The Schizoaffective Psychosis Distinction: Sensible in Theory, Impossible in Practice
This is the third in our series of posts on schizoaffective disorder. To briefly recap, the illness - if in fact it can actually be labeled as one - is virtually impossible to diagnose. There are two reasons:
First, the DSM criteria is way too technical and stringent to guide clinicians in separating out the condition from either bipolar or schizophrenia. Second, clinicians do not have the time to obtain (nor are patients in a position to reveal) an accurate history of the ebbs and flows of apparently separate psychotic and affective states over the years.
There is an additional complication, spelled out by the people working on the DSM-5, namely that schizoaffective is not a “stable” diagnosis. In other words, people who get diagnosed with schizoaffective are more than likely to get rediagnosed with something else not too much later, most likely bipolar or schizophrenia.
By contrast, those getting diagnosed with either bipolar or schizophrenia tend to stay that way, at least in the eyes of those who treat them.
So what does a schizoaffective diagnosis tell us? Basically, that a lot of psychosis is going on. Whether we view schizoaffective as bipolar with complications or as a lighter version of schizophrenia, we are talking about something clearly identifiable: the psychosis.
We all know what psychosis is, right?
You have to go fishing around the back of the DSM to get something approaching a definition, and what comes in loud and clear is that psychosis - like depression and mania - can range from very severe to mild, from total breaks with reality to various degrees of contact with reality, but with weird stuff going on.
The key appears to be insight into your condition. You may be hearing or seeing or thinking strange things, but do you believe what you perceive? Do you think your voices or visions or thoughts are real? Do you act on them?
Keep in mind, mental illness is all about functionality. The pictures on the walls may be talking to you, but if you’re cool with that and are able to lead a rewarding life, maybe putting up with some unwanted chatter inside your head is a better option than contending with the side effects of an antipsychotic medication.
But the terrifying end of psychosis makes getting on a strong medication - even one that may take years off your life - seem like a good option. Some of you have been through it. A good many of us have had close calls. We have all seen it, all around us. Truly, we do not want to go there.
But can we control the psychosis without resorting to an antipsychotic? In an ideal world, our current diagnostic system would give us a few clues. As you recall, in schizoaffective, the psychosis is free-floating, apparently unconnected to the mania or depression. In bipolar “with psychosis” on the other hand, the psychosis appears to come attached to the mania or depression. The implication is obvious, and I have heard at least one expert expound on this: Control the mood swing and the psychosis may resolve itself. Maybe only a mood stabilizer is required, with no resort to an antipsychotic.
If this is the case, then all the diagnostic fuss makes sense. We want the best result with the least medication. When greater pharmaceutical intervention is needed, we want to know precisely the appropriate circumstances.
But here is the catch: We are in the counting-angels-on-the-heads-of-pins stage of figuring things out. As Tabby put it, in response to my piece, Diagnosis Impossible:
Unlike a A1C test for Diabetes and a Lipids test and a Thyroid test and a Antibodies Test, etc, there is no test or scan or urine stick color that will tell you that you have a mental illness - what type - and how to actually treat it. It is literally all within the mind and brain.
No one knows how to put the egg back together again. He has fallen off the wall and he is in pieces but no one knows how to put him back together because though they know he is a egg, they don't know if he was a Duck Egg, or a Robin's Egg, or a Chicken's Egg at first, and for some reason that seems to make a huge difference.
We have a long way to go ....
For insight into schizophrenia and psychosis, check out Christina Bruni's very informative Schizophrenia site here at HealthCentral.