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Psychotic depression: A case study

28 July 1989


A 35 year old woman was admitted for psychiatric hospitalization with a psychotic disorder. Initially she was diagnosed as suffering from schizophrenia. The diagnosis was later changed to major depression with psychotic features. The client met the criteria for depression spectrum disease (Winokur, 1972; Winokur et al., 1973), with alcoholism and depression in her first degree relatives, and single episode unipolar depression. Relapse in this case was likely (Aronson et al., 1988) and relapse considerations were addressed. During a 13 1/2 month period, this client received outpatient chemotherapy and psychotherapy at a community mental health center. Data guided decision making was employed throughout her evaluation and treatment. Her condition required medication that was provided through cooperation with a psychiatric consultant who prescribed an antipsychotic, antidepressant and antiparkinson agent. The course of recovery was complicated by side effects of the medication. A reduction in the client's cognitive functioning was the most serious side effect (antipsychotic) and interfered with her job performance. Psychotherapy involved an eclectic approach which included psychoanalytic oriented (uncovering) psychotherapy, cognitive restructuring, relaxation training, behavior management, and communication and assertiveness skill training. The uncovering approach was discontinued early in treatment after it was determined that this effort would threaten the integrity of the client's much needed ego defense structure. However, efforts were made to educate her about the uncovering approach for possible future therapy. A criteria for determining a client's suitability for psychoanalytic oriented psychotherapy is offered. The MMPI scale two was used to assess the client's progress in treatment. The Harris-Lingoes subscales (Green, 1980) were employed to analyze the test results and provided the most useful MMPI data. Scale two was determined to be an unreliable indicator of the absence of depression when clinical signs and symptoms were absent. Eventually, the client and her husband separated and filed for divorce. He requested custody of the child because of her "mental disorder." The resulting circumstances and accompanying stress precipitated another hospitalization near the anniversary of her first hospitalization. After 18 days she was released to continue outpatient treatment. As the study concluded, the working diagnosis of psychotic depression remained in doubt as current assessment procedures rely on treatment course and phenomenology to confirm diagnoses. It was observed that the DSM III-R decision tree procedure does not consider the relative importance of the presence or absence of a sign or symptom in any quantitative way. The identifying signs and symptoms seldom include considerations of heredity, psychological testing or biological markers. Further research would establish useful biological indices and develop actuarial formulas that accommodate various categories of client data for decision making. It was concluded that the use of neuroleptics may also interfere with therapy and that research is needed to validate the phenomenon and establish guidelines for psychotherapy.


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