Mood disorders with psychotic features

Schizoaffective and mood disorder exclusion Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. 

Mood Disorder with Psychotic Features. One subtype of major depression and many episodes of mania are associated with psychotic symptoms. Like schizophrenia, the most prominent psychotic symptoms of psychotic depression or mania are delusions and auditory hallucinations. Unless a longitudinal history is available, it is often difficult to distinguish schizophrenia from a psychotic mood disorder. 

Because the most common condition studied is schizophrenia, this is the primary disorder discussed. We also consider schizophrenic spectrum (e.g., delusional, schizophreniform, schizoaffective) mood disorders with psychotic features and various nonpsychotic conditions (e.g., in the developmentally disabled) for which antipsychotics have been used (see Appendix A Appendix C Appendix E, Appendix F. and Appendix G). 

Cassano, G. B., Pini, S., Saettoni, M., Dell Osso, L. (1999). Multiple anxiety disorder comorbidity in patients with mood spectrum disorders with psychotic features. American Journal of Psychiatry, 156, 474-476. 

Schizophrenia and Schizoaffective Disorder. Cross sectionally, it is often difficult to distinguish major depression with psychotic features from the schizophrenia spectrum disorders. There are theoretically qualitative differences in the psychosis that may help to make the distinction. Psychosis in the context of a mood disorder tends to be manifested by persecutory and nihilistic themes, but schizophrenia is more often characterized by paranoia and disorganization. However,... 

When a patient with OCD has impaired insight, the distinction between obsession and delusion becomes blurred. We would argue that such a patient is in fact delusional. The with poor insight specifier is therefore the OCD equivalent to the with psychotic features specifier applied to the mood disorders. There may in fact be a continuum of insight in patients with OCD that fluctuates over time. For example, patients with OCD may recognize that their preoccupation with an obsessional idea or compulsive ritual is excessive, yet they may remain insistent that the premise underlying their anxiety is entirely reasonable. 

Maier W, Lichtermann D, Minges J, et al. Schizoaffective disorder and affective disorders with mood-incongruent psychotic features keep separate or combine Evidence from a family study. Am J Psychiatry 1992 149 1666-1673. 

Although the DSM-IV distinguishes between psychotic features that are either mood-congruent or mood-incongruent, the usefulness of this distinction remains controversial. Pope and Lipinski (12) found that schizophrenic symptoms were present in 20% to 50% of manic patients and that many of the delusions were mood-incongruent (i.e., delusions of persecution, catatonic symptoms, formal thought disorder, and auditory hallucinations not consistent with the mood state). 

When working with the bipolar 1 disorders it appears that either depressive episodes, manic episodes, or mixed episodes can be involved (Maxmen Ward, 1995). Practitioners should keep in mind that clients with bipolar I disorders will often report depressive episodes as well as the agitation and hyperactivity that often are associated with it In this condition a full depressive episode is also reported, and 20% to 30% of clients may continue to have mood fluctuations (lability) between episodes that are significant enough to disturb interpersonal or occupational relations. In some cases the development of psychotic features may occur, and when this happens subsequent manic episodes ate more likely to also have psychotic features (American Psychiatric Association, 1994). 

Bipolar affective (manic-depressive) disorder occurs in 1-3% of the adult population. It may begin in childhood, but most cases are first diagnosed in the third and fourth decades of life. The key symptoms of bipolar disorder in the manic phase are excitement, hyperactivity, impulsivity, disinhibition, aggression, diminished need for sleep, psychotic symptoms in some (but not all) patients, and cognitive impairment. Depression in bipolar patients is phenomenologically similar to that of major depression, with the key features being depressed mood, diurnal variation, sleep disturbance, anxiety, and sometimes, psychotic symptoms. Mixed manic and depressive symptoms are also seen. Patients with bipolar disorder are at high risk for suicide. 

Depressive and anxious symptoms are frequently associated with schizophrenia, but this does not necessarily mean that they fulfill the diagnostic criteria for a comorbid anxiety or affective disorder. Nevertheless, depressed mood, anxious mood, guilt, tension, irritability, and worry frequently accompany schizophrenia. These various symptoms are also prominent features of major depressive disorder, psychotic depression, bipolar disorder, schizoaffective disorder, organic dementias, and childhood... 

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