A 30-year-old man with no prior psychiatric history develops depressed mood, anhedonia, weight loss, and nihilistic delusions ('My organs are rotting away') for 6 weeks. MSE reveals mood-congruent psychotic features. He has no manic episodes. According to DSM-5, what is the MOST appropriate diagnosis?

• A Schizophrenia
• B Major Depressive Disorder with psychotic features (mood-congruent) ✓
• C Schizoaffective disorder, depressive type
• D Delusional disorder, nihilistic type

Explanation

Major Depressive Disorder with psychotic features occurs when delusions or hallucinations develop during a major depressive episode. When psychotic content is consistent with depressive themes (worthlessness, guilt, nihilism, somatic decay)—as in nihilistic delusions about organs rotting—they are classified as mood-congruent psychotic features. DSM-5 dropped the distinction between mood-congruent and mood-incongruent as separate specifiers for prognosis, but the classification remains. This differs from schizoaffective disorder where psychotic symptoms persist for ≥2 weeks independent of any mood episode. Delusional disorder would not include a full major depressive episode.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.