The process for DSM-V will better serve clinicians if it produces a DSM-V that does not just “lump” or “split” but also “takes out.” If schizoaffective disorder was removed, I believe there would be little impact on treatment but better diagnostic agreement among clinicians. I think the field will be better served by simplifying things. I vote for abandoning the concept altogether!
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It is not clear how to position this condition, especially since there is such a paucity of biological and treatment studies to inform evidence-based decisions about the status of schizoaffective disorder.
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So what does this all mean? The status of schizoaffective disorder is “up for grabs” in the review process for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). There are no “ah-ha’s” when you see these data, and I would contend that these pharmacovigilance data offer little support for the idea that schizoaffective disorder is really a different condition from schizophrenia. 2 Also, the pattern of polypharmacy appears similar overall to that seen in schizophrenia. While this polypharmacy is not a surprise, the extent is a little higher than in most studies of schizophrenia alone. We also note that only about 20 percent of patients are receiving antipsychotics alone. This resonates well with the notion that schizaffective disorder is related to schizophrenia and falls within the family of psychotic disorders. Firstly, the overwhelming majority of patients are being treated with antipsychotics. Keeping the above comments in mind, there are a number of interesting observations from these data. When diagnostic boundaries are complex and blurred, this is another source of variability on ascribing this diagnosis. So if one doctor calls the patient’s illness schizoaffective disorder, this diagnosis will likely be carried forward in care. It is also observed that when a diagnosis is made by one doctor, it tends to be retained over time. Additionally, in our mental health system, patients are more likely to be followed over time by several doctors sequentially rather than to have the same doctor for many years. This can easily happen as doctors often do not have the time to go back over years of course of illness so as to meticulously chart the pattern of mood symptoms in a patient with chronic schizophrenia. This comorbidity, common in schizophrenia, 1 is ripe to be misconstrued and then ‘labelled’ as schizoaffective disorder. For example, it is well known-and entirely logical-that people with schizophrenia become depressed over the course of their illness. In addition, pharmacological studies do not focus on schizoaffective disorder alone, and what we know about the drug treatment of schizoaffective disorder comes from analyses of large trials in patients with schizophrenia that have included a subset of patients with schizoaffective disorder.Īnother complicating factor is that, in the absence of clearly delineated features and course of this condition, schizoaffective disorder is apt to be mis/overdiagnosed. However, beyond some early, classic genetics studies and some long-term outcome studies, the aspects that would set it apart as an independent illness-namely biology, risk, course, and treatment-have rarely been studied with any methodological rigor. Some have suggested that schizoaffective disorder, depressive subtype, resembles more schizophrenia in course and treatment while schizoaffective disorder, manic subtype, is more like a bipolar disorder over time. Its course is intermediary and considered to be more favorable than schizophrenia. It was originally conceived as a third, independent entity alongside schizophrenia and bipolar disorder. Schizoaffective disorder is a contentious nosological entity. These are interesting data and should be considered in the context of our current-day understanding of schizoaffective disorder, a conditiion originally described in the 1940s.