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Suffering from depression. How to treat this psychotic syndrome?

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Practicing since : 2003
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Hypothetical case…I provided my answers to the two questions.
XXXXXXX a 32-year-old man, never married, sits tearfully in a chair. His head hangs low, and he occasionally cannot speak because he chokes up. He begins the interview by saying, "No one likes me. I couldn't make a friend if my life depended on it XXXXXXX He tears up immediately. In response to some initial questions, he agrees that he feels like this most of the time and that he feels hopeless about changing it. He agrees too that he has little appetite and no desire to socialize. His sex drive is "nonexistent XXXXXXX When asked about his sleep patterns, he avoids the question, but agrees later that he naps a lot during the day. He says that he saw a psychiatrist some time ago, who prescribed an antidepressant medication, the name of which XXXXXXX cannot recall.

As the psychologist continues the interview, XXXXXXX repeatedly says that "no one likes me XXXXXXX When the doctor asks him why he thought that was, XXXXXXX avoids the question. A few interesting facts emerge during the discussion of the depressed feelings. First, XXXXXXX says he began feeling depressed after a period of "homosexual panic" when he was about 18 years old. He denied being homosexual at this point in his life, but said he had had about six months of "terror" that he was indeed XXXXXXX when he was 18 or 19.

Following his "realization" that he was not XXXXXXX he became depressed and says that he has never come out of it. After some time, he acknowledges that he suspects people think he is in fact XXXXXXX and that that explains why they do not like him. XXXXXXX also states that he has one brother, seven years older, who is both XXXXXXX and schizophrenic. A sister, two years younger than he, has bipolar disorder, and has been well-maintained on lithium carbonate. XXXXXXX says that initially, his own depression had "terrible swings XXXXXXX in which he would become psychotic. Lately these have calmed down. "Now I don't hear the voices too often XXXXXXX he says. When asked to clarify, however, XXXXXXX dismisses the statement as an exaggeration.

John's academic performance was wonderful in grade school, high school, and early college. At about age 20, however, he failed all courses he attempted and eventually dropped out of school. He lost all his friends and became a drifter. He lived in many cities for about ten years, never keeping work and drifting from town to town. He eventually returned home (to the city of this interview) and has been living sometimes with his brother and sometimes on the street. During this discussion, the psychologist notices XXXXXXX exhibiting strange motions with his head, as if he were listening to someone talking to him on an earphone. Finally, XXXXXXX admits that "a voice" is communicating with him. The voice is coming from the computer on the psychologist's desk.

At this point, XXXXXXX begins to grow increasingly suspicious of the psychologist's motives, at one point refusing to answer questions "until you assure me that you are not tape-recording this interview XXXXXXX The psychologist reassures XXXXXXX who does not relax, though he does grudgingly answer more questions. XXXXXXX denies using alcohol or any other drugs, "except that crap the psychiatrist gave me XXXXXXX in recent weeks. XXXXXXX claims he does not drink or take drugs with any regularity, "because it makes me dull. I can't afford to be dull XXXXXXX When asked why not, XXXXXXX responds angrily that people take advantage of dull people.

Later, the psychologist is able to verify that XXXXXXX is a fairly sexually abstinent person, and one who is quite difficult to get close to. XXXXXXX readily admits that he is always suspicious of people's motives, suspecting that they only wanted to know him in order to "get in my pants XXXXXXX At one point, he accuses the psychologist of wanting to have sex with him. When the psychologist gently indicates that this is not so, within a few minutes XXXXXXX is tearful and sad again, and his conversation returns to how no one likes him.

1.     What would be your hypothetical diagnoses?

My best likely hypothesis seems to be schizophrenia. It could be some kind of medical condition, although the possible conditions are rare. All in all, one of the schizophrenias is most likely, probably either schizoaffective (since depression seems to be prominent in the symptom list) or paranoid schizophrenia (this seems less likely, again given the affective component). I’m I going in the correct direction?

Dr. Sundarakumar what would be your thought process as you see the changing picture in this hypothetical situation?

2.     Using the diathesis-stress model to assess John's case, what salient vulnerabilities and stressors come to mind?

The diathesis-stress model is a psychological theory that explains behavior as both a result of biological and genetic factors (“nature”), and life experiences (“nurture”). This theory is often used to describe the pronunciation of mental disorders, like schizophrenia, that are produced by the interaction of a vulnerable hereditary predisposition, with precipitating events in the environment. In this case, John’s homosexual panic attacks are a result of his brother being XXXXXXX and schizophrenic. John’s interaction with the environment such as, not drinking or take drugs makes him feel dull.

I’m I on the right track here Doc? Did I miss somethings?

Posted Mon, 29 Oct 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 10 hours later

Yes, you are on the right track in your diagnostic approach. In this case scenario, we see that John's superficial presentation is tearfulness, sadness, negative thoughts, hopelessness, etc. which may initially give you a picture of a mood syndrome. But as the scenario unfolds, we can see clearly that this 'depression' is just a secondary consequence of "no one liking him". There are several mentions about this in the history and later on we find that this is due to his delusional beliefs that other people think that he is XXXXXXX Later in the history, we find strong evidence for other prominent psychotic symptoms such as persecutory delusions and auditory hallucinations, thus making a psychotic syndrome as his primary diagnosis.

Like I mentioned in my tips to approach, the next step is to sub-classify the psychotic syndrome. Saleint features are:
- chronic psychotic illness
- significant and multiple delusions and hallucinations
- significant socio-occupational deterioration ("wonderful performance" till early college -- then, drastic deterioration to "the streets", the deterioration well co-relating with the onset of his illness - 18 or 19)
-- All these point to a Schizophrenia

Now, that our primary diagnosis is established, the next step is sorting out the atypical symptoms. In this case, where do we put the 'depressive' symptoms ? (...and you rightly mentioned that they are prominent)
In John's case, his 'depression' is a direct consequence of his delusional beliefs and so are only secondary depressive features.
But you can very well offer a differential diagnosis of a Schizoaffective disorder, due to the prominence of the depressive symptoms. (Note: Schizoaffective disorder is not classified as a subtype of Schizophrenia, classification-wise, it is considered as a separate entity)

So, my diagnostic opinion would be:
1) Paranoid Scizophrenia with secondary depressive features
2) D/D - Schizoaffective disorder

(Opinions about which would be the first possibility may vary from clinician to clinician, but as long as you are able to build your case for a primary 'chronic psychotic illness' with 'additional / secondary depressive features', you are on the right track.)

Regarding incorporating the the diathesis-stress model in this case, you seem to be a little unclear in your explanation. Diathesis means 'predisposition'. So, as you have rightly mentioned in the definition, the concept is that in a genetically predisposed or vulnerable individual, the 'combination with' (or superimposition of) environmental stress results in the illness.
So what is John's diathesis? A strong family history of mental illness i.e. genetic predisposition. But though he had this genetic predisposition right from birth, why did he develop Schizophrenia only at the age of 18 / 19? There comes the role of the environmental stress. His brother being XXXXXXX may have triggered the 'homosexual panic' and depressive feelings. The homosexual panic in turn could have been partly due to the social stigma / discrimination against XXXXXXX people. If you observe carefully in the history, it is mentioned that "he first had these depressive feelings when.. XXXXXXX So, this was a significant stressor, clearly corelating to the onset of his illness and probably precipitating his gradual decline (it is not mentioned that all of a sudden he went into a full blown Schizophrenia). Such stress could have lead to a decline in his social functioning further leading on to social withdrawal and he started 'drifting' from city to city. Over a period of time with the cascading negative social / environmental factors, he ended up with a full blown Schizophrenia.

So, what you are expected to highlight in the concept of diathesis-stess model is that neither the genetic predisposition nor the environmental stress BY ITSELF is sufficient for causation, but rather a dynamic interaction between these two factors results in the illness.

You're doing a good job... Keep practicing, that's the best way to learn clinical skills.

Best wishes,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
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