Major Depressive Disorder: Psychotic Depression
True clinical depression is not just about feeling a bit low or fed up. We all can feel some sadness from time to time but most of us simply snap out of it or resolve the ongoing situation causing it and get on with life. Having suffered with severe clinical depression myself a number of times, I can tell you that there is a world of difference between feeling “a bit down”, and the kind of depression that takes you into a black hole of despair from which it seems there is no escape.
When a person is severely clinically depressed, relationships suffer, usual activities grind to a halt and work becomes impossible. One feels, (if one can feel at all because often you can be emotionless), like you are in stuck in mud, sinking deeper down until there is nothing of the real you left! This is the kind of depression that needs good medical and therapeutic intervention as quickly as possible.
In this article I will discuss major depression coupled with psychotic symptoms. Thankfully, it is a rarer form of depressive illness, but nonetheless people do suffer with depression and psychosis together. I do have to say that it is not unknown for people with moderate depression to experience occasional psychotic symptoms also. Psychotic depression is also known as psychotic major depression (PMD and psychotic depressive disorder (PDD).
When people hear the term psychotic depression they tend to think immediately of schizophrenia, bipolar disorder or schizoaffective disorder. It is most definitely none of these disorders and is an entirely separate problem. Indeed it may share some of the symptoms of those disorders but it also lacks some of their symptoms. For example psychotic depression is without a manic episode as seen in bipolar and psychotic symptoms can exist in both depression and mania in bipolar disorder.
Symptoms of Psychotic Depression
When diagnosing psychotic depression, psychiatrists rely on the symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Psychotic depression is listed in the DSM under mood disorders, as a type of major depressive disorder. Psychiatrists may find it difficult to diagnose as some of the psychotic symptoms may be very subtle leading to misdiagnosis. Some people may prefer not to mention some of the more strange psychotic symptoms they encounter out of fear and embarrassment.
It is important for psychiatrists to take a thorough look at the history of the patient and their illness to be sure that the wrong diagnosis isn’t given. Bipolar disorder, schizophrenia and other psychotic disorder should be eliminated as a diagnosis before reaching the conclusion of psychotic depression.
Do I have psychotic depression?
Here are some of the symptoms a psychiatrist will look for:
- Persistent low mood
- Unexplainable chronic pain
- Unable to make decisions/confusion
- Little or no appetite
- Feeling worthless
- No motivation/immobility
- Thoughts of suicide
Delusions and hallucinations are two distinct symptoms that rule out a non psychotic depression.
I know a number of people who have suffered with psychotic depression and they appear to explain it as a terrible depression but with mental energy!
Delusions in Psychotic Depression
If you suffer with delusions in, you will believe things are true when in reality they are not. You may believe you are being followed, spied on or that your house is bugged for example. This can cause considerable agitation, fear and anxiety.
You may believe you are of high importance, superior and special but these are more usual in the manic phase of bipolar disorder. The range of delusions differs from person to person but characteristically in psychotic depression, they will portray themselves as a strong belief of victimization or persecution.
Other common delusions include the belief that special messages are being sent to you telepathically, through the media, televisions being a common source. Extreme delusions like this are more likely in schizophrenia but can occur in psychotic depressive episodes.
In psychotic depression, it is more likely that delusions may present in a less obvious fashion. You may believe you are less attractive than you actually are, that you are completely useless or that you are making bad things happen. Some people would regard these more subtle forms as a direct result of your depression and quite understandable, but there is a difference between a fleeting thought and one that is persistent, producing high levels of fear and anxiety. These subtle delusions may not be picked up on in consultation.
The delusions of psychotic depression appear to be directly connected to the symptoms of a major depression. Feelings of worthlessness, guilt, anger and inferiority tend to attract suspicion, fear of punishment and ridicule.
Hallucinations in Psychotic Depression
Auditory hallucinations are common in psychotic depression and tend to present as a voice, a whisper or mumbling. The hallucinations usually express derogatory remarks, can be belittling, or more severely may bring suggestions of blame, and suggestions to self harm. Again the levels of this will vary from person to person. Visual hallucinations tend to happen less often than auditory hallucinations.
Delusions and hallucinations could become dangerous especially when a sufferer is already severely depressed and has suicidal thoughts. That said, people who suffer with psychotic depression can react differently to these psychotic aspects. Some will simply not believe them; shrug them off as a figment of their imagination, whilst others will become more and more fearful and gain an increasing belief in their suggestive element.
Video Showing ECT Treatment
Treatment of Psychotic Depression
Depressive psychosis is usually seen as a reactionary depression which becomes severe enough for delusions and hallucinations to build but as I already mentioned, some people with a less severe depression can experience similar transient psychotic experiences. I think it is the case that this is perhaps not recognized enough. It makes one wonder how many people have a taste of psychotic depression and it goes unnoticed.
Medications and ECT
If a person with depression whether severe or not, doesn’t divulge odd thoughts or suspecting that they hear things, they may be treated for depression alone. Being prescribed antidepressants may be enough for the depression to go away and the psychotic symptoms along with it.
Many professionals consider that prescribing antidepressants is enough to eliminate all the symptoms of psychotic depression and this does seem to work for some people. There are however, those who don’t respond to antidepressants alone and a combination of treatments is tried. This usually means taking antidepressants with antipsychotics. If this doesn’t produce favourable results, the last resort may be to offer electro-convulsive therapy (ECT) alongside the medications.
It may be that the patient is experiencing such suicidal ideation in their severe depression, and has such severe psychotic symptoms, that ECT therapy is offered as a solution quite quickly. For other people who are on medication alone, it can be a while before the treatment takes good effect. SSRI antidepressants take a few weeks to start to become effective, and doses may have to be increased up to the highest acceptable dose before good results are seen.
It is fair to point out that these medications sometimes come at the price of having side effects, but for someone who is severely depressed this is often the least of their worries
Cognitive behavioural therapy (CBT) has been found to work well with psychotic depression. By looking at thoughts and perceptions of how we view ourselves and the world, these perceptions can be altered through CBT.
Psychotherapy can be useful in learning how not to react to the psychotic element of the depression, thus dispelling some of the fear and higher states of anxiety.
A mindfulness form of talk therapy called acceptance and commitment therapy (ACT) can also be useful. With this therapy, the patient will be helped to look at negative thoughts and feelings, possibly made worse by personality traits. You would be asked to recognise negative thoughts and behaviours, and then learn to be in the moment with them as they arise. The idea is to prevent the huge emotional reactions that sow the seeds for a severe clinical depression. This therapy teaches you how to stop trying to escape difficulties but learn the art of acceptance, commitment to change and a plan of action to diffuse a build up to severe depression.
Learning how to be mindful in life is an excellent mental tool for those who are prone to depressive illness. It is our thoughts and feelings that cause depression, but most importantly our reactions to them.
Some Facts about Psychotic Depression
- It is not known exactly what causes a psychotic depression but it is thought that there may be a genetic predisposition to it. The same can be said for other psychotic conditions and bipolar disorder does tend to run in families.
- It is thought that around ten to fifteen per cent of people suffering from a severe or major depression will have some psychotic experience.
- Studies have found that although it is possible to have one isolated episode of severe clinical depression, many do go on to have subsequent major depressive episodes, although these can be years apart. As the number of episodes increases, there is greater likelihood of more to come.
- Puerperal psychosis or postpartum psychosis is a form of psychotic depression, although it is believed to be antagonized by a sudden massive drop in hormones after having a baby. Apparently this condition is more likely to occur if there is a history of bipolar disorder or other psychotic illness, experienced either personally or within the family.
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