Download Schizoaffective Disorder

17th Int. Review of Psychosis & Bipolarity
IRPB in Lisbon
April 26, 2015
Schizoaffective Disorder (SAD):
history, symptoms & diagnosis
Hans-Jörg Assion
LWL-Clinic Dortmund
Psychiatry.Psychotherapy.Psychosomatic Medicine
Dortmund, Germany
Overview
• Introduction
• Diagnostic issues
• Clinical studies
• Perspective
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Introduction – Diagnosis – Studies – Perspective
What do you think?
Are you a lumper or a splitter?
lump
schizophrenia
uni-/bipolar
(with psychotic features)
split
schizophrenia
schizophrenia with depression
schizoaffective, mainly psychotic
schizoaffective, mainly affective
schizomanic
schizodepressive
uni-/bipolar with psychotic features
unipolar/bipolar
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Introduction – Diagnosis – Studies – Perspective
SAD – critical remarks
Schizoaffective disorders are psychotic
Schizoaffective disorder is a quite
mood disorders; there are no
popular diagnosis.
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.
In scientific terms it is a
problematic diagnosis.
Hypothesis:
The concept of mood-disorder
with a broad symptom-spectrum
is fully covering all of the clinical
phenomena.
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Introduction – Diagnosis – Studies – Perspective
Schizoaffective Disorder:
A problematic diagnosis
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.
Systematic study of literature of SAD
RESULTS:
Schizophrenia, Bipolar Disorder
and 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.
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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
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1Kasanin J (1933) Am J Psychiat 13:97-126
Introduction – Diagnosis – Studies – Perspective
Historical remarks
Karl Kahlbaum1, 1863:
„Die Gruppierung der psychischen Krankheiten und die
Eintheilung der Seelenstörungen“
(Grouping of psychic illnesses and classification of
the disorders of soul)
melancholic madness, mania with madness ...
Emil Kraepelin2, 1899:
„Die klinische Stellung der Melancholie“
(Clinical positioning of melancholia)
Overlap of dementia praecox and manic-depressive illness ...
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1Kahlbaum K (1863) Danzig, Kafemann
2Kraepelin E (1899) Mschr Psychiatr Neurol 6:325-335
Introduction – Diagnosis – Studies – Perspective
Psychopathology
Considerations from history
not to diagnose SAD
Psychopathological principles:
• 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
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Introduction – Diagnosis – Studies – Perspective
Principles of classification
according to ...
• biological causes
Genetics, anatomy, or other
e.g. spino-cerebellar ataxia
• clinical symptoms
e.g. symptoms of depression in operational classification
• the course of illness
z.B. depressive episode (ICD-10: F32) vs.
recurrent depressive disorder (ICD-10: F33)
• disorder prognosis
e.g. dementia praecox vs. manic-depressive illness (Kraepelin)
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Introduction – Diagnosis – Studies – Perspective
Classification – ICD-10
F2 schizophrenia, schizotypic and delusional disorder
F25 schizoaffective disorder
F25.0 schizomanic disorder
F25.1 schizodepressive disorder
F25.2 mixed schizoaffective disorder
F25.8 schizoaffective disorder, other
F25.9 schizoaffective disorder, not specified
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Intorduction – Diagnosis – Studies – Perspective
Diagnostic criteria
according to ICD-10
G1 Disorder with criteria of an affective disorder (F30, 31,32);
severity: medium to severe.
G2 Symptoms of schizophrenia for most of the time
during 2 or more weeks (F20.0-F20.3).
1. e.g., thought broadcasting, -insertion
2. e.g., delusion of control ...
3. e.g., vocal hallucinations ...
4. e.g., bizarre delusion ...
5. e.g., neologism ...
6. Intermittend catatonic features ...
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Intorduction – Diagnosis – Studies – Perspective
Diagnostic criteria
according to ICD-10
G3 Criterion G1 and G2 must be fullfilled during the same episode and
at least for some of the time. The clinical syndrome must be
characterized with symptoms out of criteria G1 and G2.
G4 Criterion for exclusion: A disorder due to an illness of the brain,
psychotropic substances, intoxication, addiction, detoxification.
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Introduction – Diagnosis – Studies – Perspective
Diagnostic criteria
according to DSM-V
A. An uninterrupted period of illness during which there is a major
mood episode (major depressive or manic) concurrent with Criterion
A of schizophrenia
B. Delusions or hallucinations for 2 or more weeks in the absence of
a major mood episode (depressive or manic) during the ilfetime
duration of the illness
C. Symptoms that meet criteria for a major mood episode are present
for the majority of the total duration of the active and residual
portions of the illness.
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Introduction – Diagnosis – Studies – Perspective
Diagnostic criteria
according to DSM-V
D. The disturbances is not attributable to the effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition.
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.
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Introduction – Diagnosis – Studies – Perspective
Classification of
(schizo-)affective disorder
bipolar
• schizoaffective disorder
manic
unipolar
depressive
• affective disorder
• schizoaffective disorder
bipolar
unipolar
manic
depressive
affect-dominant
schizo-dominant
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Introduction – Diagnosis – Studies – Perspective
Differentialdiagnosis
Organic
Psychic Disorder
Acute Polymorphic
Psychotic Disorder
No
Emotionally agitated and/or
psychosis in context of
critical incident
Psychotic Affective
Disorder
No
Yes
Ja
Affective syndrome at the same time
No
Symptoms of depressive or manic episode with psychotic
features
YES
No
Psychotic symptoms according to
criteria of schizophrenia
Yes
Schizoaffective
Disorder (SAD)
Characteristic schizophrenic symptoms
for a months or more
No
Psychotic Affective
Disorder
Yes
Schizophrenia
No
Schizophreniform
Disorder
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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.
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Introduction – Diagnosis – Studies – Perspective
Unnecessary diagnosis?
Yes
• Heterogeneous nosolgy
• No specific illness
• No neuro-biological correlate
• Part of spectrum of bipolar
disorder or unipolar depression
or part of schizophrenia
• Monomorphic or polymorphic
course of illness with the same
prognosis
• ...
No
• Mixed syndromes are
described for long time
• Course of illness is
characteristic with
onset and end
• Prognosis better compared
to schizophrenia
• Risk of schizophrenia is
lower in families
• Represents a distinct entity
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Introduction – Diagnosis – Studies – Perspective
Bipolar Spectrum
Mania
Hypomania
Normal
Depression
severe
Depression
Normal
moodcycle
Zyklothymic
personality
Zyklothymia
Bipolar II
Disorder
Unipolar
Mania
Bipolar I
Disorder
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Goodwin et al. Manic-depressive Illness. Oxford: Oxford University Press, 1990
Introduction – Diagnosis – Studies – Perspective
Epidemiology
• Epidemiological data is missing (completely)!1
• Estimated incidence for unipolar schizoaffective
psychosis: 4/100 0002
• Estimated incidence for bipolar schizoaffective
psychosis: 1,7/100 0002
• Gender ratio:
f>m (1,7:1) for unipolar SAD
f=m for bipolar SAD
• First manifestation about 3 yrs later in comparison
to schizophrenia2??
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1Marneros A (2004) Thieme, Stuttgart
2Angst J (1986) Schizoaffective Psychoses. Springer, Berlin
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
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1Maier W et al. Am J Psychiat 1992;149:1666-1673
2Cohen et al. Arch Gen Psychiat 1972;26:539-546
3Kendler et al. Arch Gen Psychiat 1994;51:456-468
Introduction – Diagnosis – Studies – Perspective
Neurocognitive function
BD vs. SAD
Methods: Several domains of neurocognitive function, executive
function, memory, attention, concentration and perceptuomotor
function were examined in 28 euthymic SAD patients 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
impairment than 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
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patients.
Assion et al. 2010
Introduction – Diagnosis – Studies – Perspective
Study on cognition
BD vs. SAD
Test dimension
TMT-A (sec.)
TMT-B (sec.)
Bipolar patients
(n=32)
MANCOVA/ ANCOVA♯
Schizoaffective
patients (n=28)
Mean
SD
Mean
SD
F
df
P
D
42.61
22.71
64.21
42.88
2.91
1; 47
0.09*
0.63
106.78
50.52
139.29
82.79
1.63
1; 43
0.21*
0.47
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Assion et al. 2010
Introduction – Diagnosis – Studies – Perspective
Prognosis
Few systematic research1, 2:
• Schizodominant SAD predictive for worse outcome.
• „Mixed SAD “ has a worse prognosis.
• Missing of critical incidents is a worse predictor.
• Positive predictor:
Coping strategies
pure melancholic episodes
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1Steinmeyer
2McGlashan
EM, Marneros A et al. Eur Arch Psychiat Neurol Sci 1989;238:126-134
TH, Williams PV. J Nerv Ment Dis 1990;178:518-520
Introduction – Diagnosis – Studies – Perspecttive
Study on psychopharmacological
treatment
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.
Methods:
• Data of 3100 medical doctors
• Jan 2008 unti Dec 2008
• Diagnose according to ICD-9
Results:
Number of medication-class:
1 medication-class
13 %
2 medication-classes
48 %
3 medication-classes
39 %
Antipsychotics (AP)
AP + mood stabilizer (MS)
AP + antidepressants (AD)
AP + MS + AD
other
22 %
20 %
19 %
18 %
31 %
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Introduction – Diagnosis – Studies – Perspective
Conclusion
• SAD is a heterogenous group of syndromes,
illnesses and disorders.
• Criteria for diagnosis are imprecisely used.
• Data of SAD resarch (e.g., genetics, prognosis)
are overlapping with data of research on affective
disorder or schizophrenia.
• Do we need SAD?
Is SAD a variation of bipolar disorder?
• Research in detail is necessary!
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Thank you very much
for your attention!