`
`COMPREHENSIVE
`TEXTBOOK OF
`
`PSYCHIATRY/VI
`
`VOLUME1
`SIXTH EDITION
`
`EDITORS
`
`HAROLDI. KAPLAN,M.D.
`Professor of Psychiatry, New York University School of Medicine
`Attending Psychiatrist, Tisch Hospital, the University Hospital of the New York
`University Medical Center
`Attending Psychiatrist, Bellevue Hospital Center
`Consultant Psychiatrist, Lenox Hill Hospital
`New York, New York
`
`BENJAMIN J. SADOCK,M.D.
`Professor and Vice Chairman, Departmentof Psychiatry, New York University
`Schoo! of Medicine
`Attending Psychiatrist, Tisch Hospital, the University Hospital of the New York
`University Medical Center
`Attending Psychiatrist, Bellevue Hospital Center
`Consultant Psychiatrist, Lenox Hill Hospital
`New York, New York
`
`(i995)
`
`\
`
`Williams & Wilkins
`BALTIMORE © PHILADELPHIA © HONG KONG
`LONDON © MUNICH = SYDNEY © TOKYO
`A WAVERLY COMPANY
`
`[\
`
`1 of 173
`
`Alkermes, Ex. 1060
`
`1 of 173
`
`Alkermes, Ex. 1060
`
`

`

`
`
`Editor: David C. Retford
`Managing Editor: Kathleen Courtney Millet
`Production Coordinator: Barbara J, Felton
`Copy Editor: Hockett Editorial Service
`Designer; JoAnne Janowiak
`Illustration Planner: Lorraine Wrzosek
`Project Editor; Lynda AbramsZittell, M.A.
`
`Copyright © 1995
`Williams & Wilkins
`351 West Camden Street
`Baltimore, Maryland 21201-2436, USA
`§00-638-D0672
`
`
`
`All rights reserved. This book is protected by copyright. No partof 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,
`
`Notice. The indications and dosagesofall drugs in this book have been recommended
`in the medicalliterature and conform to the practices of the general medical community.
`The medications described do not necessarily have specific approval by the Food and
`Drug Administration for use in the diseases and dosages for which they are recom-
`mended. The package insert for each drug should be consulted for use and dosage as
`approved by the FDA. Becausestandardsfor usage change, it is advisable to keep abreast
`of revised recommendations, particularly those conceming new drugs.
`
`Printed in the United States of America
`
`First Edition 1967
`Second Edition 1975
`Third Edition 1980
`Fourth Edition 1985
`Fifth Edition 1989
`
`Library of Congress Cataloging-in-Publication Data
`
`Comprehensive textbook of psychiatry/VI / editors, Harold I. Kaplan, Benjamin J,
`Sadock.—6th ed.
`p.
`cm
`Includes bibliographical references and index.
`ISBN 0-683-04532-6 (hard cover)
`1. Psychiatry,
`1. Kaplan, Harold !,
`Benjamin J.
`[DNLM:1. Mental Disorders.
`RC454.C637
`1995
`616.89—de20
`DNLM/BLC
`for Library of Congress
`
`I. Sadock,
`
`2. Psychiatry, WM 100 C737 1995]
`
`95-10275cIP
`
`95 96 97 98 99
`12345678910
`
`2 of 173
`
`Alkermes, Ex. 1060
`
`2 of 173
`
`Alkermes, Ex. 1060
`
`

`

`
`
`CHAPTER 15
`
`OTHER PSYCHOTIC
`DISORDERS
`
`15.1
`SCHIZOAFFECTIVE DISORDER,
`SCHIZOPHRENIFORM DISORDER, AND
`BRIEF PSYCHOTIC DISORDER
`
`. SAMUEL G. SIRIS, M.D,
`MICHAEL R. LAVIN, M.D.
`
`INTRODUCTION
`
`proper diagnostic category has been challenged. Nevertheless,
`the presenting symptoms andhistories of asizable number of
`patients seem to forcethe useof the diagnostic category, which
`thefirst part of this section considers.
`The later parts of the section, concerning schizophreniform
`disorder and brief psychotic disorder, address those patients
`whose presenting psychotic symptoms are consistent with
`schizophrenia but whose remitting courses and favorable psy-
`chosocial outcomes do not conform to the typical longitudinal
`patterns of schizophrenia.
`
`SCHIZOAFFECTIVE DISORDER
`
`t
`
`1019
`
`ti
`
`3 of 173
`
`Alkermes, Ex. 1060
`
`Throughout the 20th century, psychiatry has traditionally cat-
`egorized the functional psychoses as belonging to one of two
`basic groupsof disorders, either to the group of disorders now
`DEFINITION=Schizoaffective disorderis defined by the fourth
`known as schizophreniaor to the group of disorders now known
`edition of DSM (DSM-IV) as a psychiatric illness that includes
`as mood disorders. That diagnostic distinction has been based
`significant and enduring mood symptoms, thus satisfying cri-
`on two arenas of observation: symptoms and Jongitudinal
`teria that, in the absence of psychotic symptoms, would qualify
`course. Patients with predominantly perceprual and cognitive
`for a diagnosis of a major mood disorder, In schizoaffective
`problems (hallucinations, impaired reality testing, and thought
`disorder, however, the mood symptoms overlap with prominent
`disorders) and with a deteriorating social or vocational course
`psychotic symptoms that are also persistent and that continue
`have come to be classified as having schizophrenia. Patients
`to be present during a substantial interval of illness when the
`whose symptoms are predominantly in the realm of a disorder
`patient lacks prominent mood symptoms. However, the symp-
`of mood regulation (either in the direction of depression or in
`tomsthat meetcriteria for a mood episode mustalso be present
`the direction of euphoriaorirritability) and who tend to have a
`for a substantial portion ofthe total duration of active and resid-
`more fully remitting course have cometo beclassified as having
`ual periods of that episode ofillness. In addition, if the mood
`mood disorders.
`episode is a major depressive episode, pervasive depressed
`That characterization, however, does not work well forall
`mood must be present. The specific DSM-IV diagnosticcriteria
`B Patients encounteredin clinical practice. Somepatients present
`are listed in Table 15,j-1.
`E With mixtures of those characteristics. That Is, Some patients
`DSM-IV also specifies the diagnosis of schizoaffective dis-
`}
`have symptomsthat have prominentand persistent aspects of
`order in two ways.It distinguishes between a bipolar type and
`, both perceprual-cognitive disturbances and mood disturbances.
`| Otherpatients seem to have predominantly perceptual-cognitive
`.
`‘ymptoms but have a favorable psychosocial course, with full
`@ ‘mission after an episode ofrelatively short duration, Still
`f olier patients present with symptomsthat are predominantlyin
`t
`‘he realm of mood, but the disorders fail to remit or the patients
`& ‘Xperience deteriorating psychosocial courses. Those observa-
`lions have Jed to the hypothesis that a so-called third psychosis
`- “usts, and to the alternative formulationthatall psychoses are
`- A spectrum reaching from pure schizophrenia at one extreme
`¢'9 pure mood disorders at the other. Adhering to a nontheoret-
`al approach, the editors of Diagnostic and Statistical Manual
`ofMental Disorders (DSM)have grouped patients with mixed
`‘acteristics into the larger and potentially heterogeneous cat-
`"ory of psychotic disorders not otherwise specified.
`Over time, many patients with prominentor persistent symp-
`‘Sms in both the perceptual-cognitive andaffective realms have
`F Me to be spoken ofas having schizoaffective disorder, a term
`that ‘self implies the two notions, However, many definitions
`e
`| schizoaffective disorder have been used over the years,
`°*atly complicating its conceptualization and the accumulation
`j
`Pan empirical data base concerning patients with the disorder,
`Mdeed, at times the existence of schizoaffective disorder as a
`
`
`
`TABLE 15,]-1
`Diagnostic Criteria tor Schizoaffective Disorder
`A. An uninterrupted periodof illness during which, at sometime, there
`is either a major depressive episode, a manic episode, or a mixed
`episode concurrent with symptoms that meet criterion A for
`schizophrenia.
`Note: The major depressive episode must include criterion Al:
`depressed mood,
`B. During the sameperiod of illness, there have been delusions or
`hallucinations for at least two weeks in the absence of prominent
`mood symptoms.
`C. Symptomsthat meetcriteria for a mood episode are present for a
`substantial
`portion of the total duration of
`the active and residual
`riods of the illness.
`The disturbance is not due to the direct physiological effects of a
`substance (e.g., a drug of abuse, a medication) or a general medical
`condition.
`Specify type:
`Bipolar type:if the disturbance includes a manic or a mixed
`spree (or a manic or a mixed episode and major depressive
`isades)
`Denrasive type:if the disturbance only includes major depressive
`episodes
`Table from DSM-IV, Diagnostic andStatistical Manual ofMental Dis-
`orders, ed 4. Copyright
`American Psychiatric Association, Washing-
`ton, 1994, Used with pennission.
`
`D.
`
`3 of 173
`
`Alkermes, Ex. 1060
`
`

`

`1020
`
`OTHER PSYCHOTIC DISORDERS / CHAPTER 15
`
`a depressive type on the basis of whether the interval of illness
`includes a manic or mixed episode (bipolar type) or only 4
`depressive episode or episodes (depressive type).
`HISTORY Ac the end ofthe 19th century, Emil Kraepelin prpased
`a two-entity model for functional psychiatric disorders. The elegant
`simplicity ofthat model and the massive scholarship underlying it have
`dominated psychiatric niesology ever since. According to that model,
`a deteriorating course and an otherwise poor prognosis were intimately
`linked with dementia precox (later defined as schizophrenia by Eugen
`Bleuler); a favorable or remitting course ofillness was associated with
`a manic-depressive(that is, mood disorder) diagnosis.
`The practical clinical world, however, was not to be divided up that
`easily; a substantia) number of patients did not fit cleanly into one
`category or the other, The term “‘schizoaffective’ was first used by
`Jacob
`Kasanin in 1933 to describe a group of patients with acute By.
`choses that contained both schizophrenic and affective features. T
`patients’ premorbid functioning tended to be good, their psychotic epi-
`sodes brief, and their prognoses relatively favorable. Four years later
`Gabriel Langfeldt, exploring apparently schizophrenic patients who
`atypically pees recovery or otherwise good outcomes, coined
`the term “‘schizophreniform.’” That Prouping of patients, otherwise
`thought to have important features © schizophrenia, who experience
`relatively favorable outcomespersists to this day.
`
`COMPARATIVE NOSOLOGY
`
`DSM-I, DSM-Il, and DSM-III The first edition of DSM (DSM-,
`published in 1952, continued the traditionof classifying schizoaffective
`disorder as a subtype of schizophrenia, which was consistent with the
`tendency to overdiagnose schizophreniain the United States during the
`mid-20th century, in comparison with European practices. During the
`next decade and
`a half
`the antipsychotic drugs that were discove
`and that began to revolutionize many aspects of psychiatry were often
`thought ofas being antischizophrenic; consequently,thesecond edition
`of
`DSM (BSNLD), published in 1968, made few pangs in the diag-
`nostic position of schizoaffective disorder. However,
`the
`rogressive
`developmentoflithium (Eskalith) in the 1960s and the early 1970s as
`a treatment for mania helped stir a reassessment of the nosological
`position of schizoaffective disorder, Citing the usefulness oflithium in
`at least some cases of schizoaffective disorder and the early studies of
`outcome and family history, several authors began to propose that
`schizoaffective disorder beclassified with affective illnesses. Other
`authors, challenging the simplistic two-entity model, suggested the
`existence of a third entity or, alternatively, a spectrum model of
`psy-
`chosis with no point of ranty
`between the purely affective and
`the
`purely schizophrenic types.
`That position was supported when several
`symptom cluster analyses failed to reveal clear bimodal or trimodal
`aggregates of characteristics. Other authors persisted with the argument
`that schizoaffective disorder was really a misnomer andthat patients
`so classified had been misdiagnosed.
`Throughout the 1970s opinion
`was divided on the issue, and
`the modest amountof empirical data was
`sufficiently contradictory
`that, when the third edition of DSM (DSM-
`Ill) was published in 1980, a category was inserted for schizoaffective
`disorder, but it was the only specific disorder for which no operation-
`alized diagnostic criteria were included.
`Research diagnostic criteria, DSM-III-R, and DSM-IV
`Reflecting additional research, the revised third edition of DSM (DSM-
`IM-R), published in 1987, resolved DSM-ILI's ambiguity by ad
`ting
`operationalized diagnostic criteria for schizoaffective disorder.
`Those
`criteria were descriptively similar to the Research Diagnostic Criteria
`(RDC), which had
`been in existence since the mid-1970s, In contrast
`to the RDC, though, DSM-III-R recognized the difficulty of making a
`purely cross-sectional diagnosis of schizoaffective disorder and incor-
`porated certain longitudinal characteristics in the definition (for exam-
`ple, a requirementforat least two weeks of psychotic symptoms in the
`absence of reat mood symptoms).
`The bulk of
`the farapil research currently available concernin,
`schizoaffective disorder has used either the
`or the DSM-IIl-
`system ofclassification. The RDC further subdivides schizoaffective
`sorder into mostly affective and mostly schizophrenic on the basis
`of(1) core schizophrenic symptomsbeing presentfor at least one week
`in the absence of manic or depressive features and (2) features of dete-
`rioration—such as social withdrawal, impaired occupational function-
`ing, eccentric behavior, and unusual
`thoughts or
`erceplual experi-
`ences—having occurred before the onset of
`the
`affective features, If
`either or both of those two characteristics are
`present, the patient is
`classified as mostly
`schizophrenic. The DSM-III-R criteria for schizo-
`affective disorder
`basically resemble the RDCoriteria for the mostly
`schizophrenic subtype of schizoaffectivedisorder. Most patients meet-
`ing the RDC for the mostly affective type of schizoaffective disorder
`have been classified by DSM-III (or later by DSM-ID-R) as having
`
`a.
`affective (or mood) disorders with mood-incongruent
`@
`P8ychotic
`features.
`DSM-IV retains the fundamental structure of the DSM-ITL-R gin,
`nostic criteria for schizoaffective disorder but resolves some oftes
`temporal ambiguities concerning the relationship of psychotic
`mood symptoms, DSM-IV retains the DSM-III-R subdivision4
`schizoaffective disorderinto a bipolar type and a depressive type of
`the basis of whetherthe patient has ever had a manic or mixed
`a
`That subdivision in DSM-III-R was originally based on the informatiye
`nature of the bipolar-unipolar distinction among patients with mood
`disorders, It has been continued in DSM-IV because empirical gar
`have emerged that the distinction may correlate with certain fam),
`history, outcome, and treatment response data,
`y
`
`q
`
`
`
`—snornnantsanosersaae.
`
`1
`EPIDEMIOLOGY Changesin diagnostic standards overtime
`haveleft studies ofthe epidemiologyof schizoaffective disorde,
`difficult to interpret. Depending on which ofthe various diag.
`
`nostic criteria have been used,patients with schizoaffective dis.
`3
`
`order have been reported to constitute between 10 and 30 per-
`|
`
`centof psychiatric hospital admissionsfor functional psychosis,
`
`Studies have estimated the annual incidence of schizoaffective
`
`disorderto be 0.3 to 5.7 per 100,000 population andthelifetime
`
`prevalence of the disorder to be 0.5 to 0.8 percent. Those figures
`
`may be underestimates,however, inasmuchas one study (based
`
`on RDCcriteria) that
`prospectively followed patients with an
`
`operationalized admission diagnosis of schizophrenia and re-
`
`diagnosed them on a weekly basis found that in 20 percentof
`
`such patients the diagnosis was changed to schizoaffective dis-
`
`order before discharge. Nevertheless, schizoaffective disorder
`
`is generally thought to be less common than schizophrenia,
`
`The age at onset of schizoaffective disorder, as for schizo-
`
`phrenia,
`is typically late adolescence or early adulthood. No
`
`specific associations have been reported with sex, race, geo-
`
`eraphic area, or social class.
`
`
`ETIOLOGY Psychological, psychodynamic, environmental,
`
`and interpersonal factors may play precipitating or triggering
`|
`roles whenthey coincide with the biomedical diathesis that cre- a
`ates the vulnerability for decompensations of a schizoaffective
`j
`nature. Little has been written concerning which psychological
`or interpersonal stresses are the most noxious to specifically
`schizoaffective persons, so hypotheses remain speculative in
`that regard. Issues considered to be important for patients with
`schizophrenia in particular and psychoses in general may well
`be applicable. Those issues include concemsregarding bound-
`aries and difficulties
`in processing information overload
`because of a faulty stimulus barrier for external and intemal
`stimuli, Similarly, themes known to be importantin depression
`and mania, such as loss, loss of love, and internal standards,
`may also be importantin schizoaffective disorder.
`
`Proposed models of the diathesis Several hypotheses
`have been advanced concerning the nature of the underlying
`biological diathesis of schizoaffective disorder: (1) Schizoat-
`fective disorderis a variant of schizophrenia. (2) It is a variant
`of a mooddisorder. (3) Itis a third psychosis,distinct from both
`schizophrenia and affective disorder. (4) Schizoaffective dis-
`order is heterogeneous and consists of a subtype related to
`schizophrenia, a subtype elated to a mood disorder, and per
`haps a subtype that represents a third psychosis. (5) A unitary
`spectrum offunctional psychosis extends from schizophrenia at
`one extreme to mood disordersat the other extreme, and schizo-
`affective disorder occupies an intermediate position on that
`spectrum. (6) Schizoaffective disorder is an interaction of
`schizophrenic and major mood disorder diatheses (a shared-
`diathesis model). Because notissue diagnosis exists for either
`schizophrenia or mood disorders, those six hypotheses remain
`speculative, and the data relevant to them must be regarded
`
`4
`i
`¥
`
`Faeetasasne
`
`4 of 173
`
`Alkermes, Ex. 1060
`
`4 of 173
`
`Alkermes, Ex. 1060
`
`

`

`
`SECTION 15.1
`| SCHIZOAFFECTIVE DISORDER, SCHIZOPHRENIFORM DISORDER, AND BRIEF PSYCHOTIC DISORDER
`1021
`
`of schizophrenia thatthey are destined to develop that disorder
`inferentially. The evidence has also tended to vary, not unex-
`virtually independently of any other circumstances
`they
`pectedly, with the definition of schizoaffective disorder used.
`encounter. Toward the right side of the figure are the many
`The family
`study and outcome data associated with the DSM-III-R
`persons with such a small loading for schizophrenia that they
`definition of
`schizoaffective disorder, especially the depressive sub-
`will probably never manifest any symptoms resembling the dis-
`, have often tended to oe est a relation to schizophrenia. That has
`order. However, in the intermediate region are a substantial
`also been the case for the
`definition of the mostly schizophrenic
`schizoaffective disorder. For example, studies using each of those def-
`number of persons with some loading but not enough to make
`;nitions have found thattherelatives of schizoaffective patients havea
`the occurrence ofthe disorder inevitable. For those people, psy-
`rate of schizophrenia similar to the rate occurringin relatives of schizo-
`chotic
`symptoms
`reflecting their
`schizophrenic diathesis
`hrenic patients. Similarly, a twin-pair study found schizoaffective dis-
`order to assort with schizophrenia, not with mood disorders. Studies
`become manifest in the presence of additional biopsychosocial
`using the cross-sectional R
`definition of schizoaffective disorder in
`insults of sufficient magnitude, For patients who come to man-
`eneral or the RDC mostly affective type in particular have tended to
`ifest schizophrenia (or, in milder cases, schizophreniform dis-
`End acloser familial association of schizoaffective disorder with mood
`order), those insults may result from early brain injury (obstet-
`disorders than did studies that used DSM-IILRcriteria. Earlier studies
`involving schizoaffective disorder patients with good outcomes had led
`rical complications); early viral infection (consistent with sea-
`to similar results, as did a more recent study involving schizomanic
`son of birth findings); early poor nutrition, psychological
`atients. Still other studies have provided evidence that atypical
`psy-
`traumas, and social deprivations(all associated with poverty);
`chosesbreed true—thatis, shee schizophrenic patientstend to
`have
`schizophrenic relatives and mood disorder patients tend to have rela-
`substance abuse; or major psychological or social stresses at the
`tives with mood disorder, schizoaffectivesient were found to have
`time of the onset of the episode (the stress-diathesis model),
`relatives with schizoaffective disorder and
`noteither schizophrenia or
`Similarly, according to the shared diathesis model, an episode
`mood disorder. Those results support the third-psychosis hypothesis;
`however, the findings have not always beenreplicated. Severalstudies
`of a major mood disorder may constitute a sufficient stressor to
`have found schizoaffective patients to have more relatives with mood
`activate (or, in combination with other insults, help activate) the
`disorder than do schizophrenic patients or controls, but fewer relatives
`with mood disorder than do patients with primary mood disorder. Anal-
`underlying psychotic diathesis.
`ogous intermediate results were also found regarding schizophrenic
`Such a model explains the close proximity of most psychotic
`relatives for those patients. Those results support the spectrum hypath-
`symptoms to episodes of mood dysregulation in schizoaffective
`esis,
`the heterogeneity hypothesis, or
`the diathesis
`interaction
`patients yet does not require the full diathesis of schizophrenia
`hypothesis.
`to be present in schizoaffective patients. Lack of requirement
`¢ heterogeneity hypothesis has been supported by an argument
`that, although at least some data sepa each of the other hypothe
`for a full diathesis in this situation is consistent with schizoaf-
`other dala argue agains! each of the other hypotheses, and
`no data
`fective patients’ more favorable premorbid course and outcome
`clearly contradict
`the heterogeneity hypothesis. That SEs how-
`than schizophrenic patients. It is also congruent with the larger
`ever, is weakened bythe fact thatit is hard to contradict a heterogeneity
`hypothesis—thatis, mane findings can be considered to be
`number of schizoaffective patients identified clinically than
`part of the hetero eneity. Furthermore, almostall the genetic and fam-
`would be predicted on the basis of a requirement for a full
`ily data can also be interpreted as consistent with a shared diathesis
`schizophrenia diathesis coinciding with a full mood disorder
`hypothesis.
`diathesis. Therefore, the shared-diathesis model, although spec-
`ulative, appears to be consistent with available family and
`genetic findings.
`DIAGNOSIS AND CLINICAL FEATURES Considerable
`variability is possible in the presenting symptoms of schizoaf-
`fective disorder. All or any of the psychotic symptoms com-
`monly associated with schizophrenia may be present during an
`acute episode. Those symptoms include delusions of various
`sorts, hallucinations, and evidence ofthinking disturbances. The
`delusions are often paranoid in nature, although any kind of
`delusion is possible, including delusions of thought insertion or
`
`Shared diathesis model The shared diathesis hypothesisis
`based on the assumption, supported by neuropsychiatric data,
`that the diathesis for schizophrenia is itself a continuum or a
`spectrum. A small numberofpatients have a high loading for
`the biological diathesis of schizophrenia, and presumably they
`will go on to develop schizophrenia, no matter whatelse occurs.
`A much larger number of persons have. progressively smaller
`loadings with the schizophrenia diathesis. That relation is
`depicted by the curve in Figure 15.1-1. Toward the extreme left
`on the figure are those few persons who have such a massive
`biological loadingforthe perceptual and cognitive dysfunctions
`
`Vulnerability so great that schizophrenia will
`erupt undervirtually any expected life circumstance
`
`FIGURE 15.1-1 Vulnerability to schizophrenic psy-
`chasis and its interaction with other stress factors.
`
`KY under extraordinary stress (|. 8. substance abuse,
`Lf extreme psychosocial stress, 4 concomitant
`
`[| Vulnerability trivial, even under extraordinary stress
`
`Propensity for
`Perceptual and
`Cognitive
`disabillties
`Prototypic for
`Schizophrenia
`
`Prototypic schizophrenic symptomatology will emerge neuropsychiatric diathesis)
`
`0%
`
`Proportion of Population
`
`100%
`
`5 of 173
`
`Alkermes, Ex. 1060
`
`5 of 173
`
`Alkermes, Ex. 1060
`
`

`

`1022
`
`OTHER PSYCHOTIC DISORDERS / CHAPTER 15
`
`
`parameters. Specifically, the rate of nonsuppression on the dexameth-
`withdrawal, delusions of control, and fantastic or bizarre delu-
`(DST) has been reported to be as low in patients
`asone suppression test
`sions. In addition, the delusions may be either congruent or
`
`with schizoaffective Spee as it is in patients with eens
`incongruent with the patient's prevailing mood state. In the
`or in normal control subjects and distinguishable from the higher rate
`
`noted in major depressive disorder. Similarly, the response of thyroid-
`realm of perceptual aberrations, auditory hallucinations are the
`stimulating hormone (TSH)and prolactin to an infusion of thyrotropin-
`
`most common, followed in order by visual, tactile, olfactory,
`releasing hormone (TRH) in schizoaffective patients has been observed
`
`and gustatory hallucinations. Illusions or other perceptual dis-
`to be similar to the response in schizophrenic patients and normal con-
`
`trols and not blunted, as is the case in many patients with majo depres-
`tortions are also possible. Many of the disturbances of thinking
`sive episodes. Nevertheless, those schizoatfective patients who do have
`
`in patients with schizoaffective disorder are also similar to those
`neuroendocrine responses paralleling endogenous depression are more
`
`of schizophrenic: patients. Although schizoaffective manic
`likely to fully recover than are other schizoaffective patients. That
`
`observation appears to be independent of any family loading for mood
`patients, like manic patients, have been noted to produce a sub-
`
`disorders. Few studies have been undertaken in schizoaffective manic
`
`stantial numberof responses, the productions of schizoaffective
`patients, though, and at least one of those studies presented results
`
`patients often lack the humor or playfulness of those of manic
`suggesting that the results of DST and TRHtests more closely approx-
`
`imate the results seen in patients with mood disorders than in nonmanic
`patients. Schizoaffective patients also tend to generate a high
`schizoaffective disorder patients. One study also found schizoaffective
`percentage of idiosyncratic verbalizations,autistic thinking, and
`
`patients to resemble patients with bipolar disorder, rather than schizo-
`confusion. Schizoaffective depressed patients have also been
`their rate of urinary 3-methoxy-4-hydroxyphenyl-
`phrenic
`patients, in
`
`glycol
`) excretion,
`noted to produce idiosyncratic and absurd responses on
`
`occasion.
`
`Prominent mood disorder symptoms are also present in
`DIFFERENTIAL DIAGNOSIS=Schizoaffective disorder must
`schizoaffective disorder. The symptoms may be ofeither the
`be differentiated from mood disorders, schizophrenia, and other
`
`manic or the depressive variety (or both) and reach full and
`psychotic states with whichit could be confused diagnostically.
`
`sustained syndromal proportions. Manic episodes include a dis-
`
`tinct period of consistently elevated or irritable mood, with such
`associated features as grandiosity, a decreased need forsleep,
`overtalkativeness,
`racing thoughts, distractibility,
`increased
`activity or agitation, and a tendency toward excess without
`proper regard for the consequences. Patients in that manic state
`generally have a driven or excited quality. When they are in the
`throes of a manic episode, their behavioral aberrations are often
`fully ego-syntonic, doubt is absent, and they may exhibit an
`impenetrable sense of self-righteousness. Depressive episodes,
`however, are dominated by a blue mood, with such accompa-
`nying features as sleep or appetite disturbances; diminished
`level of interest or pleasure in usual activities; psychomotor
`retardation or agitation; subjective sense of energy loss; exces-
`sive or inappropriate guilt; feelings of worthlessness; dimin-
`ished ability to think, concentrate, or make decisions; and recur-
`rent thoughts of death or suicide. Depressive patients often feel
`hopeless and helpless, and their minds tendto be filled with the
`most negative images of themselves and upsetting, pessimistic,
`or otherwise gloomy thoughts, Although not all the character-
`istics of mania or depression are presentin all patients, the clear
`gestalt is present and overlaps significantly with the time during
`which the patient is flagrantly psychotic. The psychotic and
`mooddisorder symptoms are also of sufficient magnitude to
`impair social, occupational, and self-care functioning.
`Also central to the concept of schizoaffective disorder is the
`episodic nature of the disturbance. Intervalsof intensive illness
`tend to punctuate quiescent periods during which psychosocial
`functioning is adequate. Several researchers have emphasized
`the importance of that course-related characteristic in defining
`schizoaffective disorder, despite the convenience of ignoring
`that issue and making a symptom-based cross-sectional diag-
`nosis at the time of a specific episode.
`
`Mood disorders Mood disorders that need to be differenti-
`ated include mania and psychotic depression. Manic patients
`
`can be flagrantly psychotic on occasion, manifesting halluci-
`
`nations, delusions, and thought disorders, along with their full
`
`manic syndromes; thus, they resemble schizoaffective manic
`
`patients. The difference is that patients with pure mania do not
`
`have extended intervals (two weeks or more) during which hal-
`
`lucinations or delusions persist in the absence of prominent
`
`mood disorder symptoms. Similarly, although psychoticly
`depressed patients may manifest either mood-congruent or
`
`mood-incongruent delusions and hallucinations, those features
`do not continue for as much as two weeksata stretch in the
`
`absence of prominent mood disorder symptoms, as they doin
`&
`
`schizoaffective disorder. In the midst of an episode, therefore, 4
`the diagnosis may not be clear, so the definitive assessment @
`
`should be reserved for a time when the episode has concluded.
`jj
`
`
`
`
`Schizophrenia One key to the differential diagnosis of
`schizoaffective disorder from schizophreniais that a full affec- 4
`tive syndrome—mania or depression—must be present in
`schizoaffective disorder. Mood symptomsofvarious types may 4g
`
`be present or even prominent inthe course of an episode of @
`
`schizophrenia, but, in the absence of a full and sustained mood =
`syndrome, the diagnosis of schizoaffective disorder should not %
`
`be made. The appropriate diagnosis is schizophrenia, not
`-3%
`schizoaffective disorder, even when a full mood syndrome is |}
`
`present, if all the episodes of mood disturbance are brief in -
`
`comparison with the full duration of the psychotic episode. In 4
`addition, the appropriate diagnosis is schizophrenia if the full.
`
`mood syndrome occurs only during the residual phase of
`schizophrenia and not during the course of the flagrant psy
`
`chotic episode.
`
`That last circumstance is the one that applies in the diag
`
`of the syndrome of postpsychotic depression in schizophreni4
`
`Postpsychotic depressionis diagnosed when the full depressly.
`
`syndrome occurs in schizophrenic patients who are either 1
`psychotic or only residually psychotic, The syndrome ma.
`
`occur either soon after the resolution of a psychotic episode OF
`substantially later; and it has been estimated to occur in abou
`
`25 percent of schizophrenic patients. Postpsychotic depressi0!
`
`has been reported to respondto the gradual introduction of ant
`depressant medication,in addition to an ongoing antipsycho
`
`antiparkinsonian regimen, whereas an adjunctive antidepressa”
`
`examination Specific morpholog-
`Famology and laboratory
`ical,
`phystological, neuropsychological, and biochemical studies have
`usu
`not been undertaken in schizoaffective disorder. That lack is
`probably due to diagnostic inconsistencies and disagreements over the
`years and to the general assumption that the wisest course is to char-
`acterize such issues first in the well-defined pure mood disorders and
`schizophrenia, Nevertheless, a numberof biological studies of schizo-
`phrenia have included patients with the RDC mostly schizophrenic type
`of schizoaffective disorder, because internal data analyses have failed
`to See them from the larger group of schizophrenic patients
`stu
`Several neuroendocrine studies of schizoaffective disorder have
`been undertaken, and they have tended to