paranoid schizophrenia is a psychotic mood disorder?

[ClinPsycMasters]

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What do you think? I was actually looking at some articles regarding validity of schizoaffective disorder and came across this 2008 article in Schizophrenia Bulletin which I found interesting. Here's the abstract:

Hypothesis: Grandiosity and Guilt Cause Paranoia; Paranoid Schizophrenia is
a Psychotic Mood Disorder; a Review

Charles Raymond Lake

Delusional paranoia has been associated with severe mental
illness for over a century. Kraepelin introduced a disorder
called ‘‘paranoid depression,’’ but ‘‘paranoid’’ became
linked to schizophrenia, not to mood disorders. Paranoid
remains the most common subtype of schizophrenia, but
some of these cases, as Kraepelin initially implied, may
be unrecognized psychotic mood disorders, so the relationship
of paranoid schizophrenia to psychotic bipolar disorder
warrants reevaluation.

To address whether paranoia
associates more with schizophrenia or mood disorders, a
selected literature is reviewed and 11 cases are summarized.
Comparative clinical and recent molecular genetic data find
phenotypic and genotypic commonalities between patients
diagnosed with schizophrenia and psychotic bipolar disorder
lending support to the idea that paranoid schizophrenia
could be the same disorder as psychotic bipolar disorder. A
selected clinical literature finds no symptom, course, or
characteristic traditionally considered diagnostic of schizophrenia
that cannot be accounted for by psychotic bipolar
disorder patients. For example, it is hypothesized here that
2 common mood-based symptoms, grandiosity and guilt,
may underlie functional paranoia. Mania explains paranoia
when there are grandiose delusions that one’s possessions
are so valuable that others will kill for them.

Similarly, depression explains paranoia when delusional
guilt convinces patients that they deserve punishment. In
both cases, fear becomes the overwhelming emotion but patient
and physician focus on the paranoia rather than on
underlying mood symptoms can cause misdiagnoses. This
study uses a clinical, case-based, hypothesis generation approach
that warrants follow-up with a larger representative
sample of psychotic patients followed prospectively to determine
the degree to which the clinical course observed herein
is typical of all such patients. Differential diagnoses, nomenclature,
and treatment implications are discussed

 

[Regnvejr]

Schizophrenia foremost is a thought disorder. Paranoia and/or hallucinations by themselves don't necessarily make Schizophrenia.

I see lots of crappy diagnoses of schizophrenia, often carried over for years, until I start reviewing the criteria, and patients' thoughts are clear and logical as can be. I end up diagnosing a variety of problems instead, from MDD-severe with psychosis to PTSD to Bipolar mixed.

 

[ClinPsycMasters]

Yes, sometimes I do wonder if schizophrenia is being over-diagnosed. Psychotic mood disorders can be very similar to schizophrenia.

The relation between psychotic symptoms and mood is important...and confusing. Sometimes a person appears to have psychotic symptoms, no mood disorder, and blunted affect, which makes me wonder if they have schizophrenia. Yet the psychotic symptoms are organized around a common theme (e.g. persecutory delusions). Slowly and over time I realize that the person has severe depression, and that her psychotic symptoms, that sense of adventure and excitement (and pure terror too), actually gave her life meaning and lifted her out of depression. This may not be evident at first at all.

 

[erg923]

Although I disagree with the title of the thread, there is plenty of biologic evidence (primarily neuroendocrinological) that suggest psychotic major depression is a distinct entity, not merely a subtype of major depressive disorder.

 

[erg923]

Slowly and over time I realize that the person has severe depression, and that her psychotic symptoms, that sense of adventure and excitement (and pure terror too), actually gave her life meaning and lifted her out of depression. This may not be evident at first at all.

Um...I find this highly unlikely.

People who have true psychotic major depression (PMD) do NOT find their delusions or hallucinations to be fun or exciting (there is rarely a formal thought disorder in PMD). Paranoia, delusional notions of guilt and worthlessness and/or mood congruent auditory hallucinations are the hallmarks in true PMD. I work on PMD studies at our medical school and have never SCIDed anyone who has found that their psychotic symptoms actually help their depression.

Second, research indicates that PMDs actually have a greater likelihood of recurrence of depression and longer depressive episodes compared to their non-psychotic depressed counterparts. That is, the presence of psychosis decreases the likelihood of timely symptom remission.

 

[ClinPsycMasters]

Okay, what about schizophrenia. Do you think delusions serve a purpose? Could it have anything to do with depression and anhedonia, of creating some sort of meaning and purpose? Of course there is Kapur's "aberrant salience" hypothesis, of delusions seen as patient's cognitive effort at making sense of the aberrant experiences.

 

[loveoforganic]

I know of a paper in the works that found a surprising correlation between depression and something else (intentionally vague) where the something is thought to serve as a defense mechanism. So in that sense, your postulation doesn't seem absurd to me, strictly theoretically. I don't have any experience that I'm aware of with pmd patients.

 

[erg923]

There is no doubt that there are happily (AKA; content) delusional patients, we have all probably seen one. But this is not that kind of delusions one would see in true PMD...and..... just because one is happily and pleasantly delusional does NOT mean their social, occupational functioning has not been adversely effected.

 

[Ibid]

What I see all the time are people who have had every aspect of their lives pathologized to the extent that the reward for being “better” is the loss of an entire way of life not to mention a personal identity contingent on their status as a patient.

ClinPscheMasters - Do you think delusions serve a purpose?

Purpose and meaning; I don’t have a strictly objective view but I would say that delusions can have value. That of course is another matter but I really like your question.

 

[erg923]

Okay, what about schizophrenia. Do you think delusions serve a purpose? Could it have anything to do with depression and anhedonia, of creating some sort of meaning and purpose? Of course there is Kapur's "aberrant salience" hypothesis, of delusions seen as patient's cognitive effort at making sense of the aberrant experiences.

Of course they do! So do the ones in PMD, they just dont happen to be adaptive.

 

[ClinPsycMasters]

What would be an adaptive delusion then?

 

[Ibid]

Who is to decide what is adaptive and what is not? You just end up making a value judgement.

 

[Manicsleep]

What would be an adaptive delusion then?

Some people might consider religion or a belief in God to be one example where it can be adaptive and maladaptive.

 

[erg923]

I believe a key caveat in diagnosing almost all mental illnesses is to establish a that the behaviors/feelings interfere with social or occupational functioning. So the answer to your question is-YOU. You determine what is or is not adaptive behavior everytime you give a diagnosis to someone.

 

[Ibid]

erg 923 Pity it is so often wrong.

 

[snarfer]

Yes, sometimes I do wonder if schizophrenia is being over-diagnosed. Psychotic mood disorders can be very similar to schizophrenia.

I agree and mood disorders do often coexist with psychoses. Hence schizoaffective disorder was added.

 

[loveoforganic]

I don't think being adaptive woul necessarily mean not diagnosable (not sure if that's what you're saying erg). The delusion that you're worshiped by millions could help free someone from their depression to an extent (beneficial), but the narcissism that would likely result not so much. So there could be therapy needed to eventually resolve both issues.

That said, I'm speaking pretty off the cuff and I'm vastly under experienced relative to you, so if what I'm saying is crap, feel free to call me out on it!

 

[ClinPsycMasters]

Some people might consider religion or a belief in God to be one example where it can be adaptive and maladaptive.

Those people's beliefs can also be considered as adaptive/maladaptive delusion, depending on how functional their view of God/religion is in their current environment (e.g. maladaptive for NAS members). 😛

 

[ClinPsycMasters]

I believe a key caveat in diagnosing almost all mental illnesses is to establish a that the behaviors/feelings interfere with social or occupational functioning. So the answer to your question is-YOU. You determine what is or is not adaptive behavior everytime you give a diagnosis to someone.

I can see using this definition for personality traits, like narcissistic traits in surgeons, for instance. But for delusions? Imagine a patient with the narcissistic delusion that he really is superman or Zeus or Scorpion from Mortal Kombat video games. How adaptive is that?

 

[Ibid]

ClinPsyMasters
How adaptive is that?

Why don't you ask some one who has had those thoughts that excellent question? Frankly most of the people on here with all due respect are just guessing at the answer.

They won't be hard to find. It will be like looking for hay in a hay stack.

 

[Manicsleep]

I believe a key caveat in diagnosing almost all mental illnesses is to establish a that the behaviors/feelings interfere with social or occupational functioning. So the answer to your question is-YOU. You determine what is or is not adaptive behavior everytime you give a diagnosis to someone.

I can see using this definition for personality traits, like narcissistic traits in surgeons, for instance. But for delusions? Imagine a patient with the narcissistic delusion that he really is superman or Zeus or Scorpion from Mortal Kombat video games. How adaptive is that?

Well if this patient thought he could fly and wanted to jump off a building then it isn't adaptive. If its your patient YOU determine that.

Those people's beliefs can also be considered as adaptive/maladaptive delusion, depending on how functional their view of God/religion is in their current environment (e.g. maladaptive for NAS members). 😛

Thats not a delusion. The primary criteria for a delusion is not how functional the belief system is in the persons environment.

It is a fixed, false belief. If Thor came to walk the earth (or whatever he does) trust me, I will believe and so will the NAS members.

 

[erg923]

I don't think being adaptive woul necessarily mean not diagnosable (not sure if that's what you're saying erg). The delusion that you're worshiped by millions could help free someone from their depression to an extent (beneficial), but the narcissism that would likely result not so much. So there could be therapy needed to eventually resolve both issues.

That said, I'm speaking pretty off the cuff and I'm vastly under experienced relative to you, so if what I'm saying is crap, feel free to call me out on it!

You kinda lost me there, but the point is for most (not all) DSM-IV diagnosis there has to be some evidence that symptoms are severe enough thay they interfere with a persons social or occupational functioning. In the above case, it would probably be the depression that caused the most interference, unless the guy was shouting out his grandiosity at the office or something. Either way, of course this gentleman could be diagnosed. For psychotic disorders specifically I think it is worded as:

"Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work,interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement)."

I think you are aware that the interference clause is not necessary for the diagnosis of personality disorders, since they are viewed as egosyntonic conditions, for the most part anyway.

 

[erg923]

I can see using this definition for personality traits, like narcissistic traits in surgeons, for instance. But for delusions? Imagine a patient with the narcissistic delusion that he really is superman or Zeus or Scorpion from Mortal Kombat video games. How adaptive is that?

Um..its not! Although this might be good for his self-esteem, its generally not gonna be good for his functioning in the real world...

 

[ClinPsycMasters]

Um..its not! Although this might be good for his self-esteem, its generally not gonna be good for his functioning in the real world...

I understand but you're the one who said delusions can be adaptive. So give me a few examples.

 

[erg923]

when did i say that?

 

[ClinPsycMasters]

ClinPsyMasters
How adaptive is that?

Why don't you ask some one who has had those thoughts that excellent question? Frankly most of the people on here with all due respect are just guessing at the answer.

They won't be hard to find. It will be like looking for hay in a hay stack.

Well, the patient is not going to tell you how adaptive his delusion is. We have to take a guess.

My initial post was about psychotic mood disorder so here's a hypothetical example (which is very lightly based on a mix of multiple real cases and all identifying information has been changed):

Let's say Mr. X feels extremely guilty for having done some horrible things that resulted in his lover's death. His guilt is way out of proportion to what he has actually done to him. Being a gay man he thinks it is improbable to find another understanding and caring partner, and absolutely impossible to find the kind of lover he had. His depression, that sense of nihilism and meaninglessness, gets worse and worse over the years and eventually reaches the point of psychosis. Now he is convinced that some masked men are after him, trying to murder him! You see, years ago he was involved in some gay politics and he has always been very conscious of his identity as a gay man and all the stigma associated with it.

Now his life is an adventure. His life is filled with terror but he can run away from it...at least temporarily. Everyday he makes plans. There is purpose to his life. What kind of purpose? Is it adaptive? Is it better to run away from murderers than to wish for death and constantly think about suicide in face of unmanageable guilt? I don't know but when he has refused psychiatric treatments all his life, maybe the delusions are all he has to fill the emptiness.

 

[ClinPsycMasters]

when did i say that?

I'm sorry I'm making several posting at the same time and mistook you for someone else.

Here, you said "People who have true psychotic major depression (PMD) do NOT find their delusions or hallucinations to be fun or exciting (there is rarely a formal thought disorder in PMD)."

I just made a post about how the delusions can give some sort of meaning and purpose, though you're perhaps right and they're not exactly "fun".

 

[erg923]

Well, the patient is not going to tell you how adaptive his delusion is. We have to take a guess.

My initial post was about psychotic mood disorder so here's a hypothetical example (which is very lightly based on a mix of multiple real cases and all identifying information has been changed):

Let's say Mr. X feels extremely guilty for having done some horrible things that resulted in his lover's death. His guilt is way out of proportion to what he has actually done to him. Being a gay man he thinks it is improbable to find another understanding and caring partner, and absolutely impossible to find the kind of lover he had. His depression, that sense of nihilism and meaninglessness, gets worse and worse over the years and eventually reaches the point of psychosis. Now he is convinced that some masked men are after him, trying to murder him! You see, years ago he was involved in some gay politics and he has always been very conscious of his identity as a gay man and all the stigma associated with it.

Now his life is an adventure. His life is filled with terror but he can run away from it...at least temporarily. Everyday he makes plans. There is purpose to his life. What kind of purpose? Is it adaptive? Is it better to run away from murderers than to wish for death and constantly think about suicide in face of unmanageable guilt? I don't know but when he has refused psychiatric treatments all his life, maybe the delusions are all he has to fill the emptiness.

Not really sure what your question is, but.....

If you're looking for diagnostic ideas, thats not nearly enough info.

The first place to start would be asessing to see if he meets current criteria for a MDE. If not, does he meet criteria for Mania, or has he ever had a manic episode? The second step would be tracing the temporal development of his suspected delusional thinking. This is tough, as delusional-level guilt is often difficult to tease apart from the ruminations and catastrophizing inherent to severely depressed mood states. Moreover, are his current fears for his life from "masked men" in anyway plausible? Any basis in reality such as current, or even past threats? Could this be subtle paranoia and hyperarosual do to PTSD? Whats the trauma history? Was he ever really attacked or threatened?

If you deem them to truly be at the level of fixed delusions, then you have a psychosis of some sort at the least. Next step depends on if the delusions dissipate when he is not depressed. If so, then you might have PMD (delusions only in the context of the depressed mood episode). If they exist to the same degree in the absence of a depressed episode, or in fact developed before the mood symptoms, then you are probably looking at either delusional disorder, or more likely, schizophrenia or schizoaffective disorder depending on timelines and prominence of the mood componet. Obviously ruling out substance-induced things and medical as you go along on all this, etc. This was all very simplified, but I'm sure you get the idea I'm trying to convey.

In terms of whether any of this is adaptive....I'm not sure how clinically important that really is here. His delusions may keep from suicide (although I still not sure why you think that), but what kind of quality of life does he have because of them? Can he hold down a job or have meaningful relationships if he is constantly on guard for masked men... and probably depressed as well. Probably not, IMHO

 

[ClinPsycMasters]

Not really sure what your question is, but.....

If you're looking for diagnostic ideas, thats not nearly enough info.
....
In terms of whether any of this is adaptive....I'm not sure how clinically important that really is here. His delusions may keep from suicide (although I still not sure why you think that), but what kind of quality of life does he have because of them? Can he hold down a job or have meaningful relationships if he is constantly on guard for masked men... and probably depressed as well. Probably not, IMHO

This was partly in response to post #20, speaking about how adaptive delusions are, and also in reply to your post about delusions being far from fun/exciting.

I was not looking for diagnostic ideas (this is not a real case), seeing how I would need to provide a more comprehensive history at the very least. I was trying to use an example for our discussion of adaptiveness of delusions in psychotic depression.

This discussion is more philosophical than psychological. We're talking about next-to-zero quality of life in either case. Assuming that the person is unwilling to take medications--and let's ignore euthanasia--we're left with guilt-ridden nihilistic existence or the life of a "criminal" on the run. If it were me, I'll take the fear/terror and excitement of adventure over the misery of nihilistic existence.