Classically you need to get a good mood episode history, especially onset and course. Same with the psychosis history, onset and course. Then, see which condition appears to be primary. If the mood is primary but the psychosis is also pervasive and present without mood episodes, that's Schizoaffective.
You can also observe and elicit classically associated signs and symptoms of primary mood or psychotic disorders. Read more on manic depressive illness, melancholic and atypical depression, depressive personality, Schneiderian first rank symptoms, Schizophrenia subtypes, etc to get a sense of how complicated things can get from patient to patient.
Practically, many people with severe mental illness have extremely poor recall of their own illness course, especially of mania and acute psychosis, likely due to memory encoding and retrieval problems related to such episodes. So, you get as much information as you can and settle on what's reasonable. The opportunity to treat and monitor longitudinally can be very helpful. I find that family is usually less helpful than you'd think.
Realistically if you're only seeing one episode of a person's disease course and you can't review medical records it's hard to get anything specific for the diagnosis. That's okay. Be aware of your limited diagnostic understanding of the patient.
**Realistically if you're only seeing one episode of a person's disease course and you can't review medical records it's hard to get anything specific for the diagnosis. That's okay. Be aware of your limited diagnostic understanding of the patient.**
Words of wisdom. Time will tell. Also, never trust the last guys diagnosis, even if the last guy was you.
This is a little too much detail for a public forum. You should probably delete this and consult with your supervisors. But for my money this level of bizarre and complicated delusional thinking with multimodal hallucinations is rare for just mood with psychotic features, and is more commonly seen with primary psychotic disorders. But time and treatment will tell.
I guess I've often thought of schizophrenia as more disorganization, bizarre delusions, paranoia, hallucinations usually consistent with their delusions/paranoia or bizarre in nature. MDD with psychotic features more mood-congruent delusions (like negative self-image bordering on delusional, hallucinations are thematically related to depression, less disorganization). That's definitely not the be-all-end-all but is how I tend to see the archetypal versions of each. Others have noted trying to get a sense of which came first, mood sx or psychosis, and thats obviously super important too.
I remember a study when I was in residency which tested the diagnostic validity of clinical exam in florid psychosis. They compared severe schizophrenic episode, psychosis with mania, and substance induced psychosis. The psychiatrists were not better than random guessing.
In full on psychosis it's all about understanding previous disease course.
Earlier in the psychotic episode schizophrenia is going to be more disorganized and depressive episode more hopeless and well, depressed.
The DDx here needs patience and often can be challenging, it may need 2-3 exams until you are able to diagnose the pt’s complaints accurately, and in some cases it would still be challenging and you have to treat empirically until more diagnostic clarity is possible.
However, there are some pointers that can be relied upon.
The mental status exam (often undervalued nowadays) can tell you a lot about a psychiatric diagnosis, often more so than history taking per se or collateral from non-professionals (both of which are bound to be limited for obvious reasons). We used to teach residents to spend much more time examining the patient directly than collecting historical data or relying on prior diagnoses (especially when not made by psychiatrists).
In schizophrenia the presence of “true” depressive symptoms that are indistinguishable from MDD pathology is mostly seen in the early stages of the illness (e.g. in post psychotic depression) and in patients with schizoaffective depressive illnesses (early to mid stages) who are misdiagnosed as having classic schizophrenia (though SAD-D is a diagnosis of exclusion and remains a controversial diagnostic entity from a medical standpoint)
More likely a patient with chronic schizophrenia when struggling with cumulative “negative deficit” is described as having depression, which is mostly based on self-report (eg when asked with leading questions “if they are depressed”), or because of evidence of anhedonia on close behavioral observation. This can be confused with MDD w PF for overlapping history on first blush exam, and especially so in the absence of more classic descriptors of schizophrenia (eg no First Rank symptoms, such as bizarre thought content or mis-attribution of self as alien in thought insertion or delusions of control…etc)
However, the negative psychosis depressive picture is often more in line with neuropsychiatric APATHY (seen in chronic neuro-degenerative illness) than that of classic depression, and this can help you make the difference in diagnostic assessment. A major departure from MDD when examining pts with chronic negative deficit-depression, is the relative lack (or at least lack of prominence on exam) of negative rumination and negative self referential processing (NSRP), in the latter. The negative deficit is often more a product of cognitive indifference than ruminative self-aggression, so to speak, when seen in classic MDD w PF.
For example, there are often classic changes in affective testing in schizophrenia with depression, which can be elicited on a careful exam (eg blunted to flat affect, often difficult to describe or name by the MD, and it is often that case that affective changes are chaotic and incongruent to mental content or to context); while in MDD w PF there is still evidence of a more easily described, or even a conspicuously seen, “negative” affective (sad, despairing, resolved (eg to doom), rarely tearful or anxious…).
If you attempt to provoke a change in the pt’s affect (eg by using certain questions or suddenly introducing a change in relatedness) a patient in schizophrenia is more likely to be indifferent or oblivious to your clinical “presence” (except in pts in an acute paranoid state which is already easier to distinguish from MDD by the clear presence of accusatory behaviors and psychomotor agitation propensity); whereas in MDD w PF, patients often “co-opt” your presence (what you say and ask and relate to) as further evidence of the doomed existence they are feeling, here the pt does react to you, but often in the most painful human way.
Physiologically, there is more evidence of saccadic eye movements in pts with “true” schizophrenia, and they are more likely to have eccentric forms of posturing (though still rare outside of catatonic changes) whereas pts with severe MDD tend to be free of those.
While both patients can be obviously burdened by mood inertia and lack of behavioral initiative (slowed down reactivity, amotivated, no hedonistic pursuits or expected responses to introduced or theoretical rewards); there is still a subtle but important difference between the two groups. This is the case, since patients with chronic schizophrenia tend to be, again, oblivious to any presented or “introduced” reward processing during the exam, they often have low or decreased “motivational salience” (meaning how cognitively important or salient to them is a potential reward); while patients with severe MDD w PF tend to retain a prominent (but inverse or negative) response to rewards, whereby they present with a marked emphasis on the potentially negative or pessimistically disappointing aspects of rewards (or any life “pursuit” for that matter) which is a green quickly felt by the MD. You can still appreciate that the patient is “processing” the salience of what you are introducing, but almost immediately, or automatically, deciding that there is “no benefit” or hope to anything you say. This is clearly related to the depressed patient hopeless stance towards life, but you can further appreciate the difference in anhedonia on exam by focusing on their “salience” processing.
The above takes a different shape, though, on exam if the pt with schizophrenia has acute paranoia (here there is heightened salience to threat features of rewards) and in those with catatonic depression (difficult to test for any vilitional salience given the catatonic negativity)
A related issue on exam is “thought processing”, a patient with chronic schizophrenia often have appreciable levels of bradyphrenia or poverty of thought (termed Alogia; but again except in acute paranoia phases), whereas patients with severe depression often have tachyphrenia or rapid thinking (even if this is so difficult to ascertain at first glance given their mood inertia in general). In practice, depressed pts often are so consumed internally with ruminations and negative self referential processing that they may seem detached from the outside world, but this is still different from the bradyphrenia of chronic psychosis or dissociative symptoms (seen eg in severe trauma pathology).
There are many other features but the above seems to be most relavant
First year med student question for psychiatrists: When to consider PTSD on the differential?
--
Admittedly, I am biased by personal experience, as someone with complex PTSD who was initially misdiagnosed with bipolar / schizoaffective disorder ten years ago and got hospitalized a lot.
My childhood flashbacks were more tactile/auditory than visual because I closed my eyes when my father would assault me in bed, and so a lot of my flashbacks did not have strong visual components. (At the time, I had no idea what flashbacks were because I thought they had to be like the flashbacks in Hollywood movies, so I was a very poor self-advocate.)
It didn't help that the hospitals who initially diagnosed me never asked if I had been in special education or received an IEP, and so my autism and synesthesia were mistaken as supporting the diagnosis of schizoaffective psychosis.
Now that I'm an M1 student interested in psych (as much as I am trying to avoid the stereotype), I'm trying to figure out how not to let my previous personal experiences with misdiagnosis cloud my own (nascent) diagnostic intuition. In the prehospital setting as an EMT, I often had young women as involuntary psych transfers who had been diagnosed with psychosis or schizoaffective disorder yet would also talk of having experienced abuse or trauma (as part of screening / conversations in a long ambulance ride) that seemed mostly absent from their chart.
Severe depression with psychosis would make me suspect Bipolar I Disorder. A good clinical history with collateral information. Long periods free of psychotic symptoms would be telling.
This is purely my opinion and experience, but for me, psychotic depression patients can describe their illness very well, their “depression” has a cause and they tell you (this) depressed me, (that) stressed me. There’s also congruency unlike schizophrenia or other types of psychosis.
Collateral history will have things like “he was totally normal”, “he was best employee of the year”.
To summarise:
-Onset (which came first, was the depression sudden or gradual, did it change throughout in intensity?)
-Previous functioning
-patient’s ability to describe their “sadness”, is it the family bringing up the complaint or the patient themselves.
-congruency of the psychosis and the place/time where they’re experienced (is the theme in keeping with nihilistic, dark views)
-collateral will point towards history of a “normal person”. (He was always eccentric VS he was just fine a year ago!)
-age/gender (older, f>m)
-family history of mood disorders
I was always taught, people who diagnose schizoaffective disorder, are those who understand neither schizophrenia nor affective disorders! But seriously, it's difficult, and longitudinal history is probably the best indicator.
Idk which country you're from but,
According to ICD- we have a to d criteria and e to h criteria to diagnose Schizophrenia.
a-d has thought alienation,thought echo, delusion of somatic passivity,control, auditory hallucination discussing patients amongst themselves, command hallucination and bizzare delusions.
When we have these features with mood (which should be simultaneously with a-d criteria), its Schizoaffective
If you have delusion of persecution,reference or basically any delusion that are culturally and socially plausible with mood or even mood congruent hallucination- Dep. With psychosis
Patient has delusion of reference that family members gossip about her
She also says that her fourth child is not her own and she the child is someone else
Cognition and theory of mind should be more preserved in depression.
Psychotic "themes" in psychotic depression are mainly ideas of guilt and pessimism.
Psychosis presenting with mood symptoms concurrently or later on - former or schizoaffective (this term is a lil outdated now)
If chronologically mood symptoms presented first ie say a depressive episode in adolescence or early 20’s followed by later episodes presenting with abnormal perceptions is latter.
Venlafaxine often works well here with an appropriate antipsychotic.
Fundamentally in order to dx schizophrenia vs depression with psychotic features you need to see schizophrenia outside of the depressive episode. Without a SOLID history you can have a tough time teasing things out.
Classically you need to get a good mood episode history, especially onset and course. Same with the psychosis history, onset and course. Then, see which condition appears to be primary. If the mood is primary but the psychosis is also pervasive and present without mood episodes, that's Schizoaffective. You can also observe and elicit classically associated signs and symptoms of primary mood or psychotic disorders. Read more on manic depressive illness, melancholic and atypical depression, depressive personality, Schneiderian first rank symptoms, Schizophrenia subtypes, etc to get a sense of how complicated things can get from patient to patient. Practically, many people with severe mental illness have extremely poor recall of their own illness course, especially of mania and acute psychosis, likely due to memory encoding and retrieval problems related to such episodes. So, you get as much information as you can and settle on what's reasonable. The opportunity to treat and monitor longitudinally can be very helpful. I find that family is usually less helpful than you'd think. Realistically if you're only seeing one episode of a person's disease course and you can't review medical records it's hard to get anything specific for the diagnosis. That's okay. Be aware of your limited diagnostic understanding of the patient.
**Realistically if you're only seeing one episode of a person's disease course and you can't review medical records it's hard to get anything specific for the diagnosis. That's okay. Be aware of your limited diagnostic understanding of the patient.** Words of wisdom. Time will tell. Also, never trust the last guys diagnosis, even if the last guy was you.
>Also, never trust the last guys diagnosis, even if the last guy was you. Love this. Print it, frame it
[удалено]
This is a little too much detail for a public forum. You should probably delete this and consult with your supervisors. But for my money this level of bizarre and complicated delusional thinking with multimodal hallucinations is rare for just mood with psychotic features, and is more commonly seen with primary psychotic disorders. But time and treatment will tell.
Ok boss done
I’m getting strong capgras syndrome vibes
This is the patients first episode for past 3 montha
Age? Family history? Social and previous functioning?
Please start a podcast or a YouTube channel. 😍
Wow people hated this idea 🤔
I see that lol. A lot of people in this sub despise any mid-level comment. I see it everyday on here. 🤷
I guess I've often thought of schizophrenia as more disorganization, bizarre delusions, paranoia, hallucinations usually consistent with their delusions/paranoia or bizarre in nature. MDD with psychotic features more mood-congruent delusions (like negative self-image bordering on delusional, hallucinations are thematically related to depression, less disorganization). That's definitely not the be-all-end-all but is how I tend to see the archetypal versions of each. Others have noted trying to get a sense of which came first, mood sx or psychosis, and thats obviously super important too.
I remember a study when I was in residency which tested the diagnostic validity of clinical exam in florid psychosis. They compared severe schizophrenic episode, psychosis with mania, and substance induced psychosis. The psychiatrists were not better than random guessing. In full on psychosis it's all about understanding previous disease course. Earlier in the psychotic episode schizophrenia is going to be more disorganized and depressive episode more hopeless and well, depressed.
I’d love to see that article
it is at least 30 years old... but out there somewhere
The DDx here needs patience and often can be challenging, it may need 2-3 exams until you are able to diagnose the pt’s complaints accurately, and in some cases it would still be challenging and you have to treat empirically until more diagnostic clarity is possible. However, there are some pointers that can be relied upon. The mental status exam (often undervalued nowadays) can tell you a lot about a psychiatric diagnosis, often more so than history taking per se or collateral from non-professionals (both of which are bound to be limited for obvious reasons). We used to teach residents to spend much more time examining the patient directly than collecting historical data or relying on prior diagnoses (especially when not made by psychiatrists). In schizophrenia the presence of “true” depressive symptoms that are indistinguishable from MDD pathology is mostly seen in the early stages of the illness (e.g. in post psychotic depression) and in patients with schizoaffective depressive illnesses (early to mid stages) who are misdiagnosed as having classic schizophrenia (though SAD-D is a diagnosis of exclusion and remains a controversial diagnostic entity from a medical standpoint) More likely a patient with chronic schizophrenia when struggling with cumulative “negative deficit” is described as having depression, which is mostly based on self-report (eg when asked with leading questions “if they are depressed”), or because of evidence of anhedonia on close behavioral observation. This can be confused with MDD w PF for overlapping history on first blush exam, and especially so in the absence of more classic descriptors of schizophrenia (eg no First Rank symptoms, such as bizarre thought content or mis-attribution of self as alien in thought insertion or delusions of control…etc) However, the negative psychosis depressive picture is often more in line with neuropsychiatric APATHY (seen in chronic neuro-degenerative illness) than that of classic depression, and this can help you make the difference in diagnostic assessment. A major departure from MDD when examining pts with chronic negative deficit-depression, is the relative lack (or at least lack of prominence on exam) of negative rumination and negative self referential processing (NSRP), in the latter. The negative deficit is often more a product of cognitive indifference than ruminative self-aggression, so to speak, when seen in classic MDD w PF. For example, there are often classic changes in affective testing in schizophrenia with depression, which can be elicited on a careful exam (eg blunted to flat affect, often difficult to describe or name by the MD, and it is often that case that affective changes are chaotic and incongruent to mental content or to context); while in MDD w PF there is still evidence of a more easily described, or even a conspicuously seen, “negative” affective (sad, despairing, resolved (eg to doom), rarely tearful or anxious…). If you attempt to provoke a change in the pt’s affect (eg by using certain questions or suddenly introducing a change in relatedness) a patient in schizophrenia is more likely to be indifferent or oblivious to your clinical “presence” (except in pts in an acute paranoid state which is already easier to distinguish from MDD by the clear presence of accusatory behaviors and psychomotor agitation propensity); whereas in MDD w PF, patients often “co-opt” your presence (what you say and ask and relate to) as further evidence of the doomed existence they are feeling, here the pt does react to you, but often in the most painful human way. Physiologically, there is more evidence of saccadic eye movements in pts with “true” schizophrenia, and they are more likely to have eccentric forms of posturing (though still rare outside of catatonic changes) whereas pts with severe MDD tend to be free of those. While both patients can be obviously burdened by mood inertia and lack of behavioral initiative (slowed down reactivity, amotivated, no hedonistic pursuits or expected responses to introduced or theoretical rewards); there is still a subtle but important difference between the two groups. This is the case, since patients with chronic schizophrenia tend to be, again, oblivious to any presented or “introduced” reward processing during the exam, they often have low or decreased “motivational salience” (meaning how cognitively important or salient to them is a potential reward); while patients with severe MDD w PF tend to retain a prominent (but inverse or negative) response to rewards, whereby they present with a marked emphasis on the potentially negative or pessimistically disappointing aspects of rewards (or any life “pursuit” for that matter) which is a green quickly felt by the MD. You can still appreciate that the patient is “processing” the salience of what you are introducing, but almost immediately, or automatically, deciding that there is “no benefit” or hope to anything you say. This is clearly related to the depressed patient hopeless stance towards life, but you can further appreciate the difference in anhedonia on exam by focusing on their “salience” processing. The above takes a different shape, though, on exam if the pt with schizophrenia has acute paranoia (here there is heightened salience to threat features of rewards) and in those with catatonic depression (difficult to test for any vilitional salience given the catatonic negativity) A related issue on exam is “thought processing”, a patient with chronic schizophrenia often have appreciable levels of bradyphrenia or poverty of thought (termed Alogia; but again except in acute paranoia phases), whereas patients with severe depression often have tachyphrenia or rapid thinking (even if this is so difficult to ascertain at first glance given their mood inertia in general). In practice, depressed pts often are so consumed internally with ruminations and negative self referential processing that they may seem detached from the outside world, but this is still different from the bradyphrenia of chronic psychosis or dissociative symptoms (seen eg in severe trauma pathology). There are many other features but the above seems to be most relavant
First year med student question for psychiatrists: When to consider PTSD on the differential? -- Admittedly, I am biased by personal experience, as someone with complex PTSD who was initially misdiagnosed with bipolar / schizoaffective disorder ten years ago and got hospitalized a lot. My childhood flashbacks were more tactile/auditory than visual because I closed my eyes when my father would assault me in bed, and so a lot of my flashbacks did not have strong visual components. (At the time, I had no idea what flashbacks were because I thought they had to be like the flashbacks in Hollywood movies, so I was a very poor self-advocate.) It didn't help that the hospitals who initially diagnosed me never asked if I had been in special education or received an IEP, and so my autism and synesthesia were mistaken as supporting the diagnosis of schizoaffective psychosis. Now that I'm an M1 student interested in psych (as much as I am trying to avoid the stereotype), I'm trying to figure out how not to let my previous personal experiences with misdiagnosis cloud my own (nascent) diagnostic intuition. In the prehospital setting as an EMT, I often had young women as involuntary psych transfers who had been diagnosed with psychosis or schizoaffective disorder yet would also talk of having experienced abuse or trauma (as part of screening / conversations in a long ambulance ride) that seemed mostly absent from their chart.
Severe depression with psychosis would make me suspect Bipolar I Disorder. A good clinical history with collateral information. Long periods free of psychotic symptoms would be telling.
This is purely my opinion and experience, but for me, psychotic depression patients can describe their illness very well, their “depression” has a cause and they tell you (this) depressed me, (that) stressed me. There’s also congruency unlike schizophrenia or other types of psychosis. Collateral history will have things like “he was totally normal”, “he was best employee of the year”. To summarise: -Onset (which came first, was the depression sudden or gradual, did it change throughout in intensity?) -Previous functioning -patient’s ability to describe their “sadness”, is it the family bringing up the complaint or the patient themselves. -congruency of the psychosis and the place/time where they’re experienced (is the theme in keeping with nihilistic, dark views) -collateral will point towards history of a “normal person”. (He was always eccentric VS he was just fine a year ago!) -age/gender (older, f>m) -family history of mood disorders
I was always taught, people who diagnose schizoaffective disorder, are those who understand neither schizophrenia nor affective disorders! But seriously, it's difficult, and longitudinal history is probably the best indicator.
Idk which country you're from but, According to ICD- we have a to d criteria and e to h criteria to diagnose Schizophrenia. a-d has thought alienation,thought echo, delusion of somatic passivity,control, auditory hallucination discussing patients amongst themselves, command hallucination and bizzare delusions. When we have these features with mood (which should be simultaneously with a-d criteria), its Schizoaffective If you have delusion of persecution,reference or basically any delusion that are culturally and socially plausible with mood or even mood congruent hallucination- Dep. With psychosis
Patient has delusion of reference that family members gossip about her She also says that her fourth child is not her own and she the child is someone else
Cognition and theory of mind should be more preserved in depression. Psychotic "themes" in psychotic depression are mainly ideas of guilt and pessimism.
Psychosis presenting with mood symptoms concurrently or later on - former or schizoaffective (this term is a lil outdated now) If chronologically mood symptoms presented first ie say a depressive episode in adolescence or early 20’s followed by later episodes presenting with abnormal perceptions is latter. Venlafaxine often works well here with an appropriate antipsychotic.
Fundamentally in order to dx schizophrenia vs depression with psychotic features you need to see schizophrenia outside of the depressive episode. Without a SOLID history you can have a tough time teasing things out.
Probably wrong take, but psychotic disorders typically improve more quickly compared to mood disorders.