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Re: Schizophrenia/ Neuropathology

Posted by Toby on August 19, 1998, at 9:53:32

In reply to Re: Schizophrenia/ Neuropathology , posted by Levi on August 14, 1998, at 1:02:38

At times it does seem that 295.7 is indeed a dumping ground for patients that present with a complicated picture of psychosis and mood symptoms. It is precisely for that reason that the criteria is the DSM are written the way they are. The DSM should prevent a patient with a mood disorder with psychotic features from being diagnosed as schizphrenic. It doesn't always work because docs sometimes don't look closely enough at the patient and plot the course of illness adequately.
From all the available data, it seems that patients with a diagnosis in their chart of schizoaffective disorder are a very varied group: some have schizophrenia with prominent affective symptoms, others have a mood disorder with prominent schizophrenic symptoms, and a third group have a distinct clinical syndrome (which goes to your thought that it is maybe an error in the Kraeplin dichotomy). It does not seem that these patients have BOTH schizophrenia and a mood disorder as separate but co-existing entities. In clinical practice a preliminary diagnosis of schizoaffective disorder is frequently used when the clinician is uncertain of the dignosis (and that's OK if they then go on to figure what the real diagnosis is, but often the patient gets stuck with this diagnosis and that goes on to shape what treatment they get and affects the prognosis as well -- the prognosis of 295.7 is better than schizophrenia but worse than bipolar with psychotic features and much worse than depression with psychotic features).
Schizophrenia and mood disorders seem to be closely related genetically. Relatives of patients with 295.7 (depressed type) are more at risk for having schizophrenia than for having a mood disorder. But relatives of patients with 295.7 (bipolar type) are not at higher risk for schizophrenia. And there aren't alot of schizoaffective patients who also have relatives with schizoaffective disorder (supporting the idea that it is not a distinct disorder; but I think it CAN be a distinct disorder that just isn't genetically based).
Now, as to the DSM criteria... The clinical signs and symptoms include all the signs and symptoms of schizophrenia, mania dn depressive disorders. The schizophrenic and mood disorder symptoms can present together or in an alternating fashion. The course can vary from one of exacerbations and remissions to one of a long-term deteriorating course. There is a lot of debate about the mood incongruent psychotic features. In general, if there are mood-incongruent psychotic features during a mood episode, that is a poor prognostic indicator. The reason the psychotic symptoms must be present for at least 2 weeks without mood symptoms (and 2 weeks was pretty arbitrary I think but they had to have some guideline) is to prevent a diagnosis of schizoaffective disorder from being made when it's really just a severe episode of a mood disturbance with psychotic features (remember that 295.7 has a worse prognosis and that 295.7 would probably require lifelong treatment with an antipsychotic, whereas the psychosis that occurs only during a mood episode can be treated temporarily, until the mood episode is over). The same is true for the criteria that says the mood symptoms must be present for a SUBSTANTIAL portion of the total duration of the active and residual periods of the illness -- you don't want to put somebody on lifelong Lithium for a diagnosis of schizoaffective disorder when they are just having a post-psychotic depression that can be treated with an antidepressant for awhile and then stopped. As an aside, I feel that many patients can be treated with only mood stabilizers (and/or antidepressants) and that the antipsychotics should be used as needed for short-term control. Only if mood stabilizers are not effective on an ongoing basis should antipsychotics be used continuously.
That's all I can think of right now.




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