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8


Schizoaffective mixed states
¨ ¨
Andreas Marneros, Stephan Rottig, Andrea Wenzel, Raffaela Bloink
and Peter Brieger
Martin-Luther University Halle-Wittenberg, Halle, Germany




Introduction
Hardly any studies on schizoaffective mixed states exists. However, an exception is
the Cologne study carried out by Marneros et al. in the 1980s and 1990s (Marneros
et al., 1991). The rarity of research on schizoaffective mixed states is, on the one
hand, a paradox, but on the other hand, an understandable phenomenon. Why a
paradox? There are two reasons: first, while schizoaffective disorders are well
established as diagnostic categories in both Tenth Revision of the International
Classification of Diseases (ICD-10: World Health Organization, 1991) and Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV: American Psychiatric
Association, 1994), it has also been determined that schizoaffective disorders
have to be divided according to their mood component into unipolar and bipolar
types, a fact that implicates the occurrence of schizoaffective mixed states (American
Psychiatric Association, 1994; Marneros et al., 1989a“c; 1990a, b; 1991; Marneros
and Angst, 2000). Second, both diagnostic systems, ICD-10 and DSM-IV, define a
schizoaffective mixed episode, as shown in Tables 8.1 and 8.2. Therefore, it is to
be expected that clinicians and researchers applying either ICD-10 or DSM-IV
criteria diagnose schizoaffective mixed episode. But neither clinical nor practical
experience, as well as a study of the literature, supports such an assumption.
Then, why do these obvious deficits seem understandable? Mainly due to two
reasons: first, the definition of schizoaffective disorders is “ in spite of their long
history and clinical reality “ still diffuse and uncertain. Second, the clinical and
psychopathological picture of schizoaffective mixed states is difficult for non-
specialized physicians to detect.
In such cases, schizophrenic, manic, and depressive symptoms form a rather
unclear and diffuse conglomerate “ sometimes dominated by schizophrenic
symptoms, sometimes dominated by affective symptoms, each in a varying way.
Sometimes the depressive symptomatology is very strong, hiding manic elements,
Cambridge University Press, 2005.
#
188 A. Marneros et al.


Table 8.1 Schizoaffective disorders (F25) according to Tenth Revision of the International
Classification of Diseases (ICD-10: World Health Organization, 1991)

G1. The disorder meets the criteria of one of the affective disorders (F30., F31., F32.) of
moderate or severe degree, as specified for each category
G2. Symptoms from at least one of the groups listed below must be clearly present for most of
the time during a period of at least 2 weeks (these groups are almost the same as for
schizophrenia (F20.0“F20.3))
G3. Criteria G1 and G2 above must be met within the same episode of the disorder, and
concurrently for at least part of the episode. Symptoms from both G1 and G2 must be
prominent in the clinical picture
G4. Most commonly used exclusion clause. The disorder is not attributable to organic mental
disorder (in the sense of F00“F09), or to psychoactive substance-related intoxication,
dependence, or withdrawal (F10“F19)



Table 8.2 Diagnostic criteria for 295.70 schizoaffective disorder Diagnostic and Statistical
Manual of Mental Disorders, 4th edn (DSM-IV: American Psychiatric Association, 1994)

A. An uninterrupted period of illness during which, at some time, there is 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
A1: depressed mood
B. During the same period of illness, there have been delusions or hallucinations for at least 2
weeks in the absence of prominent mood symptoms
C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the
total duration of the active and residual periods of the illness
D. 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 episode (or a manic or a mixed
episode and major depressive episodes)
Depressive type: if the disturbance only includes major depressive episodes

and sometimes the reverse is the case. The ability to diagnose a schizoaffective
mixed episode needs much more experience and training than required to diagnose
an affective mixed episode, which is also much more difficult to determine than a
pure manic or pure depressive episode.


Developments of the definition of schizoaffective disorders
Perhaps the paradox of the extremely rare research on schizoaffective mixed states
can be better understood when one considers the development of the definitions,
189 Schizoaffective mixed states


concepts, and nosological allocations of schizoaffective disorders. The information
that follows provides a summary of this development.
The term ˜˜schizoaffective™™ was introduced in 1933 by the American psychiatrist
John Kasanin in his paper ˜˜The acute schizoaffective psychoses™™, published in the
American Journal of Psychiatry, originally presented at the American Psychiatric
Association annual meeting in Philadelphia the previous year (Kasanin, 1933). But
descriptions of what was later called schizoaffective disorder are much older. Perhaps
the German psychiatrist Karl Kahlbaum can be considered the first psychiatrist in
modern times to describe schizoaffective disorders as a separate group in vesania
typica circularis (1863). Kahlbaum applied cross-sectional and longitudinal aspects.
Later, Kraepelin recognized a ˜˜great number™™ of cases having the characteristics of
both groups of psychoses, dementia praecox and manic-depressive insanity. He also
recognized the existence of such cases, which seriously challenged the clear dichot-
omy between schizophrenia and mood disorders (Kraepelin, 1920; see also Marneros
and Angst, 2000). Such cases were also recognized by Kurt Schneider, who distin-
guished between concurrent and sequential types and called them ˜˜cases-in-between™™
¨
(Zwischen-Falle) (Schneider, 1959). But John Kasanin gave these ˜˜cases-in-between™™
their present name, although the cases described by him are only partly related to
what we today define as schizoaffective disorder. ICD-9 defined schizoaffective
psychosis (295.7) as a psychosis in which conspicuous manic or depressive symptoms
are mixed with schizophrenic symptoms (World Health Organization, 1968). The
diagnosis can only be made when affective and schizophrenic symptoms are promin-
ent. How unclear this ICD-9 was can be demonstrated by its synonyms: amongst
others, one finds terms such as ˜˜cycloid psychoses™™ or ˜˜schizophreniform psychoses,
affective type,™™ which are nowadays seen as fundamentally different syndromes
¨
(Perris, 1986; Pichot, 1986; Stromgren, 1986; Marneros and Pillmann, 2004).
What we presently define as schizoaffective disorders (for example, the definitions
provided by the World Health Organization (ICD-8, 1968; ICD-10, 1991) or
American Psychiatric Association (DSM-IV, 1994), as well as empirical definitions
(Marneros et al., 1986), is much more strongly related to Kurt Schneider™s
˜˜cases-in-between™™ than to Kasanin™s ˜˜schizoaffective psychoses.™™
Pierre Pichot, who analyzed Kasanin™s concept, observed (1986) that Kasanin™s
paper contained three main chapters:
1. General considerations are presented regarding the alleged pessimism of the
Kraepelinian nosology and the specificity of American psychiatry, with Adolf
Meyer™s teachings and the psychoanalytic approach being particularly empha-
sized. Kasanin then suggests the separation (from the ˜˜nuclear constitutional
cases™™ of schizophrenia) of a subgroup of patients defined by special criteria,
probably etiologically related to emotional conflicts of a mainly sexual nature.
This, in turn, prompts him to suggest that ˜˜psycho-therapy is strongly
190 A. Marneros et al.


indicated, and [that] a thorough analytic procedure would be in the best
interest of the patient if one wishes to prevent the recurrence of such attacks.™™
2. A synthetic description of schizoaffective psychoses is introduced based on nine
cases, which can be summarized into four points:
(a) ˜˜The patients are between twenty and thirty . . . in excellent physical health.™™
The personality ˜˜is not very much different from the general run of people
in the community,™™ and the ˜˜social and industrial adjustment™™ is normal.
(b) There is ˜˜definite and specific environmental stress,™™ although some of the
cases reported by Kasanin are not very convincing in this respect.
(c) There is ˜˜a very sudden onset in a setting of emotional turmoil, with
a distortion of the outside world and presence of false sensory impressions
in some cases.™™ The symptomatology is made up of ˜˜a blending of schizo-
phrenic and affective symptoms.™™ ˜˜Absence of passivity and of withdrawal
are good prognostic features.™™
(d) ˜˜The cases presented describe a single episode with a return to a perfectly
normal adjustment.™™ Kasanin states that ˜˜there is usually a vague history of a
previous breakdown™™ and that ˜˜these psychoses tend to repeat themselves.™™
3. Detailed observations of five of the nine cases are presented. The literature quoted by
Kasanin in support of his concept includes classical references to Kraepelin, Bleuler,
Lange, and four American papers. In particular, two contributions by Dunton,
who, in 1910 had described a ˜˜cyclic (or intermittent) form of dementia praecox™™
were quoted, as well as two French papers by Henri Claude ˜˜in which concepts
´
of schizomanie, schizophrenie, and demence precoce are discussed™™ (Pichot, 1986).
The history of the development of the concepts of the schizoaffective disorders was
already described by Maj (1984), Marneros and Tsuang (1986), and Marneros
(1999, 2001). As Pichot (1986) pointed out, the official American history of the
disorder ˜˜schizoaffective™™ can be followed in the successive editions of DSM from
the American Psychiatric Association. DSM-I (American Psychiatric Association,
1952) describes, among the ˜˜schizophrenic reactions,™™ their ˜˜schizo-affective
type.™™ The criteria used in DSM-I are different from Kasanin™s original description.
No mention is made of sudden onset, shortness of episode, or complete recovery.
DSM-II (American Psychiatric Association, 1968) included the category ˜˜schi-
zophrenia, schizoaffective type.™™ The definition, however, had become brief and
noncommittal: ˜˜Patients showing a mixture of schizophrenic symptoms and
pronounced elation and depression.™™ ICD-8, published in the same year, con-
tained the same category (World Health Organization, 1968).
In 1978, the Task Force on Nomenclature and Classification of the American
Psychiatric Association published the draft of DSM-III (American Psychiatric
Association, 1978). It included a special category, schizoaffective disorders, which
191 Schizoaffective mixed states


was completely distinct from schizophrenic disorders. The criteria proposed as
essential were ˜˜a depressive or manic syndrome . . . that preceded or developed
concurrently with certain psychotic symptoms thought to be incompatible with a
purely affective disorder.™™ The DSM-III draft stated, ˜˜[t]he term schizoaffective
has been used in many different ways . . . at the present time there is a controversy
as to whether this disorder represents a variant of Affective Disorder of
Schizophrenia, a third independent nosological entity, or part of a continuum
between pure Affective Disorder and pure Schizophrenia.™™ The separate listing is
justified by ˜˜the accumulated evidence that individuals with a mixture of ˜affective™
and ˜schizophrenic™ symptoms, as compared with individuals diagnosed as having
schizophrenia, have a better prognosis, a tendency towards acute onset and
resolution, more likely recovery to [a] premorbid level of functioning, and an
absence of an increase of prevalence of schizophrenia among family members.™™
Two years later, in the final printed edition of DSM-III (APA, 1980), the
category had practically disappeared. The manic episode and the major depressive
episode now included cases ˜˜with mood-incongruent psychotic features™™ which,
in the draft, would have belonged to the schizoaffective disorders. It is true that
DSM-III has formally retained a category called schizoaffective disorders but,
being without diagnostic criteria, it was considered a residual class ˜˜for those
instances in which the clinician is unable to make a differential diagnosis between
Affective Disorders and either Schizophreniform Disorder or Schizophrenia.™™
A new category, schizophreniform disorder, appears. As Pichot (1986) pointed
out, this category is very similar to Kasanin™s original schizoaffective psychosis
as far as the evolution is concerned: ˜˜The duration . . . is less than six months . . .
[there is] a tendency towards acute onset and resolution . . . [and] recovery to
premorbid levels of functioning,™™ but the symptomatic criteria are those of schizo-
phrenia, with the exception of ˜˜a greater likelihood of emotional turmoil and
confusion.™™ No mention is made of affective symptoms (Pichot, 1986).
In DSM-III-R (American Psychiatric Association, 1987), schizoaffective dis-
orders were reborn “ this time classified independently from both schizophrenia

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