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Online Discussions

Updated 15 December 2009 E-mail discussion
Printable version

Live Discussion: Do We Need Schizoaffective Disorder?


Stephan Heckers

Rajiv Tandon

SRF Live Discussion Series: Anticipating the DSM-V
Schizophrenia Research Forum is presenting a series of live discussions focusing on areas of contention within the evolution of the Diagnostic and Statistical Manual (DSM) psychotic disorders area.

The first discussion on 22 July 2009, Is the Risk Syndrome for Psychosis Risky Business?, focused on the proposal to create a diagnostic category for people possibly in the prodrome for schizophrenia.

The discussion on 15 December 2009 was led by Stephan Heckers of Vanderbilt University and Rajiv Tandon of the University of Florida, and addressed the value of the schizoaffective diagnosis. Please read the backgrounder below and the article by Heckers mentioned therein. Then add your comments.

Suggested Reading: Heckers S. Is schizoaffective disorder a useful diagnosis? Curr Psychiatry Rep. 2009 Aug ;11(4):332-7. Abstract

Our apologies; due to copyright issues, we will not be able to provide access to Stephan Heckers's article, "Is schizoaffective disorder a useful diagnosis?"

See Draft of proposed DSM-V modifications.

Click on the images below to launch the slidecasts.

View Transcript of Live Discussion — Posted 14 April 2010

View Comments By:
Rajiv Tandon — Posted 4 December 2009
Amresh Shrivastava — Posted 5 December 2009
Eugenia Radulescu — Posted 9 December 2009
Pamela DeRosse — Posted 14 December 2009
Abraham Rudnick — Posted 14 December 2009
Nick Craddock — Posted 14 December 2009
Ray DePaulo, Fernando Goes — Posted 14 December 2009
Jan Fawcett — Posted 15 December 2009


Background Text
Hakon Heimer

Emil Kraepelin divided the psychoses into non-affective (dementia praecox, later schizophrenia) and affective (manic depression, later bipolar disorder) types. This dichotomy continues to this day in diagnostic manuals (see SRF related Live Discussion). As discussed by Stephan Heckers in the background text below, Jacob Kasanin introduced the diagnosis schizoaffective disorder in 1933 (Kasanin, 1933) to describe patients with both prominent psychotic and affective symptoms. The diagnosis, with minor variations, has been part of the DSM since its first edition in 1952.

“However, the current DSM-IV-TR diagnosis of schizoaffective disorder is not reliable and is of limited clinical utility,” Heckers writes. He traces the evolution of the current schizoaffective disorder diagnosis in the DSM and reviews options for revision (see list of options below, courtesy of S. Heckers). Some modifications are minor, whereas others are more radical. Do we have enough evidence to remove the diagnosis from the DSM? What does a revision of the diagnosis schizoaffective disorder mean for the more fundamental dichotomy of affective and non-affective psychoses? We invite your preliminary commentary on the options presented.

References:
Kasanin J. The acute schizoaffective psychoses. Am J Psychiatry 1933, 90:97–126.

Heckers S. Is schizoaffective disorder a useful diagnosis? Curr Psychiatry Rep. 2009 Aug ;11(4):332-7. Abstract


Comments on Online Discussion
Comment by:  Rajiv Tandon
Submitted 4 December 2009 Posted 4 December 2009

Schizoaffective Disorder Considerations for DSM-V
Although dementia praecox or schizophrenia has been considered a unique disease entity for the past century, its definitions and boundaries have varied over this period. The relationship between schizophrenia and the major mood disorders (bipolar disorder and major depressive disorder) has been a topic of much ambiguity with ill-defined and fluctuating boundaries. Schizoaffective disorder has been at the interface of the boundary between schizophrenia and the major mood disorders, and opinions about its nature vary considerably. The following are four characterizations of schizoaffective disorder:

1. A unique condition clearly demarcated from both schizophrenia and major mood disorders
2. A subtype of schizophrenia
3. A subtype of major mood disorders with psychosis
4. Not a unique entity but an admixture of schizophrenia and major mood disorders that are difficult to differentiate

Despite its uncertain nature, schizoaffective disorder is widely diagnosed and is considered by clinicians to be a...  Read more


View all comments by Rajiv Tandon

Comment by:  Amresh Shrivastava
Submitted 5 December 2009 Posted 5 December 2009

The question, which has come up for discussion, is a significant one.

One of my professors taught me that the most important thing in creating effective psychiatric treatment is the diagnosis. While this point may be obvious, it becomes problematic when a diagnostic dilemma is brought to the foreground. The fact that there is a DSM-V position paper that questions the existence of one of the subgroups of schizophrenia is significant (Srivastava, 2009).

Before I comment on whether or not the diagnosis of schizoaffective disorder ought to be contained under the rubric of schizophrenias, mood disorders, or as an independent psychiatric disorder, it is useful to recap what constitutes a diagnosis. Clinical psychiatry continues to function through an exploratory model of descriptive symptoms, signs, and syndromes. A definitive diagnosis is exclusively clinical in nature. Considerable differences of opinion and conflicting viewpoints exist regarding whether a particular symptom in a given disorder is part of...  Read more


View all comments by Amresh Shrivastava

Comment by:  Eugenia Radulescu
Submitted 9 December 2009 Posted 9 December 2009

The proposed discussion is fundamental as the clinical diagnosis imposes the therapeutic management and the orientation of the scientific research in the psychoses field.

When confronted with a possible case of schizoaffective disorder (SAD), the clinician has to make important decisions, often with profound consequences. The background paper by Heckers (Heckers, 2009) highlights the difficulty of the longitudinal diagnosis due to the lack of reliable information and the doubtful accuracy of self-report, especially from a patient with psychosis. Consequently, the diagnosis is merely cross-sectional, based on clinical observation and interview, but necessary for the immediate therapeutic endeavor. Moreover, as it is well known, the context of the therapeutic decision does not simplify treatment choices, since the available therapies mostly comprise symptomatic medication and are not etiologically based. Practically, the clinician who needs to provide care for a patient with SAD has to answer questions like, Are the depressive...  Read more


View all comments by Eugenia Radulescu

Comment by:  Pamela DeRosse
Submitted 14 December 2009 Posted 14 December 2009

Contrary to most other areas of investigative medicine, the term “diagnosis” in psychiatry does not define the etiology of an illness but rather specifies a set of observable behavioral phenomena that arise as a result of some presumably common, yet unidentified etiological factor. Thus, the utility of a psychiatric diagnosis depends upon how well it lends itself to the discovery of these etiological factors. From a research perspective, then, it seems that the primary question that needs to be addressed is whether or not a change in the diagnostic criteria for schizoaffective disorder, by either including it as a subtype of schizophrenia or the affective disorders or by providing clearer diagnostic criteria, will enhance our ability to identify the pathophysiological mechanisms responsible for the symptoms associated with the diagnosis.

Presently, there is a paucity of data on the molecular mechanisms that might differentiate schizoaffective disorder from other psychotic and affective disorders. In molecular genetic studies, schizoaffective cases may be viewed as...  Read more


View all comments by Pamela DeRosse

Comment by:  Abraham Rudnick
Submitted 11 December 2009 Posted 14 December 2009

The diagnosis of schizoaffective disorder may be either too broad or redundant as it stands. It could be too broad as major depression may be a comorbidity of schizophrenia, similar to comorbid anxiety disorders, thus requiring the narrowing down of schizoaffective disorder to schizophrenia with bipolar disorder. It may be redundant, as if the century-old assumption, inherited from Kraepelin, that dementia praecox (schizophrenia) and manic-depressive illness (bipolar disorder) are mutually exclusive, is not endorsed anymore; bipolar disorder can also be viewed as a comorbidity of schizophrenia. Research on such comorbidity possibilities is needed in order to determine the nosological status and value of schizoaffective disorder.

View all comments by Abraham Rudnick


Comment by:  Nick Craddock
Submitted 14 December 2009 Posted 14 December 2009

I am afraid that due to access difficulties I have read the abstract only. I am aware that it has been suggested that the schizoaffective category be abolished. I do not think this would be helpful at the present time. I have some comments:

1. The difficulty with poor reliability comes in large part from the very "narrow" definition currently used and common interpretation of "schizoaffective" as being used only when a case cannot be fitted to either schizophrenia or mood disorder categories (i.e., starting with the assumption of a dichotomy). A broader definition would be more reliable, stable—and useful.

2. Incorporating dimensional measures to sit alongside categories is an excellent idea and will obviously help with recognition of overlapping psychosis and mood features.

3. However, abolishing the schizoaffective category whilst retaining mood and schizophrenia categories would send a completely inappropriate message that would reinforce the idea of a dichotomy when we really need to be thinking about clinical spectra.

4. Accumulating genetic data...  Read more


View all comments by Nick Craddock

Comment by:  Ray DePauloFernando Goes
Submitted 14 December 2009 Posted 14 December 2009

As noted by Marneros, schizoaffective disorder remains “a nosological nuisance but a clinical reality” (Marneros, 2003). It is a category that lacks reliability and is used with highly varying frequency in the field. Though we use the diagnosis only infrequently here at Johns Hopkins, it is applied to 20 percent or more of admissions at other academic and non-academic psychiatric inpatient units. Since the higher rate is the norm, removing the diagnoses from DSM-V would leave many clinicians in the lurch, particularly since some of the alternative proposals (e.g., the use of dimensions) might increase reliability, but are, as yet, untested constructs of uncertain clinical utility. While the use of dimensional measures (particularly in complement to categorical constructs) may turn out to have greater validity and/or clinical utility, we believe that, at present, this is a question that must be addressed by empirical research before it can be implemented in DSM-V. To implement such a major change without a substantial empirical...  Read more


View all comments by Ray DePaulo
View all comments by Fernando Goes

Comment by:  Jan Fawcett
Submitted 15 December 2009 Posted 15 December 2009

The Mood Disorders Committee in general currently supports the retention of the schizoaffective diagnosis in DSM-V. One basis for this is the very frequent use of this diagnosis in the Medicaid and Privately Insured Data Base published June 23, 2009, by Mark Olfson, MD, MPH. A study of first-episode psychoses by Mauricie Tohen found that these patients, initially diagnosed Psychosis NOS, when followed, showed the highest switch in diagnosis to schizoaffective disorder than any other diagnosis.

My own personal take is based on the study by Andreasen et al. (1987) from the Collaborative Depression Study which showed that the relatives of patients with schizoaffective disorder, depressed, had a preponderance of relatives with schizophrenia, while the relatives of patients with schizoaffective disorder, bipolar type, had a preponderance of bipolar I disorder. This suggests to me a Solomonesque solution of dividing the baby, schizoaffective disorder, in half, the schizoaffective bipolars being diagnosed as bipolar I with...  Read more


View all comments by Jan Fawcett
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