Psychiatric Annals

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Schizoaffective Disorder: Conceptually Flawed, Clinically Relevant

Oliver Freudenreich, MD, FACLP

A map is not the territory it represents, but, if correct, it has a similar structure to the territory, which accounts for its usefulness.1

Schizoaffective disorder has survived as a diagnostic category despite serious challenges regarding its nosology, validity, and reliability.2 As demonstrated by its ubiquitous clinical use, there clearly exists a need for a category like schizoaffective disorder that overcomes the Kraepelinian dichotomy of schizophrenia versus bipolar disorder, with features of both schizophrenia and mood disorders. Unfortunately, schizoaffective disorder is too-often used simply as a catch-all category, based on cross-sectional symptoms and without awareness of its history and theoretical assumptions about the nature of psychiatric illness. This is problematic, as a diagnosis of schizoaffective disorder without a deeper understanding of its roots and theoretical underpinnings cannot guide treatment and prevents scientific progress.

Although conceptual progress has not resolved the conundrum of schizoaffective disorder (ie, “What exactly is it? Is it real?”) since Goodwin and Ghaemi3 reviewed schizoaffective disorder in this journal a decade ago, I appreciate the invitation to organize this issue of Psychiatric Annals to update clinicians on the field's current view of schizoaffective disorder.

In hopes of providing conceptual clarity and practical guidance to clinicians, this issue contains four articles about schizoaffective disorder covering the history, neurobiology, diagnosis, and treatment.

The first two articles aim to provide a conceptual framework. The introductory article, “Classification of Schizoaffective Disorder: The History of a Vexing Concept,” by Drs. Nicholas Kontos, John Querques, and myself describes the development of the diagnosis of schizoaffective disorder and historical attempts to make this diagnosis more useful and valid, while acknowledging the limitations of our mostly surface-based nosology (phenomenology), as the epigraph by the father of general semantics, Alfred Korzybski, pithily points out. The second article, “The Neurobiology of Schizoaffective Disorder,” by Drs. Shreedhar Paudel, Hannah Brown, and myself describes the underlying geology (neurobiology), summarizing our understanding of the biological underpinnings of schizoaffective disorder, particularly vis-à-vis schizophrenia, and argues for an emphasis on dimensional and transdiagnostic approaches for disorders of brain development, including schizoaffective disorder.

The final two articles address clinical concerns—diagnosis and treatment. The article, “Approach to the Diagnosis of Schizoaffective Disorder,” by Drs. David Beckmann, Kristina Schnitzer, and myself provides a diagnostic approach that accurately applies the Diagnostic and Statistical Manual of Mental Disorders, fifth edition,4 criteria for schizoaffective disorder. The article emphasizes a broader differential diagnosis for cases of atypical psychosis beyond schizoaffective disorder (eg, cycloid psychosis, acute and transient psychotic disorders, medical mimics). The final article, “Schizoaffective Disorder: Treatment Considerations,” by Drs. Kristina Schnitzer, David Beckmann, and myself offers a pragmatic treatment algorithm for patients with schizoaffective disorder that synthesizes the conceptual and diagnostic considerations laid out in the previous articles.

I thank my colleagues for contributing to this issue on schizoaffective disorder while we still have this diagnosis, which may eventually become absorbed into a transdiagnostic classification system that replaces the Kraepelinian dichotomy.

References

  1. Korzybski A. Science and sanity: an introduction to non-Aristotelian systems and general semantics. International Non-Aristotelian Library Publishing Company; 1933.
  2. Heckers S. Is schizoaffective disorder a useful diagnosis?Curr Psychiatry Rep. 2009;11(4):332–337. doi:10.1007/s11920-009-0048-3 [CrossRef]. PMID:19635243
  3. Goodwin FK, Ghaemi SN. The conundrum of schizoaffective disorder: a review of the literature. Psychiatr Ann. 2010;40(3):168–171. doi:10.3928/00485713-20100303-08 [CrossRef]
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
Authors
Oliver Freudenreich, MD, FACLP

Oliver Freudenreich, MD, FACLP, is the Co-Director, Schizophrenia Clinical and Research Program, Massachusetts General Hospital; and an Associate Professor of Psychiatry, Harvard Medical School.

Address correspondence to Oliver Freudenreich, MD, FACLP, Erich Lindemann Mental Health Center, 25 Staniford Street, Boston, MA 02114; email: freudenreich.oliver@mgh.harvard.edu.

Disclosure: Oliver Freudenreich has been a consultant for Alkermes, Neurocrine, Janssen, Novartis, and Roche; has performed contracted research for Otsuka, Janssen, Avanir, and Alkermes; receives royalties from UpToDate, Wolters Kluwer, and Springer; and has received payments from Medscape, Elsevier, and Global Medical Education for writing.

10.3928/00485713-20200409-03

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