Affective paraphrenia has a remitting or insidious course, with early expression of ideas of reference. Moreover, affect fluctuations of anxiety or ecstasy are often seen during the onset of the disorder and not infrequently during its later course. Moods are always associated with pathological idea construction; anxiety with self-references and hallucinations, ecstasy with false perceptions, particularly ideas of happiness. At the onset, it is hard to differentiate between affective paraphrenia and benign anxiety-happiness psychosis, but generally it soon becomes recognizable that the delusions and hallucinations are no longer derived from anxiety and ecstasy, but become illogical. Somatic delusions which patients with anxiety-happiness psychosis usually relate to their abnormal mental state in affective paraphrenia have a hallucinatory character with patients feeling influenced from outside. Affective fluctuations are often associated with irritability which grows out of anxiety. This is an irritated reference syndrome, which contains fewer anxious but more hostile reinterpretations of the environment. At this stage, affective paraphrenia may be arrested. Similarly, mild ecstatic mood may persist and produce chronic delusions of grandeur. Finally, and more commonly, affect may be disturbed in both directions, with delusions of persecution and of grandeur existing simultaneously. Systematization of the delusions may occur at times to a high degree, producing the picture of Kraepelin’s paranoia.

Often affective paraphrenia does not stop at this stage, but progresses further. The illogical component, present as a tendency from the start, becomes more pronounced so that eventually fantastic delusions of grandeur, errors of memory, misidentification, absurd ideas, and hallucinations in all spheres are present. These traits are rarely as evenly developed as in the systematic forms of fantastic schizophrenia. Some may be absent, while others may dominate the foreground. The key to the diagnosis is in the affect. While patients with systematic fantastic paraphrenia appear to have no emotional ties to their inner world of delusions and consequently talk about it without affective display, in patients with affective paraphrenia the delusions remain strongly anchored in the affect. Patients may speak of their ideas with deep irritation or with pride and enthusiasm. Similarly, the paranoid affect is maintained in the formation of absurd ideas. Apart from their delusions the patients may become quite dull.