The schizoaffective phenomenon: the state of the art
Marneros A;
Commented by , 30 Sep 2003
Aim of the study
The nosological meaning of schizoaffective disorders remains debated. Although the existence of the disorder has been accepted already decades ago, its definition according to international diagnostic criteria keeps changing.
For example, the definition in the International Classification of Diseases (ICD)-10 requires that schizophrenic symptoms have to be present for at least two weeks. In the Diagnostic and Statistical Manual of mental disorders (DSM)-IV, however, the schizophrenic symptoms have to be present for at least two weeks in the absence of prominent mood-disorder.
Because of this lack of clarity and insecurity concerning the concept of schizoaffective disorder, the historical development and modern concepts of schizoaffective disorder are presented.
Methods
The author undertook a critical literature review from Kahlbaum (1863) to the 21st century. He explains the historical development of the term schizoaffective disorder, points out to the difficulty of classifying the concerned patients and explains a differentiation in ‘concurrent and sequential’ types as well as ‘unipolar, bipolar and mixed’ states.
Results
In brief, the term "schizoaffective psychosis" was coined by the American psychiatrist Kasanin in 1933, but descriptions of the disorder had already been presented before. Kahlbaum described the patients as a separate group as ‘vesania typical circularis’.
Cases between "dementia praecox" and "manic depressive insanity" were well known to Emil Kraepelin and they were a problem for him, because they were not classifiable within his dichotomous concept of endogeneous psychoses.
Eugen Bleuler called overlaps between schizophrenia and affective disorders "Mischpsychosen" (mixed psychoses) and Kurt Schneider called them "Zwischenfälle" (cases-in-between). The author points out that the modern classification systems ICD-10 and DSM-IV are insufficient to describe the "schizoaffective phenomenon".
Both require the concurrent occurrence of schizophrenic symptoms with a major affective disorder. This does not do justice to the longitudinal aspect of the disorder where patients frequently have e.g. pure schizophrenic symptoms in one episode, pure affective symptoms in another episode and mixed schizophrenic and affective symptoms in a third episode.
To overcome this problem he suggests defining two types of schizoaffective disorders: the ‘concurrent’ and the ‘sequential’ type.
In addition he describes that schizoaffective disorders must also be divided into unipolar and bipolar types. Many features of the latter two entities have analogous differences e.g. in terms of premorbid and sociodemographic patterns and course as unipolar and bipolar affective disorders.
Discussion
The main point of the author is that a 'concurrent' and 'sequential' type of schizoaffective disorders must be distinguished. The first type means that patients have a coincidence of both - schizophrenic and affective symptoms.
Patients classified as having the 'sequential' type of the disorder have – following their long-term course - a symptom change between different episodes as described above. The second type is currently not covered by ICD-10 and DSM-IV.
Therefore, using the available criteria such patients must currently be diagnosed in a descriptive way according to the symptoms they present in each episode. This means that patients may have in one year a schizophrenic episode, some months later a manic episode and again some months later a schizodepressive episode.
The classification suggested by the author would avoid this unsatisfactory strategy. More research is needed before the author’s well elaborated theory, which intuitively makes sense, will be accepted by textbooks and official international classification systems.