COMPREHENSIVE
`TEXTBOOK OF
`PSYCHIATRY/ IZ
`
`VOLUME 1
`FOURTH EDITION
`
`EDITORS
`Harold I. Kaplan, M.D.
`Professor of Psychiatry, New York University School of Medicine
`Attending Psychiatrist, University Hospital of the New York University Medical Center
`Attending Psychiatrist, Bellevue Hospital, New York, New York
`Benjamin J. Sadock,M.D.
`
`Professor and Vice Chairman, Department of Psychiatry,
`New York University School of Medicine,
`Attending Psychiatrist, University Hospital of the New York University Medical Center;
`Attending Psychiatrist, Bellevue Hospital, New York, New York
`
`WILLIAMS & WILKINS
`Baltimore /London
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`Editor: Sara A, Finnegan
`Associate Editor: Victoria M. Vaughn
`Design: Joanne Janowiak
`Development Editor: Anne D. Craig
`Illustration Planning: Lorraine Wrozsek
`Production: Norvell E. Miller, II] and Raymond E. Reter
`
`Copyright ©, 1985
`Williams & Wilkins
`428 East Preston Street
`Baltimore, MD 21202, U.S.A.
`
`All rights reserved. This book is protected by copyright. No part of this book may be
`reproduced in any form or by any means, including photocopying, or utilized by any
`information storage and retrieval system without written permission from the copyright
`owner.
`
`The editors and the publisher of this textbook have made every effort to ensure that
`the drug dosage schedules herein are accurate and in accord with the standards accepted
`at the time of publication. Readers are advised, however, to check the product: infor-
`mation sheet included in the package of each drug they plan to administer to be certain
`that changes have not been made in the recommended dose or in the indications and
`contraindications for administration and for adverse reactions, This recommendation
`is of particular importance in regard to new or infrequently used drugs.
`
`Madein the United States ofAmerica
`
`First Edition, 1967
`Second Edition, 1975
`Reprinted 1976
`Third Edition, 1980
`Reprinted 1981, 1983
`
`Library of Congress Cataloging in Publication Data
`
`Main entry undertitle:
`
`Comprehensive textbook of psychiatry/IV.
`
`Rev.ed. of: Comprehensive textbook of psychiatry/III. 3rd ed. c1980.
`Bibliography: p.
`Includes index.
`__. III. Com-
`I. Sadock, Benjamin J.,1933-
`I. Kaplan, Harold I.
`1. Psychiatry.
`prehensive textbook of psychiatry/II. [DNLM: 1, Mental disorders, 2. Psychiatry—
`History. WM 100 C736]
`RC454.C637 1985
`616.89
`83-25952
`ISBN 0-683-04510-5
`
`Composed and printed
`in the United States of America
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`mepeptytn&
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`CHAPTER 17
`
`SCHIZOAFFECTIVE
`DISORDERS
`
`SAMUEL B. GUZE, M.D.
`
`INTRODUCTION
`
`The third edition of the American Psychiatric Association’s
`Diagnostic and Statistical Manual ofMental Disorders (DSM-
`Ill) provides no definition for schizoaffective disorders, nor
`doesit provide diagnostic criteria. The category is included
`among Psychotic Disorders Not Elsewhere Classified to indi-
`cate strong reservations aboutits validity as a separate disor-
`der. Experienced clinicians recognize, however, that certain
`patients present with a mixture ofaffective and psychotic
`features, especially early in the course oftheir illnesses, that
`suggest either schizophrenia or a majoraffective disorder, but
`a confidentdifferential diagnosis is not possible. Usually, the
`clinical course ultimately permits a diagnosis ofeither schizo-
`phrenia oraffective disorder in these patients, but when first
`seen, a diagnosis ofschizoaffective disorderis frequently made
`to indicate uncertainty while defining the diagnostic problem.
`Obviously, implicit in any effort to distinguish among schiz-
`ophrenic, affective, and schizoaffective disorders is the as-
`sumption that the distinction has validity; that is, that the
`classificationis associated with some significantdifferences in
`clinical course, response to treatment, outcome, familial ill-
`ness patterns, cause, or pathogenesis.
`
`HISTORY AND DEFINITION Eversince Kraepelin's work on
`dementia precox, debate about the concept and definition of schizo-
`phrenia hasinterested psychiatrists. For some psychiatrists, persuaded
`by Kraepelin, the diagnosis ofschizophrenia should be reserved for a
`relatively narrow groupofpsychotic patients whosegeneral prognosis,
`both clinica! and social, is poor. For other psychiatrists, who follow
`Bleuler’s views, the diagnosis of schizophrenia includes a wider range
`of patients with variable prognoses,
`It
`is somewhat paradoxical,
`however, to note that Kraepelin claimed that about10 to 15 percent
`ofhis schizophrenic patients recovered completely, whereas Bleuler
`insisted that none ofhis patients ever returned fully to their premorbid
`state.
`perspective, psychiatrists influ-
`As a result of these differences in
`diagnostic cntena associated
`enced by Kraepelin sought to identify
`with a generally
`poor
`prognosis and have defined schizophrenia
`accordingly. Emphasis
`focused on the insidious onset ofthe
`disorder, the schizoid prepertonpersonality, theabsence ofobvious
`precipitatinglife events,
`the restricted affect, the tendencyto a celibate
`life, the inability to establish oneself in a career, and the increased
`familial prevalence ofsimilar illnesses,
`As noted, psychiatrists influenced by Bleuler adopted a much
`broader view of schizophrenia. The diagnosis of schizophrenia was
`made whenever patients showeda functional psychoticillness. Bleuler
`emphasized certain primary symptoms—autistic thinking, ambiva-
`lence, certain affective disturbances—that he believed were always
`present in schizophrenic patients. He assigned delusions and halluci-
`nations to a secondary role, thus making it possible to make the
`diagnosis of schizophrenia in patients showing few, if any, unequiv-
`ocal
`psychotic features.
`.
`Psychoanalysts went one step further. By emphasizing a defective
`ego as the hallmark ofschizophrenia, they were ready to include a
`still broader range of psychopathology in
`the diagnostic category.
`It is easy to understand,
`therefore, that major differences became
`evident in the way that the diagnosis of schizophrenia was made,
`Such opposing views even led to striking national differences: most
`Western European authorities used a narrow definition, in keepin
`with Kraepelinian
`ices, whereas most Americansused a b
`setinttion, in keeping with the Bleulerian and psychoanalytic ap-
`proaches,
`
`Attempts to clarify these opposing views have been reported during
`the course of the past 45 years. An early leader in these efforts was
`Langfeldt, who studied patients resembling more narrowly defined
`schizophrenics whose long-term course and prognosis, however, sug-
`ted that they were nottypical Kraepelinianschizophrenics. Lang-
`cldt referred to such disorders as schizophreniform and emphasized
`their relativelygoodprognoils and response to treatment. Since then,
`many investigators
`have worked on the classification of psychotic
`patients according to their long-term course and prognosis. As a
`result, nondemented psychotic patients may be usefully divided into
`two broad groups, one with a relatively poor prognosis and the other
`with a relatively good prognosis. Such diagnostic terms as chronic
`schiigopheess,proccss schizophrenia, nuclear schizophrenia, and
`nonremitting
`schizophrenia have been applied to the former cases,
`and such terms as acute schizophrenia, remitting schizophrenia,
`reactive schizophrenia, schizophreniform disorders, and schizoaffec-
`tive disorders have been applied to the latter cases. Somepsychiatrists
`have argued that these prognostic differences, although valid, do not
`represent fundamentally different disorders, other psychiatnsts have
`concluded that the differences reflect different basic conditions.
`Intercurrentaffective syndromes developin patients suffering from
`long-established cnsaprsa but such
`patients are excluded here
`from the category of schizoaffective disorders, because such affective
`disturbances apparently do not have the samesignificance asaffective
`symptoms that precede or develop concurrently with a
`psychotic
`syndromeor that appear soon after the acute psychosis has subsided.
`_ Schizoaffective disorders are defined here as syndromes of depres-
`sive or manic features that develop before or concurrently with certain
`psychotic symptoms, such as a preoccupation with a mood-incon-
`gruentdelusion or hallucination, or that ae immediately after the
`acute psychotic symptomsremit. The psychotic symptomsare such
`as to be considered unusual in an uncomplicated affective disorder.
`If the illness is due to any organic mental disorder, the diagnosis of
`schizoaffectiveillness is not made,
`Twokinds of
`psychotic symptoms are included in schizoaffective
`disorders. The first kind includes symptoms that are part of the
`criterion list for schizophrenia, such as delusions of control and
`certain types of auditory hallucinations, and that would suggest
`schizophrenia, if there were no accompanying affective syndrome.
`The second kind includes symptomsthat arise in the context of an
`affective syndrome without an apparentrelationship to depression or
`elation. Otherwise,the clinical features consist of various mixtures of
`affective and schizophrenia-like symptoms.
`
`EPIDEMIOLOGY
`
`Few data are available concerning the prevalence and epide-
`miological distribution ofschizoaffective disorders. Most pop-
`ulation surveys of the incidence or prevalence of psychotic
`disorders have ignored the distinctions discussed here and
`have tended to include nondemented psychotic patients in
`the schizophrenia category. Those investigators who have
`included some psychotic persons in the affective disorder
`category have generally done so on the basis of unspecified
`clinical judgment, rather than on the basis of explicit criteria.
`Certain observations are pertinent, however, and permit
`some tentative conclusions. Most patients with depression
`whoconsult psychiatrists do not report psychotic symptoms.
`Probably no more than one-quarter to one-third of such
`depressed patients experience hallucinations, delusions, or
`prominentideas of reference. Such psychotic features proba-
`bly increase the likelihood ofconsulting a psychiatrist, so that
`the percentage of depressed persons with psychotic features
`included in the over-all group of depressed persons is most
`hkely significanily less than the percentage seen by psychia-
`trists. At most, an estimated 5 to 10 percent of the persons
`seeking any professional help have both depressive and psy-
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`chotic symptoms, The percentage is probably even lower,
`perhaps between 2 and 5 percent, among persons who never
`seek professionalhelp, because this group includes many with
`mild and brief depressions.
`Thelifetime general population risk for depression has been
`estimated to be between 5 and 20 percent, depending on the
`diagnostic criteria and sampling methods that are used, Tak-
`ing the aboveestimates for the frequency of psychotic features
`in depression, one may conclude that a maximum of some-
`where between 0.1 percent and !.0 percentofthe population
`experience a depression with psychotic features.
`Combining the estimated prevalence of manic disorders—
`0.2 percent—with the estimated percentage of manic patients
`who show psychotic features—about 50 to 70 percent—the
`population prevalence of mania with psychosis may be esti-
`mated at about 0.! percent.
`;
`Most population studies place the prevalence of schizo-
`phreniaat less than | percent. Most schizophrenics experience
`affective syndromes sometime during the course ofillness, so
`that an estimate of the association of schizophrenia and
`affective syndromes, usually depressive, is about 0.5 percent
`of the population.
`If the estimated frequencies of depression with psychotic
`features, mania with psychotic features, and schizophrenia
`with affective syndromes are combined, a total estimated
`frequency of between 0.7 and 1.6 percent is obtained. The
`estimate of 1.6 percent may be considered the approximate
`maximum frequency of schizoaffective conditions, The fre-
`quency of schizoaffectiveillness as defined in DSM-III, how-
`ever, is almost certainly considerably less, because intercur-
`rent affective episodes during the course of schizophrenia are
`excluded, as are many patients whose psychotic features seem
`clearly part of an affective illness. Therefore, a reasonable
`estimate of the prevalence of schizoaffective disorders, as
`defined here, does not exceed | percent.
`A majorjustification for separating schizoaffective disorders
`from schizophreniais the difference in the associated familial
`illness patterns. Close relatives of patients with schizoaffective
`disorders tend to show a lower prevalence of schizophrenia
`thanis seen in relatives of schizophrenics; instead, the relatives
`of patients with schizoaffective disorders tend to show a
`frequency ofaffective illness similar to that seen in the rela-
`tives of patients with affective disorders.
`Differential patterns of psychiatric illness in close relatives
`constitute one ofthe most important parameters for validating
`diagnostic categories. Regardless of the relative importance of
`genetic and environmental factors, nearly all psychiatric dis-
`orders have been found to be familial. Thus,
`finding an
`increased prevalence of the same disorder amongclose rela-
`tives provides strong support for the validity of any particular
`diagnosis. Whenill, most of the relatives of schizoaffective
`patients suffer from uncomplicated, straightforward affective
`illnesses; however, an increased frequency of schizoaffective
`conditions may be seen among them. Some authors,especially
`authors reporting the latter increase, have argued that this
`findingjustifies considering schizoaffective disorders as a third
`functional psychosis, in addition to affective psychosis and
`‘schizophrenia. Other authors prefer to consider patients with
`schizoaffective disorders as a heterogeneous group with vary-
`ing proportions of depression, mania, and schizophrenia,
`depending on the method ofselecting the samples. The ques-
`tion of a possible third psychosis is usually left unresolved.
`Nostriking sex differences in the frequency ofschizoaffec-
`tive disorders have been reported.
`
`CHAPTER 17 | SCHIZOAFFECTIVE DISORDERS
`
`‘37
`
`CAUSES
`
`little is known about the causes of all functional
`As yet,
`psychoses, including schizoaffective disorders. Evidence for
`some genetic predisposition to schizophrenic and affective
`disorders has been obtained from a wide range of pedigree,
`twin, and adoption studies. Unfortunately, as noted above,
`relatively little attention has been paid thus far to separating
`out schizoaffective conditions.It is hardly surprising that most
`speculation, whether psychodynamicor biological, concern-
`ing depressive, schizophrenic, and manic psychopathology
`has also been applied to schizoaffective conditions.
`
`CLINICAL FEATURES
`
`Patients present with a mixture of affective features, depres-
`sive or manic, and one or more hallucinations or delusions
`that are considered characteristic of schizophrenia or that,
`because they have no apparent relation to the disordered
`mood, are unusual in uncomplicated affective disorders.
`The psychosis typically begins abruptly, either coincident
`with an affective disturbance or after an affective syndrome
`has been present for days or even weeks. Often,it is difficult
`to be sure which feature was the first to begin. The psychotic
`and affective components mayparallel each other in intensity
`throughout theillness, or one component may wax and wane
`while the other one holdssteady.
`Generally, the psychotic and affective features begin more
`or less simultaneously; then the hallucinations or delusions
`subside, leaving the patient with a typical depression or mania.
`When depression follows,
`it
`is
`frequently described as
`“postpsychotic depression.” The psychotic features are usually
`dramatic and overt, creating disturbancesforrelatives, neigh-
`‘bors, and friends.
`Episodes may be brief, but usually they last for either weeks
`or months. Some patients experience repeated episodes, sep-
`arated by months or years of apparently normal psychological
`functioning. Other patients have several similar episodes that
`are followed by other episodes oftypical depression or mania.
`Sometimes these episodesare supplanted by a persistentillness
`that is indistinguishable from typical chronic schizophrenia,
`with or without associated periods of disturbed mood.
`Suicidal thinking and completed suicide are common in
`these patients, It is not yet known what proportion of young
`schizophrenics who commit suicide were suffering from
`schizoaffective disorders, rather than from uncomplicated
`schizophrenia, As with the familial illness pattern, the suicide
`risk suggests to some psychiatrists that many, if not most,
`schizoaffective illnesses are, in fact, atypical cases of depres-
`sion or mania, rather.than cases of schizophrenia.
`
`COURSE AND PROGNOSIS
`
`The long-term course and outcome of schizoaffective disor-
`ders cannot be discussed separately from the course and
`outcomeofschizophrenia itself. The course of schizoaffective
`disorders is quite variable, but on average, it seems to be
`significantly better than the course of schizophrenia. The
`better prognosis applies to the clinical course of the illness
`and to the social adjustment and appears to be true for
`untreated patients, as well as for treated ones.
`Typically, the psychotic features develop acutely, and the
`patient comes for professional help within weeks of such
`onset, because the patient's family or the patient himself
`recognizes that a significant change in functioning has taken
`place. Therelatively acute onset of the psychotic features has
`long been recognized as an important favorable prognostic
`factor. During the psychotic period, it may be difficult to
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`SCHIZOAFFECTIVE DISORDERS / CHAPTER 17
`
`assess adequately the patient's affective state, although pa-
`tients usually discuss their moods freely. Sometimes the pa-
`tient is severely catatonic and is, therefore, inaccessible; but
`usually such periods are brief, and the patient communicates
`more freely afterward. Catatonic features may be as evident
`in schizoaffective disorders as in schizophrenicstates.
`
`DIAGNOSIS
`
`The diagnosis of schizoaffective disorders follows directly
`from their definition and the clinical picture.
`
`PSYCHIATRIC EXAMINATION ‘The psychiatric examina-
`tion may reveal quite variable findings. In one patient, psy-
`chotic features may be more prominent than affective fea-
`tures; in another patient, the situation may be reversed. Yet
`again, in any single patient, the two types of features may
`fluctuate together or independently. Usually, the delusions or
`hallucinations are quite striking and are easy to recognize.
`Patients are grossly disturbed and create considerable diffi-
`culty for their families and friends. In general, the more
`floridly disturbed the patient, the more there is a likelihood
`that the illness is schizoaffective, rather than schizophrenic.
`The affective features are usually similar to the features seen
`in uncomplicated depression and mania.
`
`DIFFERENTIAL DIAGNOSIS Thedifferential diagnosis in-
`cludes affective disorders, schizophrenia, organic mental dis-
`orders, and certain substance-abuse disorders, particularly
`those disorders associated with the abuse of lysergic acid
`diethylamide (LSD), amphetamines, and other hallucinogens.
`Substance abuse should always be considered when an
`acutely psychotic patient is seen, including a patient with
`striking affective symptoms. Outside history, blood and urine
`screeningfor appropriate metabolites, and careful observation
`frequently permit the correct diagnosis. The majority of sub-
`stance-abuse illnesses usually subside a few days after discon-
`tinuing the drug, and such illnesses rarely last more than 10
`to |2 days after the drug has been discontinued.
`Someschizoaffective patients show clouding of conscious-
`ness early in an episode; therefore, an organic mental disorder
`must sometimes be seriously considered. Generally, however,
`the confusion and bewildermentare short-lived and leave the
`patient with a clear sensorium, despite the continuation of
`other symptoms. Mild confusion or disorientation may oc-
`casionally be evident throughoutthe illness; in such cases,it
`may be simply a matier of policy whetherthe patient receives
`a diagnosis of schizoaffective disorder or, alternatively, of
`organic mental disorder.
`The major differential diagnostic problems relate to schizo-
`phrenia and affective disorders. The history of the concept
`and the definition of schizoaffective disorders suggest that
`such patients are a heterogeneous group suffering from schizo-
`phrenia, affective disorders, and, possibly, a third functional
`psychosis. The relative proportions of the mixture probably
`vary with different circumstances and different diagnostic
`methods. Also, there is still disagreement as to whether re-
`mitting or good-prognosis cases of schizophrenia should be
`classified as schizophrenia or as affective disorders; to some
`extent, differential diagnosis is a matter of convention.
`Patients with these disorders vary greatly in course and
`outcome, and a major concern when such patients are first
`seenis that of estimating prognosis. Efforts to separate patients
`prospectively into two groups—patients with a relatively good
`prognosis and a remitting course and patients with a relatively
`poor outcome and a chronic course—have achieved varied
`SUCCESS.
`
`In general, successful efforts to discriminate good-prognosis
`and poor-prognosis cases have relied on the course of the
`illness up to the time of study, rather than relying on the
`clinical picture. A poor prepsychoticlife adjustment—mani-
`fested by a schizoid personality, few friends, a limited or
`absent sex life, and an insidious onset of illness, so that it is
`difficult to tell when the illness began—is the characteristic
`prognostic feature in poor-prognosis cases. The absence of
`schizoid personality features or life-style and an acutely de-
`veloping psychosis, which often seems to have been precipi-
`tated by some life event and is usually accompanied by
`prominentaffective symptoms, are the important prognostic
`features in good-prognosis cases,
`Emphasizing the clinical picture, rather than the previous
`history, has been less successful. Prominent affective symp-
`toms seem to besignificant in predicting a remitting course
`only when seen in the context of an acute psychosis with a
`good premorbid life history. In the past, when interest in
`psychiatric diagnosis was more limited,little effort was made
`to distinguish affective disorders from schizophrenia, so that
`any patient with psychotic features was simply called schizo-
`phrenic. This lack of effort was particularly noted in the
`United States. As interest in this differential diagnosis has
`grown, however, patients have been less likely to receive a
`diagnosis of schizophrenia based simply on the presence of
`psychotic features. Most affective disorders with psychotic
`features are recognized as affective illnesses, and in the re-
`maining cases, the presence of affective features alone may
`not be as helpful in the differential diagnosis.
`
`PSYCHOLOGICAL TESTS
`
`Psychological test results, not surprisingly, show a mixture of
`features associated with both schizophrenia and affective dis-
`orders. Few studies have dealt with schizoaffective disorders
`as a separate classification.
`
`TREATMENT
`
`Because their psychotic features, affective disturbances,or risk
`of suicide are generally striking, patients with schizoaffective
`disorders usually require hospitalization. Antipsychotic agents
`(such as the phenothiazines and butyrophenones), tricyclic
`antidepressants, antimanic drugs (such as lithium and the
`phenothiazines), and electroconvulsive therapy are the main-
`stays oftreatment.
`The choice ofdrug or combination ofdrugs usually depends
`on the mixture ofclinical features and on the relative severity
`of the various clinical elements, Patients usually do not re-
`spond as well to tricyclic antidepressants alone as they do to
`antipsychotic drugs, with or withouttricyclic antidepressants.
`Similarly, although lithium alone is sometimes effective, it
`generally is not as satisfactory as antipsychotic drugs, with or
`withoutlithium. Many patients do quite well with pharma-
`cological eatment, but a significant number of patients
`respond so poorly or so slowly to such treatmentthat electro-
`convulsive therapy is recommended.
`Most patients have a good response to electroconvulsive
`therapy. As yet, it is unclear whether such patients are further
`improved by concomitant drug administration, but many
`experiencedclinicians believe that patients make better prog-
`ress if the antipsychotic or antimood agentis continued after
`the electroconvulsive therapy.
`Most patients respond to the available treatments. For
`many, drugs or electroconvulsive therapy or a combination
`of the two results in prompt recovery and the ability to return
`to work, school, or home. To what extent the continuation of
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`CHAPTER 17 | SCHIZOAFFECTIVE DISORDERS
`
`759
`
`cea P J: Schizoaffective disorders. J Nerv Ment Dis /70: 646,
`Fowler RC, Liskow BI, Tanna V L, Lytle L, Mezzich J: Schizophre-
`nia-primary affective disorder discrimination. I, Developmentofa
`data-based diagnostic index. Arch Gen Psychiatry 37: 811, 1980.
`Fowler R C, Mezzich J, Liskow B I, Van Valkenburg C; Schizophre-
`nia-primary affective disorder discrimination. II. Where unclassi-
`fied psychosis stands. Arch Gen Psychiatry 37. 815, 1980.
`Goodwin D W, Guze § B: Psychiatric Diagnosis, ed 3, Oxford
`University Press, New York, 1984.
`Goplerud E, Depue R_A:Affective symptoms, schizophrenia, and the
`eeetananabipuity of pastpsychotic depression. Schizophr Bull
`Guze § B, Cloninger C R, Martin R L, Clayton P J: A follow-up and
`family study of schizophrenia. Arch Gen Psychiatry 40; 1273, 1983.
`Johnson D A W;:Studies of depressive symptoms in schizophrenia.
`I. The prevalence of depression and its possible cause, Br J Psy-
`chiatry /39: 89, 1981.
`Langfeldt G: The prognosis in schizophrenia. Acta Psychiatr Neurol
`Scand (Suppl), 110, 1956.
`Pope HG,Jr, Lipinski J F, Cohen B M, Axelrod D T: “Schizoaffective
`disorder": An invalid diagnosis? A comparison of schizoaffective
`anes aa and affective disorder. Am J Psychiatry
`137:
`921,
`
`an antipsychotic or antimood drug prevents relapse is unclear,
`but evidence indicates that such a prophylactic effort may be
`helpful in certain cases. Unfortunately, some patients relapse
`after only a brief remission and must be treated vigorously to
`achieve a more lasting remission. A minority ofpatients show
`very little improvement, despite the application of all the
`above-mentioned treatments, and they progress to a chronic
`state ofillness.
`
`SUGGESTED CROSS REFERENCES
`The schizophrenic disorders are discussed in Chapter 15, and
`the affective disorders are discussed in Chapter 18. Drug
`dependenceis discussed in Chapter 22. Examination ofthe
`psychiatric patient is discussed in Chapter 12. The organic
`therapies are discussed in Chapter 30.
`
`REFERENCES
`Brockington I F, Leff J P: Schizoaffective psychosis: Definitions and
`incidence. Psychol Med 9: 91, 1979.
`
`R
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`CHAPTER 18
`
`AFFECTIVE DISORDERS
`
`descriptions of melancholia and mania are as clinically valid today
`as when written. He also attributed the origin of mental illness to
`natural rather than divine causes, Remarkably, it was Hippocrates
`who placed mental functions and malfunctions in the brain, He
`hypothesized that in mentalillness the brain was unhealthyas a result
`of
`imbalancesin the internal humors.
`,
`The early Roman physicians also made important contributions
`to our understanding of the affective disorders. Aretaeus made a
`distinction between exogenous and endogenous depressions, arguing
`thatalthough they shared a similar symptomatology they had different
`ongins. He also recognized that mania and depression frequently
`coexisted in the same individual. He, in fact,
`argued that mania and
`melancholia were part of a single disorder and
`that its origin was
`related moreto the patient's emotional state than to internal humors,
`With the Renaissance there was ape an emphasis on rational
`explanations and natural causes for
`the mental disorders including
`depression and mania. The role of witchcraft and the influence ofthe
`stars became increasingly de-emphasized and was ultimately elimi-
`nated, The distinction between the mind and the soul was also helpful
`in giving natural science a domain separate from that which belonged
`to theology. Finally, by the 16th and 17th century there was general
`agreementthat the brain was indeed implicated in mental disorders.
`For the next 200 years there was an increasing
`emphasis on the
`humane and enlightened treatment ofthe mentally ill. The spirit of
`the French revolution and the age of enlightenment combined with
`an emphasis on moral treatmentto lead increasingly to a more: useful
`anpiontt to all mental disorders including depression and mania,
`y the end of the 19th century, Kraepelin separated illogical
`psychoses without a tendency toward deterioration from illogical
`psychoses with a tendency toward deterioration. The former group
`was labeled the manic-depressive psychoses and constitutes the core
`of what is meant by the affective disorders today. Kraepelin’s view
`was basically organic, but was complemented by the psychoanalytic
`theories of Freud, Abraham, Rado, and others. The psychoanalytic
`writers emphasized the role of loss and the turning inward of anger
`against the introjected object. Freud also emphasized the role of
`environmental experience and its meaning to the individual in the
`pathogenesis of depression. Morerecently, the importance of cogni-
`tion in depression has been recognized by Beck and his co-workers,
`Finally, with the advent of the psychopharmacological revolution,
`biological theories have achieved increasing importance.
`
`CLINICAL DESCRIPTIONS
`
`18.]
`OVERVIEW OF AFFECTIVE DISORDERS
`
`ROBERT CANCRO, M.D., Med.D.Sc.
`
`INTRODUCTION
`
`The affective disorders constitute a large group ofillnesses
`characterized by alterations of mood. The vast majority of
`people suffering from affective disorders show analteration
`of mood toward depression. Estimates of how many people
`are depressed in any particular year range widely, Conserva-
`tive estimates place the number of people who in any given
`year experience a depressive episode, which is potentially
`diagnosable, at between 10 and 20 million. In the United
`States 1
`in 20 persons is actually diagnosed as having a
`significant depression at least once in theirlifetime.
`
`DEFINITION
`
`The very term “depression”is in many ways ambiguous.It is
`used to refer to a mood, a symptom, a syndrome, and possibly
`even a disease entity. Clearly, the Queen of Hearts did not
`restrict her authority to the world ofAlice, but reigned in the
`world of clinical nosology as well. All human beings show
`fluctuations in mood as a reactionto life events. A depressed
`mood in this sense does not represent a disorder. Obviously,
`happiness is to be desired, but unhappiness—particularly as
`an appropriate response—does not constitute a diagnostic
`category. Unhappiness or normal sadness should not be con-
`fused with depression as a syndrome. It would be better in
`many ways if the mental status examination did not use the
`term “depression” as a symptom, but replaced it with the
`term “sadness.” Depression as a syndromeordisorderis the
`only clinically sound usage of the term, and its use should be
`so restricted.
`Just as the mood of an individual can be altered in the
`direction ofdepression, so can it be altered in the direction of
`elation. Elation is an important symptom in that larger con-
`stellation called mania. Mania should not be confused with
`good spirits and a high energy level. Most energetic people do
`not have a manic disorder, and most manic individuals ex-
`pend considerable energy, but accomplish very little of value
`during their manic episodes.
`
`
`<—<——_———_——HOSSSSESS
`
`
`
`The subclassification of Affective Disorders utilized by the
`third edition of the Diagnostic and Statistical Manual of
`Mental Disorders (DSM-III) does not follow the model for
`most other disorders. Affective Disorders are subgrouped into
`major affective disorders, other specific affective disorders,
`and atypical affective disorders. The majoraffective disorders
`demonstrate a full affective syndrome, whereas the other
`specific affective disorders show only a partial syndrome of a
`minimum of2 year’s duration. The atypical group includes
`those syndromes that cannotbe classifie