Schizoaffective: Diagnosis Impossible
This is the second installment in our conversation on schizoaffective disorder. We sort of understand the illness as some type of hybrid, incorporating elements of bipolar and schizophrenia, but then our understanding breaks down.
Here is the problem, as stated by the DSM-5 work group charged with looking into schizoaffective:
The diagnosis of schizoaffective disorder requires longitudinal data ...
In other words, if you ‘re a clinician, do not presume to make the diagnostic call without first obtaining a very detailed patient history. There is way too much going on with the patient to get it right on the first take. We are talking of an illness with a plethora of symptoms that needs to be assessed in terms of their temporal relationships with each another.
So, if a patient walks in the door with a history of both manic and psychotic symptoms, what is it? A manic state in Bipolar I? Schizophrenia with a mood complication? Schizoaffective disorder?
Does it really make any difference? Does it make all the difference in the world?
According to the DSM, schizoaffective requires strong evidence of psychosis not connected to the mania, in essence a free-floating psychosis. If the mania and psychosis are both occurring at around the same time, the DSM considers the phenomenon as essentially a complex mania in bipolar. If the mania and psychosis seem to be tracking independently, on the other hand, that is schizoaffective.
But wait, isn’t that also schizophrenia? Perhaps it’s best to think of schizoaffective as schizophrenia lite. The psychosis only has to last for two weeks (as opposed to a month in untreated schizophrenia) and there is no mention of six months of disturbances (as in schizophrenia).
Clear as day, right? All you need for an accurate diagnosis is to have a clinician with a stopwatch follow you around every day of your life, 24 hours-a-day, for the next ten years, tracking the ebbs and flows of all your symptoms. Barring that, a clinician who is willing to take the time to sit down and listen. We need a detailed history, after all.
Tabby writes (in response to my first piece):
If anyone has a psychiatrist that actually spends more than 10 minutes with them - more than 4 times in a 12 month period... consider yourself fortunate and hold on to them.
Do you see a major problem, here? Most of us have been misdiagnosed at least once, and that usually involves the easy stuff. For instance, I was initially diagnosed with unipolar depression. The manic episode my antidepressant sent me into made the second call of bipolar a no-brainer. This is a very common occurrence.
Now imagine an illness as complex as schizoaffective - in the order of magnitude of counting of angels on the head of a pin. The best psychiatrist in the world, with no time to listen, with no time to follow up, is no wiser than the worst psychiatrist in the world. Faced with the same constraints, both are equally stupid. In short: Diagnosis Impossible.
Much more to come ...