In three pieces this week on my blog Knowledge is Necessity, I happened to use a clinical trial of Invega on patients with schizoaffective disorder as a case study in how randomized, double-blind, placebo controlled studies - the gold-standard in treatment research - all too often tell us nothing.
The exercise got me thinking about schizoaffective, and when I noticed that Marcia Purse had just posted something on the topic here at BipolarConnect, I thought now would be a good time to jump in.
Back in the early twentieth century, the pioneering diagnostician Emil Kraepelin separated out "manic-depression" (bipolar and recurrent depression) from "dementia praecox" (which his followers changed to schizophrenia). In effect, this gave psychiatry its basic navigating system which we still use today. But even back then Kraepelin had second thoughts about making such a decisive distinction.
In 1933, American psychiatrist Jacob Kasanind proposed "schizoaffective psychosis" in the Freudian context as a type of a good prognosis schizophrenia. In 1959, German psychiatrist Kurt Shneider employed the term schizoaffective to fill in the middle ground between Kraepelin’s manic-depression and schizophrenia.
Schizoaffective is probably the most confusing of all the 297 psychiatric disorders listed in the DSM-IV. The DSM-5 work group responsible for coming up with something better actually acknowledged that "the current DSM-IV-TR diagnosis schizoaffective disorder is unreliable," but failed to do anything to remedy the situation. Is schizoaffective a type of "schizophrenia lite" or "heavy-duty bipolar?" Or do we have both bipolar and schizophrenia co-occurring together?
Or is it some of one and some of the other? Or is it a separate illness in its own right? Perhaps none of the above?
The DSM appears to lean on the side of "schizophrenia lite" combined with a mood disorder. The illness is classified under "Schizophrenia and Other Psychotic Disorders." Thus, a patient must present with schizophrenia symptoms (such as delusions and disorganized speech) but without six months of continuous disturbance (involving at least one month of being fully symptomatic). But at the same time, the patient is experiencing a full-blown depressive, manic, or mixed episode.
Clear as day, right?
So, what if you experience psychosis (such as delusions) when you are manic or depressed? Schizoaffective, right? Not necessarily. Psychosis occurs across a number of disorders. Thus we have DSM bipolar "with psychotic features" and DSM depression "with psychotic features."
Meanwhile, we know that a lot of individuals with schizophrenia also experience depression.
Confused? So is your psychiatrist. I can almost guarantee that if you are currently diagnosed with schizoaffective you were first diagnosed with something else. Likewise, a good many of you with a current bipolar diagnosis may have received a schizoaffective diagnosis in your past.
My guess is that even though the DSM-IV leans on the side of "schizophrenia lite," your average clinician applies the schizoaffective diagnosis as a form of "heavy-duty bipolar," almost in frustration.
A number of experts propose eliminating the schizoaffective diagnosis altogether. Instead, clinicians would be encouraged to look at how various conditions fit into the "general psychosis syndrome," or, conversely, how psychosis fits into mood disorders and schizophrenia. In practice, this would probably change things very little. Whether you have one name for what is going on or fifty, clinicians will carry on with what they’ve been doing for the past half-century - namely treat anything that resembles psychosis with an antipsychotic.
But you need to be smarter than your doctor. A psychosis is no more just a psychosis than a depression is just a depression. Here are two key points to consider:
- Does stress seem to bring on your psychosis? In other words, do you start feeling anxious or overloaded or overwhelmed before you lose control? In which case, your primary concern is managing the stress rather treating the psychosis. It may be as simple as stopping to smell the roses or taking an antianxiety med on an as-needed basis. The catch is you need to be adept at picking up your early warning signs of stress, and this typically takes years to master.
- Does your psychosis occur ONLY when you are depressed or manic? In which case, managing your mood becomes your primary concern. Perhaps (emphasis on perhaps) a mood stabilizer alone - without an antipsychotic - will do the job. I heard one expert mention this possibility at a conference I attended.
One final thing: Schizoaffective should not be regarded as a life sentence. Both bipolar and schizophrenia present very differently over the course of time, even within a single episode. At any given moment, your mood may be flaring up more than your psychosis, or vice-versa. Your doctor may be too busy to play spot-the-pattern, but - again - you need to be smarter.
What’s in YOUR psychosis?
I’m looking forward to this being the first in a series of posts on managing psychosis, which means consulting with the real experts - you. Please do not hesitate to share your experiences and insights. Even if you have experienced nothing but frustration, please share that, as well.
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