This document discusses the diagnostic criteria and challenges of schizoaffective disorder. It notes that schizoaffective disorder involves a combination of schizophrenia and mood disorder symptoms. However, the diagnostic criteria have varied between classifications and the disorder has very low inter-rater reliability. Differential diagnosis is also difficult given similarities to other psychotic and mood disorders. In summary, schizoaffective disorder remains a controversial and diagnostically complex condition.

1. Schizoaffective Disorder
A Diagnostic Conundrum
Mohamed Ibrahim
Psychiatry Specialist
TPCH – August2023

2. Kraepelinian
dichotomy
Emil Kraepelin (1896): divided psychosis into two groups,
i.e. Dementia Praecox & Manic-Depressive Insanity.
Dementia Praecox → Schizophrenia
(Eugen Bleuler; 1857 – 1939)
Manic-Depressive Insanity → Affective disorder
overarching category for mood disorders
(Henry Maudsley;1835-1918)

3. The Acute Schizoaffective Psychoses
Jacob Kasanin (1897-1946) a Russian-born,
American-trained psychiatrist who introduced the
term ‘schizoaffective psychoses’. In 1933 in The
American Journal of Psychiatry, he published a
paper entitled '"The Acute Schizoaffective
Psychoses" In his article Kasanin described 9 case
studies who had both schizophrenic symptoms
comorbid with affective symptoms.

4. Inclusion in the classification system
• DSM-I (1952): Schizophrenic reaction, schizoaffective type.
• DSM-II (1968):Schizophrenia, schizoaffective type. (excited / depressed)
• DSM-III (1980):schizoaffective disorder (a separate diagnosisunder the
heading:Psychotic Disorders not Elsewhere Classified)
• DSM III-R (1987): introduced the first operationalised diagnostic criteria
for schizoaffective disorder.
• DSM-IV (1994): schizoaffective disorder; bipolar & depressive types (in the
chapter: schizophrenia and other psychotic disorders)
• DSM-5 (2013): schizoaffective disorder; bipolar & depressive types (in the
chapter: SchizophreniaSpectrum and Other Psychotic Disorders)
❖ ICD-9 (1977):the first appearance of schizoaffective in ICD; as a subtype
of schizophrenia.

5. What is schizoaffective
disorder?
• Since its original description, over 24
different definitions have been
generated (Winokur et al 1996).
• Schizoaffective disorder is a mental
disorder that is marked by a
combination of schizophrenia and a
mood disorder.

6. Diagnostic
Criteria:
DSM-5
• A. An uninterrupted period of illness during which there is a major
mood episode (major depressive or manic) concurrent with Criterion A
of schizophrenia. Note: The major depressive episode mustinclude
Criterion A1: Depressed mood.
• B. Delusions or hallucinations for 2 or more weeks in the absence
of a major mood episode (depressive or manic) during the lifetime
duration of the illness.
• C. Symptoms that meet criteria for a major mood episode are
present for the majority of the total duration of the active and residual
portions of the illness.
• D. The disturbance is not attributable to the effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition.
❑ Specify whether:
o Bipolartype
o Depressive type

7. Diagnostic
Criteria:
DSM-5
A. An uninterruptedperiod of illnessduring which there is a major mood
episode (major depressive or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1: Depressed mood.
• Criterion A Schizophrenia:Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or less if successfully
treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganised or catatonicbehaviour.
5. Negativesymptoms (i.e., diminished emotionalexpression or avolition).
❖ICD-11: All diagnosticrequirements for Schizophreniashould be met
concurrently with the full diagnostic requirementsof a Mood Episode.

8. Diagnostic
Criteria:
DSM-5
B. Delusions or hallucinations for 2 or more weeks
in the absence of a major mood episode (depressive or
manic) during the lifetime duration of the illness.
o This differentiates schizoaffectivedisorder from
mood disorders.
o Reliability of self-reports?
o A meta-analysisof 53 studies showed a 28.6%
prevalence of comorbid depressive symptoms in
schizophrenia (Wen Li 2020).
❖ ICD-11:does not require a period of psychotic
symptoms without affectivesymptoms

9. Diagnostic
Criteria:
DSM-5
C. Symptomsthat meet criteria for a major mood
episode are present for the majority of the total duration of
the active and residual portions of the illness.
o DSM IV: a substantialportion of the total duration
➢ Majority: > 50% of the total duration of the illness!
➢ Diagnostic Fluctuation!

10. Diagnostic
Criteria:
DSM-5
D. The disturbance is not attributable to the
effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
❖ Substance misuse can alter the picture of the
original mental disorder:
o Precipitating incongruent psychotic symptomsin people
with a mood disorder.
o Precipitating mood symptoms in people with
schizophrenia.

11. DSM 5 versus ICD-11
• People who meet the DSM
5 criteria for schizoaffective
disorder most probably will be
diagnosed with schizophrenia
under ICD 11.
• People who meet the ICD-
11 criteria for schizoaffective
disorder most probably will be
diagnosed with a primary mood
disorder under DSM 5.

12. Demographics
❖Vague of diagnostic criteria → No large-scale studies
on the epidemiology, incidence, or prevalence.
❖Overall, the clinical and demographic characteristics
are in-between those of bipolar disorder and of
schizophrenia but more similar to schizophrenia.
o Prognosis: Bipolar Disorder > Schizoaffective >
Schizophrenia
o 30% of cases occur between the ages of 25 and 35
o Lifetime prevalence appears to be around 0.3%
o Gender prevalence: Females > Males

13. Diagnostic Reliability
Since its inception, Schizoaffective Disorder diagnosis has been
controversial in terms of its diagnostic necessity, validity and
reliability. (Hung et al., 2018).
"schizoaffective disorder is a nosological nuisance but a clinical
reality" Marneros 2003.

14. Diagnostic
Reliability
Test–retestreliability of
schizoaffective disorder
compared with
schizophrenia, bipolar
disorder, and unipolar
depression
(H Santelmann 2016)
Schizoaffective
disorder had the
lowest Kapp among
the four disorders.

15. Diagnostic
Reliability
(JE Schwartz · 2000)
➢Data from the Israeli National Psychiatric Registry
on 16,341 adults diagnosed with schizophrenia or
schizoaffective, hospitalised at least twice in 1963–
2017, were analysed: Reliability between the last
and first diagnosis was 60 % for schizoaffective
disorder and 94 % for Schizophrenia (Florentin,
2023).
Percentof patients retaining diagnosis over 24 months
schizophrenia 92%
Bipolar disorder 83%
Major depression 74%
Psychosis not otherwise specified 44%
Schizoaffective disorder 36%
Brief psychosis 27%

16. Differential Diagnosis
• Schizophrenia
• Mania with psychotic symptoms
• Depression with psychotic symptoms
• Drug-induced psychosis
• Personality vulnerabilities

17. Take Home Messages
SCHIZOAFFECTIVE DISORDER SHOULD NOT
BE A COMMON DIAGNOSIS.
WHENEVER YOU SEE THE DIAGNOSIS OF
SCHIZOAFFECTIVE DISORDER TRY TO BE A
SCHIZODETECTIVE.
PLEASE THINK TWICE BEFORE INITIATING
THE DIAGNOSIS OF SCHIZOAFFECTIVE
DISORDER.