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Schizoaffective Disorder: History, Symptoms & Diagnosis

This article provides an overview of the history, symptoms, and diagnosis of schizoaffective disorder. It discusses the diagnostic issues, clinical studies, and offers a perspective on the disorder.

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Schizoaffective Disorder: History, Symptoms & Diagnosis

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  1. 17th Int. Review ofPsychosis & BipolarityIRPB in Lisbon April 26, 2015 SchizoaffectiveDisorder (SAD):history, symptoms & diagnosis Hans-Jörg Assion LWL-Clinic Dortmund Psychiatry.Psychotherapy.Psychosomatic MedicineDortmund, Germany

  2. Overview • Introduction • Diagnosticissues • Clinical studies • Perspective __________________________________________________________________________________________________________

  3. Introduction – Diagnosis– Studies – Perspective What do you think?Are you a lumper or a splitter? lump split schizophrenia schizophreniawithdepression schizoaffective, mainlypsychotic schizoaffective, mainlyaffective schizomanic schizodepressive uni-/bipolar withpsychoticfeatures unipolar/bipolar schizophrenia uni-/bipolar(withpsychoticfeatures) __________________________________________________________________________________________________________

  4. Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders Lake CR, Hurwitz N Psychiatry Res. 2006 Aug 30;143(2-3):255-87 The scientific justification for SA D/O and schizophrenia as disorders distinct from a psychotic mood disorder has been questioned. The "schizo" prefix in SA D/O rests upon the presumption that the diagnostic symptoms for schizophrenia are disease specific. They are not, since patients with severe mood disorders can evince any or all of the "schizophrenic" symptoms. Introduction – Diagnosis– Studies – Perspective SAD – critical remarks Schizoaffective disorder is a quitepopular diagnosis. In scientific terms it is aproblematic diagnosis. Hypothesis: The concept of mood-disorderwith a broad symptom-spectrum is fully covering all of the clinicalphenomena. __________________________________________________________________________________________________________

  5. Schizoaffective disorder: diagnostic issues and future recommendations. Malhi GS, Green M, Fagiolini A, Peselow ED, Kumari V Bipolar Disord. 2008 Feb;10(1 Pt 2):215-30 OBJECTIVE: Difficulties surrounding the classification of mixed psychotic and affective syndromes continue to plague psychiatric nosology. This paper addresses the controversy regarding the diagnostic validity of schizoaffective disorder (SAD), a diagnosis that is used in both DSM-IV and ICD-10 and one that encroaches on both schizophrenia (SCZ) and bipolar disorder (BD). METHODS: A systematic synthesis of clinical and empirical literature, including evidence from cognitive, neurobiological, genetic, and epidemiological research, was undertaken with the aim of evaluating the utility of the SAD classification. Introduction – Diagnosis– Studies – Perspective SchizoaffectiveDisorder:A problematicdiagnosis • Systematic study of literature of SADRESULTS: • Schizophrenia, Bipolar Disorderand Schizoaffective Disorder are overlapping categories. • HYPOTHESIS: • Schizoaffective is a comorbid syndrome of schizophrenia or bipolar disorder. • SAD stands between schizophrenia and bipolarity • RECOMMENDATION:Diagnosis of SAD should be omitted with the next revision of DSM or ICD. __________________________________________________________________________________________________________

  6. Introduction – Diagnosis– Studies – Perspective „schizoaffective“ for 80 Yrs John Kasanin1, 1933:„The Acute Schizoaffective Psychoses“ • 9 patients, age between 20 to 30 yrs. • general health and social adaptation are well • history of mood-disorder in some of the families • acute psychosis with „schizophrenic“ and „affective“ symptoms • remission of symptoms within weeks __________________________________________________________________________________________________________ 1Kasanin J (1933) Am J Psychiat 13:97-126

  7. Karl Kahlbaum1, 1863: „Die Gruppierung der psychischen Krankheiten und die Eintheilung der Seelenstörungen“ (Grouping of psychic illnesses and classification of the disorders of soul) melancholicmadness, maniawithmadness ... Emil Kraepelin2, 1899:„Die klinische Stellung der Melancholie“ (Clinical positioning of melancholia) Overlapofdementiapraecoxandmanic-depressive illness ... Introduction – Diagnosis– Studies – Perspective Historical remarks __________________________________________________________________________________________________________ 1Kahlbaum K (1863) Danzig, Kafemann 2Kraepelin E (1899) MschrPsychiatrNeurol 6:325-335

  8. Introduction – Diagnosis– Studies – Perspective Psychopathology Considerationsfromhistory not todiagnose SAD Psychopathologicalprinciples: • Principle of dichotomy (E. Kraepelin)either schizophrenic or manic-depressive syndrome • Principle of hierarchy (K. Jaspers)schizophrenic symptoms primarily, mood symptoms secondly • Principle of differential typology (K. Schneider) no differential diagnosis, but a typology • Basic symptoms (Grundsymptome) primarily (E. Bleuler) • psychosis with schizophrenic symptoms: diagnosis of schizophrenia in consequence __________________________________________________________________________________________________________

  9. Introduction – Diagnosis– Studies – Perspective Principlesofclassification • accordingto ... • biologicalcausesGenetics, anatomy, orother e.g. spino-cerebellarataxia • clinicalsymptoms e.g. symptomsofdepression in operational classification • thecourseofillness z.B. depressive episode (ICD-10: F32) vs.recurrent depressive disorder (ICD-10: F33) • disorderprognosis e.g. dementiapraecox vs. manic-depressive illness (Kraepelin) __________________________________________________________________________________________________________

  10. Introduction – Diagnosis – Studies – Perspective Classification – ICD-10 F2schizophrenia, schizotypicanddelusionaldisorder F25schizoaffectivedisorder F25.0schizomanicdisorder F25.1schizodepressivedisorder F25.2mixedschizoaffectivedisorder F25.8schizoaffectivedisorder, other F25.9schizoaffectivedisorder, not specified __________________________________________________________________________________________________________

  11. Intorduction – Diagnosis – Studies – Perspective Diagnosticcriteriaaccordingto ICD-10 G1Disorderwithcriteriaof an affectivedisorder (F30, 31,32);severity: medium tosevere. G2 Symptoms ofschizophreniaformostofthe timeduring2 ormoreweeks(F20.0-F20.3).1. e.g., thoughtbroadcasting, -insertion 2. e.g., delusionofcontrol ... 3. e.g., vocalhallucinations ... 4. e.g., bizarre delusion ... 5. e.g., neologism ... 6. Intermittendcatatonicfeatures ... __________________________________________________________________________________________________________

  12. Intorduction – Diagnosis – Studies – Perspective Diagnosticcriteria accordingto ICD-10 G3CriterionG1andG2 must befullfilledduringthe same episodeandat least forsomeofthe time. The clinicalsyndrome must becharacterizedwithsymptoms out ofcriteriaG1andG2. G4 Criterionforexclusion: A disorder due to an illnessofthebrain,psychotropicsubstances, intoxication, addiction, detoxification. __________________________________________________________________________________________________________

  13. Introduction – Diagnosis – Studies – Perspective Diagnosticcriteriaaccordingto DSM-V A. An uninterruptedperiodofillnessduringwhichthereis a majormoodepisode (major depressive ormanic) concurrentwithCriterion A ofschizophrenia B. Delusionsorhallucinationsfor2 ormoreweeks in theabsenceof a majormoodepisode (depressive ormanic) duringtheilfetimedurationoftheillness C. Symptoms thatmeetcriteriafor a majormoodepisodearepresentforthemajorityofthe total durationoftheactiveand residual portionsoftheillness. __________________________________________________________________________________________________________

  14. Introduction – Diagnosis – Studies – Perspective Diagnosticcriteriaaccordingto DSM-V D. The disturbancesis not attributabletotheeffectsof a substance (e.g., a drugofabuse, a medication) oranothermedicalcondition. Specify ... Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episode may also occur. Depressive type: This subtype applies if only major depressive episodes are part of the presentation. __________________________________________________________________________________________________________

  15. bipolar • schizoaffectivedisorder manic unipolar depressive bipolar • affectivedisorder manic unipolar depressive affect-dominant • schizoaffectivedisorder schizo-dominant Introduction – Diagnosis – Studies – Perspective Classificationof(schizo-)affectivedisorder __________________________________________________________________________________________________________

  16. OrganicPsychicDisorder AcutePolymorphicPsychoticDisorder PsychoticAffectiveDisorder No No Ja Emotionallyagitatedand/orpsychosis in contextofcriticalincident Yes Affectivesyndromeatthe same time No Symptoms of depressive ormanicepisodewithpsychoticfeatures YES No Psychoticsymptomsaccordingtocriteriaofschizophrenia Characteristicschizophrenicsymptomsfor a monthsormore Yes No Yes No SchizoaffectiveDisorder (SAD) PsychoticAffectiveDisorder SchizophreniformDisorder Schizophrenia Introduction – Diagnosis – Studies – Perspective Differentialdiagnosis __________________________________________________________________________________________________________

  17. Introduction – Diagnosis – Studies – Perspective „popular, but imprecise“ • Schizoaffective Disorder is diagnosed too often.In clinical routine care SAD:BPD - 3:1 • Diagnosis „SAD“ covers a bunch of various diagnosis, concomittent disorders or mixed syndromes. • Diagnostic criteria are not used appropriately. • SAD is popular and ends up in treatment decisions with antidepressants, neuroleptics, mood-stabilizers and/or benzodiazepins. __________________________________________________________________________________________________________

  18. Yes No Introduction – Diagnosis – Studies – Perspective Unnecessarydiagnosis? • Mixed syndromesaredescribedforlong time • Courseofillnessischaracteristicwithonsetand end • Prognosis bettercomparedtoschizophrenia • Riskofschizophreniaislower in families • Represents a distinctentity • Heterogeneousnosolgy • Nospecificillness • No neuro-biologicalcorrelate • Part ofspectrumof bipolardisorderor unipolar depression • orpartofschizophrenia • Monomorphicorpolymorphiccourseofillnesswiththe sameprognosis • ... __________________________________________________________________________________________________________

  19. Mania Hypomania Normal Depression severe Depression Normal ZyklothymicZyklothymia Bipolar II Unipolar Bipolar I mood- personality Disorder Mania Disorder cycle Introduction – Diagnosis – Studies – Perspective Bipolar Spectrum __________________________________________________________________________________________________________ Goodwin et al. Manic-depressive Illness. Oxford: Oxford University Press, 1990

  20. Epidemiologicaldataismissing (completely)!1 • Estimatedincidenceforunipolarschizoaffectivepsychosis: 4/100 0002 • Estimatedincidenceforbipolarschizoaffectivepsychosis: 1,7/100 0002 • Gender ratio: f>m (1,7:1) for unipolar SAD • f=m for bipolar SAD • First manifestationabout 3 yrslater in comparisonto schizophrenia2?? Introduction – Diagnosis– Studies – Perspective Epidemiology __________________________________________________________________________________________________________ 1Marneros A (2004) Thieme, Stuttgart 2Angst J (1986) SchizoaffectivePsychoses. Springer, Berlin

  21. 1Maier W et al. Am J Psychiat 1992;149:1666-1673 2Cohen et al. Arch Gen Psychiat 1972;26:539-546 Introduction– Diagnosis– Studies – Perspective Genetics • Relatives of bipolar SAD patients more often have relatives with diagnosis of bipolar affective or bipolar schizoaffective disorder than relatives of unipolar SAD1. • Correlation between schizodominant SAD and schizophrenia3. • Twin studies are mostly from the 1980´s. No standardised diagnosis! No case series2. • No association studies __________________________________________________________________________________________________________ 3Kendler et al. Arch Gen Psychiat 1994;51:456-468

  22. Introduction – Diagnosis– Studies – Perspective Neurocognitivefunction BD vs. SAD Methods: Several domains of neurocognitive function, executive function, memory, attention, concentration and perceptuomotor function were examined in 28 euthymic SADpatients and 32 BD patients by using a neuropsychological test battery. Hamilton Depression Rating Scale (HAMD), Montgomery-Asberg Depression Rating Scale (MADRS) Young Mania Rating Scale (YMRS) Data analysis: multivariate analysis of covariance (ANCOVA/MANCOVA). Results: Euthymic SAD patients showed greater cognitive impairmentthan euthymic BD patients in the tested domains including declarative memory and attention. Putative significant group differences concerning cognitive flexibility vanished when controlled for demographic and clinical variables. Age and medication were robust predictors to cognitive performance of both SAD and BD patients. __________________________________________________________________________________________________________ Assion et al. 2010

  23. TMT-A (sec.) TMT-B (sec.) Test dimension 106.78 42.61 Bipolar patients (n=32) 22.71 50.52 Schizoaffective patients(n=28) 139.29 64.21 82.79 42.88 1.63 2.91 MANCOVA/ ANCOVA♯ 1; 43 1; 47 0.09* 0.21* 0.47 0.63 Mean SD Mean SD F df P D Introduction – Diagnosis– Studies – Perspective Study on cognition BD vs. SAD __________________________________________________________________________________________________________ Assion et al. 2010

  24. Schizodominant SAD predictiveforworseoutcome. • „Mixed SAD “ has a worse prognosis. • Missingofcriticalincidentsis a worsepredictor. • Positive predictor: Copingstrategies pure melancholicepisodes Introduction – Diagnosis– Studies – Perspective Prognosis Fewsystematic research1, 2: __________________________________________________________________________________________________________ 1Steinmeyer EM, Marneros A et al. EurArchPsychiatNeurolSci 1989;238:126-1342McGlashan TH, Williams PV. J Nerv Ment Dis 1990;178:518-520

  25. Treatment of schizoaffective disorder. Elisa Cascade, Amir H. Kalali, Peter Buckley   Psychiatry (Edgmont). 2009; 6 (3): 15-17 In this article, we investigate the range of treatments prescribed for schizoaffective disorder. The data show that the majority of those treated, 87 percent, receive two or more pharmaceutical classes. From a therapeutic class perspective, 93 percent of schizoaffective disorder patients receive an antipsychotic, 48 percent receive a mood disorder treatment, and 42 percent receive an antidepressant. An expert commentary is also included. Introduction – Diagnosis– Studies – Perspecttive Study on psychopharmacologicaltreatment • Methods: • Data of 3100 medicaldoctors • Jan 2008 untiDec 2008 • Diagnose accordingto ICD-9 • Results: • Numberofmedication-class: • 1 medication-class 13 % • 2 medication-classes 48 % • 3 medication-classes 39 % • Antipsychotics (AP) 22 % • AP + moodstabilizer (MS) 20 % • AP + antidepressants (AD) 19 % • AP + MS + AD 18 % • other 31 % __________________________________________________________________________________________________________

  26. Introduction – Diagnosis– Studies – Perspective Conclusion • SAD is a heterogenousgroupofsyndromes,illnessesanddisorders. • Criteriafordiagnosisareimpreciselyused. • Data of SAD resarch (e.g., genetics, prognosis)areoverlappingwithdataofresearch on affectivedisorderorschizophrenia. • Do weneed SAD? Is SAD a variationof bipolar disorder? • Research in detailisnecessary! __________________________________________________________________________________________________________

  27. Thankyouverymuchforyourattention!

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