If you are wondering what psychotic depression actually is, you are not alone. This issue raises many questions and concerns, especially when it affects ourselves or our loved ones. Psychotic depression is indeed a serious mental disorder that affects about 20% of severely depressed people, but we want to reassure you – there are effective treatments.
Unlike “ordinary” depression, psychotic depression is characterized by additional symptoms, such as delusions or hallucinations. It may sound scary, but remember – the more we know about this disorder, the better we can deal with it. Modern medicine offers many effective solutions, and early diagnosis greatly improves the chances of recovery.
In this article, we will take you through everything you need to know about psychotic depression. We will discuss its causes, symptoms and, most importantly, effective treatments.
What is psychotic depression?
Psychoticdepression is a mental disorder in which symptoms typical of depression occur alongside delusions and hallucinations of various content. And it happens more often than we might think – psychotic symptoms in the course of depression are experienced by up to 20% of patients. It is most often diagnosed in the elderly and adolescents, but can develop at any age.
Depression with psychotic symptoms – a characteristic symptom
Psychotic symptoms in depression have one important feature – they are usually consistent with a lowered mood. What does this mean? If someone suffers from psychotic depression, his delusions or hallucinations will be of a “depressive” nature – they will be about guilt, punishment, disaster or death.
This distinguishes psychotic depression from schizophrenia, where delusions can be very varied and not always related to mood. In psychotic depression, we rarely see complex paranoid systems – the symptoms are more directly related to the feelings that accompany depression.
Depressive symptoms include:
- a sense of despondency that persists for most of the day, lowered mood
- reduced interest in everyday things,
- reduced ability to feel joy in things that previously gave pleasure,
- change in appetite and associated weight loss or gain,
- persistent fatigue and lack of energy (this can make such simple activities as getting out of bed or taking care of personal hygiene difficult),
- sleep problems (trouble falling asleep, waking up in the middle of the night, sleeping excessively long or waking up early),
- psychomotor retardation (making slow body movements, reduced rate of uttering words, delayed reaction time), or problem sitting in one position and needing to move constantly,
- thoughts of harming oneself or feeling the urge to take one’s own life,
- feelings of worthlessness and hopelessness,
- decreased ability to make decisions,
- feelings of inner turmoil,
- difficulty concentrating attention,
- feelings of guilt.
Characteristic psychotic symptoms are:
- stupor (stasis – reduced contact with the outside world, limited reactions to stimuli), which makes it impossible to perform basic daily activities,
- delusions and hallucinations (the most common forms of which are outlined below).
Psychotic depressive episode – types of delusions and hallucinations
Delusions of guilt and punishment
Delusions of guilt and punishment are manifested by the patient’s conviction that he has done something terrible and will soon suffer the consequences. This could be committing a grave sin, a crime threatened with many years in prison, or causing an accident or natural disaster (even hundreds or thousands of miles away).
Example: Many people have suffered because of me. I have caused the greatest evil in the world. This hurricane that is sweeping across the United States … I caused it.
Catastrophic delusions
Catastrophic delusions are beliefs about impending disaster. It can be understood in many ways and can affect both the sufferer himself and humanity in general. Sometimes there is fear of an impending natural disaster, and other times there is fear of life’s problems. Among patients with psychotic depression, delusions of impoverishment – the conviction that one has lost all one’s possessions – are common.
Example: I have nothing anymore – neither money nor house. After all, this is a drama, I have nothing left. How will I continue to live?
Nihilistic delusions
Nihilistic delusions involve the patient’s belief that parts of his body do not exist. It seems to him that he is losing organs (he has no control over them or insists that he doesn’t have them at all). Sometimes he also claims that he doesn’t exist at all – his body has disintegrated, lost its form and turned into nothingness.
Example: I won’t eat or drink, because I have no stomach. In fact, I don’t exist at all after all. Please see, I have no body of my own.
Hypochondriacal delusions
Hypochondriacal delusions are those in which the patient appears to be suffering from an incurable disease. He may maintain that he is measuring himself against a specific disease entity (for example, cancer, stomach ulcers) or feel a generalized fear that something very bad is happening to his body and he is on the verge of death. Hypochondriacal delusions are not alleviated by doctors’ assurances of good results or by ruling out further serious illnesses by performing detailed tests.
Example: Today somehow this hand hurts me so much – you see, the cancer continues to grow and that’s why. For me there is no salvation anymore. It’s too serious for doctors to handle.
Xobic delusions
Xobic delusions involve putting oneself in the spotlight of others (even complete strangers). The patient is convinced that someone is watching him, lurking or following his every move. He notices “hidden signs” – for example, newspaper headlines directed at him, journalistic reports on TV or articles on websites.
Example: Today they were talking about me in the news again. And when I leave the house, everyone is looking at me. And they still point their finger at me and laugh at me.
Persecutory delusions
Persecutory delusions refer to the belief that other people want to do harm to the patient. The most common claim is that some person or group is watching him, following his every move and lurking about. The patient may also throw away electronic equipment, change phone numbers and search the apartment for fear that someone has installed a wiretap on him.
Example: They have colluded against me. They are waiting for me to leave the house to attack me. They want to kidnap me.
Auditory hallucinations
Auditory hallucinations are voices that the patient hears. They are hostile to him – condemning, taunting and ridiculing his every move. They may accuse him of misconduct, criticize his appearance, convince him of the meaninglessness of life and urge him to harm himself.
Olfactory hallucinations
In addition to auditory hallucinations, olfactory hallucinations may also occur in psychotic depression. These involve the sensation of smells – usually the smell of rot. They are generally associated with nihilistic delusions and a belief in the gradual decay of one’s own body.
Symptoms of psychotic depression vs. symptoms of schizophrenia
Symptoms of psychotic depression may beg the question, “And how do you know it’s not schizophrenia?” After all, it is with schizophrenia that we associate delusions and hallucinations that alter our perception of the world and of ourselves.
However, unlike schizophrenia, in psychotic depression delusions are not arranged in complex paranoid systems. This means that multi-layered, detailed stories are not formed on the basis of delusions about oneself, life and the surrounding world. The patient also often remains critical of his symptoms and realizes that they are not consistent with reality. He sees that something unusual is happening to him and seeks help on his own.
Psychotic depression vs. bipolar disorder
For many years now, researchers have been leaning into the relationship between psychotic depression and bipolar affective disorder (ChAD). Their results indicate that patients diagnosed with psychotic depression are more likely to develop bipolar disorder than those who are not diagnosed with manufacturing symptoms.
Moreover, bipolar disorder is more likely to be diagnosed among relatives of people struggling with psychotic depression. A family history of bipolar disorder is considered a risk factor for developing psychotic depression.
Psychotic depression – an example
Ewelina arrives at the ward terrified.
She had already been feeling worse and worse for several weeks. At first she thought she had “fallen into an emotional hole.” She had less energy and began to worry that she wouldn’t be able to cope with her daily duties. At the time, her husband explained to her that she was probably “going a little crazy” because she had been sitting at home taking care of the baby for two years. Previously, when she worked as a nurse, she never had such mood drops after all.
One day she thought about her old job and said with dismay:
– Surely I gave that patient from under three the wrong injection and he died because of me!
She began to panic that the consequences would reach her – someone from the hospital would come and lock her up, and she would not be able to do anything.
When she went out into the street, it seemed to her that someone was constantly watching her. From the bushes, from behind a storefront or from inside a parked car. “I have to be under constant surveillance. They’re about to arrest me.” – she thought, running toward the house and barricading the door.
Just before her hospitalization, her condition deteriorated badly. Ewelina’s last night was sleepless. The woman kept insisting that the police were standing in the driveway and were about to break down the door. She frantically tried to hide somewhere, and her husband forcibly dragged her away from the window she wanted to evacuate.
Causes of psychotic depression
The causes of psychotic depression are complex and multifaceted. There is no single simple explanation for why some people develop this disorder. Instead, there is an interaction of various biological, genetic and environmental factors.
The role of stress and hormones in the body
One of the key mechanisms in the development of psychotic depression is the dysfunction of the hypothalamic-pituitary-adrenal axis, abbreviated as the HPA axis. It sounds very scientific, but in practice it’s all about how our body deals with stress.
When you are under stress, your body produces cortisol, a hormone that helps you cope with difficult situations. In people with psychotic depression, this system malfunctions, producing too much cortisol. Excess of this hormone can negatively affect the brain, especially the areas responsible for memory, and can directly contribute to psychotic symptoms.
This explains why people with psychotic depression often have memory problems and why stress can exacerbate their symptoms. The good news is that by understanding this mechanism, doctors can better tailor treatment.
Neurotransmitters – Chemical Messengers of the Brain
Your brain is an extremely complex network of neurons that communicate with each other using special chemicals called neurotransmitters. In psychotic depression, three of them play a particularly important role: serotonin, dopamine and norepinephrine.
Serotonin is often called the “happy hormone” – it regulates mood and well-being. When its levels are too low, you may feel sadness, hopelessness and other depressive symptoms.
Dopamine, in turn, is responsible for how we perceive reality and process information. When the dopamine system is not working properly, hallucinations and delusions can occur.
Norepinephrine regulates attention, arousal and stress responses. Its dysfunction can contribute to both depressive symptoms and perceptual problems.
The important thing is that these three systems influence each other. This is why treatment of psychotic depression often requires drugs that affect several neurotransmitter systems simultaneously.
Psychotic depression – forum is not the place to seek help
Many people experiencing unpleasant symptoms open a search engine. After describing the ailment, all they have to do is click enter, and in less than a second a number of pages with case reports, personal confidences and “good advice” appear.
Very often we can come across detailed stories of the development of disorders, lists of symptoms experienced by other patients and their insights into the effects of particular medications. But even reading such online forums for hours will not bring us any particular benefit.
Remember – the Internet is not a doctor. When you feel that your mental health has deteriorated, turn to a psychiatrist.
Psychotic depression – test. Can I have psychotic depression?
It’s also not worth looking for free tools to assess the symptoms of psychotic depression. While you can take the Beck Depression Scale at home on your own, it only targets the depressive symptom. To be sure what type of depressive disorder you are facing, a visit to a doctor’s office is necessary.
Psychotic depression – diagnosis of depression. Treatment of psychotic depression
Diagnosing psychotic depression can be a challenge for several reasons. First, sufferers often have difficulty communicating – they may be closed off, silent, or so immersed in their symptoms that it is difficult to make contact with them.
Second, symptoms may resemble other mental illnesses, requiring careful analysis by a specialist. Sometimes additional tests or consultations are needed to make a proper diagnosis.
Diagnosis is a process in which a doctor collects information from us, analyzes our condition and identifies what ails us. Only with a proper determination of the disease is it possible to prescribe medication that will effectively deal with unpleasant ailments and bring us relief.
During the diagnosis for psychotic depression, attention is paid primarily to the presence of symptoms characteristic of depression (which must persist for at least two weeks), with the simultaneous presence of psychotic symptoms. It is also important to distinguish symptoms of psychotic depression from those characteristic of other disorders.
This is because it sometimes happens that psychotic depression is confused with:
– depressive disorders without psychotic symptoms (especially when contact with the patient is difficult and he will not reveal the presence of hallucinations or delusions),
– personality disorders (usually borderline disorder),
– schizophrenic and schizoaffective disorders,
– post-traumatic stress disorder.
Psychotic depression – treatment time
It is difficult to estimate the time needed to treat psychotic depression. Everything depends on the severity of symptoms and how the patient responds to the implemented treatment. Sometimes it is necessary to change a set of medications or modify their dosage several times. When, on the other hand, daily functioning deteriorates severely, the risk of harming oneself or bargaining for one’s own life increases, a referral to the hospital becomes necessary. Here, too, it is difficult to judge after how much time spent in the ward there will be improvement.
Psychotic depression – prognosis
Usually the prognosis for psychotic depression is worse than for depression without manufacturing symptoms. This is because this type of depression is associated with a higher risk of psychotic symptoms in subsequent episodes, more frequent hospitalizations, shorter remissions (periods without symptoms) and higher mortality.
However, this does not mean that hope should be lost. Today’s pharmacological treatment options are plentiful and allow for significant improvement in most patients.
Psychotic depression – pharmacotherapy
Treatment of psychotic depression differs significantly from treatment of ordinary depression. Studies unequivocally show that the most effective is the simultaneous use of antidepressants and antipsychotics. Using only one type of medication is much less effective.
Why are both types of drugs needed? Antidepressants, especially those in the SSRI group like fluvoxamine or sertraline, help regulate serotonin levels in the brain, which improves mood and reduces depressive symptoms. Antipsychotics, on the other hand, act on the dopamine system, reducing hallucinations and delusions.
Modern antipsychotics, such as olanzapine, risperidone and quetiapine, are much better tolerated than older preparations. They have fewer side effects and allow for better functioning in daily life.
If you are worried about side effects of the drugs, remember that your doctor always selects doses individually and monitors your condition regularly. Most people tolerate the treatment well, and the benefits far outweigh the potential risks.
Psychotic depression – psychotherapy as a complement to treatment
Although medication is the mainstay of treatment for psychotic depression, psychotherapy plays a very important complementary role. Cognitive-behavioral therapy (CBT) helps change negative thinking and behavioral patterns that can sustain symptoms.
In therapy, you learn to recognize and challenge irrational thoughts, replacing them with more realistic interpretations. This is especially important for delusions – the therapist helps you gradually regain contact with reality.
Therapy also includes learning stress management techniques, relaxation methods and social skills. These tools are extremely useful not only during treatment, but also in preventing relapse.
Remember that psychotherapy for psychotic depression always complements, not replaces, drug treatment. Both approaches work synergistically to produce the best results.
Coping with psychotic depression
Successfully coping with any health challenge begins with understanding what we are dealing with. Psychotic depression is not just “ordinary” depression – it is a complex disorder that combines depressive symptoms with psychotic symptoms, such as delusions or hallucinations.
When psychotic depression symptoms escalate, they can include deep feelings of sadness, hopelessness, but also beliefs that have no basis in reality. These delusions often involve guilt, punishment or disaster – consistent with a lowered mood. Understanding this mechanism helps you better manage your symptoms when they occur.
It’s also important to understand that the first episode usually occurs between the ages of 20 and 40, which means that early recognition and intervention can make a significant difference in the course of the disease. People struggling with psychotic depression can regain control of their lives – studies show that about 50% of properly treated patients achieve full remission of symptoms.
A key element of understanding is also accepting that this is an illness, not a character weakness or lack of willpower. This awareness allows for a more constructive approach to treatment and reduces the guilt that often accompanies people with mental disorders.
Daily strategies for symptom management
Managing psychotic depression in daily life requires the development of specific, practical strategies. These techniques are not a substitute for professional treatment, but they can significantly aid the recovery process and improve quality of life.
One of the most important strategies is to establish a regular daily rhythm. Psychotic depression often disrupts the natural sleep-wake cycle, so consciously creating a structure for the day can provide significant relief. Getting up and going to bed at consistent times, regular meals and scheduled activities help the brain recover.
Monitoring symptoms is another key skill. Keeping a simple mood and symptom diary allows you to recognize early warning signs. When psychotic depression symptoms affect daily life, a quick response can prevent an episode from escalating. Keep a record of how you’re feeling, what thoughts are bothering you and how your body is reacting – this information will be invaluable when you visit your doctor.
Relaxation and mindfulness techniques can be especially helpful in managing the anxiety and tension that often accompany psychotic depression. Simple breathing exercises, progressive muscle relaxation or short meditation sessions can provide relief during difficult times. You don’t have to be an expert – even a few minutes a day can be beneficial.
Physical activity, tailored to your abilities, also plays an important role. It doesn’t have to be an intense workout – a walk in the park, gentle stretching or gardening can have a positive effect on your mood and well-being. Movement helps produce endorphins, the body’s natural “happy hormones.”
Creating a safe space at home is also important. Remove objects that can be dangerous during psychotic episodes, and create a quiet place where you can take refuge when symptoms flare up. This could be a comfortable corner with your favorite books, calming music or objects that give you a sense of security.
Factors affecting recovery
The prognosis of psychotic depression depends on several key factors. The most important of these is the timing of treatment – the earlier therapy is instituted, the better the chances of full remission of symptoms.
Support from family and loved ones plays a huge role in the recovery process. Studies show that patients who receive emotional and practical support from their loved ones have a much better prognosis and go through the various stages of treatment more easily.
Psychoeducation – or education about the disease – is also crucial. When the patient and family understand what psychotic depression is, how treatment proceeds and what to watch out for, it is much easier to maintain continuity of treatment and prevent relapse.
Summary – hope for a better tomorrow
Psychotic depression, despite its complexity and seriousness, is not a sentence. Modern medicine offers effective treatments that allow most patients to return to a normal, full life.
The key to success is early recognition of symptoms and prompt initiation of appropriate treatment. The earlier therapy is instituted, the greater the chances of full recovery and the lower the risk of recurrence.
Remember that you are not alone in this struggle. There are many specialists – psychiatrists, psychologists, therapists – who have the knowledge and experience needed to effectively treat psychotic depression. There are also organizations and support groups that can help both patients and their families.
Treating psychotic depression is a process that takes time and patience. There may be better days and worse days, but with the right medical and emotional support, lasting improvement is possible.
If you suspect symptoms of psychotic depression in yourself or a loved one, don’t wait – contact your doctor. Early intervention can significantly improve the prognosis and shorten recovery time.
Bibliography:
Bidzan, L. (2004). Psychotic depression – clinical picture, diagnosis, treatment, Psychiatry in General Medical Practice 4(1), pp. 21-26.
Filip, M., Galecki, P.(2020). Psychotic symptoms in the course of depression – principles of therapeutic intervention, CNS Reviews, 4(1), pp. 29-39.
Perzynski, J., Michalak, M., Perzynska-Starkiewicz, A. (2012). Psychotic depression or schizophrenia, Current Problems of Psychiatry, 13(3), pp. 157-159.
Zdanowicz, A., Wierzbinski, P. (2017). Psychotic depression, Psychiatry and Clinical Psychology 17(2), pp. 115-119.
https://www.sciencedirect.com/science/article/pii/S0010440X1930080X