleep disturbance Memory disturbance Suicide attempt
73/83 53/83 13/83 0/83 0/83 0/83 2/83 43/83 29/83 28/83 48/83 27/83 3/83
88 63.9 15.7 0 0 0 2.4 51.8 34.9 33.7 57.8 32.5 3.6
Table 3 Type of Delusion & Hallucination. N = 83 n/N
%
Delusion Persecutory Reference Misinterpretation Infidelity Grandiose Infestation Bizarre Other
67/83 32/83 10/83 3/83 2/83 1/83 0/83 0/83
80.7 38.5 12.0 3.6 2.4 1.2 0 0
Hallucination 2nd person auditory hallucination 3rd person auditory hallucination Running commentary Visual hallucination Tactile hallucination Extracampine hallucination Intracorporeal hallucination Pseudo hallucination
43/83 12/83 0/83 10/83 2/83 1/83 1/83 1/83
51.8 14.4 0 12.0 2.4 1.2 1.2 1.2
3.3. Cognitive function and activities of daily living Although one third of the patients had some memory disturbances, their cognitive functions and their ability to function independently remained largely intact (Table 4), with mean HMSE and EASI scores being 24.5 4.9 & 2.3 2.8 respectively. Most patients had an EASI score of 0 indicating they were functioning independently. Cognitive functions were slightly lower in females Table 4 Cognitive function & Activities of daily living. Mean
SD
HMSE (score out of 31) Female Male
24.50 23.34 26.50
4.9 4.4 3.5
EASI (score out of 15) Female Male
2.3 2.5 2.1
2.8 2.9 2.7
HMSE &
Pearson’s correlation P* value 0.74 0.67 0.83
Current age Age at onset of illness Duration of illness
HMSE: Hindi Mental Status Examination, EASI: Everyday Abilities. Scale for India, Correlation significant at p* value < 0.05.
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compared to males. There is no significant association between cognitive functions and age, age at onset of illness or duration of illness (P values 0.74; 0.67; 0.83 respectively). 4. Discussion 4.1. Sociodemographics and clinical characteristics This study evaluated the clinical characteristics of nonaffective, non-organic, late onset psychosis in a sample of Indian population seeking care in special clinic. A minimum of 3 month follow up was included as a part of study criteria in order to validate the diagnosis and to allow for any revision after initial consultation. Most participants in this study were above 60 years of age at the time of onset of psychosis, the “age of onset” is defined as a change from a state without psychotic features to a clearly abnormal psychotic state as evidenced by the presence of any of the characteristic symptoms of psychosis according to ICD-10. Female preponderance was noted in overall sample which is comparable to other studies (Castle and Murray, 1993; Harish et al., 1996). Many were uneducated in our sample which could be due to female preponderance and also most of them were from rural background, according to Indian government census in 2001 on literacy rate in India, overall literacy rate works out to be 64.8%, the male literacy rate is 75.3% and that for females is 53.7%, showing a gap of 21.6 percentage points between the sexes at the national level and the gap is more in the rural areas. In our sample almost all were married and had a stable occupation suggesting a good premorbid functioning in these patients, in concurrence with other studies done in western countries (Alici-Evcimen et al., 2003; Lacks et al., 2006), the higher marriage rate and fairly good adjustment in occupation may also merely reflect the late onset of illness in this group, this finding good pre-morbid functioning is in contrast to early onset group, with some researchers speculating early onset patients perhaps represents pernicious form of the illness particularly associated with pre-morbid dysfunction (Castle and Howard, 1992; Pearlson et al., 1989). In our study co-morbid Axis II disorder was found only in 3.6% of participants and with only one patient diagnosed to have paranoid personality disorder, our study contradicts other studies which reported as high as 45% of patient with late onset psychosis having paranoid or schizotypal personality (Jeste et al., 1988; Kay and Roth, 1961; Kay et al., 1976). Family history of psychiatric disorder was noted in just over 20% of patients, among which family history of psychosis and mood disorder are 10.8% and 4.8% respectively, family history studies almost all show a familial risk of late-onset schizophrenia lower than that of early onset patients but greater than that of the general population (Howard et al., 1997). 4.2. Symptomatology In our population delusions and hallucinations are the common symptoms, which are in concordance to other studies (Castle and Howard, 1992; Pearlson et al., 1989) which also reported delusions and hallucinations being common among late onset psychosis. On further analysis of type of delusions we found certain differences when compared to other studies. Though delusion of persecution was the commonest (88%) none of the patients had partition delusion which is in contrast to other studies that reported a high prevalence of this delusion (Howard et al., 1997; Pearlson et al., 1989).In addition only 2.4% had grandiose delusion, whereas other studies reported grandiose delusion in 14%-17% of subjects (Howard et al., 1997; Pearlson et al., 1989).Though accusatory, abusive, 3rd person auditory hallucination and hallucinations in other modalities were noted in our sample, none had running
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commentary type hallucination which is not in accordance with other studies (Harish et al., 1996; Howard et al., 1997). In our study negative symptoms was reported in 2.4% of subjects and none had any formal thought disorder which is consistent with an overall lower prevalence of these symptoms in other published reports (Almeida et al., 1995; Howard et al., 1994, 1997; Pearlson et al., 1989). Some affective symptoms was noted in half of these subjects, but they appeared secondary to psychotic symptoms and were not severe enough or lacked associated symptoms that would warrant a diagnosis of mood disorder or schizoaffective disorder. As we all know well even in core schizophrenia it is not uncommon to have depressive or anxiety symptoms, which could in fact be secondary to psychotic symptoms. It is possible to misdiagnose patients with severe depression with psychotic symptoms as late onset psychosis, but in this study we recruited only those patients who followed up for at least 3 months, and we excluded those patients if diagnosis was revised to affective disorder. 3.6% of patients attempted suicide which is a cause for concern, as the intentionality and lethality of such attempts are very high in geriatric population. There was no difference in Symptomatology between sexes. This perhaps suggests that the clinical presentation of late onset schizophrenia is similar in both sexes. Diagnosis wise most patients would fall under the category of Psychosis Not otherwise Specified (Psychosis NOS) as per ICD-10, as our sample is not restricted to schizophrenia. Memory disturbance either subjective or objective was reported in one third of the subjects despite having a stable cognitive functions and ability to take care of themselves as indicated by HMSE (Mean-24.5) and EASI (Mean-2.3) scores, in our study there was no correlation between cognitive functioning and age, age of onset of illness or duration of illness, this could be because of our strict selection criteria this in turn can validate our initial diagnosis. However it’s worth evaluating the longitudinal course of these patients as two of these patients diagnosis was revised to fronto temporal dementia after nearly 1.5 years of follow-up, and there are many studies that suggest late onset psychosis is a prodrome of dementia (Brodaty et al., 1999). 4.3. Strengths Strengths of this study are it adds to the existing knowledge on late onset psychosis in this part of the world as there is paucity of research in India on this area, relatively large sample size compared to many earlier studies done in west (Jeste et al., 1988, 1995; Pearlson et al., 1989)as well as in India (Harish et al., 1996), stricter diagnostic criteria making the sample more homogenous. We felt compared to late onset psychosis as such (which could be secondary to other cause) non-affective nonorganic late onset psychosis forms a distinct group with unique manifestations which warrants further research for better understanding. 4.4. Limitations Some of the major limitations of this study are its retrospective study design, reliance on medical records to collect details; lack of control groups (like early onset group, late onset group with organic psychosis) that would have helped us to distinguish the clinical features of these groups. One can always question the reliability of determination of symptoms from medical records, as interpretation of psychopathology can vary between individuals, the symptoms which were not mentioned in the medical records were considered as absent, No inter-rater reliability test done, which could have made the data more reliable, and the severity of symptoms could not be assessed. However since we use validated
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scales and follow a standard protocol at geriatric clinic in NIMHANS, Bangalore, we hope some of these limitations were reduced. 5. Conclusion Despite its rarity non affective, non organic, late onset psychosis forms a distinct group and validity of this psychiatry entity is undeniable. Though our study has certain striking similarities with other published research like female preponderance, delusions and hallucinations being the common symptoms, lack of negative symptoms and formal thought disorder, there are subtle variations with respect to the type of delusion and hallucination. Further systematic research is needed for better understanding of phenomenology, epidemiology, biological underpinnings, psychosocial issues, as well as course and outcome of this condition. References Alici-Evcimen, Y., Ertn, T., Eker, E., 2003. Case series with late-onset psychosis hospitalized in geriatric psychiatry unit in Turkey: experience in 9 years. Int. Psychogeriatr. 15, 69–72. Almeida, O., Howard, R., Levy, R., David, A.S., 1995. Psychotic states arising in late life (late paraphrenia): psychopathology and nosology. Br. J. Psychiatry. 166, 205– 214. Bleuler, M., 1943. Die spatschizophrenenKrankheitsbilder. Fortschritte der Neurologie und Psychiatrie 15, 259–290. Brodaty, H., Sachdev, P., Rose, N., Rylands, K., Prenter, L., 1999. Schizophrenia with onset after age 50 years. I: Phenomenology and risk factors. Br. J. Psychiatry 175, 410–415. Castle, D.J., Howard, R., 1992. What do we know about the aetiology of late onset schizophrenia? Eur. Psychiatry 7, 99–108. Castle, D.J., Murray, R.M., 1993. The epidemiology of late-onset schizophrenia. Schizophr. Bull. 19, 691–700. Copeland, J.R.M., Davidson, I.A., Dewey, M.E., Gilmore, C., Larkin, B.A., McWilliam, C., et al., 1992. Alzheimer’s disease, other dementias, depression and pseudodementia: prevalence: incidence and three-year outcome in Liverpool. Br. J. Psychiatry. 161, 230–239. Copeland, J.R.M., Dewey, M.E., Scott, A., Gilmore, C., Larkin, B.A., Cleave, N., et al., 1998. Schizophrenia and delusional disorder in older age: community prevalence incidence, comorbidity and outcome. Schizophr. Bull. 24, 153–161. Ganguli, M., Ratcliff, G., Chandra, V., Sharma, S., Gilby, J., Pandav, R., et al., 1995. A hindi version of the MMSE: The development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int. J. Geriatr. Psychiatry 10, 367–377. Harish, M.G., Suresh, K., Rajan, I., Janardhanreddy, Y.C., Sumant, K., 1996. Phenomenological study of late-onset schizophrenia. Indian J. Psychiatary 38, 231–235.
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