Psychiatry · Year 3 · from Psychiatry
Case 3: Depression with Psychotic Features
Patient Demographics
- Age: 67 years old
- Sex: Female
- Occupation: Retired nurse
Chief Complaint
Brought by daughter who states: "She thinks she's dying from a disease that's eating her insides."
History of Present Illness
The patient is brought to the emergency department by her adult daughter, who reports progressive deterioration over the past 6 weeks. The patient has been convinced that she has a fatal illness that doctors have "missed," believing her "organs are rotting away." She has refused to eat, stating "there's no point, I'm already dead inside," and has lost 20 pounds. She has stopped bathing and changing clothes, saying "why bother when I'll be dead soon." She sits in her chair for hours staring at nothing. She was found this morning trying to give away her belongings, telling her daughter "you'll need these after I'm gone." The patient's husband passed away 8 months ago, and she had a previous depressive episode 10 years ago that responded well to sertraline.
Mental Status Examination
Appearance: Elderly woman appearing cachectic and frail, malodorous, wearing stained nightgown, unkempt hair
Behavior: Psychomotor retardation severe - minimal spontaneous movement, does not make eye contact, whispers responses
Speech: Markedly decreased rate and volume, latency of several seconds before responding
Mood: "I'm already dead"
Affect: Flat, blunted, no emotional reactivity
Thought Process: Slowed, poverty of content, goal-directed when engaged
Thought Content:
- Nihilistic delusions: Believes her body is dead/dying, organs rotting
- Somatic delusions: Convinced of fatal illness despite no medical evidence
- Guilt delusions: "I deserve this suffering for all the bad things I've done"
- Passive suicidal ideation: "I wish it would end soon"
- No homicidal ideation
Perceptions: Endorses olfactory hallucination - "I can smell my body decaying"
Cognition: Alert, oriented to person only, disoriented to place and time; attention impaired; unable to complete cognitive testing due to poor engagement
Insight: Poor - convinced delusions are real
Judgment: Poor - not eating, poor self-care, giving away possessions
Psychiatric Workup
Screening Tools:
- PHQ-9: Unable to complete (severely impaired)
- Clinical assessment indicates severe depression with psychotic features
Laboratory Studies:
- CBC: WBC 5.8, Hgb 10.2 (mild anemia)
- CMP: BUN 32, Cr 1.4 (mild dehydration), albumin 2.9 (malnutrition)
- TSH: 3.1 mIU/L (normal)
- Urinalysis: Concentrated, no infection
- B12: 220 pg/mL (low)
- Folate: 5 ng/mL (low-normal)
- CT Head: Age-appropriate atrophy, no acute abnormality
Diagnosis
Major Depressive Disorder, Recurrent Episode, Severe with Psychotic Features (F33.3)
DSM-5 Criteria:
- Meets criteria for major depressive episode (depressed mood, anhedonia, weight loss, psychomotor retardation, worthlessness, passive SI)
- Psychotic features present:
- Nihilistic delusions (body is dead/dying)
- Somatic delusions (fatal illness)
- Delusions of guilt
- Olfactory hallucination (mood-congruent)
- Delusions are mood-congruent (themes of death, disease, guilt consistent with depressive themes)
Differential Diagnosis:
- Delirium (ruled out by normal workup except mild metabolic derangements)
- Dementia with behavioral disturbance (less likely given acute onset, no prior cognitive complaints)
- Medical illness causing symptoms (workup negative)
Treatment Plan
Acute Management:
- Psychiatric admission (voluntary status - daughter has healthcare POA and patient assented)
- IV fluid resuscitation
- Nutritional support, B12 supplementation
- 1:1 observation for safety
Pharmacotherapy:
- Start olanzapine 5 mg QHS (for psychotic symptoms)
- Start sertraline 50 mg daily (previous good response)
- Monitor for refeeding syndrome given malnutrition
Consider ECT:
- Depression with psychotic features responds particularly well to ECT
- May be first-line given severity, psychosis, and poor oral intake limiting medication absorption
- Family meeting to discuss ECT as preferred treatment
- Consent obtained from healthcare POA
ECT Course:
- Bilateral electrode placement (more effective for psychotic depression)
- 3 times weekly
- Typical course 6-12 treatments
Prognosis:
- Depression with psychotic features has high response rate to ECT (80-90%)
- Maintenance treatment needed after acute stabilization (antidepressant + low-dose antipsychotic or maintenance ECT)
Follow-up:
- Daily evaluation during inpatient stay
- Involve family in treatment planning and psychoeducation