Depression, Schizoaffective?

[tyagee]

A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her.

Which of the following is the most appropriate diagnosis for this patient?

a. Delusional disorder
b. Schizoaffective disorder
c. Schizophrenia, paranoid type
d. Schizophreniform disorder
e. Major depression with psychotic features

[Mondoshawan]

The question is a little tricky because of the timing of symptoms and the nature of her delusions, but I would choose B. Schizoaffective disorder. In real life, I would probably diagnose her with E. Major depression with psychotic features, but I think the wording of the question is asking for B. Both are treated with a combination of antidepressant and antipsychotic.

1. Delusional disorder - No, because of the bizarre nature of her delusions and the malignant course
2. Schizoaffective disorder - Yes, depressive type. Bizarre delusions, depressive episodes, and most importantly the persistence of the delusions during periods of euthymia
3. Schizophrenia, paranoid type - No, because of the lack of schizophrenic features like disordered thinking and thought, negative symptoms that persist with treatment
4. Schizophreniform - No, same as schizophrenia for more than one and less than six months
5. Major depression with psychotic features - I think that this would be the answer except for the line "Throughout this time, she has never stopped believing that the devil is persecuting her". This indicates psychosis without mood and makes me think they are asking for schizoaffective

The reason why I would have chosen the last one in real life is because of the guilt that is shown by her delusion being of persecution by the devil. This seems more like her delusions are stemming from her depression rather than the other way around. While the pharmacologic treatments are the same, an emphasis on self-esteem and mood in treatment, rather than on psychosis, would be better for the patient, especially if she changes providers.

[tyagee]

Originally Posted by Mondoshawan

[*]Schizophrenia, paranoid type - No, because of the lack of schizophrenic features like disordered thinking and thought, negative symptoms that persist with treatment
.

Thanks for explanation. Read it twice. Cant get it. Can u explain it in simple terms.
I think it should be schizophrenia because patient has bizarre delusions ever since, which is part of diagnosis.
Being suicidal can be part of schizophrenia/isn't?

[Mondoshawan]

Originally Posted by tyagee

Thanks for explanation. Read it twice. Cant get it. Can u explain it in simple terms.
I think it should be schizophrenia because patient has bizarre delusions ever since, which is part of diagnosis.
Being suicidal can be part of schizophrenia/isn't?

So, a lot of disorders have bizarre delusions - let us take schizophrenia as the base and build off of that:

• Schizophrenia: all the criteria (can find it on wikipedia) for >6 months
• Schizophrenia for <1 month = brief psychotic episode
• Schizophrenia for 1-6 months = schizophreniform
• Schizophrenia + mood disorder = schizoaffective
• Major depressive d/o + schizophrenia = MDD c/ psychotic features

The last two can be hard to differentiate, but (as in this question) in schizoaffective d/o the psychosis is still there between mood flare-ups. Hope that helps?

[tyagee]

Originally Posted by Mondoshawan

Hope that helps?

rest everything fine but cant figure out the affect part of schizoaffecive .... which part of q mentions "affect" part? can u quote that for me...thanks

[Mondoshawan]

Originally Posted by tyagee

rest everything fine but cant figure out the affect part of schizoaffecive .... which part of q mentions "affect" part? can u quote that for me...thanks

The "affective" refers to mood disorder, and means that the patient has criteria for a mood disorder as well as psychosis. In this question, I read the multiple suicide attempts as indicating major depressive episodes, and thought that their use of sertraline as part of the tx was a hint the writer was giving that there was a mood component. If the writer had been portraying a classically schizophrenic person, they would have just mentioned antipsychotics and the suicide would have been something like "the voices told me to do it." You are right that schizophrenics commit suicide, and all of these overlap and are controversial diagnoses in actual practice - but for the USMLE, they are supposed to give us specific clues that enable us to differentiate.

[tyagee]

thank u so much.

[dr.dhruvdesai]

Mdd with psychotic features will have "predominant" depressive and episodic psychosis

Schizoaffective can have Both Psychotic as well as Mdd with features of schizo

so this pt with predominance of schizo features with episodic depressive episodes suggest

ans is B

n not E

[Ayman Qasrawi]

In USMLE, would not they give me more features that indicate major depression (I can not see any criteria except suicide attempt), and as I know, there should be either depressed mood or anhedonia to diagnose a major depressive episode. The question did not mention that !
At the same time, according to DSM-IV: a bizarre delusion ALONE is sufficient to diagnose schizophrenia, but they did not mention a time-frame to let us say it is breif psychotic, or schizophreniform, or schizophrenia ...

[step_enhancer]

Originally Posted by Ayman Qasrawi

In USMLE, would not they give me more features that indicate major depression (I can not see any criteria except suicide attempt), and as I know, there should be either depressed mood or anhedonia to diagnose a major depressive episode. The question did not mention that !
At the same time, according to DSM-IV: a bizarre delusion ALONE is sufficient to diagnose schizophrenia, but they did not mention a time-frame to let us say it is breif psychotic, or schizophreniform, or schizophrenia ...

Schizoaffective needs only 2 weeks of bizzare delusion with depressive features ,we are not talking about major depression .

Suicide attempt is a red flag for depressive symptoms.

I agree Schizophrenia needs 6 months for diagnosis and shizophreniform needs >1 month for Dx.That one of the reasons it is incorrect here.

[Ayman Qasrawi]

Originally Posted by step_enhancer

Schizoaffective needs only 2 weeks of bizzare delusion with depressive features ,we are not talking about major depression .

Suicide attempt is a red flag for depressive symptoms.

I thought the mood disturbances in schizoaffective disorder should meet the criteria of either major depression, mania, or mixed episode !! Is that true ?

[Novobiocin]

Originally Posted by tyagee

A 47-year-old woman is brought to the emergency room after she jumped off an overpass in a suicide attempt. In the emergency room she states that she wanted to kill herself because the devil had been tormenting her for many years. After stabilization of her fractures, she is admitted to the psychiatric unit, where she is treated with risperidone and sertraline. After 2 weeks she is no longer suicidal and her mood is euthymic. However, she still believes that the devil is recruiting people to try to persecute her. In the past 10 years, the patient has had three similar episodes prior to this one. Throughout this time, she has never stopped believing that the devil is persecuting her.

Which of the following is the most appropriate diagnosis for this patient?

a. Delusional disorder
b. Schizoaffective disorder
c. Schizophrenia, paranoid type
d. Schizophreniform disorder
e. Major depression with psychotic features

She has Schizoaffective disorder because she always had bizarre delusion and developed (superimposed) depression leading to suicide attempt(s).

[step_enhancer]

Bizzare delusion + any mood disorder ,For 2 weeks =Schizoaffective disorder.

Do not limit the mood disorder to major depression ,mania ,I think it could be hypomania and mild depression also .But I am not sure

[step_enhancer]

Schizoaffective disorder

The diagnosis is made when the patient has features of both schizophrenia and a mood disorder but does not strictly meet diagnostic criteria for either illness alone.

Source - http://emedicine.medscape.com/article/294763-overview

[Ayman Qasrawi]

Originally Posted by step_enhancer

Bizzare delusion + any mood disorder ,For 2 weeks =Schizoaffective disorder.

Do not limit the mood disorder to major depression ,mania ,I think it could be hypomania and mild depression also .But I am not sure

DSM-IV-TR criteria

The following are the revised criteria for a diagnosis of schizoaffective disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR):[2]
Two (or more) of the following symptoms are present for the majority of a one-month period (or a shorter period of time if symptoms improved with treatment):
delusions
hallucinations
disorganized speech (e.g., frequent derailment or incoherence) which is a manifestation of formal thought disorder
grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior
negative symptoms—e.g., affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), avolition (lack or decline in motivation), anhedonia (lack or decline in ability to experience pleasure), social withdrawal (sometimes called social anhedonia). Negative symptoms refers to symptoms that are not present or that are diminished in the affected individual but are usually found in healthy persons.[13]
If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the individual's actions or of hearing two or more voices conversing with each other, only that symptom is required to meet criterion A above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication and at some time during the illness there is either one, two or all three of the following:
major depressive episode
manic episode
mixed episode
During the illness, delusions or hallucinations were present for a minimum of two weeks, without major mood symptoms.
For a substantial part of the overall duration of both the active and residual period of the illness, symptoms meeting criteria for a mood episode are present.
Symptoms are not caused by drug abuse, medication (including antidepressant or sleeping medication) or another medical condition.

That's why I am confused, I know the question sound like schizoaffective. but as I said, I am confused because the question did not mention or meet the criteria for major depression EXCEPT suicide attempt which CAN happen in schizophrenia

[step_enhancer]

I hope u read my above post and the link .The criteria are not strict for diagnosis .Schizoaffective is like in the middle .please read the link I gave you

[Ayman Qasrawi]

Originally Posted by step_enhancer

I hope u read my above post and the link .The criteria are not strict for diagnosis .Schizoaffective is like in the middle .please read the link I gave you

Thanx alot ... I got your point

I was not aware of the link

[Novobiocin]

Originally Posted by Ayman Qasrawi

That's why I am confused, I know the question sound like schizoaffective. but as I said, I am confused because the question did not mention or meet the criteria for major depression EXCEPT suicide attempt which CAN happen in schizophrenia

Don't go into the details of DSM etc for the Step 2 purpose. It is for the Psychiatry boards.
Just remember,
If the question describes a patient with features of psychosis throughout and intermittent episodes of depression then it is schizoaffective

If the question describes a patient with features of depression throughout and intermittent episodes of psychosis then it is Major depression with psychotic features.
The major criteria being which is present for longer duration.

Suicide can happen in both but the way to differentiate is that in Schizo the voices tells the patient to commit while in depression patient does it because they feel worthless.

[Ayman Qasrawi]

Originally Posted by Novobiocin

Don't go into the details of DSM etc for the Step 2 purpose. It is for the Psychiatry boards.
Just remember,
If the question describes a patient with features of psychosis throughout and intermittent episodes of depression then it is schizoaffective

If the question describes a patient with features of depression throughout and intermittent episodes of psychosis then it is Major depression with psychotic features.
The major criteria being which is present for longer duration.

Suicide can happen in both but the way to differentiate is that in Schizo the voices tells the patient to commit while in depression patient does it because they feel worthless.

I got the point, thanx for explanation

[Novobiocin]

Another point for suicide (for 99% score):

A patient with schizophrenia can commit suicide (without having delusions) after being successfully treated for schizophrenia because they can go into depression.