• DOI:10.1111/j.1600-0447.2006.00763.x
• Corpus ID: 22029255

Do schizoaffective disorders exist at all?

@article{Maier2006DoSD,
  title={Do schizoaffective disorders exist at all?},
  author={Wolfgang Maier},
  journal={Acta Psychiatrica Scandinavica},
  year={2006},
  volume={113}
}

• W. Maier
• Published 1 May 2006
• Psychology, Medicine
• Acta Psychiatrica Scandinavica

More than 100 years ago Kraepelin proposed a very practical and persuasive solution to a longstanding problem in clinical psychiatry. He proposed to reduce heterogeneity by splitting the perplexing variety of psychopathological signs and symptoms, of patterns of deviant behavior and experiences, of shortand long-term course and outcome of functional disturbances into two major groups: schizophrenia (dementia praecox) and affective disorders (manic-depressive illness) (1). In this way, he created the so-called Kraepelinian dichotomy , which turned out to be clinically useful for subsequent decades. However, he himself got skeptical subsequently (2) if this simplistic solution really worked in practice as the number of cases in-between were too numerous. About 70 years ago, the concept of schizoaffective disorders emerged from difficulties in practicing Kraepelin’s dichotomy by separating schizophrenia and affective disorders. In 1933, Kasanin first coined this term (3). Although originally related to reactive psychoses in the Scandinavian tradition (4), the term became transformed to indicate the intraindividual co-occurrence of both severe affective as well as severe psychotic syndromes, which did not fit in either of Kraepelin’s categories. The widespread use of this term reflected the clinical need to consider border-cases separately. Many clinicians are probably motivated to use this category because of implications on the course of illness. However, qualitative inter-class differences cannot be detected: the most recent outcome study (5) saw a less poor outcome in schizoaffective disorders compared with schizophrenia, but it was difficult to distinguish schizoaffective and mood disorders with psychotic symptoms; a progressively worsening intermediate course was reported for both diagnostic groups. Thus, a dimensional view of schizoaffective outcome is recommended. In contrast to its clinical popularity, research investigations in this diagnostic category – although operational definitions became available – remained relatively rare as it becomes evident fromaPubMed search (search terms in titles: schizoaffective disorder 1⁄4 230 citations; schizophrenia 1⁄4 13.297; bipolar disorder 1⁄4 2.355; during a 10-year period 1995–2005). If this category became a research topic at all, it was a border-category of schizophrenia and/or affective disorders. Thus, the biological basis and the nature of this category inbetween remained obscure. Several reasons might account for this fact. An unequivocal definition of schizoaffective disorder was never attained. For example, the concepts of ICD-10 and DSM-IV strongly differ by the criterion of simultaneity or temporal contiguity. The available diagnostic definitions include so complex criteria that the reliability is relatively low (6). Thus, it does not come as a surprise that most cases with a schizoaffective episode change this diagnosis in subsequent episodes (7). Furthermore, both most widely used diagnostic manuals propose criteria which are fully different from the clinical conventions. This is now demonstrated by a careful diagnostic re-evaluation of a representative Danish in-patient sample (n 1⁄4 59) with the diagnosis of schizoaffective disorder byVollmer-Larsen et al. (8): not a single patient fulfilled either theDSM-IVor the ICD-10 criteria (full criteria) for schizoaffective disorder. The vast majority of cases were allocated either to schizophrenia or to affective disorders (ICD-10), both by the rater of the clinical records or by an automatic OPCRIT algorithm. This observation is important because the basic assumption for proposing the diagnostic entity of schizoaffective disorders is losing its validity. At the starting point for this diagnostic category inbetween schizophrenia and bipolar affective disorders were assumed to be due to two distinct disease processes. Doubts in this unproven hypothesis emerged already in the 1970s. Thus, the relationship between depression and schizophrenia has been studied in a variety of contexts in the past. For example, it was recognized that (i) postpsychotic depression was a common phenomenon, and (ii) postpsychotic depression was often preceded by depression, already at the beginning of the psychotic episode but overseen by the clinician [e.g. (9)]. Very recently, a most carefully conducted retrospective epidemiological study reported depressive symptoms and syndromes to be very common precursors of the first negative and psychotic symptoms in subjects developing Acta Psychiatr Scand 2006: 13: 369–371 All rights reserved DOI: 10.1111/j.1600-0447.2006.00763.x Copyright 2006 The Authors Journal Compilation 2006 Blackwell Munksgaard