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I did this as a blog post for a CB'er who requested it, and thought it might also be useful to post here.

Schizoaffective disorder is a less well-known diagnosis than schizophrenia, depression, or bipolar disorder, and it tends to confuse people. It was categorized under schizophrenia in earlier versions of the DSM, but in the current version you have to have a mood episode for a "substantial portion" of the time, as well as having psychotic symptoms outside of a mood episode.

That last bit is important because some people with bipolar disorder have psychotic symptoms during manic periods, and some people with bipolar disorder and some people with major depressive disorder have psychotic symptoms during depression. But (according to the DSM-IV) they don't have psychotic symptoms outside of mood episodes.

But we don't know from this what schizoaffective disorder actually is. Is it having both a mood disorder and schizophrenia at the same time? Is it a separate disorder from either? (And what about if your depression isn't long enough or severe enough to be schizoaffective disorder and you get diagnosed with schizophrenia with comorbid depression? Is that a totally different thing?)

Goodwin and Jamison (2007; the new edition of the "classic work on bipolar disorder") do a quick review, which I will summarize:

The five major schools of thought are:

* a separate disorder (but it doesn't run in families, so this seems less likely)

* "an intermediate form on the continuum of psychosis" (I think this means that if you think of disorders as lying along a continuum of psychosis, like you could think of bipolar symptoms as lying along a continuum of severity,schizoaffective is inbetween schizophrenia and bipolar with psychotic symptoms)

* comorbid schizophrenia and depression/bipolar

* more severe bipolar

* less severe variant of schizophrenia

Another school of thought might be that schizoaffective disorder is actually several different things, which is what they tentatively suggest (we're a little short on actual research to draw strong conclusions):

* People who are primarily manic and less pronouncedly psychotic may have an especially severe form of bipolar disorder (suggested by studies showing that it is more associated with bipolar disorder and has a worse course: Gershon et al, 1982; Coryell et al., 1990).

* People who are predominantly psychotic and have less prominent, exclusively depressive symptoms may have a less severe variant of schizophrenia (suggested by studies showing outcomes or neuropsych profiles similar to schizophrenics: Brockington et al, 1980; Tsuang and Coryell, 1993; Evans et al, 1999).

* People who have about an equal mix are the unlucky bastards who just happened to get both a mood disorder and schizophrenia. (suggested by the epidemiological prevalence of the disorder being a fraction of a percent, about what you'd expect for those two just happening to co-occur: Kendler et al, 1993, 1996).

Again, this is still speculative and we don't have enough research to confirm (or deny) it. But it's pretty interesting, no? Maybe we'll get a bipolar 0.5 to complement I and II? Since all the love's been going in the other direction, maybe it's time the crazier among us got a little more attention. And what kind of "less severe" schizophrenia manages to hit you with something akin to major depressive disorder, yet still be less disabling than regular schizophrenia?

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There are a lot of "schools of thought" out there, that is for sure.

I was under the impression that most psychiatrists agree that schizoaffective disorder exists where schizophrenia and bipolar symptoms are both present concurrently.

Thoughts anyone?

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Schizoaffective disorder is defined as that in the DSM, and considered a separate clinical entity according to the DSM, and thus should be diagnosed by clinicians who use the DSM accordingly. Again, what I posted was largely speculative. It is also based on research, which holds a wider variety of opinions than the consensus reached by the DSM committee handling the entry for schizoaffective disorder.

So you're absolutely right - schizoaffective disorder is diagnosed when symptoms of both present concurrently, with the caveats I mentioned about "substantial portion", etc. There should be no substantial disagreement on what symptoms lead to a diagnosis of schizoaffective disorder when diagnosing according to the DSM, which clinicians in countries that use the DSM frequently do, albeit sometimes imperfectly.

Edit: If anyone has anything to add to the research above, I'd be interested in hearing it. The relationship between the need to have consensus diagnostic standards and the need to have them adequately characterize our best guess at what's going on (and the need to diagnose and treat people according to the best knowledge available) is messy sometimes. Sometimes diagnosis lags badly behind what we know, but we certainly don't want diagnostic standards to bounce around according to preliminary lines of research.

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Subtypes?

The three types of Schizoaffective d/o include Bipolar Type, Major Depressive Type and Manic Type ("Bipolar Mania Type"). However, there seems to be an on going patter of subtypes.

Schizoaffective d/o seems to be interpreted in two ways. The first being Schizophrenia with a mood component, and the second being psychosis not pertaining to mood.

Those explanations, although seemingly similar, can be taken in different ways.

Schizophrenia is more than psychotic symptoms (delusions, hallucinations, disorganized speech). Schizophrenia is a largely based disorder with criterion positive symptoms (psychotic symptoms), negative symptoms and cognitive (disorganized) symptoms.

Some people diagnosed with Schizoaffective d/o may have psychosis (with hallucinations, etc.) not during mood paterns, but fail to have many of the negative and cognitive symptoms. As well, some people diagnosed with Schizoaffective d/o may have a large base of positive (psychotic), negative and cognitive symptoms and have a smaller varient of the mood component. Others can have both a strong mood component as well as full symptoms of Schizophrenia (negative, positive and cognitive).

I wanted to poll, here, the most common variant of Schizoaffective d/o found in people diagnosed. I as well would enjoy hearing what others find in the subject of types and subtypes.

Which better describes you?

Bipolar Type with psychotic symptoms, with little or no negative symptoms

Bipolar Type with psychotic symptoms, with negative symptoms

Major Depressive Type with psychotic symptoms, with little or no negative symptoms

Major Depressive Type with psychotic symptoms, with negative symptoms

Psychosis with smaller variation of Bipolar

Psychosis with smaller variation of Major Depression

Psychosis and negative symptoms (Schizophrenia) with smaller variation of Bipolar

Psychosis and negative symptoms (Schizophrenia) with smaller variation of Major Depression

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Bipolar Type with psychotic symptoms, with little or no negative symptoms, I guess. The psychotic symptoms are the hardest for me to deal with.

I'm not really sure what the negative symptoms are. When I'm very psychotic I'm not very functional (can't speak or eat), but that's unusual for me.

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Bipolar Type with psychotic symptoms, with little or no negative symptoms, I guess. The psychotic symptoms are the hardest for me to deal with.

I'm not really sure what the negative symptoms are. When I'm very psychotic I'm not very functional (can't speak or eat), but that's unusual for me.

From what I can remember, positive symptoms are things that are present in an ill person which aren't present in the average person (hallucinations, delusions, etc), while negative symptoms are things which aren't present in an ill person which are present in the average person (ie lack of motion (catatonia), flattened affect, etc) I can't quite remember all the symptoms, because I haven't seen an abnormal psych text in about 3 years, but I hope you get the idea.

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Things have changed for me over the years. I think I used to be a pretty classic BP1, but now have been diagnosed as "suffers from an affective disorder" by the Priory which leaves of lot of openings and seems to fit the fact that I have stopped the mania side of BP and begun experience more frequent episodes of negative psychotic symptoms.

As I see it from all the conflicting information I've read, schizoaffective can be a bit of a catch-all diagnosis for those undefinable types who have more of a mixture. I described it to my pdoc that it feels like having vegetable soup for brains that sometimes has more carrots than peas and other times tastes like tomato. Bits of the variants of both psychotic and BP seem to dip in and out, but the base (MDD) is always there.

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I think (from memory) in light of brain scans that the difference between a dual diagnosis and a singular diagnosis of SA is whether the mood component is a primary or secondary symptom.

So in BP, psychosis is caused by mania or depression.

In sz, affective funkiness is caused by psychotic symptoms, (a paranoid person may retreat from society leading to reactive depression as opposed to brain deformation induced depression).

In SA, either psychosis induced affective symptoms linger after the affect has stabilised, or the affective swings are more persistent than normal residual depression (or mania resulting from delusions of grandure)

In a dual diagnosis both affect and positive symptoms (and sometimes negative symptoms in the case of disorganised sz etc) are primary symptoms arising from abnormalities in the brain.

If you have access to a decent medical journal database, search for primary negative symptoms as a start and it should give info on primary depression and then give you the medical terms I can't think of for the rest to search further... I don't currently have any access.

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Very interesting post...I always thought of schizoaffective as a milder form of schizophrenia with less cognitive defects. More time spend in depression or mania(mood affects) and less time in psychosis. Usually, but not always, higher functioning.

Someone else mentioned schizoaffectives experience psychosis not brought on by mania..I guess that fits. This is all speculation on my part and I could be wrong. Just my two cents.

Miss C.

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