The Schizoaffective Conundrum: Part One
You are all familiar with the term, schizoaffective disorder. But can you define it? Here’s a little quiz for you. Indicate which one of the following comes closest to the definition of schizoaffective:
1. Bipolar with complications - Basically, a mood disorder with psychosis.
2. Schizophrenia with complications - Basically, a thought disorder with mood swings.
3. Bipolar overlapping with schizophrenia - Basically, elements of the two illnesses bleeding into one another.
4. Bipolar plus schizophrenia - Basically, two separate illnesses co-occurring together.
5. Neither bipolar nor schizophrenia - Basically, an illness unto itself existing midway between bipolar and schizophrenia.
One more question:
How do you make God laugh?
Now to the answers:
First question, pick the closest definition: Your guess is as good as mine. Who knows? How long is a piece of string? What is the sound of one hand clapping?
Second question, on how to make God laugh: Read Him the DSM-IV criteria for schizoaffective disorder. Here’s what the people working on the DSM-5 had to say of schizoaffective: “The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable.” So would the DSM-5, due out next year, fix that? Ha!
A little bit of background:
I have sat in on sessions where some of the smartest people in the world have debated schizoaffective disorder. Fascinating stuff, great discussions. Everyone passionately agrees that that the diagnosis (along with a good deal of the rest of the DSM) needs to be blown up. This from Hagop Akiskal of UCSD at the 2007 American Psychiatric Association’s annual meeting:
"Our patients are violating our nosology every day."
In other words, sticking human behavior into diagnostic categories is a stupid idea. The patients Dr Akiskal sees in the real world don’t conveniently conform to the DSM. Said G Scott Waterman MD of the University of Vermont at the same APA session: The DSM’s tendency to set symptom lists in stone "retards development of understanding."
Do you see an irony wrapped in a paradox wrapped in a conundrum, here? We are dealing with a class of patients who do not neatly fit into two of the best known diagnostic categories - bipolar and schizophrenia. So how did psychiatry respond to the problem? By inventing yet another diagnostic category.
The bipolar-schizophrenia overlap has plagued psychiatry from the very beginning. To give the DSM credit where it’s due, it offers at least a fairly reliable rough guide in distinguishing “classic” bipolar cases from classic schizophrenia. Back in the early part of the twentieth century, the pioneering diagnostician Emil Kraepelin separated out what he called “manic-depressive insanity” (bipolar plus recurrent depression) from “dementia praecox” (schizophrenia) thus providing psychiatry with its first navigation system.
Unfortunately, Kraepelin was overshadowed by Freud, who was born the same year. Diagnostic psychiatry had to wait. The problem faced by those putting together the first modern DSM - the DSM-III of 1980 - was how to best carve nature at its joints, and they turned to Kraepelin for inspiration. The catch was that Kraepelin toward the end of his life was having second thoughts about his carving job.
The smoking gun was the name, “dementia praecox.” Unlike depression and bipolar, which could have favorable outcomes, Kraepelin attributed what would later be called schizophrenia to the brain in the process of deterioration. Patients could only get worse, not better. His followers soon realized this was not the case. Thus the replacement name, schizophrenia.
Kraepelin’s view of manic-depression is immensely more nuanced than the simplistic symptom checklists of the DSM. In Kraepelin’s view, manic-depression includes most forms of clinical depression, as well as what we now call bipolar. To this day, his conceptualizing of the “mood spectrum” remains definitive.
Conceivably, Kraepelin could have continued the spectrum into schizophrenia, as part of a mood-thought spectrum. The problem is he didn’t live long enough to do it. Instead, we have the spectacle of psychiatry trying to finish the job. Or rather giving up altogether. Despite the fact that the people working on the DSM-5 recognized the absurdity in keeping the current DSM schizoaffective diagnosis as it is, they kept it anyway.
One problem is we know too little. The other is we know too much. Or, to put it another way, we know a lot about what we don’t know. Confused? Much more to come ...