The insula, as a site of multimodal convergence, could play a key role in understanding the pathophysiology of PTSD, possibly accounting for what has been called posttraumatic alexithymia, i.e., reduced ability to identify, express and regulate emotional responses to reminders of traumatic events. Differences in activity in right frontal areas may indicate a dysfunctional PFC, which may lead to diminished extinction of conditioned fear and reduced inhibition of the amygdala.
Medscape (open access, free registration required) has an update on psychotic depression: Current Issues in the Classification of Psychotic Major Depression. It is reprinted from the Schizophrenia Bulletin. I was particularly interested in the updates onthe cognitive features and the biological correlates of the condition. They also make a very good point about the classification, with regard to severity. This is something that has bugged me for a while. I think it leads to a clinical problem: psychosis in depression is easy to overlook, especially when the vegetative symptoms are not so prominent. They mention that about half of depressed persons who do not respond to treatment have undetected psychosis.
In the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classification of mood disorders, psychotic depression is described by a severity dimension specifier for major depressive episode, "severe with psychotic features." There is no way to designate a mild or moderate depression with psychotic features. However, research has shown that the relationship of severity and psychosis is not that strong.
Annals of General Psychiatry (also open access)has a review of the treatment of bipolar disorder: Treatment of bipolar disorder: a complex treatment for a multi-facet disorder. In some ways it is disappointing, because of what it leaves out. But you can't cram everything into an eight-page paper. The list of references is longer than the text, so there is a lot of information there for someone who is looking for more.
For those interested in unusual case histories, the Irish Journal of Psychological Medicine (open access) has a report: Psychosis? Beware – case series of clarithromycin and psychosis. (PDF file)
We describe two case reports presenting approximately one year apart. These indicate a possible association between clarithromycin and psychosis. Such an association presents new challenges for clinicians based in non-psychiatric hospital settings and primary care physicians.
You have to be on your toes in this business. We've all seen things like that, things that come and go, and you never figure out what it was all about. Or you do, and it turns out to be alcohol-related. But an antibiotic? Sure, why not?
Comments
Psychotic depression should be a separate diagnosis in the next DSM, but who will listen. I disagree with the authors of the mentioned article about one aspect of their advise. They suggest adding a psychotic dimension to depressive disorder. This makes this important diagnosis less clear. To my opinion we should only use the diagnosis psychotic depression in patients with clear mood congruent delusions and/or hallucinations. Excessive feelings of guilt or mood incongruent delusions as symptoms of psychotic depression would obscure and confuse the diagnosis making research and treatment more difficult and less univocal, regards
Dr Shock
Posted by: Dr Shock | October 20, 2007 2:00 PM
I certainly agree that it would make sense to elevate the condition to the level of its own diagnosis. From a clinical standpoint, however, I think it is important for people to realize that even "soft" psychosis, such as pervasive, unrealistic guilt can be a reason for an empirical trial of an antipsychotic medication.
As you know, in the transition to DSM-V, no changes will be made unless the changes are supported by enough empirical evidence that a consensus emerges. In order to make such a change, I would want to see evidence that, once a patient develops psychotic depression, the longitudinal course is significantly different from that of depression without psychotic features. Or, that the pathophysiology is fundamentally different.
The subject is inherently difficult to study, though, because patients often seem reluctant to disclose their symptoms. The authors suggest that a short battery of tests be developed and validated. If that could be done, it might facilitate the research that would be needed to support a change in the diagnostic scheme.
Posted by: Joseph j7uy5 | October 20, 2007 6:13 PM
The use of antipsychotic medication for psychotic depression in unipolar disorder is a subject of debate (PMID: 16648526). I disagree that antipsychotic should be prescribed for all psychotic depressed patients much so for patients with excessive feelings of guilt. But I realize that we are discussing this topic from different backgrounds. Our mental health care system is probably incomparable to yours.
Regards Dr Shock
Posted by: Dr Shock | October 21, 2007 5:35 AM