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Schizoaffective Disorder Which Symptoms Should Schizoaffective disorder Which symptoms should 22 Current VOL. 2, NO. 1 / JANUARY 2003 p SYCHIATRY Current p SYCHIATRY be treated first? Stephen M. Strakowski, MD sychiatry has used the term “schizoaffective Professor of psychiatry, psychology, neuroscience, and disorder” for more than 60 years, but its spe- biomedical engineering cific meaning remains uncertain. Patients University of Cincinnati College of Medicine who meet its diagnostic criteria typically present with a con- Cincinnati, OH P fusing blend of mood and psychotic symptoms, and we often classify them as being schizoaffective because we don’t know where else to put them. Much of our difficulty in trying to determine what schizoaffective disorder is can be blamed on insufficient data. Patients with schizoaffective disorder We do not know the specific cause of either schizophrenic or mood disorders, and today’s concepts of these broad diag- present with a complicated mix noses probably encompass multiple etiologies. Based on the evidence and clinical experience, this arti- of psychotic and affective symptoms cle presents: that confound rational management. • the evolution of schizoaffective disorder as a psychiatric diagnosis All controversy aside, here is • the four main concepts that attempt to explain the dis- order’s cause a practical approach to treatment. • and a practical approach for managing these patients’ complicated symptoms. Origins of schizoaffective disorder When Jacob Kasanin1 originated the term schizoaffective dis- order in 1933, psychiatry was struggling to integrate Emil Kraepelin’s and Eugene Bleuler’s two competing and com- plementary schemes for understanding psychotic disorders. Kraepelin had proposed that the major psychoses could be divided between dementia praecox and manic-depressive insanity (and to a lesser extent, paraphrenia), based on the VOL. 2, NO. 1 / JANUARY 2003 23 Schizoaffective disorder Box tion of mental function and personality from which DSM-IV CRITERIA FOR patients rarely recovered. SCHIZOAFFECTIVE DISORDER This distinction was a landmark in psychiatry but did not offer a specific understanding of the mental or A. An uninterrupted period of illness during which, at brain dysfunctions underlying these conditions nor a some time, there is either a major depressive cross-sectional means to diagnose a patient’s condition. episode, a manic episode, or a mixed episode con- Bleuler was less concerned with predicting course current with symptoms that meet Criterion A for and outcome. Instead, he wished to understand his schizophrenia: observations that patients commonly exhibited a disjunc- Two (or more) of the following, each present tion among psychological processes that were integrated for a significant portion of time during a 1-month in healthy individuals.3 He described the cause of this loss period (or less if successfully treated): of psychological integration as the “schizophrenias” or, 1. delusions literally, “split mind.” In the schizophrenias, he identified 2. hallucinations symptoms that seemed to reflect this psychological dis- 3. disorganized speech (e.g. frequent derailment junction, such as flat affect, ambivalence, and splitting of of incoherence) cognition from emotion and behavior. Because Kraepelin described many of these same 4. grossly disorganized or catatonic behavior symptoms in dementia praecox, clinicians tended to 5. negative symptoms, i.e,, affective flattening, equate the schizophrenias with dementia praecox. alogia, or avolition However, many more patients with Bleuler’s schizophre- B. During the same period of illness, there have been nia recovered than did those with Kraepelin’s dementia delusions or hallucinations for at least 2 weeks in praecox (essentially by definition). Therefore, some “schiz- the absence of prominent mood symptoms. ophrenic” patients appeared to meet Kraepelin’s diagnosis C. Symptoms that meet criteria for a mood episode of manic-depressive insanity. At this point, Kasanin stepped are present for a substantial portion of the total into the fray with his concept of schizoaffective disorder. duration of the active and residual periods of the ill- ness. Kasanin’s conceptualization D. The disturbance is not due to the direct physiologi- Kasanin recognized that many patients exhibited a blending cal effects of a substance (e.g., a drug of abuse, a of Bleuler’s schizophrenia symptoms with those of medication) or a general medical condition. Kraepelin’s manic-depressive (affective) illness.1 Moreover, Specific type: unlike patients with dementia praecox, these blended Bipolar type: If the disturbance includes a manic or patients exhibited: a mixed episode (or a manic or a mixed episode and • good premorbid adjustment major depressive episodes) • typically a sudden illness onset with marked emotional Depressive type: If the disturbance only includes major turmoil depressive episodes. • few symptoms of withdrawal or passivity • and a relatively short course with complete recovery. Source: Diagnostic and statistical manual of mental disorders (4th ed., TR). Washington, DC: American Psychiatric Association, 2000. In reporting these patients and subsequently originating the term “schizoaffective psychosis,” Kasanin tried to identi- fy a homogeneous patient population that could be distin- guished from the more broadly conceptualized Bleulerian presenting symptoms and—importantly—course of illness:2 schizophrenias and the more narrowly defined Kraepelinian • Manic-depressive insanity typically included periods of categories. full recovery of mental functions between episodes. The term “schizoaffective disorder” has evolved from • Dementia praecox was defined by a steady deteriora- this beginning. Interestingly, most—if not all—of the nine continued on page 27 24 Current VOL. 2, NO. 1 / JANUARY 2003 p SYCHIATRY Current p SYCHIATRY continued from page 24 cases reported by Kasanin would be diagnosed with an affec- DSM-III-R and DSM-IV tive disorder with psychotic features under today’s diagnostic DSM-III-R defined schizoaffective disorder based on relation- criteria.4 Nonetheless, the term “schizoaffective disorder” ships between affective syndromes and the criteria for schiz- was adopted by psychiatry (particularly in the United States) ophrenia. Specifically, the diagnosis required the presence of and has been used to classify patients who present with fea- a full depressive or manic syndrome while the patient also tures of both schizophrenia and affective illness but cannot met criteria for schizophrenia. To distinguish schizoaffective be clearly described as having either. disorder from psychotic mood disorders, DSM-III-R required that psychotic symptoms persist for 2 weeks in the Evolutions from DSM-I to DSM-III absence of “prominent” mood symptoms. In American nosology, schizoaffective disorder was included Unfortunately, “prominent” was not defined, leaving a as a subtype of schizophrenia in DSM-I (1952)5 and DSM-II fair amount of discretion to clinicians and making it difficult (1968)6 and then reclassified in DSM-III (1980)7 as a “psy- to standardize research studies. In addition, the predictive chotic disorder not elsewhere classified.” Remarkably, none utility of 2 weeks of psychosis has not been strongly validat- of these classifications provided criteria for diagnosing ed. In fact, the time span at which psychosis without a mood schizoaffective disorder. disorder identifies a new syndrome is not known. Shortly before publication of DSM-III, Robert Spitzer, To rule out schizophrenia, the mood syndrome could MD, and colleagues at the New not have been “brief ” relative to the psychosis; again, what York Neuropsychiatric Institute devel- “brief ” meant was difficult to put into oped diagnostic criteria for schizoaffective practice. Notably, there was no specific disorder as part of their research diagnostic Few studies exist, requirement to rule out mood disorders criteria (RDC).8 The RDC separated patients so the diagnosis (i.e., that the psychosis was not brief rel- with affective and certain types of psychotic of schizoaffective ative to the duration of mood symptoms). symptoms, suggestive of schizophrenia at that disorder remains DSM-IV slightly modified these cri- time, into two types—schizoaffective mania and teria,12 but their basic flavor from DSM- schizoaffective depression—based on the polarity poorly validated III-R was retained. Despite their limita- of the mood symptoms. tions, the diagnostic criteria in DSM-III- The psychotic symptoms identified as “schiz- R and DSM-IV at least provided clinicians and ophrenic” by the RDC were certain first-rank scientists the means to consistently identify schizoaffective symptoms designated by Kurt Schneider, such disorder. The diagnostic criteria (Box) are still considered as delusions of being controlled or mood-incongruent hallu- reliable today.13 cinations. [Note: In recent studies, neither first-rank symp- toms nor other subtypes of psychotic symptoms (mood- Four concepts of schizoaffective disorder incongruent delusions or hallucinations) have been shown to Relatively few studies of schizoaffective disorder exist, so the specifically identify patients with schizophrenia.9,10 In fact, no diagnosis remains poorly validated. At least four concepts psychotic symptoms are considered pathognomonic for any have been developed (Figure).4, specific disorder at this time.] Concept 1: Schizoaffective disorder is a variant of schizo- The RDC also introduced the idea that schizoaffective phrenia. Many of the characteristics of
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