Psychotic Depression (Again): What is "Mood Congruent Psychosis"?

If it seems like I spend a lot of time writing about psychotic depression, it's because I do.  Before it happened to me, I had no idea such a thing was even possible.  In the months since it's happened to me, I've learned that there's not a ton of information out there, and some of what's out there isn't accurate (for instance, the assertion in the WebMD article that the condition requires hospitalization).  Furthermore, a lot of the information out there simply doesn't apply to my situation.

For starters, as my doctor told me, most depressed people who become psychotic are in pretty bad shape.  In his experience, they've already reached the point where they're struggling to take care of themselves.  I was actually functioning well, my mood wasn't even depressed for most of the day.

Second, most psychosis in people with mood disorders is "mood congruent".  That is, a depressed person will have "depressed" delusions, such as feelings of guilt -- that they're deserve to be punished for something that couldn't possibly be their responsibility, or that people treat them "differently" because those people "know" about the horrible things they've done.  Another common delusion is for a depressed patient to believe, without any rational cause, that they are gravely physically ill.

Not me. I had delusions of physics.



I felt like the shadows in the corners of my home, and the interiors of my cupboards and cabinets, were devouring photons.  The universe, in my delusion, only had a finite supply of these light particles.  If something wasn't done, there wouldn't be enough photons, and darkness would prevail.  Of course, I knew this wasn't true -- for that matter, I knew that darkness is "dark" not because it's absorbing photons, but because they just aren't there to begin with.  I tried telling my brain that, but it wouldn't feel better until I covered things in foil.

Was this "mood congruent" psychosis?  It didn't have anything to do with guilt, or punishment, or a belief that I was sick or dying.  If I stretch, I can sketch a relationship between my delusions and my health.  I have seasonal affective disorder, I knew my mood and cognition were suffering because it had been gloomy for most of the year, and I feared that another such year would be more than I could take.  But my delusion itself did not center around my health.  My delusion centered on the dangerously low levels of photons in the universe, in particular those places in my home where the "darkness" was "devouring" them.

In John McManamy's People's DSM, his section on psychosis draws a distinction between those episodes that are linked to the mood cycle, in both timing and congruency, and those that are not.  My psychosis was clearly linked to my mood in terms of its timing.  It happened after an acute depressive cycle, as I was finding my way out of The Pit.

So my psychosis meets the "timing" criterion for being related to my mood cycle -- but what about "congruency"?  Keep in mind, my diagnosis is psychotic depression.  When my psychotic episode happened, my mood had bottomed out and was on its way up.  Emotionally, I was actually feeling more stable.  Mentally, I clearly wasn't, as I was concerned about a piece of furniture ending the universe.

On the other hand, once it occurred to me to cover it in foil (to neutralize its photon-devouring powers) I actually felt pretty good.  There was a problem (granted, I knew it was imaginary), it was imaginary but I could still solve it.  Covering a cabinet in foil isn't even that hard.  I cheerfully set to work.

In McManamy's People's DSM, I suspect that my psychotic episode would be classed as "mood incongruent".  Even if my diagnosis were changed to bipolar instead of major depression, the 'sode doesn't fit at any place in the mood cycle, at least as McManamy describes them.  In such cases, he argues, psychosis needs a label other than "[mood disorder] with psychotic features".  He suggests "[mood disorder] with co-occurring psychosis".

The difference between the two is how they should be treated.  McManamy argues, rather reasonably, that if a psychotic episode is clearly linked to mood, the first-line treatment should be mood stabilizers rather than antipsychotics.  Antipsychotics should be used to treat co-occurring psychosis.

As far as my psychotic episode was concerned, I was treated with Abilify, an antipsychotic, and it definitely did its job.  But if I don't even have "mood congruency" to go on, preventing another episode is not just a question of keeping myself out of The Pit.