17 th Int Review of Psychosis Bipolarity IRPB

17 th Int. Review of Psychosis & Bipolarity IRPB in Lisbon April 26, 2015 Schizoaffective Disorder (SAD): history, symptoms & diagnosis Hans-Jörg Assion LWL-Clinic Dortmund Psychiatry. Psychotherapy. Psychosomatic Medicine Dortmund, Germany

Overview • Introduction • Diagnostic issues • Clinical studies • Perspective _____________________________________________________

Introduction – Diagnosis – Studies – Perspective What do you think? Are you a lumper or a splitter? lump schizophrenia uni-/bipolar (with psychotic features) split schizophrenia with depression schizoaffective, mainly psychotic schizoaffective, mainly affective schizomanic schizodepressive uni-/bipolar with psychotic features unipolar/bipolar _____________________________________________________

Introduction – Diagnosis – Studies – Perspective SAD – critical remarks Schizoaffective disorders are psychotic Schizoaffective disorder is a quite mood disorders; there are no popular diagnosis. schizoaffective disorders Lake CR, Hurwitz N Psychiatry Res. 2006 Aug 30; 143(2 -3): 255 -87 The scientific justification for SA D/O and schizophrenia as disorders distinct from a psychotic mood disorder has been questioned. The "schizo" prefix in SA D/O rests upon the presumption that the diagnostic symptoms for schizophrenia are disease specific. They are not, since patients with severe mood disorders can evince any or all of the "schizophrenic" symptoms. In scientific terms it is a problematic diagnosis. Hypothesis: The concept of mood-disorder with a broad symptom-spectrum is fully covering all of the clinical phenomena. _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Schizoaffective Disorder: A problematic diagnosis Schizoaffective disorder: diagnostic issues and future recommendations. Malhi GS, Green M, Fagiolini A, Peselow ED, Kumari V Bipolar Disord. 2008 Feb; 10(1 Pt 2): 215 -30 OBJECTIVE: Difficulties surrounding the classification of mixed psychotic and affective syndromes continue to plague psychiatric nosology. This paper addresses the controversy regarding the diagnostic validity of schizoaffective disorder (SAD), a diagnosis that is used in both DSM-IV and ICD-10 and one that encroaches on both schizophrenia (SCZ) and bipolar disorder (BD). METHODS: A systematic synthesis of clinical and empirical literature, including evidence from cognitive, neurobiological, genetic, and epidemiological research, was undertaken with the aim of evaluating the utility of the SAD classification. Systematic study of literature of SAD RESULTS: Schizophrenia, Bipolar Disorder and Schizoaffective Disorder are overlapping categories. HYPOTHESIS: • • Schizoaffective is a comorbid syndrome of schizophrenia or bipolar disorder. SAD stands between schizophrenia and bipolarity RECOMMENDATION: Diagnosis of SAD should be omitted with the next revision of DSM or ICD. _____________________________________________________

Introduction – Diagnosis – Studies – Perspective „schizoaffective“ for 80 Yrs John Kasanin 1, 1933: „The Acute Schizoaffective Psychoses“ • 9 patients, age between 20 to 30 yrs. • general health and social adaptation are well • history of mood-disorder in some of the families • acute psychosis with „schizophrenic“ and „affective“ symptoms • remission of symptoms within weeks _____________________________________________________ 1 Kasanin J (1933) Am J Psychiat 13: 97 -126

Introduction – Diagnosis – Studies – Perspective Historical remarks Karl Kahlbaum 1, 1863: „Die Gruppierung der psychischen Krankheiten und die Eintheilung der Seelenstörungen“ (Grouping of psychic illnesses and classification of the disorders of soul) melancholic madness, mania with madness. . . Emil Kraepelin 2, 1899: „Die klinische Stellung der Melancholie“ (Clinical positioning of melancholia) Overlap of dementia praecox and manic-depressive illness. . . _____________________________________________________ 1 Kahlbaum 2 Kraepelin K (1863) Danzig, Kafemann E (1899) Mschr Psychiatr Neurol 6: 325 -335

Introduction – Diagnosis – Studies – Perspective Psychopathology Considerations from history not to diagnose SAD Psychopathological principles: • Principle of dichotomy (E. Kraepelin) either schizophrenic or manic-depressive syndrome • Principle of hierarchy (K. Jaspers) schizophrenic symptoms primarily, mood symptoms secondly • Principle of differential typology (K. Schneider) no differential diagnosis, but a typology • Basic symptoms (Grundsymptome) primarily (E. Bleuler) psychosis with schizophrenic symptoms: diagnosis of schizophrenia in consequence _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Principles of classification according to. . . • biological causes Genetics, anatomy, or other e. g. spino-cerebellar ataxia • clinical symptoms e. g. symptoms of depression in operational classification • the course of illness z. B. depressive episode (ICD-10: F 32) vs. recurrent depressive disorder (ICD-10: F 33) • disorder prognosis e. g. dementia praecox vs. manic-depressive illness (Kraepelin) _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Classification – ICD-10 F 2 schizophrenia, schizotypic and delusional disorder F 25 schizoaffective disorder F 25. 0 schizomanic disorder F 25. 1 schizodepressive disorder F 25. 2 mixed schizoaffective disorder F 25. 8 schizoaffective disorder, other F 25. 9 schizoaffective disorder, not specified _____________________________________________________

Intorduction – Diagnosis – Studies – Perspective Diagnostic criteria according to ICD-10 G 1 Disorder with criteria of an affective disorder (F 30, 31, 32); severity: medium to severe. G 2 Symptoms of schizophrenia for most of the time during 2 or more weeks (F 20. 0 -F 20. 3). 1. e. g. , thought broadcasting, -insertion 2. e. g. , delusion of control. . . 3. e. g. , vocal hallucinations. . . 4. e. g. , bizarre delusion. . . 5. e. g. , neologism. . . 6. Intermittend catatonic features. . . _____________________________________________________

Intorduction – Diagnosis – Studies – Perspective Diagnostic criteria according to ICD-10 G 3 Criterion G 1 and G 2 must be fullfilled during the same episode and at least for some of the time. The clinical syndrome must be characterized with symptoms out of criteria G 1 and G 2. G 4 Criterion for exclusion: A disorder due to an illness of the brain, psychotropic substances, intoxication, addiction, detoxification. _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Diagnostic criteria according to DSM-V A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the ilfetime duration of the illness C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Diagnostic criteria according to DSM-V D. The disturbances is not attributable to the effects of a substance (e. g. , a drug of abuse, a medication) or another medical condition. Specify. . . Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episode may also occur. Depressive type: This subtype applies if only major depressive episodes are part of the presentation. _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Classification of (schizo-)affective disorder bipolar • schizoaffective disorder manic unipolar bipolar unipolar depressive manic depressive affect-dominant schizo-dominant _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Differentialdiagnosis Organic Psychic Disorder Acute Polymorphic Psychotic Disorder No Emotionally agitated and/or psychosis in context of critical incident Psychotic Affective Disorder No Yes Ja Affective syndrome at the same time No Symptoms of depressive or manic episode with psychotic features YES No Psychotic symptoms according to criteria of schizophrenia Yes Schizoaffective Disorder (SAD) Characteristic schizophrenic symptoms for a months or more No Psychotic Affective Disorder Yes Schizophrenia No Schizophreniform Disorder _____________________________________________________

Introduction – Diagnosis – Studies – Perspective „popular, but imprecise“ • Schizoaffective Disorder is diagnosed too often. In clinical routine care SAD: BPD - 3: 1 • Diagnosis „SAD“ covers a bunch of various diagnosis, concomittent disorders or mixed syndromes. • Diagnostic criteria are not used appropriately. • SAD is popular and ends up in treatment decisions with antidepressants, neuroleptics, mood-stabilizers and/or benzodiazepins. _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Unnecessary diagnosis? Yes • Heterogeneous nosolgy • No specific illness • No neuro-biological correlate • Part of spectrum of bipolar disorder or unipolar depression or part of schizophrenia • Monomorphic or polymorphic course of illness with the same prognosis • . . . No • Mixed syndromes are described for long time • Course of illness is characteristic with onset and end • Prognosis better compared to schizophrenia • Risk of schizophrenia is lower in families • Represents a distinct entity _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Bipolar Spectrum Mania Hypomania Normal Depression severe Depression Normal moodcycle Zyklothymic Zyklothymia personality Bipolar II Disorder Unipolar Mania Bipolar I Disorder _____________________________________________________ Goodwin et al. Manic-depressive Illness. Oxford: Oxford University Press, 1990

Introduction – Diagnosis – Studies – Perspective Epidemiology • Epidemiological data is missing (completely)!1 • Estimated incidence for unipolar schizoaffective psychosis: 4/100 0002 • Estimated incidence for bipolar schizoaffective psychosis: 1, 7/100 0002 • Gender ratio: f>m (1, 7: 1) for unipolar SAD f=m for bipolar SAD • First manifestation about 3 yrs later in comparison to schizophrenia 2? ? _____________________________________________________ 1 Marneros 2 Angst A (2004) Thieme, Stuttgart J (1986) Schizoaffective Psychoses. Springer, Berlin

Introduction – Diagnosis – Studies – Perspective Genetics • Relatives of bipolar SAD patients more often have relatives with diagnosis of bipolar affective or bipolar schizoaffective disorder than relatives of unipolar SAD 1. • Correlation between schizodominant SAD and schizophrenia 3. • Twin studies are mostly from the 1980´s. No standardised diagnosis! No case series 2. • No association studies _____________________________________________________ 1 Maier W et al. Am J Psychiat 1992; 149: 1666 -1673 2 Cohen et al. Arch Gen Psychiat 1972; 26: 539 -546 3 Kendler et al. Arch Gen Psychiat 1994; 51: 456 -468

Introduction – Diagnosis – Studies – Perspective Neurocognitive function BD vs. SAD Methods: Several domains of neurocognitive function, executive function, memory, attention, concentration and perceptuomotor function were examined in 28 euthymic SAD patients and 32 BD patients by using a neuropsychological test battery. Hamilton Depression Rating Scale (HAMD), Montgomery-Asberg Depression Rating Scale (MADRS) Young Mania Rating Scale (YMRS) Data analysis: multivariate analysis of covariance (ANCOVA/MANCOVA). Results: Euthymic SAD patients showed greater cognitive impairment than euthymic BD patients in the tested domains including declarative memory and attention. Putative significant group differences concerning cognitive flexibility vanished when controlled for demographic and clinical variables. Age and medication were robust predictors to cognitive performance of both SAD and BD patients. _____________________________________________________ Assion et al. 2010

Introduction – Diagnosis – Studies – Perspective Study on cognition BD vs. SAD MANCOVA/ ANCOVA ♯ Test dimension Bipolar patients (n=32) Mean SD F df P D 42. 61 22. 71 64. 21 42. 88 2. 91 1; 47 0. 09* 0. 63 106. 78 50. 52 139. 29 82. 79 1. 63 1; 43 0. 21* 0. 47 TMT-A (sec. ) TMT-B (sec. ) Schizoaffective patients (n=28) _____________________________________________________ Assion et al. 2010

Introduction – Diagnosis – Studies – Perspective Prognosis Few systematic research 1, 2: • Schizodominant SAD predictive for worse outcome. • „Mixed SAD “ has a worse prognosis. • Missing of critical incidents is a worse predictor. • Positive predictor: Coping strategies pure melancholic episodes _____________________________________________________ 1 Steinmeyer 2 Mc. Glashan EM, Marneros A et al. Eur Arch Psychiat Neurol Sci 1989; 238: 126 -134 TH, Williams PV. J Nerv Ment Dis 1990; 178: 518 -520

Introduction – Diagnosis – Studies – Perspecttive Study on psychopharmacological treatment Treatment of schizoaffective disorder. Elisa Cascade, Amir H. Kalali, Peter Buckley Psychiatry (Edgmont). 2009; 6 (3): 15 -17 In this article, we investigate the range of treatments prescribed for schizoaffective disorder. The data show that the majority of those treated, 87 percent, receive two or more pharmaceutical classes. From a therapeutic class perspective, 93 percent of schizoaffective disorder patients receive an antipsychotic, 48 percent receive a mood disorder treatment, and 42 percent receive an antidepressant. An expert commentary is also included. Methods: • Data of 3100 medical doctors • Jan 2008 unti Dec 2008 • Diagnose according to ICD-9 Results: Number of medication-class: 1 medication-class 13 % 2 medication-classes 48 % 3 medication-classes 39 % Antipsychotics (AP) AP + mood stabilizer (MS) AP + antidepressants (AD) AP + MS + AD other 22 % 20 % 19 % 18 % 31 % _____________________________________________________

Introduction – Diagnosis – Studies – Perspective Conclusion • SAD is a heterogenous group of syndromes, illnesses and disorders. • Criteria for diagnosis are imprecisely used. • Data of SAD resarch (e. g. , genetics, prognosis) are overlapping with data of research on affective disorder or schizophrenia. • Do we need SAD? Is SAD a variation of bipolar disorder? • Research in detail is necessary! _____________________________________________________

Thank you very much for your attention!