Vi
`
`Comprehensive
`Textbook of
`Psychiatry /]]I
`
`THIRD EDITION
`
`-
`-'
`"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
`Alfred M. Freedman, M.D.
`
`Professor of Psychiatry and Chairman,
`Department of Psychiatry, New York Medical College:
`Chairman, Department of Psychiatry. Psychiatric Institute.
`Weslchester Medical Center. Valhalla. New York:
`Chairman. Department of Psychiatry. Metropolitan Hospital and
`Bird S. Coler Memorial Hospital and Home‘, New York.‘ New York
`
`Benjarnind. Sadock, Mi.D.
`
`Attending Psychiatrist, University Hospital of the New York Llnlversi
`Attending Psychiatrist, Bellevue Hospital. New York. New York
`
`ty Medical Centerf
`
`WILLIAMS & WILKINS
`BaItimore/ London
`
`1 of 40
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`The Editors and the Publisher of this work have made every effort to ensure that the drug dosage schedules herein are accurate-and in accord '' _l
`with the standards accepted at the time of publication. The reader is strongly" advised. however, to check the prodi:ct'inforn1ation sheet
`included in the package of each drug he or she plans to administer to be certain that changes have not been made in the recommended dose
`or in the contraindications for administration.
`
`NOTICE
`
`Copyright ©, 1980
`Williams & Wilkins Company
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`will be pleased to make the necessary arrangements at the first opportunity.
`
`Made in the United States of America.
`
`Library of Congress Cataloging in Publication Data.
`
`Kaplan, Harold 1.
`Comprehensive Textbook of Psychiatry.
`Includes bibliographies.
`1. Psychiatry. I. Freedman, Alfred M., joint author. II. Sadock. Benjamin J.. joint author. III. Title [DNLM: 1. Mental disorders.
`2. Psychiatry. 3. Paychietry—l-listory. WM100 F855c]
`RC454.F'ir'4
`1975
`616.89
`'?-$20803
`ISBN 0-683-03357-3
`
`I
`
`Composed and Printed at the Waverly Pr__ess,_ Inc.
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`Baltimore. Maryland, 21202, USA.
`
`2 of 40
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`chapter
`
`17
`
`Schizoaffective Disorders
`
`SAMUEL B. GUZE, M.D.
`
`Introduction
`The third edition of the American Psychiatric Association’s
`{I980} Diagnostic and Statistical Manual of Mental Disorders
`(DSM~III) does not define or give diagnostic criteria for schi-
`zcaffective disorders. Instead, the diagnosis is included among
`Psychotic Disorders Not Elsewhere Classified to indicate strong
`reservations about its validity as a separate disorder. Neverthe-
`less, experienced clinicians have long recognized that certain
`patients, especially early in the course of their illnesses, present
`with a mixture of affective and psychotic features that suggest
`either schizophrenia or a major affective disorder, but for
`whom a confident differential diagnosis is not possible. In the
`past, many of these patients would have been diagnosed as
`suffering from a brief reactive psychosis, schizophreniforni
`disorder, major affective disorder demonstrating rnood-con-
`gruent or mood-incongruent psychotic symptomatology. or
`schizophrenia with an atypical affective disorder. In time, the
`clinical course permits a diagnosis of schizophrenia or affective
`disorder in most of these patients, but when they are first seen
`a diagnosis of schizonffective disorder is frequently made to
`indicate uncertainty while defining the diagnostic problem.
`Although many patients with schizophrenia experience de-
`pression, the significance of such affective features is uncertain.
`It is not clear when such depressions—because of their timing,
`clinical features, or severity—are to be viewed as merely inter-
`current complications of the underlying schizophrenia and
`when they ought to be considered as intrinsic features of the
`disorder, thus raising questions as to whether the basic disorder
`is, in fact, schizophrenia. Sirnilarly, although many patients
`with depression or mania experience delusions and hallucina-
`tions, it is not always clear when such psychotic features should
`raise questions about the underlying disorder.
`Implicit in any effort to distinguish among schizophrenic,
`affective, and Schizoaffective disorders is the assumption that
`the distinction has validity——that is, that the classification is
`associated with some significant differences in clinical course,
`response to treatment, outcome, familial illness patterns, cause
`or pathogenesis for the different disorders (Robins and Guze,
`1970).
`
`History and Definition
`Since the time of Kraepelin ([919), there has been a continuing
`debate about the deftrtition of schizophrenia. For sortie, who follow
`l(mepelin's views, the diagnosis of schizophrenia should be reserved
`for a relatively narrow group of psychotic patients whose general
`prognosis—both clinical and social—is poor, even though, as Kraepelin
`noted, about in to £5 per cent do recover completely. For others, who
`follow Bleuler’s ([950) views, the diagnosis of schizophrenia may be
`used for a wide range of psychotic patients with variable prognoses,
`although, somewhat paradoxically, ‘Bleuler insisted that none ever
`returned fully to his premorbid state.
`
`Thus, psychiatrists influenced by Kraepelin have sought to identify
`diagnostic criteria that are asmiated with a generally poor prognosis
`and have defined schizophrenia accordingly. They have emphasized
`the insidious onset of the disorder, the schizoid prepsychotic person-
`ality, the absence of‘ obvious precipitating life events,
`the restricted
`affect, the tendency to a celihate life, the inability to establish oneself
`in ii. career, and the increased familial prevalence of similar illnesses.
`Psychiatrists influenced by Bleuler have generally adopted a much
`less constricted view of schizophrenia. They have usually been willing
`to diagnose schizophrenia whenever patients showed a functional
`psychotic illness. Bleuler emphasized certain primary symptoms—au-
`tistic thinking. ambivalence, certain affective disturbances—that he
`believed were always present in schizophrenic patients. By assigning
`delusions and hallucinations to a secondary role, he led the way to
`making the diagnosis in patients who show few if any unequivocal
`psychotic features.
`Psychoanalytic theory carried this tendency even further. By eni-
`phasizing a_ defective ego as the hallmark of schizophrenia. psychoan-
`alysts have included a broad range of psychopathology in the diagnosis.
`It is not surprising, therefore. that major international differences
`have burn noted in the diagnosis of schizophrenia. Most Western
`European authorities have used a narrow definition, i.n keeping with
`Kraepelirlian views, and most Americans have used a broad definition,
`in keeping with the Bleulerian and psychoanalytic views.
`Many useful attempts have been made to clarify these opposing
`views during the past 30 years, beginning in 1939 with the work of
`Langfeldt ([956), who tried to characterize patients who may have
`resembled more narrowly defined schizophrenics but whose long-term
`course and prognosis suggested that they were not typical Kraepelinian
`schizophrenics. He referred to such disorders as schizophrenifonn and
`emphasized their relatively good prognosis and response to treatment.
`Since then, many investigators (Astr-up et a1., 1962; Astrup and Noreilr,
`1966; Fowler, 1973; Pope and Lipinski,
`l9T8; Strauss and Carpenter,
`l9'l'8; Vaillant, I918) have continued to work on the classification of
`psychotic patients according to their long-term course and prognosis.
`Nondemented psychotic patients may be usefully divided into two
`broad groups, one with a relatively poor prognosis and the other with
`a relatively good progosis. Diagnostic terms such as chronic schizo-
`phrenia. nuclear schizophrenia, process schizophrenia, and rionremit-
`ting schizophrenia have been applied to those with a relatively poor
`prognosis, and terms like acute schizophrenia, reactive schizophrenia,
`remitting schizophrenia, schizophreniform disorders. and schizoaffec—
`tive disorders have been applied to those with a relatively good
`prognosis. Some have argued that these prognostic differences, al-
`though valid, do not represent fundamentally different disorders (Vail-
`larit, l9'l3); others have concluded that the differences reflect different
`basic conditions (Taylor and Abrams,
`l9'IS; Fowler, 1918).
`
`Affective syndromes may develop in patients suffering from
`long-established schizophrenia but such patients are excluded
`here from the category of Schizoaffective disorders, because
`such affective disturbances do not appear to have the same
`significance as affective symptoms that precede or develop
`concurrently with a psychotic syndrome.
`
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`1 302
`
`Schizoaflective Disorders
`
`Chapter I?
`
`Schizoaifective disorders are defined here as a syndrome of
`depressive or manic features that develop before or concur-
`rently with certain psychotic symptoms, such as a preoccupa-
`tion with a mood-incongruent delusion or hallucination. The
`psychotic symptoms are such as to be considered unusual in an
`uncomplicated affective disorder. The diagnosis of schizoaffec-
`tive illness is not made if the illness is due to any organic
`mental disorder.
`Two kinds of psychotic symptoms define schizoaffective
`disorders. The first kind includes those 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 syn-
`drome. The second kind includes those that arise in the context
`
`of an affective syndrome without an apparent relationship 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 epi-
`demiological distribution of schizoaffective disorders. Most
`population surveys of the incidence or prevalence of psychotic
`disorders have ignored the distinctions discussed here and have
`tended to assign nondemented psychotic patients to the schizo-
`phrenia category. Furthermore,
`investigators who have in-
`cluded some psychotic persons in the affective disorder (manic-
`depressive) category have generally done so on the basis of
`unspecified clinical judgment, rather than on the basis of
`explicit criteria.
`Nevertheless, certain observations are pertinent and permit
`some conclusions. Most patients with depression who consult
`psychiatrists do not report psychotic symptoms. Probably no
`more than a quarter to a third of depressed patients experience
`delusions, hallucinations, or prominent
`ideas of reference
`(Guze et al., 1975). The presence of such psychotic features
`probably increases the likelihood of consulting a psychiatrist,
`so that the percentage of depressed persons with psychotic
`features among all depressed persons is probably significantly
`less than the percentage seen by psychiatrists. At most, an
`estimated 5 to 10 per cent among those who seek any profes-
`sional help have both depressive and psychotic symptoms. The
`percentage is probably even lower, perhaps between 2 and 5
`per cent, among those who never seek professional help, be-
`cause this group includes many with mild and brief depressions.
`The lifetime general population prevalence of depression has
`been estimated to be between 5 and 20 per cent, depending on
`the diagnostic criteria and sampling methods (Weissman et at,
`1978}. Using the above estimates for the frequency of psychotic
`features in depression, one may conclude that a maximum of
`somewhere between 0.1 per cent and [.0 per cent of the
`population experience a depression with psychotic features.
`Combining the estimated prevalence of manic disorders--
`0.2 per cent, according to Weissrnan et at. (19';'8)~—with the
`estimated percentage of manic patients who show psychotic
`features-—about 50 to 70 per cent—the prevalence of mania
`with psychosis may be estimated at about 0.1 per cent.
`Most population studies place the prevalence of schizophre-
`nia at a little under I per cent. Most schizophrenics experience
`affective syndromes sometime during the course of illness
`(plfinitflfvlty and —'0hIISt0n.
`I978), so that an estimate of the
`association of schizophrenia and affective syndromes, usually
`depressive, 15 about 0.5 per cent of the population_
`If the estimated frequencies of depression with psychotic
`features, mania with psychotic features, and schizophrenia with
`
`affective syndromes are combined, the sum is a total estimated
`frequency of between 0.‘? and 1.6 per cent. The estimate of [,6
`per cent may be taken as an approximate maximum frequency
`of schiaoaffective conditions. However, the frequency of schi,
`zoaffective illness as defined in DSM-Ill is considerably less,
`because intercurrent affective episodes during the course of
`schizophrenia are excluded, as are many patients whose psy.
`chotic features seem clearly part of an affective illness. So,
`finally, a reasonable estimate of the prevalence of sczhizoalfec.
`tive disorders, as defined here, may be no more than 1 per cent,
`One of the major justifications for discriminating schizoaf-
`fective disorders from schizophrenia is the difference in the
`familial patterns. Close relatives of patients with schizoaffective
`disorders show a lower prevalence of schizophrenia than is
`seen in relatives of schizophrenics;
`instead,
`the relatives of
`patients with schizoalfective disorders show an increased fre-
`quency of affective illness, at frequency similar to that seen in
`the relatives of patients with affective disorders (Fowler, 1918).
`Differential patterns of psychiatric illness in close relatives
`are one of the most important parameters for validating diag-
`nostic categories (Robins and Guze, 1970}. Regardless of the
`causative importance of genetic and environmental factors.
`nearly all psychiatric disorders have been found to be familial.
`Thus, finding an increased prevalence among close relatives
`provides strong support for any particular diagnosis.
`Most of the ill relatives of schizoaffective patients suffer
`from uncomplicated, straightforward affective illnesses. At the
`same time, an increased frequency of schizoaffective conditions
`may be seen among the relatives. Some authors have reported
`finding such increases and have argued. in fact, that this finding
`justifies considering schizoaffective disorders as a third func-
`tional psychosis, in addition to affective psychosis and schizo-
`phrenia (Leonhard, 1961; Mitsuda, I967; McCabe and Strom-
`gren, !9'r'S; McCabe, 1976). Others (Robins and Gaze, 1970;
`Fowler,
`l9'i'8) have preferred to consider patients with schi-
`zoaffective disorders as a heterogeneous group with varying
`proportions of depression, mania. and schizophrenia, depend-
`ing on the method of selecting the samples, with the question
`of a possible third psychosis left unresolved.
`No striking sex differences in the frequency of schizoaffective
`disorders have been reported.
`
`Causes
`
`Little is known concerning the causes of all functional psy-
`choses, including schizoaffective disorders. Evidence for some
`genetic predisposition to schizophrenic and affective disorders
`has been obtained from a wide range of twin and adoption
`studies, but relatively little attention has been given thus far to
`separating out schizoaffective conditions (see above}.
`Most speculation, whether biological or psychodynamic.
`con_cerning schizophrenic, depressive, and manic psychopa-
`thology has also been applied to schizoaffective conditions.
`This is hardly surprising, because the evidence for considering
`schizoaffective disorders as basically distinct from straightfor-
`ward schizophrenic and affective disorders is still modest.
`
`Clinical Features
`
`All patients present with a mixture of affective features.
`depressive or manic, and one or more clearly evident halluci-
`nations or delusions that are considered characteristic Of
`schizophrenia or, because they have no apparent relation to
`the disordered mood, that are unusual in uncomplicated affec-
`tive disorders.
`
`5
`
`Typically, the psychosis begins abruptly. either coincidenl
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`4 of 40
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`chapter 1?
`
`with an affective disturbance or after an affective syndrome
`has been evident for some days or weeks. It is often difficult to
`be sure which feature began First. The affective and psychotic
`components of the illness may parallel each other in intensity
`throughout. or one may wax and wane while the other holds
`steady-
`A common sequence is for the affective and the psychotic
`features to begin more or less simultaneously; then the delu-
`sions or hallucinations subside,
`leaving the patient with a
`typical depression or mania. The psychotic features are usu-
`ally dramatic and overt, creating disturbances for relatives.
`friends, and neighbors.
`Such episodes may last. very briefly, but they usually run a
`course of weeks to months. Some patients experience repeated
`episodes. separated by months or years of apparently normal
`psychological functioning. Others have several similar episodes
`that are then followed by other episodes of typical depression
`or mania.
`In yet others the episodes are supplanted by a
`persistent illness that is indistinguishable from typical chronic
`schizophrenia, with or without associated periods of disturbed
`mood.
`thinking and completed suicide are common in
`Suicidal
`these patients. In this way they are similar to those with
`straightforward affective disorders. One of the as yet unan-
`swered questions is lhe proportion among young schizophrenics
`who commit suicide of those suffering from schizoaffective
`disorders. rather than from uncomplicated schizophrenia. The
`suicide risk, like the familial illness pattern. has lent support to
`the view that many, ifnot most, schizoaffective illnesses are, in
`fact, atypical cases of depression or mania, rather than cases of
`schizophrenia.
`
`Course and Prognosis
`
`The long-term course and outcome of schinoaffective disor-
`ders cannot be discussed separately from the course and out-
`come of schizophrenia itself. The course of schizoaffective
`disorders may be quite variable, but it seems on average to be
`significantly better than the course of schizophrenia. Stephens
`(I978) summarized 38 long-term follow—up studies of hospital-
`ized schizophrenics and concluded that unspecified or Krae-
`peiinian-type schizophrenia has a much worse prognosis than
`does atypical schizophrenia, schizoaffective psychoses, or re-
`active psychosis. The better prognosis applies to the clinical
`course of the illness and to the social adjustment and is true for
`untreated patients, as well as treated patients.
`Typically. the psychotic features develop acutely, and the
`patient is brought for professional help within weeks of their
`onset, because the patient’s family or the patient himself rec-
`ognizes that a significant change in functioning has taken place.
`The relatively acute onset of the psychotic features has long
`been recognized as an important favorable prognostic factor
`(Stephens, 1978). During the psychotic period, it may be dif-
`ficult to assess the patient’s affective state adequately, although
`the patient usually discusses his or her mood freely. Sometimes
`the patient is severely catatonic and is, therefore, inaccessible,
`but usually such periods are brief‘. and the patient communi-
`cates more freely afterward. Catatonic features may be as
`evident in schizoaffective disorders as in schizophrenic states
`{Taylor and Abrams, 1977).
`
`Diagnosis
`
`The diagnosis of schizoaffective disorders follows directly
`from their definition and the clinical picture.
`
`Schizoalfective Disorders
`
`1 303
`
`PSYCHIATRIC EXAMINATION
`
`The findings on psychiatric examination may be quite vari-
`able. In one patient the psychotic features may be more prom-
`inent than the affective features; in another patient the situation
`may be reversed. In any single patient, these two types of
`features may fluctuate together or independently. Generally,
`however. the delusions or hallucinations are quite striking and
`present no problems in recognition. Patients are disturbed and
`create considerable difficulty for their families and friends. In
`general. the more floridly disturbed the patient, the more likely
`is the illness to be schizoaffective. rather than schizophrenic.
`The affective features are similar to those seen in uncompli-
`cated depression and mania.
`
`DIFFERENTIAL DIAGNOSIS
`
`The differential diagnosis should cover affective disorders,
`schizophrenia. organic mental disorders, and certain substance-
`use disorders, particularly those associated with the abuse of
`amphetamines, lysergic acid diethylarnide (LSD), and other
`hallucinogens.
`'
`Substance abuse should always be considered when con-
`fronted by an acutely psychotic patient, including one with
`striking affective symptoms. Outside history, blood and urine
`screening for appropriate metabolites. and careful observation
`usually permit the correct diagnosis. The great majority of
`substance—abuse illnesses subside within a few days after dis-
`continuation of the drug and very rarely last more than I0 to
`I2 days after discontinuation.
`Because some schizoaffective patients show some clouding
`of consciousness early in the course of an episode, an organic
`mental disorder must frequently be seriously considered. Most
`of the time, however, the confusion and bewilderment are
`short-lived and leave the patient with a clear sensorium. despite
`the continuation of other symptoms. Occasionally, though. the
`mild confusion or disorientation are present throughout the
`illness. In such cases,
`it may be simply a matter of policy
`whether the patient receives a diagnosis of schjzoaffective
`disorder or a diagnosis 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 patients
`with these disorders are a heterogeneous group suffering from
`schizophrenia, affective disorders, and possibly a third func-
`tional psychosis. The relative proportion of the mixture prob-
`ably varies with different circumstances and different diagnos-
`tic methods.
`In addition,
`there is still disagreement as to
`whether remitting or good-prognosis cases of schizophrenia
`should be classified as schizophrenia or as affective disorders
`(Fowler, 1978; Vaillant, 1978). To some extent, differential
`diagnosis is a matter of convention.
`However, patients with these disorders do var)’ considerably
`with regard to their course and outcome. A major ooncem
`when such a patient is first seen "is to estimate his or her
`prognosis. Efforts to separate patients prospectively into those
`with a relatively good prognosis and a remitting course and
`those with a relatively poor outcome and a chronic course have
`achieved varied success {Robins and Guze, 1970; Stephens,
`I978; Strauss and Carpenter, 1978).
`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 as much as, if not more than, the
`clinical picture (Fowler, 1978). A poor prepsychotic life ad-
`justrnent—-manifested by a schizoid personality, few friends, a
`
`5 of 40
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`

`
`1 304
`
`Schizoaflective Disorders
`
`limited or absent sex life, and an insidious onset of illness, so
`that it is difficult to tell when it began—is the characteristic
`prognostic feature i.n poor-prognosis cases. A history without
`schizoid personality features or life style of an acutely devel-
`oping psychosis (often seemingly precipitated by some life
`event), usually accompanied by prominent affective symptoms,
`is the important prognostic feature in good—prognosis cases.
`Efforts that have emphasized the clinical picture, rather than
`the previous history, have been less successful (Strauss and
`Carpenter, I978). Prominent affective symptoms may be sig~
`nificant in predicting a remitting course only when seen in the
`context of an acute psychosis with a good pretnorbid life
`history. In the past, w-hen interest in psychiatric diagnosis was
`limited, little effort was made, particularly in the United States,
`to distinguish affective disorders from schizophrenia, so that
`any patient with psychotic features was simply called schizo-
`phrenic. However, as interest in this differential diagnosis has
`grown, patients have been less likely to be labeled schizo-
`phrenic simply because of psychotic features. Most affective
`disorders with psychotic features are recognized as affective
`illness, and the presence of affective features alone in the
`remaining cases may not be as significant in differential diag-
`nosts.
`
`PSYCHOLOGICAL TESTS
`
`Psychological test results, not surprisingly, show a mixture
`of features associated with both schizophrenia and affective
`disorders. Few studies have taken schizoaffective disorders as
`a separate classification into consideration.
`
`Treatment
`
`Most patients with schizoaffective disorders require hospi-
`talization because of their psychotic features, affective distur-
`bances, or risk of suicide. Antipsychotic agents {such as the
`phenothiazines and butyrophenones). tricyclic antidepressants.
`antirnanic drugs {such as lithium and the phenothiazines), and
`electroconvulsive therapy are the mainstays of treatment.
`The choice of drug or combination of drugs usually depends
`on the mixture of clinical features and the relative severity of
`the various clinical elements. In general, patients do not seem
`to respond as well to tricyclic antidepressants alone as they do
`to antipsychotic drugs, with or without tricyclic antidepressants,
`although some patients do well on the antidepressants alone.
`Similarly,
`lithium alone is sometimes effective but usually
`seems less satisfactory than antipsychotic drugs, with or without
`lithium. Many patients do quite well with pharmacological
`treatment, but a significant number respond so poorly or so
`slowly that electrooonvulsive therapy is indicated.
`Most patients respond well to a course of electrooonvulsive
`therapy. It is not yet clear whether such patients are affected
`by concomitant drug administration, but many experienced
`clinicians believe that patients do better if the antipsychotic or
`
`Chapter I?
`
`antirnood agent is continued after the electroconvulsive lhey.
`apy.
`Most patients are helped by the available treatments. For
`many, drugs or electroconvulsive therapy or a. combination
`results in prompt recovery and the ability to return to work or
`school. To"what extent the continuation of an antipsychotic or
`antirnood drug prevents relapse is not clear, but some evidence
`indicates that such a prophylactic effort is helpful, at least in
`some cases. Unfortunately. some patients relapse after only a
`brief remission and must be treated vigorously to achieve a
`more lasting remission. A minority of patients show very little
`improvement, despite the application of all treatments, and
`they progress to a chronic state of illness.
`
`Suggested Cross References
`The schizophrenic disorders are discussed in Chapter I5, and
`the affective disorders are discussed in Chapters I8 and I9.
`Drug dependence is discussed in Chapter 23. Examination of
`the psychiatric patient is discussed in Chapter I2. The organic
`therapies are discussed in Chapter 31.
`REFERENCES
`
`International
`
`American Psychiatric Association. Diagnostic and Statistical Manual‘ qf Memol
`Disorders. ed. 3. American Psychiatric Association. Washington. D.C.. E980.
`Astrup. C.. Possum. E. and Holmboe. R. Prognosis and Functional Psydmses.
`Charles C Thomas, Springfield. lll_. 19-52.
`Astrup. C.. and Noreik. K. Functional Prycltoser: Diagnostic and Prognorrir
`Model: Charles C Thomas. Springfield. lll.. I966.
`Bleuler. E. Demenrro Praecox or the Group of Srlttzopltrenlos.
`Universities Press. New Yorlt. I950.
`' Fowler. R. C. Remitting schizophrenia as a variant of affective disorder.
`Schizophr. Bull. 4: 63. 1913.
`‘ Gore. 5. B.. Clayton. P.
`.l.. and Woodruff. R. A.. Jr. The significance of
`psychotic affective disorders. Arch. Gen. Psychiatry. 32:
`ll-1?. I915.
`Kraepelin. E. Dementia Praecax and Pnrapltrenia. E and 5 Livingstone. Edin-
`burgh. I9|9_
`_
`Langfeldl. G. The prognosis in schizophrenia. Acta Psychialr. Ncurol. Scand.
`(Suppl). llfl. I956.
`Leonhard. K. Cycloid psychoses Endogenous psychoses which are neither schiz-
`ophrenic nor manic depressive. J. Ment. Sci.. I03’: 633. I961.
`Mccabe. M. S. Reactive psychoses and schizophrenia with good prognosis. Arch.
`Gen. Psychiatry. 33: S"!l. £976.
`Mccahe, M. 5., and Striimgren. E. Reactive psychoses: A family study. Arch.
`Gen. Psychiatry. 32: 44?. I915.
`Milsuda. H. The concept of “atypical psychosis" from the aspect of clinical
`genetics. in Clinical Genetics in Psychiatry, H. Milsuda. editor. p. 3-4. Bunke-
`sha. Kyoto. I967.
`Planansky. K., and Johnston. R. Depressive syndrome in schizophrenia". Acts
`Psychiatr. _Scand.. 5?‘: 20?. I978.
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`depressive illness. Arch. Gen. Psychiatry. 35: B] I, l9'l'8.
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`6 of 40
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`Alkermes, Ex. 1057
`
`

`
`chapter
`
`18
`
`Affective Disorders
`
`13.1 Overview of
`
`Affective
`
`Disorders
`
`GERALD L. KLERMAN, M.D.
`
`Introduction
`
`The term “affective disorders“ groups together a. number of‘
`clinical conditions whose common and essential feature is a
`disturbance of mood accompanied by related cognitive, psy-
`chotnotor, psychophysiological, and interpersonal difficulties.
`Mood usually refers to sustained emotional states that color
`the whole personality and psychic life. Affect sometimes refers
`to the subjective aspect of emotion, apart from its bodily
`component; mood refers to the pervasive or prevailing emotion.
`Therefore. some authorities have suggested that
`the term
`“mood disorders“ would be the more precise designation. In
`the clinical disorders under consideration,
`the emotional
`changes are pervasive and sustained, meeting the definition of
`mood. However, since historical continuity and clinical usage
`have preferred “affective disorders,” that term is used in the
`third edition of the American Psychiatric Association's (i980)
`Diagnostic and Statistical Manual of Mental Drlrorders (DSM-
`[II] and here. Although human experience includes a variety
`of einotions—~such as fear, anger, pleasure, and surprise—the
`clinical conditions considered under the affective disorders
`involve depression and mania.
`Grouping the affective disorders according to the patient’s
`predominant symptoms represents less than the ideal basis for
`nosology. An ideal nosology would base classification on
`causes—-genetic, psychodynamic, and biological factors. Those
`and other factors have been proposed as causal for the affective
`disorders, and investigations are underway to establish their
`precise roles. It is probable that the conditions grouped together
`as affective disorders are heterogeneous as to cause; some or
`most are probably multifactorial in causation. involving com-
`plex interactions of genetic, biochemical, developmental. and
`environmental factors. However, in view of the limited extent
`of‘ the current knowledge about the causes of most mental
`disorders, classification by type of psychological impairment
`has had great heuristic value. Since the late l9th century,
`mental disorders have been classified by the psychological
`facul