Schizoaffective Disorder

What the hell is it? Does anyone really know?

Schizoaffective disorder symptoms. This article incorporates edited extracts from three other articles on mcmanweb. By way of a quick introduction: Think of schizoaffective as occupying that middle ground where bipolar overlaps with schizophrenia. But what are we dealing with? Schizophrenia lite, bipolar heavy, a separate illness, two co-occurring illnesses, or something occupying the psychosis spectrum?

The DSM-5, which is scheduled to replace the current DSM-IV in 2013, spells it out: "The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable," but then makes no changes to make the diagnosis reliable.

On with the show ...

The Problem with the Schizoaffective Diagnosis

In 2008, the International Society for Bipolar Disorders (ISBD) came up with their own recommendations for improving the diagnostic criteria for bipolar. According to their report, genetic studies lend credence to an overlap between bipolar and schizophrenia, with a clustering of both in family groups, and shared suspect genes in both illnesses (one example is the DAOA gene on chromosome 13).

Schizoaffective was coined in 1933. The DSM-IV maintains that schizoaffective is distinct from both bipolar and schizophrenia, but acknowledges that there are no "absolute boundaries."

Schizoaffective is thought to occur in less than one percent of the general population (women predominate), but the patient population is much higher owing to clinicians making the diagnosis when they are uncertain.

In schizoaffective, "there must be a mood episode that is concurrent with active-phase symptoms of schizophrenia." This is different than a "mood disorder with psychotic features" or "mood symptoms in schizophrenia." Not that it's easy to tell. Is a psychotic feature, for instance, congruent (more likely to be mood-related) or incongruent (more likely to be schizophrenia-related)? And is any given depression a mood disorder phenomenon or schizophrenia phenomenon?

Confounding matters is the discomforting reality that schizoaffective is a moving target - the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, not to mention over the long term. Not surprisingly, most patients who receive an initial diagnosis of schizoaffective are later diagnosed with something else.

With all this in mind, the ISBD panel considering the matter recommended eliminating the designation, schizoaffective, in its entirety and substituting it with additional specifiers to schizophrenia, bipolar I, bipolar II, and major depression.

Schizoaffective - Another Persepective

In a research article, psychiatric geneticists Craddock and Owen contend that the current definition of schizoaffective disorder is too narrow to be clinically useful. Instead, it is treated as a glorified "NOS" diagnosis. Compared with the much broader definitions of schizophrenia and mood disorders, "it is inevitable" that the schizoaffective category will seem less reliable to clinicians. This is especially true if clinicians pay little attention to the different ways psychosis presents itself over time.

A patient may appear to have bipolar at one stage in his or her life, and schizophrenia in another. The old diagnostic labels, the authors point out, merely mask the clinical reality and impede further research.

Despite the lack of respect for schizoaffective, the authors note that "genetic epidemiology supports a strong genetic component to schizoaffective illness." Based on their findings, the authors suggest a wider "schizoaffective spectrum phenotype" incorporating various shades of mood and psychosis.

Deconstructing Psychosis

At a 2007 "Deconstructing Psychosis" planning session sponsored by the American Psychiatric Association, the NIMH, and WHO, Carol Tamminga MD of the University of Texas Southwestern Medical Center noted that although mood stabilizers alone can treat psychotic symptoms in acute mania, they are not effective in treating psychosis in schizophrenia. Dr Tamminga offered three possible explanations:

1) Psychosis has a distinct pathophysiology, common to both schizophrenia and bipolar disorder, and antipsychotics target that molecular mechanism; 2) psychosis is mediated by neural systems which are different in schizophrenia and bipolar disorder, which can be stimulated and treated from multiple points and by many different pharmacologic strategies; and 3) psychosis is a response analogous to "fever" and should not be a primary target for treatment.

At the same planning session, Eduard Vieta MD, PhD of the University of Barcelona pointed out key brain differences in individuals with bipolar and schizophrenia, but noted that the absence of psychotic symptoms in diagnostic criteria for bipolar "reinforces the notion that psychosis is a core feature of schizophrenia but not bipolar disorder."

Trying to Make Sense Out of Schizoaffective

The operative phrase to the DSM-IV schizoaffective diagnosis is:

There is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.

Criterion A lists other symptoms besides psychosis, and calls for a minimum time of one month. (There is a Criterion C for schizophrenia, which mandates a six-month minimum for "continuous signs of the disturbance," but there is no reference to this in the schizoaffective diagnosis.)

Schizoaffective, then, is basically short-form schizophrenia (ie with periods of euthymia) punctuated by relatively brief overlays of depression or mania (the DSM minimum for mania, for instance, is one week). The assumption is that it is highly likely that there will be long periods when the schizophrenia symptoms manifest with no mood symptoms, and indeed this is a DSM requirement.

Thus, schizophrenia symptoms can appear without mood symptoms, but mood symptoms can't appear without schizophrenia symptoms.
Does this sound like schizophrenia to you? Short form or not? Say, schizophrenia with mood symptoms? Is schizoaffective, then, a euphemism diagnosis for clinicians too chicken to tell their patients the truth? It appears that way.

Let's kill the schizoaffective diagnosis, then, and go with the ISBD specifiers approach. Their recommendations:

In schizophrenia, these specifiers::

With symptoms meeting criteria for mania or mixed features.
With symptoms meeting criteria for major depressive disorder.

In bipolar I and bipolar II and major depression, these specifiers:

With psychotic symptoms meeting Criterion A for schizophrenia (ie hallucinations or delusions over one month) and for at least two weeks without prominent mood features.
With psychotic symptoms meeting Criterion A for schizophrenia with consistent concurrent mood features.

Meanwhile, Back in the Real World

It appears that schizoaffective is a catch-all diagnosis that includes patients presenting with both mood symptoms and psychosis. But just because you have both doesn't necessarily mean you have schizoaffective, even though your psychiatrist may think so. Confused?

There appears to be more going on with schizoaffective than just "mania with psychotic features" (as part of the Bipolar I diagnosis) or "major depression with psychotic features" (as part of the depression diagnosis). Instead, it appears the other way around, a schizophrenia-like condition where psychosis and other cognitive impairments predominate, "with mood features."

But is your psychiatrist smart enough to make that distinction, and does it matter? A few questions you need to be asking:

Is your psychiatrist using the diagnosis to bring your clinical condition into sharper relief? In other words, has a competent clinician who really knows you figured out that your bipolar comes with serious complications? And if so, is he or she ready to work with you - including spending extra time with you - in helping you manage?
Or has your psychiatrist basically given up on you? In other words, is your diagnosis a result of the frustration of a lazy clinician who barely knows you and has already written you off as untreatable?
Or is your psychiatrist over-reacting? In other words, is your diagnosis the result of a lazy clinician who barely knows you and assumes that anything that even remotely resembles psychosis must be connected to schizophrenia or schizoaffective? In other words, are you about to be over-treated and over-medicated?

What's in a name? Sometimes nothing. Sometimes everything.

This article is based on the following three articles on mcmanweb: Bipolar - Sharpening the Diagnosis * Psychosis in Mania * My Alternative Bipolar Diagnosis - II

Based on current articles on this site, extracted and consolidated into one article May 13, 2011

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