Sunday, May 15, 2011

Let's Kill the Schizoaffective Diagnosis

Following is a chopped (or should I say slashed?) version of a new article on mcmanweb (with the rather less provocative title of "Schizoaffective Disorder"), which in turn is based on copy-and-paste of extracts from several mcmanweb articles on psychosis and various diagnostic headaches in bipolar ...

Think of schizoaffective as occupying that middle ground where bipolar overlaps with schizophrenia. But what are we dealing with? Schizophrenia lite, BP 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.

What We’re Up Against

A number of years back, the International Society for Bipolar Disorders 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.

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. 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.

Another Perspective ...

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.

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 the concept of "schizoaffective spectrum phenotype" incorporating various shades of mood and psychosis.

What Are We Looking At?

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:

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.

Trying to Make Sense of All This

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 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::
  1. With symptoms meeting criteria for mania or mixed features.
  2. With symptoms meeting criteria for major depressive disorder.
In bipolar I and II and major depression, these specifiers:
  1. 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.
  2. With psychotic symptoms meeting Criterion A for schizophrenia with consistent concurrent mood features.
Meanwhile, Back in the Real World ...

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.


Anonymous said...

You raise an interesting point that should be debated by the medical profession. Our support groups don't have any professional psychologists or psychiatrists in them, but we have the luxury of time. In the cases of schizoaffective disorder that I've seen, I could not always discern a direct connection between the bipolar and schizophrenic elements, and they often appeared to operate independently of each other.

Charles Sakai
Colorado Springs

John McManamy said...

Hey, Charles. Like you, I've benefitted from what I've observed in DBSA support groups. What I've seen: the difficult cases tend to be diagnosed "down." Thus, people in the BP II range are first dx'd with unipolar depression. Those with borderline (and these individuals stand out like a sore thumb after several meetings) wear the bipolar label. Those with the schizoaffective dx give me the impression that their pdocs have no clue in what to do with them. The docs seem to want to err on the side of BP until that dx is no longer sustainable. Then they go with schizoaffective when maybe they should be considering a form of good prognosis schizophrenia. My guess is at least 3/4 of people in support groups have been mis- dx'd at least once in their lives. A rather huge indictment on the DSM.

Lizabeth said...

Wow--color me confused. The thing I am wondering about tho---was the initial 1933 coinage of the diagnosis Schizoaffective Disorder really a way to minimize schizophrenia and make it more socially acceptable? Especially in a time when they had no medications that really did anything but some patients able to function some of the time anyway this may have been a "feel good" diagnosis for doctors, patients and families.
Doctors in general absolutely HATE admitting there is nothing they can do for a patient so any diagnosis that minimized this admission would have been welcomed.
The intense, contradictory wordiness could have come later as more useful meds came on the scene.
Before that, weren't a lot of Bipolars misdiagnosed as schizophrenic? Have we come full circle?

John McManamy said...

Hey, Lizabeth. From Wikipedia:

"The term schizoaffective psychosis was introduced by the American psychiatrist Jacob Kasanin in 1933 to describe an episodic psychotic illness with predominant affective symptoms, that was thought at the time to be a good-prognosis schizophrenia."

Ever since, psychiatry has been trying to figure out this overlap between BP and SZ. It was even more confusing back in those days as there was no general agreement on what either BP or SZ looked like. Basically, anything that couldn't be treated by psychoanalysis (which was just about everything) got dx'd as SZ. So - a lot of over-dx of SZ and under-dx of BP.

My guess is in the old days schizoaffective was pretty much forgotten about. Much too confusing. May as well go with SZ.

Now it seems schizoaffective is being over-dx'd. Hard-to-treat BP? Call it schizoaffective. Afraid of the SZ label? Call it schizoaffective.

You're right. We have come full circle. Very ironic.

Anonymous said...

"Now it seems schizoaffective is being over dx'd..."

Much as Bipolar has been over diagnosed. So many people are given the Bipolar diagnosis that so really do not have it.

No one wanted Bipolar back in the day and no one wants Borderline still today. Little want Schizoaffective Disorder because it is too much likened to Schizophrenia.

No one wants a Schizophrenia diagnosis... not even the ones that truly have it.