Schizoaffective Disorder in the DSM-5

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Abstract

Characterization of patients with both psychotic and mood symptoms, either concurrently or at different points during their illness, has always posed a nosological challenge and this is reflected in the poor reliability, low diagnostic stability, and questionable validity of DSM-IV Schizoaffective Disorder. The clinical reality of the frequent co-occurrence of psychosis and Mood Episodes has also resulted in over-utilization of a diagnostic category that was originally intended to only rarely be needed. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, an effort is made to improve reliability of this condition by providing more specific criteria and the concept of Schizoaffective Disorder shifts from an episode diagnosis in DSM-IV to a life-course of the illness in DSM-5. When psychotic symptoms occur exclusively during a Mood Episode, DSM-5 indicates that the diagnosis is the appropriate Mood Disorder with Psychotic Features, but when such a psychotic condition includes at least a two-week period of psychosis without prominent mood symptoms, the diagnosis may be either Schizoaffective Disorder or Schizophrenia. In the DSM-5, the diagnosis of Schizoaffective Disorder can be made only if full Mood Disorder episodes have been present for the majority of the total active and residual course of illness, from the onset of psychotic symptoms up until the current diagnosis. In earlier DSM versions the boundary between Schizophrenia and Schizoaffective Disorder was only qualitatively defined, leading to poor reliability. This change will provide a clearer separation between Schizophrenia with mood symptoms from Schizoaffective Disorder and will also likely reduce rates of diagnosis of Schizoaffective Disorder while increasing the stability of this diagnosis once made.

Section snippets

Historical perspective

The diagnosis of Schizoaffective Disorder has undergone shifting conceptualizations in the different Diagnostic and Statistical Manual (DSM) editions. Up until the most recent edition, the DSM-5, the most influential historical perspective was that of Kraepelin (1920) who proposed that there is a dichotomy between the diagnoses of Schizophrenia (dementia praecox) versus psychotic Mood Disorders (manic-depressive insanity). According to this dichotomous perspective, avolition, decreased

Schizoaffective Disorder as specific disease entity

The validity of a diagnosis and its utility in clinical practice and research depend upon its reliability. Schizophrenia and Mood Disorders can be diagnosed with high reliability, but there is only a fair to poor diagnostic reliability for cases meeting the criteria for Schizophrenia who have Mood Episodes in addition to demonstrating at least two weeks of psychosis in the absence of a Mood Episode (Tandon and Maj, 2008). As described, the lack of specific criteria for the total duration of

Beyond the Kraepelinian dichotomy

The validity of defining Schizoaffective Disorder as a category that is distinct from Mood Disorders and Schizophrenia has been questioned. Six different classes of psychotic disorders were demonstrated based on a latent cluster analysis (Kendler et al., 1998), including Schizophrenia, Major Depression, Schizophreniform Disorder, Bipolar-Schizomania, Schizodepression and Hebephrenia. Also against the Kraepelinian dichotomy, the Wernicke–Kleist–Leonhard school proposed three major groupings of

DSM-5 Schizoaffective Disorder

One option for the DSM-5 would have been to remove the Schizoaffective Disorder category and to add mood symptoms as a dimension to Schizophrenia and Schizophreniform Disorder or to define a single category for the co-occurrence of psychosis and mood symptoms. This option was extensively debated but ultimately deemed to be premature in the absence of sufficient clinical and theoretical validating data justifying such a radical reconceptualization. Additionally, there appeared to be no practical

Mood symptoms in DSM-5 meet Mood Episode criteria for Depression, mania or Mixed States

In DSM-5, criterion C for Schizoaffective Disorder is more stringently defined than in earlier editions of the manual. Mood symptoms sufficient to meet criteria for a Mood Episode must be present for at least half of the total duration of the illness from the onset of the first psychosis including prodromal and residual phases to meet the criteria for Schizoaffective Disorder. Affective symptoms that do not meet the full episode criteria for any mood syndrome will not constitute the mood

DSM-5 Schizoaffective Disorder considers the entire illness course

In DSM-5, Schizoaffective Disorder is a lifetime diagnosis that considers the time from the onset of the psychosis up to the current episode, rather than only defining a single episode with co-morbid psychotic and mood syndromes. This change acknowledges the frequent evolution of phenomenology over the illness course. For example, the successful treatment of a Mood Disorder may result in a clinical picture that comes to be dominated by refractory psychotic symptoms, producing a picture of

Conclusions

The diagnosis Schizoaffective Disorder remains controversial because of poor reliability, low stability, weak validity, and excessive application in practice. However, the DSM-5 remains in the tradition of Kraepelin and continues to separate Mood Disorder from Schizophrenia Spectrum Disorders and recognizes the clinical utility in maintaining a diagnosis that is important to clinicians addressing the middle ground. The modest changes put in place with DSM-5 may result in better reliability, the

Role of funding source

This work was supported by the American Psychiatric Association for the preparation of the DSM-5.

Conflict on interest

The authors reported no conflicts of interest with respect to this work, as required by the APA.

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