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How Well Does the DSM-5 Capture Schizoaffective Disorder?
Abstract
Schizoaffective disorder has long been recognized and quite variably defined. It has been variably positioned as a discrete entity, a variant of either schizophrenia or of a mood disorder, as simply reflecting the co-occurrence of schizophrenia and a mood disorder, and effectively reflecting a diagnosis along a continuum linking schizophrenia and bipolar disorder. This article considers historical views, some empirical data that advance consideration of its status, and focuses on its classification in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). DSM-5 criteria seemingly weight it in the direction of a schizophrenic illness, as do some empirical studies, whereas the empirical literature examining the response to lithium links it more closely to bipolar disorder. It is suggested that DSM-5's B and C criteria are operationally unfeasible. Some suggestions are provided for a simpler definition.
... Some researchers propose it as part of schizophrenia or mood disorder others as heterogenous disease. It has always been the topic of debate for researchers and hence the purpose of this study is to determine the position of schizoaffective disorder on the schizophrenia and bipolar disorder continuum by critically assessing various findings and integrating those with some recommendations [2,3]. ...
... But in DSM-III proposed in 1980, schizoaffective disorder was denoted a diagnosis of last resort with a definition of a psychotic illness with combined symptoms of schizophrenia and affective disorder but fails to satisfy the diagnostic criteria for schizophrenia, major affective disorders, or schizophreniform disorder and was classified under "psychotic disorders not elsewhere classified." Currently, DSM-V updated the criteria of schizoaffective disorder and stated it as a life time illness 3 rather than being an episodic disorder as in DSM-IV and hence is provides a better and more reliable criteria for diagnosis [12,13]. ...
Schizoaffective disorder and its classification have always been a topic of discrepancy among researchers. The overlapping presentations of schizoaffective disorder, schizophrenia and psychotic bipolar disorder makes it difficult to classify and diagnose. This study is a narrative review of literatures and genetic and epidemiological research evidences, done to determine the similarities and differences between schizoaffective and psychotic bipolar disorder. Beginning from the introduction of schizoaffective disorder as "schizoaffective psychosis" by Kasanin in 1933, various researchers have proposed different views regarding the diagnosis and classifications for schizoaffective disorder. DSM-III considered schizoaffective disorder as a diagnosis of exclusion as it fails to fit the definite diagnostic criteria of schizophrenia, major affective disorders, or schizophreniform disorder. DSM-V updated the criteria of schizoaffective disorder and stated it as a life time illness rather than being an episodic disorder as in DSM-IV and hence is more reliable. However, some studies show that schizoaffective disorder patients are more like schizophrenia than mood disorder. It still remains unclear whether schizoaffective disorder is a heterogenous disease, a form of schizophrenia, a form of mood disorder or a midpoint in the continuation spectrum of schizophrenia and psychotic bipolar disease.
... Bipolar disorder is a chronic mental illness accompanied by depression, mania, or mixed episodes, in which functionality often improves significantly between episodes [1]. One of the problems faced by individuals with bipolar disorder and those with other severe mental illnesses in society is stigmatization [2]. ...
Background:
Stigmatization is a situation that results from the negative perspective of society toward individuals with certain mental and physical illnesses and has negative effects. It has been observed that there are not enough studies in the literature investigating the attitudes of individuals with mental illness to cope with lifelong difficulties such as stigma and especially their religious coping attitudes. However, there are many clinical studies on general psychology and religious coping with varying results. Our aim in this research is to reveal the association between religious coping and internal stigma among bipolar disorder patients.
Methods:
The religious coping scale and the Internalized Stigma in Mental Illness (ISMI) scale were administered to 79 patients with bipolar disorder. The obtained data were analyzed using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States).
Results:
Forty-two (53.1%) patients were female and 37 (46.9%) were male, the mean age was 43.41±12.57, and the mean follow-up period was 11.95±9.15 years. A positive correlation was found between negative religious coping and discrimination experience, alienation, and social withdrawal in bipolar disorder patients. A significant negative correlation was found between discrimination experience, alienation and social withdrawal, and positive religious coping.
Conclusions:
The correlation of religious coping attitudes with discrimination experience, alienation, and social withdrawal makes us think that religious coping methods may be one of the issues to be considered when dealing with self-stigma in bipolar disorder patients. In addition, the relationship between religious coping and self-stigmatization in mental illnesses can add a new dimension to psychosocial approaches. It would be beneficial for authors interested in religion and social psychology to focus on more extensive research on this subject.
... Дифференциация ШАР с аффективными психозами не менее затруднительна [92,107]. МКБ-10 указывает: «при наличии набора аффективных симптомов добавление неконгруэнтного аффекту бреда недостаточно для изменения диагноза на рубрику ШАР»; «периодически возникающие специфические для шизофрении галлюцинации или бред также могут быть оценены как неконгруэнтные настроению». ...
The article argues for the discrepancy between the artificial construction of «schizoaffective disorder» (SAD) and the principles of nosological diagnostics. The term of «acute schizoaffective psychoses», was introduced by Y. Kazanin in 1933, is still remain a controversial nosological unit. This diagnosis often made at the cut of a psychotic episode on a «dichotomous scale» by «weighing» schizophrenic and affective symptoms. In the history of the creation of the concept of SAD, there is a tendency towards reductionism and the search for universal manifestations. Each individual clinical case must be considered holistically. It is unacceptable to extract the individual signs (which does not fit syndromal structures) from general picture of the disease. However, this requirement is in contradiction with the current trends towards simplification, discreteness and loss of clinical thinking in currents classifications of diseases. The inadequacy of the available diagnostic approaches and criteria for distinguishing between SAD, bipolar disorder and schizophrenia leads to the fact that the patient’s diagnosis is based on the subjective preferences of a clinician, and during patient’s life can many times be changed. The results of the the phenotype and genotype of the corresponding disorders searching partially shed light on the features of the diagnosis; but at the same time, some researchers are artificially combine the discrete properties and coming to incorrect conclusions; often such an identity simply does not make sense. The authors join opinion of experts who suggesting the existence of a «third psychosis» or even several discrete forms of diseases, which, along with unrecognized attacks of bipolar psychosis and schizophrenia are still mistakenly dissolved in the dichotomous / dimensional hybrid SAD. Diagnostics, taking into account the follow-up, regularities of the course, pathophysiological changes and psychopathological structure, has not only clinical value, but is also responsible for the selection of effective treatment, correct preventive measures, affects the social status and, ultimately, the quality of life of the patient.
... The different patterns observed between BPD compared to SZ and SZ-AFF also provide strong evidence in support of the Kraeplinian dichotomy, suggesting that there are two main categories of MMI, psychotic and mood [72]. The main reason for theorizing that SZ-AFF is a mood disorder is the response to lithium not seen in SZ [73]. Both the general and greater than or equal to 90 SSN sets are above the critical severity metric 1.28 and are the most ill psychiatric patients as corroborated by our LOS data. ...
Background and Objectives
The evaluation of the severity of patients afflicted with major mental illness (MMI) has been problematic because of confounding variables and genetic variability. There have been multiple studies that suggest several human diseases, especially schizophrenia, are predisposed to be born in certain months or seasons. This observation implied an epigenetic effect of sunlight, likely ultraviolet radiation (UVR), which is damaging to DNA, especially in an embryo. This paper outlines a method to evaluate the severity of schizophrenia (SZ), bipolar disorder (BPD), and schizoaffective disorder (SZ-AFF) using the month/year of birth of those affected compared to the month/year of birth of the general population (GP).
Relevance
Our previous research found that more intense UVR (equal to or greater than 90 sunspot number (SSN)) had a negative effect on the average human lifespan. Also, human birth rates vary in frequency by month of birth reflecting variables like availability of food, sunlight, and other unknown epigenetic factors. We wanted to see if the patient month of birth varied from the average birth months of the general population and if UVR has an epigenetic effect promoting these diseases.
Methods
We obtained the month and year of birth of 1,233 patients admitted over a 15-year period to Maine’s largest state psychiatric hospital and counted the months of birth for each diagnosis of SZ, BPD, and SZ-AFF, and compared these results to the general population’s birth months of 4,265,555 persons from U. S. Census Year 2006. The number of patients in each month was normalized to August and compared with the normalized birth months of the general population (GP). Plots of the normalized months were considered rates of change (e.g., derivatives) and their respective integrals gave domains of each mental illness relative to the GP. Normalizing the GP to unity was then related to the factor 1.28, e.g., 28% more entropy, deduced from the Sun’s fractal dimension imprinted on biological organisms.
Results
The percent of patients meeting our criterion for severity: SZ = 27%; BPD = 26%; SZ-AFF = 100%.
Conclusions
High UVR intensity or a rapid increase in UVR in early gestation are likely epigenetic triggers of major mental illness. BPD is more epigenetically affected than SZ or SZ-AFF disorders. We found that 52% of 1,233 patients comprised the core function of a tertiary-care psychiatric hospital. Also, mental illness exacerbated when the median SSN doubled. This work also validates the Kraeplinian dichotomy.
What is new in this research
This paper offers a new paradigm for evaluating the severity of MMI and supports significant epigenetic effects from UVR.
... There has been considerable debate regarding the criteria for schizoaffective disorder and both its clinical and research validity has been challenged (Abrams et al., 2008;Maj, 1985;Malaspina et al., 2013;Malhi and Bell, 2019;Manusco et al., 2015;Parker, 2019;Pini et al., 2004;Tondo et al., 2016). Nevertheless, a diagnostic category of schizoaffective disorder exists in both ICD-11 and DSM-5 taxonomies, and it putatively encompasses those patients who present with features of both schizophrenia and mood disorders (major depressive disorder or bipolar affective disorder). ...
Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice – taking into consideration both biological and psychological interventions.
... Despite decades of research, well-validated objective biological markers (measurable signals indicative of disease, infection, or injury) for neuropsychiatric diseases have remained stubbornly out of reach. This lack of objective biomarkers has relegated clinicians to diagnose neuropsychiatric diseases on the basis of phenomenological criteria (symptoms, signs, and course of illness), which, though useful in describing the disease in a rough and ready way, continues to produce heated controversies regarding the efficacy of properly diagnosing various, if not all, neuropsychiatric diseases (Bhati, 2013;Malaspina et al., 2013;Wakefield, 2016;Parker, 2019). In addition, the absence of biomarkers indicative of early-stage neuropsychiatric diseases undermines timely delivery of therapeutic agents to diseased neurons before neural impairment becomes so severe the damage cannot be reversed. ...
The lack of early diagnostic biomarkers for schizophrenia greatly limits treatment options that deliver therapeutic agents to affected cells at a timely manner. While previous schizophrenia biomarker research has identified various biological signals that are correlated with certain diseases, their reliability and practicality as an early diagnostic tool remains unclear. In this article, we discuss the use of atypical epigenetic and/or consequent transcriptional alterations (ETAs) as biomarkers of early-stage schizophrenia. Furthermore, we review the viability of discovering and applying these biomarkers through the use of cutting-edge technologies such as human induced pluripotent stem cell (iPSC)-derived neurons, brain models, and single-cell level analyses.
... Los criterios diagnósticos del DSM-5 hacen referencia a un diagnóstico longitudinal en donde se especifican tipos depresivos y bipolares según la presentación de episodios, y se desarrollan múltiples especificadores del curso de la enfermedad con episodios únicos, múltiples o curso crónico. 13,14 Sin embargo, en el momento de utilizar los criterios diagnósticos se puede observar que estos son más apropiados para describir un episodio psiquiátrico que para una categoría nosológica. Una propuesta realizada por algunos autores sería la de diferenciar criterios diagnósticos para un episodio esquizoafectivo (transversal) y para un trastorno esquizoafectivo (longitudinal). ...
Resumen Desde su primera descripción, la enfermedad esquizoafectiva ha sufrido variaciones en cuanto a su forma de caracterización, lo que ha influido en su relevancia, aplicabilidad, validez e impacto en la práctica clínica. Hoy en día existe una discusión en torno al diagnóstico del trastorno esquizoafectivo, sustentada en la evidencia de su escasa confiabilidad y estabilidad temporal. Para comprender este debate es necesario detenerse sobre planteos actuales que afectan de manera transversal este diagnóstico, como el lugar de los manuales diagnósticos operacionales, las concep-ciones psicopatológicas de las psicosis crónicas y agudas, la determinación de la confiabilidad de los diagnósticos realizados, la presencia de trastornos longitudinales y transversales y la variedad de posiciones nosográficas. En este caso, se decide realizar una revisión narrativa sobre el surgimiento y la historia del trastorno esquizoafectivo, detallando los puntos de discu-sión actuales y planteando posibles alternativas para abordar esta problemática. Palabras clave trastorno esquizoafectivo nosografía validez diagnóstico psicopatología teoría órgano-dinámica Summary Ever since its first description, schizoaffective disorder has undergone variations in its characterization which have had an influence on its relevance, applicability, validity and impact in clinical practice. There is a discussion at present regarding the diagnosis of schizoaffective disorder, based on the evidence of its limited reliability and temporal stability. In order to understand this debate it is necessary to analyze present issues that transversally affect this diagnosis, such as the importance of operational diagnostic manuals, psychopathology of chronic and acute psychosis, reliability determination of previous diagnosis, longitudinal and transversal disorders and different nosographic theories. Authors make a narrative revision regarding the emergence and history of schizoaffective disorder, pointing out current discussions and suggesting possible alternatives when addressing this problem. Key words schizoaffective disorder nosography validity diagnosis psychopathology organodynamic theory Rev Psiquiatr Urug 2019; 83(1):20-32 Revisión S. Lema, R. Almada|Revista de Psiquiatría del Uruguay|Volumen 83 Nº 1 Octubre 2019|página 21 Introducción El diagnóstico en la medicina es un proceso de gran importancia; en psiquiatría, adquiere una particular complejidad. El diagnóstico en medicina en general es un proceso por el que se intenta someter a verificación científica la hipótesis de la per-tenencia de determinadas manifestaciones clínicas observadas en un paciente a una clase o a una dimensión, dentro de una determinada clasificación de referencia. 1 Las obras históricas como las de P. Laín Entralgo evidencian que el sustrato sólido de la medicina en su evolución ha sido la objetivación progresiva de formas clínicas típicas. 2 La identificación de formas clínicas y su diagnóstico han estado fundamentados principalmente en la nosología, la que es-tablece el vínculo entre las formas clínicas sindromáticas y su base patológica. En muchas ramas de la medicina la evolución de la nosografía y las clasificaciones se ha dado en consonancia con la evolución del desarrollo biotecnológico, que ha permitido discernir con mayor precisión la base fisiopatológica de las entidades clínicas. En psiquiatría subsiste sin embargo el problema de la distancia existente entre las manifestaciones psicopatológicas y su base, 3 distancia que implica que el proceso de identificación de formas clínicas típicas se encuentre menos influido por el conocimiento que se va generando a nivel de la base fisio-patológica de índole neurobiológica. Estas características determinan idas y venidas en cuanto a la identificación y deno-minación de las patologías, así como en cuanto a las clasificaciones de uso. Este proceso se ha visto influido a lo largo del tiempo, al igual que otro conjunto de fundamentos conceptua-les, por la existencia de cuerpos doctrinales y marcos teóricos que adoptan posiciones de dominio o de mayor influencia relativa. Así, por ejemplo, Casarotti señala que «el análisis histórico también revela que esa objetivación de las formas clínicas con sus reglas diagnós-ticas y pronósticas guarda estrecha relación y es inseparable de los cambiantes contextos de la teorización y de la praxis que caracterizan a cada etapa». 2 La noción de discontinuidad subyacente a tales «idas y venidas» se contrapone con una idea positivista de desarrollo constante, homogéneo, unidireccional y de acumulación y mejoría del conocimiento, según el cual podría asumirse que «lo último es lo más verdadero», noción que es cuestionada por el análisis histórico de la disciplina. 4 Según un análisis esquemático puede sos-tenerse que a lo largo de la historia las clasi-ficaciones en psiquiatría estuvieron guiadas primero por la búsqueda de formas clínicas que reflejaran la existencia de procesos etiológicos identificables, en el primer siglo de la discipli-na. Luego, con Kraepelin fundamentalmente, clasificaciones basadas en la descripción clínica observable y su evolución; más tarde, a partir de Bleuler, por la identificación y descripción de los procesos psicopatológicos subyacentes, hasta que en el último período han predomi-nado las clasificaciones criteriológicas que, mediante la utilización de criterios claros, simples y objetivos, pretenden la descripción sindromática de los cuadros clínicos que constituyeran diagnósticos fiables, evitando las referencias etiológicas y psicopatológicas. 1 Es en referencia a este último marco teórico que ha obtenido notoriedad en la nosografía psiquiátrica el trastorno esquizoafectivo. Nuestro objetivo en este caso es presentar las principales discusiones en torno a la validez y utilidad de esta categoría nosográfica. Metodología Para la realización de este trabajo se utilizó una combinación de métodos incluyendo una búsqueda de actualización, en conjunto con la utilización selectiva de autores de relevancia como fuente. Para la primera se utilizaron los descriptores «trastorno esquizoafectivo», «diagnóstico» y «revisión» en las bases de datos Scielo y Google Scholar, tanto en inglés como español, seleccionando entre los resul-tados obtenidos aquellos que resultaran más Revisión página 22|Volumen 83 Nº 1 Octubre 2019|Revista de Psiquiatría del Uruguay|Trastorno esquizoafectivo: un diagnóstico controversial informativos. El trabajo constituye revisión narrativa. Trastorno esquizoafectivo Los manuales diagnósticos actuales entien-den la realidad de la presencia de pacientes que presentan un solapamiento de «síntomas esquizofrénicos» y «reacciones afectivas», asignándoles un lugar particular que los discrimina de otras categorías. El lugar del trastorno esquizoafectivo ha variado en sus criterios diagnósticos y en su concepción. Considerando el Manual diagnóstico y es-tadístico de trastornos mentales (DSM) en un inicio, se consideraba esta presentación clínica como un subtipo dentro de la esquizo-frenia: DSM-I: reacción esquizofrénica, tipo esquizoafectivo; DSM-II: esquizofrenia, tipo esquizoafectivo excitado y depresivo. Luego, en la versión de 1980, el DSM-III establece el trastorno esquizoafectivo como una entidad nosológica particular, pero es el único diag-nóstico sin criterios operacionales explícitos. 5 En la revisión del DSM-III-R se establecen los criterios diagnósticos, que van a determinar una diferencia clara con la Clasificación inter-nacional de enfermedades (CIE), destacándose que la remisión sintomática interepisódica y la mejor evolución no fueron incluidas como criterios diagnósticos. Las siguientes revisiones no realizaron modificaciones significativas hasta el actual DSM-5. 6 Si bien el término «psicosis esquizoafectiva» fue establecido por Jacob Kasanin en 1933, ya existía la idea de identificar un tipo de presentación clínica que incluía los síntomas característicos de la esquizofrenia, pero sin la evolución deteriorante clásica de esta pa-tología (psicosis esquizofreniforme, psicosis cicloide, psicosis reactiva). Esta situación llevó a diferentes concepciones de esta nueva entidad nosológica, ya que el modelo dicotó-mico establecido por Emil Kraepelin dividía las psicosis entre la esquizofrenia (dementia praecox) y trastornos del humor (psicosis maníaco-depresiva), basándose en que estas categorías presentaban una etiología, hallazgos neuropatológicos y una evolución particular. 7 Como se desprende etimológicamente de su nombre, el trastorno esquizoafectivo sugiere una asociación entre esquizofrenia y síntomas de la esfera afectiva. 8 La descripción clínica realizada por Jacob Kasanin se centraba en pacientes con psicosis agudas que tenían una remisión completa en período de tiempo corto. 7 En esta descripción, a los nueve casos considerados se les describe características singulares, atípicas, que se apartan de los criterios formales de la esquizofrenia. Son pacientes jóvenes, con un adecuado ajuste social premórbido e inteligencia normal o superior, que presentan una psicosis de co-mienzo brusco, súbito, usualmente precedida por un estado de depresión latente y con el antecedente de un evento vital estresante significativo que actúa como desencadenante. Estos casos presentaron una compensación rápida e intensa y de duración limitada. Cursaron con inestabilidad emocional, dis-torsión de la realidad y en algunos casos con presencia de impresiones sensoriales falsas. Se recuperaron rápidamente y evolucionaron a largo plazo sin defecto. 9 La enfermedad esquizoafectiva sin embargo no adquiere un lugar de notoriedad en el uso de los psiquiatras sino hasta su designación como trastorno esquizoafectivo en los ma-nuales categoriales criteriológicos. Pese a su permanencia hasta las recientes ediciones, ha sido siempre una entidad cuestionada y sometida a la crítica. El DSM-III menciona al respecto: «se necesitarán investigaciones futuras para determinar si existe la necesidad de esta categoría y, de ser así, cómo se debe definir y cuál es su relación con la esquizo-frenia y el trastorno afectivo», mientras que el DSM-IV reconoce las dificultades en su aplicabilidad: «la categoría llena un agujero necesario e importante en el sistema de diag-nóstico, pero desafortunadamente no hace su trabajo muy bien». La discusión sobre la validez y utilidad de este diagnóstico puede organizarse en una serie de puntos clave. Revisión S. Lema, R. Almada|Revista de Psiquiatría del Uruguay|Volumen 83 Nº 1 Octubre 2019|página 23 1. Problemas que surgen de la comparación de las distintas versiones del DSM y la CIE
... Los criterios diagnósticos del DSM-5 hacen referencia a un diagnóstico longitudinal en donde se especifican tipos depresivos y bipolares según la presentación de episodios, y se desarrollan múltiples especificadores del curso de la enfermedad con episodios únicos, múltiples o curso crónico. 13,14 Sin embargo, en el momento de utilizar los criterios diagnósticos se puede observar que estos son más apropiados para describir un episodio psiquiátrico que para una categoría nosológica. Una propuesta realizada por algunos autores sería la de diferenciar criterios diagnósticos para un episodio esquizoafectivo (transversal) y para un trastorno esquizoafectivo (longitudinal). ...
El desarrollo de los antipsicóticos ha cambiado el genio evolutivo de la esquizofrenia. La falta de cumplimiento terapéutico llevó al desarrollo de antipsicóticos de depósito a mediados de la década del sesenta del siglo pasado. Los primeros antipsicóticos de depósito fueron el enantato de flufenazina y el decanoato de flufenazina. Luego siguieron pipotiazina y haloperidol en depósito, y en la actualidad estamos asistiendo a un nuevo desarrollo de antipsicóticos de depósito de segunda generación. Los antipsicóticos de depósito han sido y son objeto de controversia en lo referente a eficacia seguridad y utilización. El presente trabajo tiene el objetivo de analizar aspectos de eficacia, seguridad y accesibilidad.
Ağır ruhsal hastalıklarda toplumsal damgalama sık karşılaşılan bir durum olup damgalamanın içselleştirilmesi bireylerin psikolojik iyilik halini, tedavi uyum ve seyrini etkileyen bir durum olarak karşımıza çıkmaktadır. Bu nedenle damgalanma ile ilişkili faktörleri ortaya koymak önemlidir. Bu araştırmadaki amacımız şizoaffektif bozuklukta dini başa çıkmanın içselleştirilmiş damgalanma ile olan ilişkisini ortaya koymaktır. Toplum ruh sağlığı merkezi tarafından ayaktan takip edilen ve araştırmaya dahil edilme kriterlerini karşılayan şizoaffektif bozukluk hastalarında Dini Başa Çıkma Ölçeği ve Ruhsal Hastalıklarda İçselleştirilmiş Damgalanma Ölçeği (RHİDO) uygulanmış ve elde edilen sonuçlar istatistiksel olarak analiz edilmiştir. Pozitif dini başa çıkma ile içselleştirilmiş damgalanma toplam skoru, yabancılaşma ve kalıp yargıların onaylanması alt boyutu arasında anlamlı ve negatif bir korelasyon saptanmıştır. Negatif dini başa çıkma ile içselleştirilmiş damgalanma ölçeği toplam skoru, yabancılaşma, kalıp yargıların onaylanması ve algılanan ayrımcılık alt boyutları arasında anlamlı ve pozitif bir korelasyon saptanmıştır. Ayrıca negatif ve pozitif dini başa çıkma arasında istatistiksel olarak anlamlı ve güçlü bir negatif korelasyon saptanmıştır. İçselleştirilmiş damgalanmanın ilişkili olduğu faktörlerden olumlu veya olumsuz dini başa çıkma tutumlarının tedavi sürecinde ele alınması, hasta ile görüşmede bu tutumların saptanması, bunların içselleştirilmiş damgalanmaya etkisinin araştırılması, psikoterapötik müdahalelerin parçası olarak tedavi sürecine katkıda bulunabilir.
Considerable debate surrounds the inclusion of schizoaffective disorder in psychiatric nosology. Schizoaffective disorder may be a variant of schizophrenia in which mood symptoms are unusually prominent but not unusual in type. This condition may instead reflect a severe form of either major depressive or bipolar disorder in which episode-related psychotic symptoms fail to remit completely between mood episodes. Alternatively, schizoaffective disorder may reflect the co-occurrence of two relatively common psychiatric illnesses, schizophrenia and a mood disorder (major depressive or bipolar disorder). Each of these formulations of schizoaffective disorder presents nosological challenges because the signs and symptoms of this condition cross conventional categorical diagnostic boundaries between psychotic disorders and mood disorders. The study, evaluation, and treatment of persons presently diagnosed with schizoaffective may be more usefully informed by a dimensional approach. It is in this context that this article reviews and contrasts the categorical and dimensional approaches to its description, neurobiology, and treatment. Based on this review, an argument for the study and treatment of this condition using a dimensional approach is offered.
Studies that compare the treatment response of patients diagnosed as primary affective disorder or schizoaffective disorder
are reviewed. Although relatively few controlled or uncontrolled studies of the chemotherapy of schizoaffective disorders
have been conducted, available evidence suggests that: (1) lithium carbonate is effective in the initial treatment of both
schizoaffective mania and mania; (2) antidepressants alone, neuroleptics alone, or their combination can be effective in the
initial treatment of both schizoaffective depression and primary depression; and (3) prophylactic administration of lithium
carbonate may reduce the frequency and duration of relapse in both schizoaffective manic and schizoaffective depressed patients.
Thus, treatment studies indicate that the schizoaffective disorders are very similar to the primary affective disorders with
regard to response to pharmacologic treatment. Evidence from this laboratory that schizoaffective manic patients respond more
slowly than manic patients to lithium or neuroleptic treatment is presented.
Diagnostic changes may reflect evolution of an illness, emergence of newly disclosed information, or unreliability of assessment. This study evaluates the stability of research diagnoses in a heterogeneous first-admission sample with psychosis.
A group of 547 subjects initially diagnosed with a psychosis were reassessed 6 and 24 months after enrollment. The DSM-IV consensus diagnoses were formulated by psychiatrists blind to previous research diagnoses. The analysis focuses on agreement over time and the effects of demographic, family history, and clinical variables on the shift from a nonschizophrenia diagnosis to schizophrenia.
Seventy-two percent of 6- and 24-month diagnoses were congruent. The most temporally consistent 6-month categories were schizophrenia (92%), bipolar disorder (83%), and major depression (74%); the least stable were psychosis not otherwise specified (44%), schizoaffective disorder (36%), and brief psychosis (27%). The most frequent shift in diagnosis at 24 months was to schizophrenia spectrum (n=45). These 45 subjects had a similar illness course after 6 months as the 171 subjects in this category at both assessments, but their prior clinical functioning was better. Risk factors predicting change to a schizophrenia spectrum diagnosis include facility variables (schizophrenia diagnosis, longer stays, and given antipsychotic medication on hospital discharge); prehospital features (psychotic > or =3 months before admission, poorer adolescent adjustment, lifetime substance disorder); and negative symptoms.
Changes in diagnosis, particularly to schizophrenia, are mostly attributable to the evolution of the illness. Rigid adherence to DSM-IV requirements may have led to underdiagnosis of schizophrenia. The findings support the need for a longitudinally based diagnostic process in incidence samples.
Objectives:
The diagnosis of schizoaffective disorder (SAD) is well established in clinical practice but is heavily disputed on theoretical grounds. We analyzed the extent and direction of diagnostic shift in SAD patients.
Methods:
We searched Medline, Embase, and PsycINFO systematically for all studies documenting two diagnostic assessments at different points in time (rediagnosis studies) and used meta-analytic methods to quantify diagnostic shift. Multiple prespecified and post-hoc subgroup analyses (e.g., rater blinding) and meta-regressions (e.g., year of publication) were carried out.
Results:
We included 31 studies out of 4,415 articles screened: 27 studies on the shift from and 23 studies on the shift to SAD (median time span was two years). A total of 36% of patients with a diagnosis of SAD at first assessment switch, many to schizophrenia (19%), 14% to affective disorders, and 6% to other disorders. Among patients diagnosed with SAD at second assessment, 55% had received a different diagnosis at first assessment, a large portion of whom had been initially diagnosed with affective disorder (24%), schizophrenia (18%), and other disorders (12%).
Conclusions:
Diagnostic shift in SAD patients is substantial. Psychiatrists need to reassess the diagnosis during the course of the illness and to adjust treatment. Slightly more diagnoses of SAD are changed to schizophrenia than to affective disorders, and among patients rediagnosed with SAD, fewer have been diagnosed with schizophrenia than with affective disorders. Thus, at the diagnostic level, there seems to be a slight trend toward schizophrenia during the course of functional psychoses.
Objectives:
Schizoaffective disorder is a frequent diagnosis, and its reliability is subject to ongoing discussion. We compared the diagnostic reliability of schizoaffective disorder with its main differential diagnoses.
Methods:
We systematically searched Medline, Embase, and PsycInfo for all studies on the test-retest reliability of the diagnosis of schizoaffective disorder as compared with schizophrenia, bipolar disorder, and unipolar depression. We used meta-analytic methods to describe and compare Cohen's kappa as well as positive and negative agreement. In addition, multiple pre-specified and post hoc subgroup and sensitivity analyses were carried out.
Results:
Out of 4,415 studies screened, 49 studies were included. Test-retest reliability of schizoaffective disorder was consistently lower than that of schizophrenia (in 39 out of 42 studies), bipolar disorder (27/33), and unipolar depression (29/35). The mean difference in kappa between schizoaffective disorder and the other diagnoses was approximately 0.2, and mean Cohen's kappa for schizoaffective disorder was 0.50 (95% confidence interval: 0.40-0.59). While findings were unequivocal and homogeneous for schizoaffective disorder's diagnostic reliability relative to its three main differential diagnoses (dichotomous: smaller versus larger), heterogeneity was substantial for continuous measures, even after subgroup and sensitivity analyses.
Conclusions:
In clinical practice and research, schizoaffective disorder's comparatively low diagnostic reliability should lead to increased efforts to correctly diagnose the disorder.
Nosological distinctions among schizoaffective disorder (SA), bipolar I disorder with psychotic features (BDp), and schizophrenia (SZ) remain unresolved.
We compared 2269 subjects with psychotic features in DSM-IV-TR diagnoses (1435 BDp, 463 SZ, 371 SA) from 8 collaborating international sites, by 12 sociodemographic and clinical measures, all between diagnostic pairs.
In bivariate comparisons, SA was consistently intermediate between BDp and SZ for 11/12 features (except onset stressors), and SZ vs. BDp differed in all 12 factors. SA differed from both BDp and SZ in 9/12 factors: SA and BDp were similar in education and suicidal ideation or acts; SA and SZ were similar in education, onset stressors, and substance abuse. Meta-analytic comparisons of diagnostic pairs for 10 categorical factors indicated similar differences of SA from both SZ and BDp. Multivariate modeling indicated significantly independent differences between BDp and SZ (8 factors), SA vs. SZ (5), and BDp vs. SA (3). Measurement variance was similar for all diagnoses.
SA was consistently intermediate between BDp and SZ. The three diagnostic groups ranked: BDp > SA > SZ related to lesser morbidity or disability. The findings are not consistent with a dyadic Kraepelinian categorization, although the considerable overlap among the three DSM-IV diagnostic groups indicates uncertain boundaries if they represent distinct disorders.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Background: Diagnostic changes may reflect evolution of an illness, emergence of newly disclosed information, or unreliability of assessment. This study evaluates the stability of research diagnoses in a heterogeneous firstadmission sample with psychosis. Methods: A group of 547 subjects initially diagnosed with a psychosis were reassessed 6 and 24 months after enrollment. The DSM-IV consensus diagnoses were formulated by psychiatrists blind to previous research diagnoses. The analysis focuses on agreement over time and the effects of demographic, family history, and clinical variables on the shift from a nonschizophrenia diagnosis to schizophrenia. Results: Seventy-two percent of 6- and 24-month diagnoses were congruent. The most temporally consistent 6-month categories were schizophrenia (92%), bipolar disorder (83%), and major depression (74%); the least stable were psychosis not otherwise specified (44%), schizoaffective disorder (36%), and brief psychosis (27%). The most frequent shift in diagnosis at 24 months was to schizophrenia spectrum (n=45). These 45 subjects had a similar illness course after 6 months as the 171 subjects in this category at both assessments, but their prior clinical functioning was better. Risk factors predicting change to a schizophrenia spectrum diagnosis include facility variables (schizophrenia diagnosis, longer stays, and given antipsychotic medication on hospital discharge); prehospital features (psychotic $3 months before admission, poorer adolescent adjustment, lifetime substance disorder); and negative symptoms. Conclusions: Changes in diagnosis, particularly to schizophrenia, are mostly attributable to the evolution of the illness. Rigid adherence to DSM-IV requirements may have led to underdiagnosis of schizophrenia. The findings support the need for a longitudinally based diagnostic process in incidence samples. Arch Gen Psychiatry. 2000;57:593-600
To the Editor—
Although we welcome discussion of the relative merits of different research criteria for Psy chiatric diagnosis, the article by Drs Overall and Hollister in the Archives (36:1198-1205, 1979) "Comparative Evaluation of Research Diagnostic Criteria for Schizophrenia" troubles us for several reasons. First of all, the authors do not address the issue of the different purposes of various sets of research diagnostic criteria. Whereas the purpose of the actuarial approach taken by Drs Overall and Hollister is to simulate competent or expert clinical practice, the purpose of the Washington University criteria, research diagnostic criteria (RDC), and DSMIII criteria is to improve usual clinical practice by incorporating into the criteria distinctions that have been shown by research study to have some validity in terms of such variables as course, response to specific therapy, familial pattern, etc. Given this difference in purpose, it is hardly adequate to approach the evaluation
The purpose of this study was to determine whether the preponderance of data support a continuum hypothesis of the psychoses or a concept of separate, autonomous illnesses. Patients (N = 70) were hospitalized for nonmanic psychoses, given structured interviews and a dexamethasone suppression test (DST), and diagnosed according to the Research Diagnostic Criteria (RDC). Patients were then evaluated at 7 year and 6 years with a structured interview. Diagnoses were made at three points of time: intake, 1 year, and 6 years. The patients were divided into groups that had a consistent (over the three points) set of affective disorder diagnoses (affective disorder or schizoaffective disorder, mainly affective [AD group]) and those that had a consistent set of schizophrenic diagnoses (schizophrenic or schizoaffective disorder, mainly schizophrenic [S group]). A third group (inconsistently diagnosed) consisted of subjects who at one point were diagnosed in the AD group and at another in the S group. A series of discriminant function analyses suggested that the AD group differs widely from the S group; and the inconsistently diagnosed group most closely resembled the AD group. The family background of the inconsistent group was similar to that of the AD group. The DST and outcome showed that the inconsistent group was more like the AD group than the S group. Using the characteristics of the medical model—clinical picture, outcome, laboratory tests, and family history—the group that was inconsistent with regard to diagnosis over time appeared similar to the AD group. Taking the follow-up evaluation into account, the data favor the possibility that patients who have a variable clinical diagnosis overtime do not suffer from schizophrenia.
A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC). The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria.
We examined thought disorder in 22 patients with schizoaffective disorder (12 schizoaffective-manic and ten schizoaffective-depressed) using Research Diagnostic Criteria. The Thought Disorder Index was used to tag 22 categories of thought disorder that ranged from mild to severe. Qualitative patterns in the thought disorder of schizoaffective patients were compared with those of 20 manic and 43 schizophrenic patients. Manic and schizoaffective-manic patients produced a high number of combinatory responses, but those produced by the schizoaffective-manic patients lacked the humor and playfulness of those of the manics. The schizoaffective-manic patients, like the schizophrenic patients, produced a high number of responses in the categories of idiosyncratic verbalizations, autistic thinking, and confusion. Unlike the manic patients, schizoaffective-depressed patients generally produced a few absurd and idiosyncratic responses in a setting of constricted output. The data strongly suggest that the thinking disorders of schizoaffective patients are like those of the schizophrenic patients.
The authors compared patients meeting widely accepted criteria for the diagnosis of schizoaffective disorder, manic type, with patients meeting rigorous criteria for manic disorder and schizophrenia, using three methods of validation: family history, short-term treatment response, and long-term outcome. No significant differences were found between patients with manic disorder and schizoaffective disorder. However, consistent and often highly significant differences separated patients with schizophrenia from those with manic disorder and schizoaffective disorder. The findings suggest that schizoaffective disorder, as currently defined, is not a valid and independent entity. The authors suggest that psychotic disorders not diagnosable as manic-depressive illness or schizophrenia and without apparent organic basis would best be called "undiagnosed" or "atypical" psychosis. Further, while proposals for new diagnoses or for subtyping of schizophrenia or manic-depressive illness should be encouraged, these should undergo rigorous screening for validity before being accepted into clinical use.
1. A group of 9 cases is presented in which there is a blending of schizophrenic and affective symptoms. 2. The psychosis is characterized by a very sudden onset in a setting of marked emotional turmoil with a distortion of the outside world and presence of false sensory impressions in some cases. The psychosis lasts a few weeks to a few months and is followed by a recovery. 3. Our patients are young people, in the twenties or thirties, in excellent physical health, in whom there is usually a history of a previous attack in late adolescence.
Schizoaffective disorders are well established. Nevertheless, the definition in the International Classification of Diseases (ICD)-10 and the Diagnostic and Statistical Manual (DSM)-IV are insufficient.
Critical review of the literature from Kahlbaum (1863) to the 21st century.
Many authors have described people suddenly developing a disorder with both 'schizophrenic' and 'affective' symptoms. In DSM-IV and ICD-10, the schizoaffective disorder is defined as the concurrent occurrence of schizophrenic symptoms with a major affective disorder. However, there is no reason for a chronological distinction regarding the co-existence of schizophrenic and affective symptomatology. Moreover, longitudinal aspects are not included in the definitions.
Two types of schizoaffective disorder must be distinguished: the 'concurrent' and the 'sequential' type. The first includes people having only a coincidence of schizophrenic and affective symptoms. The 'sequential' type is defined as the schizoaffective disorder under a longitudinal aspect subsuming disorders with a symptom change between different episodes. Consequences for further research are discussed in detail.
The cross-sectional clinical differentiation of schizophrenia or schizoaffective disorder from mood-incongruent psychotic mania or mixed mania is difficult, since pathognomonic symptoms are lacking in these conditions.
To compare a series of clinical variables related to mood and cognition in patient groups with DSM-III-R diagnosis of schizophrenia, schizoaffective disorder, mood-incongruent psychotic mania and mood-incongruent psychotic mixed mania.
One hundred and fifty-one consecutive patients were evaluated in the week prior to discharge by using the structured clinical interview for DSM-III-R-patient edition (SCID-P). Severity of psychopathology was assessed by the 18-item version of the brief psychiatric rating scale (BPRS) and negative symptoms by the scale for assessment of negative symptoms (SANS). Level of insight was assessed with the scale to assess unawareness of mental disorders (SUMD).
There were no differences in rates of specific types of delusions and hallucinations between subjects with schizophrenia, schizoaffective disorder, psychotic mania and psychotic mixed mania. SANS factors scores were significantly higher in patients with schizophrenia than in the bipolar groups. Patients with mixed state scored significantly higher on depression and excitement compared to schizophrenia group and, to a lesser extent, to schizoaffective group. Subjects with schizophrenia showed highest scores on the SUMD indicating that they were much more compromised on the insight dimension than subjects with psychotic mania or mixed mania.
Negative rather than affective symptomatology may be a useful construct to differentiate between schizophrenia or schizoaffective disorders from mood-incongruent psychotic mania or mixed mania.
This study was conducted (1) to assess the prophylactic efficacy of lithium and carbamazepine in the maintenance treatment of schizoaffective disorder (SAD) with long-term follow-up, (2) to find predictors of the success or failure of prophylaxis, and (3) to search for differences in outcome between schizoaffective patients diagnosed according to either ICD-10 or DSM-IV.
Participating patients met the ICD-10 and/or DSM-IV criteria for schizoaffective disorder. Outcome was assessed using the Morbidity Index and time elapsed until the first recurrence during prophylaxis. Predictor variables were age at onset of illness, gender, and family history, as well as the following parameters prior to prophylaxis: time between onset of illness and start of prophylactic treatment (latency), severity of illness (hospitalization rate), number of hospital admissions and polarity of schizoaffective disorder (schizobipolar vs. schizounipolar). The time spent in the hospital per year was used to compare the course of illness before maintenance therapy to the time during maintenance therapy. Co-medication was taken into account. The clinical data during prophylaxis were ascertained prospectively.
Forty-nine patients met the ICD-10 criteria for schizoaffective disorder, 34 of whom also met the DSM-IV criteria. All 49 patients underwent prophylactic therapy with either lithium (n=41) or carbamazepine (n=8) for an average of 6.8 years. After initiating prophylaxis, the number of days spent in the hospital declined dramatically from an average of 71 days to 11 days per year. No independent variable proved to be a consistent predictor of the course of treatment. In regard to the subgroup of patients diagnosed according to DSM-IV, no significant differences were observed when this subgroup was compared to the whole sample.
As this is a naturalistic study it does not allow for exact quantitative measures of effectiveness.
This study is the first of its kind to investigate the efficacy of maintenance therapy in SAD over such an extended period of time. The results of the study show that lithium and carbamazepine appear to be highly effective in treating patients with schizoaffective disorder. However, it remains unclear how many schizoaffective patients will respond to mood stabilizer treatment and whether predictors of clinical relevance exist. In our sample, differences in the ICD-10 and DSM-IV diagnostic criteria for schizoaffective disorder were not related to significant differences in clinical outcome.
Comparative studies of thought disorders. II. Schizoaffective disorder. Arch Gen Psychiatry
- M Shenton
- M R Soloway
- P Holzman
Shenton M, Soloway MR, Holzman P. Comparative studies of
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