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Psychotic depression
A 60-year-old man has had low mood, early morning waking, loss of appetite and 9 kg weight loss since his wife died eight months ago. For the past three weeks he has insisted that his intestines have rotted away and that he no longer needs to eat. He is not eating and has become withdrawn. What is the most likely diagnosis?
- A. Somatic symptom disorder
- B. Persistent delusional disorder
- C. Schizophrenia
- correctD. Depression with psychotic features
Explanation
Key fact
In psychotic depression the mood comes first and the delusions are mood-congruent - guilt, nihilism, poverty, deserved punishment.
Depression with psychotic features. The depressive syndrome came first, and the nihilistic delusion grew out of it.
Why
The biological features - early waking, appetite and weight loss - came first, over months.
The delusion appeared only three weeks ago, on top of established depression.
Believing one's organs have rotted is a nihilistic delusion, the Cotard type.
It is mood-congruent: it fits the themes of decay, guilt and worthlessness.
Bereavement is a precipitant, but the duration and severity take this beyond grief.
The mood came first, and the delusion grew out of it
Why not the others
- A. Somatic symptom disorder — involves distressing physical symptoms with disproportionate concern, but the belief is not held with delusional conviction and there is no depressive syndrome of this severity.
- B. Persistent delusional disorder — requires an encapsulated delusion with otherwise preserved functioning and no prominent mood disturbance. Here the mood disturbance dominates.
- C. Schizophrenia — would show bizarre or mood-incongruent delusions, thought disorder and negative symptoms, usually with onset far earlier in life.
Remember
Ask what came first. Mood before psychosis is psychotic depression; psychosis before or without mood change is schizophrenia.
Go deeper
Treatment is an antidepressant plus an antipsychotic; an antidepressant alone responds poorly.
Electroconvulsive therapy is highly effective and is used where there is food refusal, severe suicidal risk or failure of drug treatment - all relevant here.
Psychotic depression carries a higher suicide risk than non-psychotic depression, and risk must be assessed directly at every contact.
Kaplan & Sadock's Synopsis of Psychiatry, 12th ed. (Wolters Kluwer, 2022).