Psychosis Ddx

MDD with psychosis

This is a severe subtype of unipolar major depression in which the depressive episode is accompanied by delusions and/or hallucinations, typically with depressive themes (eg, deserving punishment, worthlessness, nihilism). E.g.:

• "Something is very wrong with my brain since my wife died 6 months ago." Over the past month, he has become convinced that he has brain cancer and is being punished for sins he committed as a young man.

• He denies suicidal ideation but says, "It doesn't matter because I am dying anyway and the end is near."

Identification of psychotic features is important as psychotic depression is treated differently than nonpsychotic depression. First-line treatment of major depressive disorder with psychotic features is combination pharmacotherapy with an antidepressant and antipsychotic or electroconvulsive therapy.

Schizoaffective

Schizoaffective disorder is distinguished from major depressive disorder (MDD) with psychosis in the following way:

• Schizoaffective is psychosis with intermittent mood disorders. Psychosis in the absence of a mood disorder rules out MDD.

• MDD with psychosis is a constant mood disorder with intermittent psychosis (delusions/hallucinations).

Schizoaffective disorder must be differentiated from schizophrenia and bipolar disorder:

• If mood symptoms occur in schizophrenia, they are typically present for a small portion of the illness. In contrast, schizoaffective's mood symptoms appear to be present for a significant portion of illness.

• In bipolar I disorder, psychotic symptoms occur exclusively during manic or depressive episodes. The persistence of hallucinations when patient's mood is stable rules out a bipolar I diagnosis.

GAD vs Adjustment

• Adjustment: exclude GAD first

• GAD: > 6 mo, multiple areas of life

Questions

Schizoaffective

Schizoaffective