delusional or not

[erg923]

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Our lab was discussing a common clinical issue that we see quite often. So, I wanted to poll SND members. Because of the nature of our research, we sometimes see depressed patients who are not grossly psychotic (not hearing voices or grossly delusional), but who describe themselves as "guilty for even existing" or "guilty for taking up space." Describing themselves as "a piece of garbage" is also a common one we hear. I of course ask them to expand on these comments and what exactly that means to them. I do not get that they feel like they are garbage in the physical form, but rather, they explain that they feel different from others, unreal, and they feel truly feel as if they were equatable to "garbage." Alot of us debate on whether these specific endorsements reach the threshold for the delusional guilt and delusional worhlessness seen in Psychotic Major Depression (PMD). The delusional and psychotic element is more straight forward when a patient tells you that they feel their illness is a "punishment from god/universe," or have some more elaborate delusional system. However, statements of guilt and worthlessness (eg., describing oneself as "human scum," "garbage," " intrusive feelings of guilty for " even "existing" or "taking up space") that are so grossly out of proportion, even for most depressed patients, is a tough call. Would you call this delusional or suggestive of some underlying psychotic dimension? Sure seems like there is a psychotic element here to me, but I'm not sure.

 

[Ollie123]

Personal view? I have no literature to support my thoughts, though really it seems more like a philosophical question than one that can truly be answered with data.

No, not delusional. I view it as a separate symptom. Two reasons behind this. 1) Even in its most extreme form, it frequently is limited to that one facet. Generally speaking, its relatively rare for delusions/psychosis to be THAT limited in scope (at least from what I have read) without elements of it presenting in other forms as well. They certainly CAN be limited, but there are at least signs/hints of a seperation from reality across multiple dimensions in what I view as the typical presentation of delusions.

2) Guilt at the very least, is an emotion. I'm hesitant to call excessive presentation of any emotion a delusion. If someone said they were "really really really sad", I wouldn't categorize that as a delusion. If someone said they felt "really really really guilty", I think you would be less inclined to consider it a delusion - I see the use of the phrase "Guilty for taking up space" as an artifact of language or a hypersensitivity to negative reactions by others. Now if someone were to start feeling guilty for things that had not actually happened, that would obviously be a different story. As ridiculous as it sounds, they ARE taking up space - so as long as they physically exist I see it as simply an excessive presentation of an emotion. While I certainly see how a case could be made in some circumstances, I think we need to be very wary about equating that with a delusion.

That's my thought process anyways. It is definitely an interesting question.

 

[The2abraxis]

I agree with Ollie.

edit- (no post is complete without an edit 🙄 ) Im guessing it really depends on their reasoning for feeling useless. If they feel they are useless because aliens told him/her that they belong on mars, then there might be something going on there. If they feel they are useless because they feel everything they do is a failure and they can never do anything right, then that might not be so delusional 😀

 

[Markro311]

I agree with Ollie's second point. But from what I've learned thus far, it seems that many delusions/delusional disorders ARE very specific and narrow. I haven't really heard that delusions are usually spread across multiple dimensions. But maybe you can shed some more light in terms of what you mean, maybe I'm not understanding what you mean by "multiple dimensions."

 

[erg923]

I agree with Ollie.

edit- (no post is complete without an edit 🙄 ) Im guessing it really depends on their reasoning for feeling useless. If they feel they are useless because aliens told him/her that they belong on mars, then there might be something going on there. If they feel they are useless because they feel everything they do is a failure and they can never do anything right, then that might not be so delusional 😀

Well, yes obviously those would be delusions. I am not questioning the obvious cases though. Delusions come in many flavors, and not all of them will be a straightforward as that, especially non-bizarre delusions. I cant tell you how many times we have questioned whether the subtle paranoia/persecutory thoughts in some of our subjects were of a psychotic nature, because frankly, many of them are plausible. The psychosis seen in psychotic major depression is often this subtle undercurrent of ideas of reference, paranoia, and delusional guilt. "The Universe is punishing me" kinda of thing. You don't typically see alot of florid psychosis, or bizarre thought insertion type delusions in this population.

What we are really struggling with are these cases where the person has alot of derealization/depersonalization and irrational amounts of guilt. Often times, we find this guilt to be way out of proportion to the guilt expressed by most depressed subjects, and out of proportion to the depression itself. I have seen several people who were indeed very depressed, but functioning at work and socially, but who expressed the feeling that they often felt as if they were not like other humans/people, and literally felt like as if they were human scum. They had ruminative and intrusive thoughts of guilt for even existing and taking up space. All day and everyday. Clinically, I find this to be a qualitatively different kind of belief than the common low self esteem and the "I wish I was never born" kind of attitude you see in most with chronic MDD. Sometimes the line is a fine one, and alot of times we find our participants are running a fine line between severe depression and psychotic irrationality.

Ollie:
Yep, I understand your rationale. And I can certainly see it that way as well. Two things though. Technically, irrational or excessive guilt can be considered representative of a psychotic process. By itself, it's not always enough, but coupled with other things (paranoia, persecutory ideas), it suggests an underlying psychotic process. I think your example of being "really really sad" is different from what I was talking about. This emotion is seen in all severe depressions. It is normal for those with MDD to have guilt, worthlessness, etc. It is NOT normal for those with MDD to equate themselves to garbage or to have intrusive thoughts of guilt for existing. Typically, the guilt seen in MDD is attached to a person or specific events. This is guilt for existing, and thats all. To me, expressing that one feels as if they are "human garbage" is expressing more than the usual worthlessness. I of course ask them to expand on these comments and what exactly that means to them. I do not get that they feel like they are garbage in the physical form, but rather, they explain that they feel different from others, unreal, and they feel truly feel as if they were equatable to "garbage. Coupled with frequent feelings of derealization and subtle persecutory undertones (nothing frankly delusional), to me, this suggests some sort of psychotic process.

I am not trying to argue or defend my position, I am really just thinking out loud here. Id like to hear others perspectives. Anyone? Anyone?

 

[Ollie123]

I agree with Ollie's second point. But from what I've learned thus far, it seems that many delusions/delusional disorders ARE very specific and narrow. I haven't really heard that delusions are usually spread across multiple dimensions. But maybe you can shed some more light in terms of what you mean, maybe I'm not understanding what you mean by "multiple dimensions."

Certainly many exist in a narrow framework. To elaborate on what I was saying, from what I have seen, it is pretty rare to see someone with a very clear, concise psychotic belief who is perfectly lucid and has a very clear grasp on reality in every other way. The classic psychotic schizophrenic does not have a perfect grasp of reality aside from that pesky belief that they're Jesus. I'm sure it happens, but I think its safe to say that is atypical. Though I'm far from an expert on psychosis so take this with a huge grain of salt.

My point about people feeling really really guilty was that I'm not entirely sure "feeling guilty for taking up space" IS different from really really guilty. I feel like its more a result of language (i.e. you can legitimately say you are sad without explaining further, but the nature of how we define guilt generally means you have to say "I feel guilty about x, y or z". I'd argue that this, along with "human garbage" has more to do with artifacts of language than a true psychotic process, though only in isolation. "I'm just a piece of garbage" is using language to illustrate a point, and represents the endpoint on a continuum of emotion rather than a delusion. Now if someone truly cannot define the differences between them and an old newspaper, that would obviously be a delusion.

Now, the OTHER point, when it is coupled with persecutory thoughts, is a seperate matter. That can definitely represent a delusion in my eyes, but I think its that component that when combined points to a delusion. The guilt in isolation is not, which is why I said I thought it was dangerous territory to venture into if we assign excessive expression of one emotion as psychosis.

Its definitely an interesting question though. I'm not sure if the answer would result in any clinical differences in treatment.

 

[erg923]

I try try to parse out the language issues as best I can during interviews. I of course ask them to expand on these comments and what exactly that means to them. I do not get that they feel like they are garbage in the physical form, but rather, they explain that they feel different from others, unreal, and they feel truly feel as if they were equatable to "garbage." When coupled with other subtle things, especially derealization, or persecutory/paranoid ideation, it just feels qualitative different to me.

Clinically, it might not make a difference for treatment. But it may, as psychotic depression is treated with an antipsychotics too. More salient for our purposes is that this is a clinical trials study. Diagnosis is suppose to be a "pure" as we can get it, and MDDs and psychotic MDDs are in separate groups and separate treatment conditions. So naturally, this becomes an important diagnostic concern for us.

 

[The2abraxis]

Well, yes obviously those would be delusions. I am not questioning the obvious cases though. Delusions come in many flavors, and not all of them will be a straightforward as that, especially non-bizarre delusions. I cant tell you how many times we have questioned whether the subtle paranoia/persecutory thoughts in some of our subjects were of a psychotic nature, because frankly, many of them are plausible. The psychosis seen in psychotic major depression is often this subtle undercurrent of ideas of reference, paranoia, and delusional guilt. "The Universe is punishing me" kinda of thing. You don't typically see alot of florid psychosis, or bizarre thought insertion type delusions in this population.

What we are really struggling with are these cases where the person has alot of derealization/depersonalization and irrational amounts of guilt. Often times, we find this guilt to be way out of proportion to the guilt expressed by most depressed subjects, and out of proportion to the depression itself. I have seen several people who were indeed very depressed, but functioning at work and socially, but who expressed the feeling that they often felt as if they were not like other humans/people, and literally felt like as if they were human scum. They had ruminative and intrusive thoughts of guilt for even existing and taking up space. All day and everyday. Clinically, I find this to be a qualitatively different kind of belief than the common low self esteem and the "I wish I was never born" kind of attitude you see in most with chronic MDD. Sometimes the line is a fine one, and alot of times we find our participants are running a fine line between severe depression and psychotic irrationality.

I see what you are getting at. To me, what may be confusing is the defintion of delusional/psychotic we are going by. I hve not used these terms much myself, but it seems like most peope would be delusional/psychotic when they are out of touch with reality?? (is that not the definition?)

So if someone is seen using logical biases in their views of reality, would this be psychotic/delusional? (ex: generalizing that everything bad will happen to them and no good, making them feel like they are worthless). How much in touch with reality does a person have to be in to be considered not psychotic/delusional??

 

[Neuro-Dr]

I think two things come to mind that may help. First, psychotic symptoms are an outgrowth of SEVERE depression and not mild or moderate. Hence the structure for that qualifier. Second, you can/should consider an objective measure like the MMPI-2 for exclusion of those with elevations on say Sclae 8, Sc6 or BIZ. This happens frequently in research when studying mood outside of anxiety. Is someone depressed if they..watch a sad movie, report sadness, have a BDI of 15, MMPI-2 Scale 2 score of 70, mother just died? Obviously the self reports of current symptoms may share similarities; but the underlying constructs are quite different.

 

[erg923]

I see what you are getting at. To me, what may be confusing is the defintion of delusional/psychotic we are going by. I hve not used these terms much myself, but it seems like most peope would be delusional/psychotic when they are out of touch with reality?? (is that not the definition?)

So if someone is seen using logical biases in their views of reality, would this be psychotic/delusional? (ex: generalizing that everything bad will happen to them and no good, making them feel like they are worthless). How much in touch with reality does a person have to be in to be considered not psychotic/delusional??

"Psychosis" is a general term. Not all psychosis is of the magnitude and severity you are thinking of. I think you are thinking more of florid psychosis and the intensity of psychosis seen in schizophrenia (eg., elaborate and/or clear cut delusions, hallucinations, disorganized speech/thought, etc). Remember, delusions can be be bizarre (implausible/impossible) or non-bizarre (strange and unlikely, but certainly within the realm of possibility). Delusional disorder, which is considered a psychotic disorder, is when people only have these non-bizarre delusions. In addition, Capgrass syndrome is an example of a psychotic disorder (although this is a bizarre delusion), where the psychotic element is confined to that one domain and no other signs of psychotic disturbance is seen. Although these are relatively rare disorders to see in practice. Would you call someone with these circumscribed Delusional disorders "psychotic?" It's a relative judgment really. They have a "Psychotic Disorder," but if they are lucid beyond their delusion would you still consider call them psychotic? I would say, yes, technically speaking, they are. It just not very obvious on the surface. "Psychotic Major Depression" is also called "Delusional Depression," since this is the hallmark feature. As I said before, the typical PMD is not floridly psychotic, like schizophrenics sometimes are. The typical profile of someone with psychotic major depression is EXTREME depression with mood congruent delusions, ideas of reference, or irrational guilt. Florid psychosis, they way you are thinking of it, is relatively rare in PMD, although it certainly can happen. So it's not always as straightforward as you might imagine. I think we have reached a consensus that we should not rate such statements as possibly delusional/psychotic if they occur in isolation (i.e., no other red flags in the clincial presentation). I think we are going start leaving that rating blank and just come back to that rating after the entire interview has been completed. That way we have a better overall diagnostic impression/picture to inform our judgment of that item.

Neuro-Dr.
I did wish we had more objective measures in the protocol for the psychosis issue. They of course have to meet DSM criteria for MDE. Diagnosis is done using the SCID. Additionally, subjects have to reach a certain threshold on the HAM-D and BPRS. We use several other scales, but nothing directly quantifying psychosis except BPRS. They get the MCMI-III to rule out Axis II stuff, but no MMPI. Oh well, I didn't right the protocol.

 

[The2abraxis]

what do your interviews consist of (im guessing medical history, mental health history, family history, life situation, main complaints, etc...)? It would seem like a good idea to wait until it is over to make the judgement.

Also (i dont think this was answered before), is any false interpretation/view of reality considered delusional/psychotic? Like you said, there are varying degrees, is this what you were referring to? If it is it would seem like most cases of depression include delusional/psychotic elements to it (if it is going by the definition used in the pervious post).

Sorry if this is confusing, I am trying to clearly differentiate delusional/psychotic and see if having a false sense of reality is the same thing :-D

 

[erg923]

what do your interviews consist of (im guessing medical history, mental health history, family history, life situation, main complaints, etc...)? It would seem like a good idea to wait until it is over to make the judgement.

Also (i dont think this was answered before), is any false interpretation/view of reality considered delusional/psychotic? Like you said, there are varying degrees, is this what you were referring to? If it is it would seem like most cases of depression include delusional/psychotic elements to it (if it is going by the definition used in the pervious post).

Sorry if this is confusing, I am trying to clearly differentiate delusional/psychotic and see if having a false sense of reality is the same thing :-D

The interviews are done using the Structured Clinical Interview for DSM-IV Disorders (SCID-I), the research version. And it consists of everything you mentioned. Participants are also assessed using the Hamilton Rating Scale of Depression (HAM-D) and the Brief Psychiatric Rating Scale (BPRS). Among a couple of other things, MCMI-III to rule out Axis II stuff.

Most depressions do not have a psychotic element. Low self esteem, subjective feelings of worthlessness are common to all depressions. Irrational reasoning is common in depression as well (i.e., Beck's depressive schemata), but these do not qualify as delusions. They're simply flawed reasoning and usually not held with any delusional conviction. If it was, CBT therapy to challenge these beliefs would be useless. To be a delusion, it has to be held to with absolute conviction, despite reassurance or evidence to the contrary. The patients that tell me they are literally "pieces of garbage," hold this with a conviction that I (nor anyone they know) could not dissuade them of. And we do our best to get them to elaborate on this statement, so we can decide whether its just a unusual figure of speech expressing extreme worthlessness, or if there is some more to it than that. Assuming its the later, this represents something far more extreme than the usual depressive schematas seen in most depressed individuals. Most of these people in question also had other subtle signs of a psychotic thought processes. More than the normal amount of paranoia, very odd persecutory thoughts (but not held with delusional conviction) and depersonalization. Again, nothing that reached threshold by themselves, but taken all together, its enough to make you suspicious that something is going on. As I discussed before, determining the conviction with which they hold these beliefs, and what exactly constitutes a delusional belief can get confusing here. When a person says, "I believe my illness is a punishment from god," what does this mean exactly? Do they believe the depression is actually being superimposed on them by a supernatural force, or were they just using this a figure of speech? Should we consider this a false belief that reaches the delusional threshold? It can be a tough call. It really just depends on the conviction with which they believe this. If they accept reassurance that it may not be a punishment from god, or voice that it's possible that thats not the case, then its not a delusion, in the technical sense (i.e., no delusional conviction). Then again, they might still really believe it, but are just telling you the answer they know they are suppose to give. Sometimes people just give the socially acceptable answer. So who knows really. See what I mean? This is why the art of clinical interviewing is so important in our work. Getting a person to explain what exactly this mean to them and how firmly they believe it is often difficult.

You are right though, we have backed off on rating those endorsements at the delusional/psychotic level until after the entire interview is over and we have better clinical picture. We then will be going back to that rating and make that judgment based on our best clinical judgment considering the overall diagnostic impression/presentation.

 

[The2abraxis]

ahh, so the extent to which they believe it makes it delusional or not. it does seem hard to know if they truly believe it, and if they can be shown that it is not true for themselves to change.

so treatment wise, if one believes that the belief cannot be changed (delusional), how does one go about with the treatment?? It seems that at first they will not believe anything contrary to their beliefs at first, but they may change.

So would one try and test their beliefs (really see if they are dogmatic in their beliefs) to see if they are able to be reality tested first, or would that step be ignored if through interviewing one believes that the person is delusional??

sorry for all the questions, this is an interesting topic :-D

 

[erg923]

Treatment of psychotic major depression should target the depression primarily. Unless of course the psychosis is florid and represents the more immediate danger to the patient (ie., if the patient is having command hallucination to kill themselves, then the pharmacologic treatment of the psychosis should be the first priority). But as I mentioned before, this is not the case for most PMDs. By definition, psychotic symptoms are only seen during the depression in true PMD. If the delusions persist after the depression has lifted, then you are probably dealing with a whole different disorder (i.e., schizoaffective).

Psychopathology this severe requires pharmacological intervention. Our study is looking at the efficacy of the experimental drug Mifepristone for PMD. This is the ultimate aim of the study, but this in not my, nor my adviser's focus within the study actually. Our group is really looking at the elevated cortisol levels in PMD patients and their relationship to the psychosis and the severity of cognitive deficits seen in the disorder. The pharmacological treatment aspect is really the focus of the psychiatrists in our group.

This is purely research, so I do not see these patients for therapy or anything. I have worked with individuals with schizophrenia and schizoaffective disorder clinically in therapy practicums, however, most of my patients were functioning quite well and not overtly psychotic. From my experience, if a therapist is seeing a client who has an elaborate delusional system, but is otherwise functioning well enough to be out of the hospital, then there is no sense in harping on the client's delusion and trying to disprove it to them. I think this would be counter therapeutic in many cases actually. In the course of psychotherapy, working on other issues such as coping skills, social skills, insight, and medication compliance is the priority with this population.

 

[The2abraxis]

ya I was thinking medication would be the best route for that (mainly if the delusions are a threat). Sounds like a good research lab :-D

But relating to the original question, I think we answered it. It would depend on how much they believe those thoughts to be true, which is tough to decide as well. But through a good interview, one can probably make a good judgement call.

On a side note, it would be interesting to see if with the use of medication, harmful delusions were brought down and the person was ready to reality test them (and believe the evidence before them). So basically a mix of medication and psychotherapy :-D (Ive read in a few places this is a good route anyway). But, like you said, if the delusions do not seem to be a main complaint or damaging part of the depression, best to use the time spent on problems that are affecting the patient.

 

[WannaBeDrMe]

I just wanted to toss in that I love what you wrote about delusions coming in all flavors. There's some cool stuff about delusions as OCD compulsions that is coming out of Duke. I'll try to find the source. Saw it at a conference, followed it for a while, but lost touch. It was by far the most interesting tidbit of research I'd learned since some psychopharm stuff back in undergrad. I found it really attractive and it caused me to replay some of my most challenging cases.

The treatment for that would vary even from the ones you listed above... if indeed what they are experience isn't a true psychotic delusion but rather a re-occurring, persistent, and nearly impossible to control intrusion of thought/behavior.

That being said, I've never considered that statements of worthlessness could take on delusion - status... but I appreciate you making me consider that approach.

So many blurry lines, no? Your research sounds pretty nifty.