Hi, I'm Dr. Tracey Marks, a psychiatrist,
and I make mental health education videos.
Today, I'm answering a viewer question from Mr. R.
"Hi, Dr. Marks.
"Could you please make a video on how to differentiate
"between the negative symptoms of schizophrenia
"and major depression with psychotic features,
"and the difference in treatment?"
Thank you, Mr. R, for your question.
There's definitely some overlap
between the negative symptoms of schizophrenia
and the depressive symptoms in a person
who has depression with psychosis.
First, let me define negative versus positive symptoms.
Negative symptoms were described by Eugen Bleuler.
He was a Swiss psychiatrist who first introduced
the term schizophrenia in the early 1900s.
Before he came on the scene, what we now know
as schizophrenia was called dementia preacox,
or pray-cox as some people pronounce it.
It was thought of as a dementing illness
because of the effect that it has
on your thinking and problem solving.
I have a video talking in more detail about schizophrenia
that you can watch after this video.
The dementia aspect of schizophrenia is important
because the cognitive decline that you get
with schizophrenia is one of the hallmark differences
between that illness and the mood disorders,
like depression or bipolar illness.
And the psychosis you get with depression or mania
looks different from the psychosis
that you see in schizophrenia.
So Bleuler came along and expanded our understanding
of schizophrenia by introducing the four A's, alogia,
autism, affective blunting and ambivalent.
These four A's are now called
negative symptoms of schizophrenia.
They're negative because of
they're the absence of something.
Positive symptoms are additional or extra stuff going on
that's not supposed to be there, like delusions,
hallucinations and disorganized thinking or behavior.
Let's look more closely at the four A's.
Alogia is called poverty of speech.
Your speech is empty of details,
and this is more than having trouble starting conversations.
You don't have much to say,
even if someone asks you a question.
In fact, if you're talking to someone
with impoverished speech, they may not answer your question
and not because they don't want to.
They may have disruptive thoughts
that make them not even register the question.
Here's an example of how our conversation should go.
"How are you today?" "Good."
"What'd you do today?" "Not much."
"Can you give me some more examples of what you did?" "No."
It can be very hard to keep this kind of conversation going,
and many people will just give up.
If you don't know that the person has a mental illness,
it may just look like they're being difficult.
Number two is autism. Some people call this asociality.
It's not the same as autism spectrum disorder.
The negative symptom refers to the general concept
of being detached from your environment.
Because you're consumed with your inner thoughts,
you don't relate that well to people.
And in the example of the alogia conversation,
there's a disconnect.
The person isn't being defiant or shy.
They're answering these questions
to the best of their ability,
and they aren't concerned about how they come across
because they don't see the interaction as lacking.
The depressed person who doesn't want to talk
may look aggravated or sad and communicate
with their body language that they don't want to talk.
The person with alogia and a negative symptom of autism
can just matter-of-factly answer questions
with one word and appear unfazed.
You're the one who's left
feeling like you're not connecting.
Number three is affective blunting.
This refers to a restricted emotional expression.
Usually when we express emotion,
we smile if we're happy, we frown if we're sad
or we scowl if we're angry,
and you can see this range of expression
in your face, your eyes, your forehead,
body position and tone of voice.
Reading someone's facial expressions
and body language is instinctual.
We're not given a cheat sheet
that defines what facial expressions mean.
We learn over time by associating
what someone's face looks like
in relation to what they're saying.
We learn to match expressions,
voice tone and speech content.
So with affective blunting,
you have a limited range of emotional expression,
as well as a mismatch of expression.
If I have a flattened or blunted affect,
I can talk about something and show very little emotion.
I can say that I was promoted to supervisor position
at work, and I got a $10,000 raise.
You may say, "Wow, $10,000.
"You must be happy about that."
And I'd say, "Yes, I'm pretty excited."
If I was depressed and telling you this,
my answer may be, "I guess it was nice.
"Uh, it's going to be a lot of work though,
"and I'm probably going to have to work longer hours.
"and I don't know if I'm going to do a good job."
Do you see the difference?
With depression, you have more negativity
and pessimism in the answer.
With the pure blunting without depression,
my answer isn't negative.
It's just that my emotional expression
doesn't match what I'm saying.
I'm telling you about something great that's happening,
but the way I express it is flattened.
If you're talking with me, you may think,
"Is there a catch here?
"Am I missing something that makes this not a good thing?"
And that might prompt you to ask more questions.
Then I could start to feel annoyed and say,
"Why are you asking so many questions?"
Because, remember, with schizophrenia, I have trouble
giving a lot of details and I don't want to be grilled.
So you say, "Well, I'm just confused.
"Is this a good thing?" "Yes."
"Well, you don't look happy." "I am happy."
Here, you were just trying to tell someone
about what happened to you,
and now the conversation has deteriorated.
And this kind of exchange feeds into your desire
to stay in your head and socially withdraw.
That interchange would look different
with the depressed person because it would be more obvious
that they're in a low place,
and it would be easier to know how to respond to them.
It's important to point out that you can also
get this blunting of emotional expression
as a medication side effect,
particularly with antidepressant.
I have a video talking about this problem.
If this happens from a medication,
usually your depression has improved,
and you won't have the psychotic symptoms.
The blunting is a standalone problem.
The last negative symptom is ambivalent,
and it's a little harder to understand.
It involves having both positive and negative beliefs
about something occurring at the same time.
Typically, people who are depressed
tend to have more strongly negative feelings,
but the sense of not having clarity
about how you feel about something
can occur in either depression or schizophrenia.
So it's an overlapping symptom.
Ambivalence can lead to apathy,
which is a state of indifference.
You don't care much about things
or have much interest in things.
You're just there.
Ambivalence can cause you to be unmotivated and indecisive,
and indecision is very common with depression.
So how does all this relate to psychotic depression?
If your depression becomes really severe,
you can become psychotic.
The psychotic symptoms you have
tend to be more positive symptoms,
like hallucinations or delusions.
The hallucinations are commonly auditory,
which is hearing things that aren't there.
Then there's visual hallucinations,
which is seeing things that aren't there.
Delusions are false beliefs.
A psychotically depressed person tends to have delusions
about being harmed, persecuted or followed.
The delusions can also have a nihilistic theme,
like everything is senseless, nothing has meaning.
The world needs to be completely deconstructed,
and I'm going to make that happen.
With schizophrenia, the delusions can be bizarre
and unrealistic, like a government entity
has authorized placing chips in our heads,
and that's happening while we sleep.
But the person with schizophrenia
can also have non-bizarre delusions of being followed
or persecuted similar to the depressed person.
So to recap what I've just said,
there are negative and positive symptoms.
Think of schizophrenia as having negative symptoms
always running in the background,
with periods of more prominent, positive symptoms
of delusions, hallucinations
and disorganized speech or behavior.
On the other hand, depression
can have some negative symptoms,
but there is a predominance of pessimistic thinking
and sadness that you don't really see with schizophrenia.
Psychosis in depression happens
when the depression becomes severe,
and you can get delusions and hallucinations,
You don't really get the disorganized speech or behavior
that you see with schizophrenia.
Once the depression improves, the psychosis goes away.
But with schizophrenia, you get lingering negative symptoms,
like the impoverished speech,
even if you're not having delusions or hallucinations.
The negative symptoms hang around in schizophrenia,
but they don't really hang around
in the person with depression.
Mr. R also asked about treatment differences.
Schizophrenia requires treatment with an antipsychotic.
Some antipsychotic medications are better than others
at treating the negative symptoms.
Vryalar is one of the newer antipsychotic medications
that is supposed to be better
at treating the negative symptoms.
Other ones are Clozapine, Olanzapine and Risperidone.
If none of these work well enough for you,
your doctor may try an antidepressant.
I don't think that any of the medications
completely resolve the negative symptoms.
Skills training is something that can help.
You can learn how to better interact with people
by establishing proper eye contact
or learning to start and maintain conversations.
60% of people with schizophrenia have also gotten depressed,
and if this happens, your doctor would add an antidepressant
for your depression symptoms.
For the person with depression who is also psychotic,
the treatment protocol would be to add an antidepressant
and antipsychotic medication at the same time.
Then as you get better,
you would taper off the antipsychotic
and stay on the antidepressant for longer.
A typical time to stay on the antidepressant
would be six months to a year.
I usually recommend a year of treatment.
With schizophrenia, though, you need to stay
on the antipsychotic to keep the psychotic symptoms
under control because the negative symptoms
usually stay around to some degree,
and the positive symptoms can come and go.
Watch this video for more on psychotic depression
and this one for more on schizophrenia.
Thanks for watching. See you next time.