Descriptive Psychopathology: The Signs and Symptoms of ...

283 Chapter 11: Delusions and abnormal thought contentThe older literature also recognized monomania with depression. At present,such conditions are considered as schizoaffective disorder, delusional disorderwith depressive content, or psychotic depression. The disorder was characterizedby a fixed delusion with melancholic-like content that influencedthe sufferer’s actions (e.g. apprehension of impending catastrophe elicitingthe patient to take evasive actions when in public to avoid being followed,or barricading himself in his home). The actions were described as circumscribedand other functions initially were undisturbed. Sufferers were notincapacitated. As the condition progressed, ideas of reference emerged.Hallucinations and illusions occurred but were not prominent. Delusions ofpersecution also developed. Patient 11.3 illustrates the diagnostic ambiguity ofthis syndrome.Patient 11.3A 40-year-old woman was hospitalized because of her family’s concerns. Formuch of the past year she had been convinced that her husband was unfaithfuland was trying to poison her. She saw evidence in unfamiliar automobilesdriving past her home, strange odors emanating from the furniture, and herpossessions being “replaced” by similar but “different” ones. Despite theseideas, she continued to adequately perform her family and household responsibilities.When she expressed thoughts of suicide her family brought her tothe hospital.The patient was neither manic nor depressed. Her emotional expression wasrestricted, but she became irritable if her convictions were challenged. She hadno movement disorder. Her speech and language were normal. She had nodiscernable cognitive impairment. Her general medical health was good andher neurologic assessment normal. Twenty years earlier she had suffered apostpartum psychotic depression that was incapacitating and which lasted thebetter part of a year, resolving gradually without treatment.Bilateral ECTwas prescribed for the index condition and after 12 treatmentsthe delusional syndrome fully resolved. Maintenance ECT kept her well for thenext six months, after which she was lost to follow-up.Patient 11.3 illustrates the advantage of applying Sutton’s law and the Rule ofParsimony to the diagnostic process when the duck principle fails (see Chapter 5).The patient’s index presentation was ambiguous (failed duck principle), butthe postpartum depression 20 years earlier suggested that the present episodereflected the same pathophysiology (the rule of parsimony). Psychotic depressionis also much more common than delusional disorder (Sutton’s law).