Relationship of schizo-affective psychosis to manic depressive psychosis and shizophrenia. Findings in 15,909 veteran pairs

Les états délirants aigus : essai de caractérisation anamnestique, sociodémographique et symptomatique

L’individualisation nosographique au sein des états délirants aigus des bouffées délirantes aiguës, des schizophrénies chroniques avec troubles thymiques, psychoses maniaco-dépressives bipolaires et des états schizophreniques aigus, est, depuis les travaux de Magnan, une particularité de la psychiatrie française ; elle n’a été étayée, jusqu’à présent, que par des appréciations anamnestiques, symptomatiques et évolutives subjectives.

La revue de la littérature a mis en évidence la multiplicité des appellations diagnostiques et le polymorphisme des tableaux cliniques correspondant à ces états délirants aigus. Si la symptomatologie dans un premier temps a permis d’établir cette classification diagnostique, il semble actuellement que ce soit, pour beaucoup d’autres, l’étude de l’anamnèse et du mode évolutif de la maladie, qui pourrait permettre de fixer le diagnostic.

Afin de caractériser ces éléments anamnestiques, socio-démographiques et symptomatiques, une étude statistique a été effectuée à partir d’une population de 471 patients hospitalisés à la Clinique des Maladies Mentales et de l’Encàphale entre 1979 et 1985 se ràpartissant, selon la classification INSERM, de la façon suivante :

Groupe 1 : bouffées délirantes aiguës (BDA) : 53 sujets catégories 041, 042 et 049.

Groupe 2 : schizophrénies avec troubles thymiques (Sch. T) : 109 sujets, états de dépression ou d’excitation atypiques, catégorie 024.

Groupe 3 : psychoses maniaco-dépressives bipolaires (PMD) accès mélancolique et maniaque : 290 sujets, catégories 010, 011, 012, 019.

Groupe 4 : schizophrénies aiguës ou états délirants aigus, probablement schizophréniques (Sch. A), catégorie 040, 19 sujets.

L’ensemble de cette population a été systématiquement évalué à partir de deux instruments d’évaluation quantifiée : l’échelle abrégée d’antécédents psychiatriques (BPHF/F69) et une échelle de psychopathologie générale (BPRS, forme à 18 items, Pichot P., Overall J. E. 1967). 3 types d’analyse ont été réalisés :

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Les résultats

Il ne semble pas exister de profil anamnestique et socio-démographique particulier dans les quatre catégories diagnostiques analysées (BDA, Sch. I , PMD, Sch. A) : en particulier, l’absence de facteurs déclenchants de type d’antécédents familiaux propres à l’un ou l’autre des groupes diagnostiques, de corrélation significative entre une pathologie donnée et le lien de parenté avec le ou les membres de la famille atteints d’une affection psychiatrique. Par contre, l’installation des troubles survient significativement plus tôt chez les Sch. T et Sch. A que chez les DBA et PMD ; seules les BDA et Sch. A ont des accès inférieurs à 6 mois, et des hospitalisations antérieures deux fois moins nombreuses (tableaux 1 et 2).

L’analyse factorielle de la BPRS après rotation varimax permet de retrouver un profil factoriel proche pour les BDA et Sch. A. Le premier facteur est en effet composé de nombreux items communs (désorientation, désorganisation, retrait affectif, émoussement affectif), mais l’item comportement hallucinatoire n’est retrouvé que dans les BDA (avec la saturation la plus élevée des items). Le deuxième facteur comporte aussi des items communs (tension, excitation). Le troisième facteur est de nature thymique dépressive dans les deux groupes (tableau 4).

L’analyse factorielle des Sch. T et des PMD après rotation individualise une structure factorielle propre à ces deux catégories diagnostiques. Néanmoins, le profil factoriel du sousgroupe PMD accès maniaque est assez proche de celui des Sch. T. Chez les Sch. T, le premier facteur est de nature psychotique (méfiance, hostilité, désorganisation conceptuelle, non coopération, pensées inhabituelles, maniérisme). Le deuxième facteur bipolaire est de nature thymique. Le troisième facteur regroupe des items de type négatif (retrait et émoussement affectifs). Il n’apparaît donc pas clairement de facteur général thymique chez les Sch. T. Les PMD se caractérisent par un premier facteur de nature psychotique, un deuxième facteur bipolaire thymique pur dans le sous-groupe accès mélancolique, et de type “négatif” dans le sous-groupe accès maniaque. Le troisième facteur est commun aux deux sous-groupes : il est de nature thymique dépressive (tableau 4).

L’analyse discriminante a permis de définir une première fonction discriminante centrée sur un axe psychotique, une deuxième fonction centrée sur un axe “retrait bizarrerie”, et une troisième centrée sur un axe “anergie”. Le reclassement des sujets par rapport à leur groupe d’origine après analyse discriminante confirme l’autonomie du groupe des PMD puisque 92.4 % des sujets sont bien classés ; les Sch. T sont classés à part égale soit dans le groupe des Sch. T, soit dans celui des PMD. Quant aux BDA, si plus de la moitié des sujets (56.6 %) est correctement classée, le reste de l’effectif est éclaté entre les trois autres groupes diagnostiques restant.

Les Sch. A se répartissent principalement après reclassement, à la fois dans leur groupe d’origine (42.1 %) et dans celui des BDA (36.8 %) ; ceci confirme l’absence d’autonomie de ces deux dernières catégories diagnostiques et la nécessité de compléter cette étude par une analyse portant sur une population plus importante, et comportant un sous-groupe de schizophrénies paranoïdes (analyse en cours) (tableaux 6 et 7).

Cohort Profile: The National Academy of Sciences-National Research Council Twin Registry (NAS-NRC Twin Registry)

The National Academy of Sciences-National Research Council Twin Registry (NAS-NRC Twin Registry) is a comprehensive registry of White male twin pairs born in the USA between 1917 and 1927, both of the twins having served in the military. The purpose was medical research and ultimately improved clinical care. The cohort was assembled in the early 1960s with identification of approximately 16,000 twin pairs, review of service records, a brief mailed questionnaire assessing zygosity, and a health survey largely comparable to questionnaires used at that time with Scandinavian twin registries. Subsequent large-scale data collection occurred in 1974, 1985 and 1998, repeating the health survey and including information on education, employment history and earnings. Self-reported data have been supplemented with mortality, disability and medical data through record linkage. Potential collaborators should access the study website [http://www.iom.edu/Activities/Veterans/TwinsStudy.aspx] or e-mail the Medical Follow-up Agency at [Twins@nas.edu]. Questionnaire data are being prepared for future archiving with the National Archive of Computerized Data on Aging (NACDA) at the Inter-University Consortium for Political and Social Research (ICPSR), University of Michigan, MI.

Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders

Schizoaffective disorder (SA D/O), introduced in 1933 by Dr. Jacob Kasanin, represented a first, modest change in our concept about the diagnoses of psychotic patients away from the beliefs of E. Bleuler, i.e., that hallucinations and delusions define schizophrenia, and toward the recognition of a significant role for mood disorders. SA D/O established a connection between schizophrenia and mood disorders, traditionally considered mutually exclusive, a connection that has strengthened progressively toward the diagnostic unity of all three disorders. A basic tenet of medicine holds that if discrepant symptoms can be explained by one disease instead of two or more, it is likely there is only one disease. The scientific justification for SA D/O and schizophrenia as disorders distinct from a psychotic mood disorder has been questioned. The "schizo" prefix in SA D/O rests upon the presumption that the diagnostic symptoms for schizophrenia are disease specific. They are not, since patients with severe mood disorders can evince any or all of the "schizophrenic" symptoms. "Schizophrenic" symptoms mean "psychotic" and not any specific disease. These data and a very low interrater reliability for SA D/O suggest that the concepts of SA D/O and schizophrenia as valid diagnoses are flawed. Clinically SA D/O remains popular because it encompasses both schizophrenia and psychotic mood disorder when there is a diagnostic question. We present a review of the literature in table form based on an assignment of each article assigned to one of five categories that describe the possible relationships between SA D/O, schizophrenia and psychotic mood disorders. We conclude that the data overall are compatible with the hypothesis that a single disease, a mood disorder, with a broad spectrum of severity, rather than three different disorders, accounts for the functional psychoses.

A source-imaging (low-resolution electromagnetic tomography) study of the EEGs from unmedicated men with schizophrenia

Imaging studies and quantitative electroencephalography (EEG) have often, but not consistently, implicated the left hemisphere and the prefrontal cortex in schizophrenia. To help clarify this picture, a spatial filter shown to be effective for enhancing differences between EEG populations was combined with low-resolution electromagnetic tomography and used to compare the source-current densities from a group of 57 male subjects with schizophrenia and a group of 65 matched controls. To elicit differences, comparisons were made during resting conditions and during verbal and spatial cognitive challenges to the subjects. Estimates of the source-current density were derived from 43-electrode recordings of the EEG reduced to the delta, alpha and beta frequency bands. The patients were unmedicated and were selected according to DSM-IV criteria. As a group, they were severe, chronic states with both deficit negative and superimposed florid psychotic symptomatology. The results confirm that schizophrenia is a left-hemispheric disorder centered in the temporal and frontal lobes. They also suggest that, in schizophrenia, functions normally performed by these regions in controls are assumed by homologous regions in the opposite hemispheres.

Schizoaffective psychoses: genetical clues to classification

The diagnostic classification of schizoaffective psychoses has varied much since Kasanin introduced the concept in 1933. The various classifications have agreed that schizoaffective psychoses present a combination of schizophreniform and affective symptoms, but the diagnostic criteria differ as to the number, quality, and time sequence of the symptoms even in recent classifications like RDC, DSM-III-R, and ICD-10. The classifications are syndromatical, and the etiology of the schizoaffective psychoses is still undetermined apart from evidence for a strong genetic factor. Results from family, twin, and adoption studies are divergent, but all the same, support a separate classification of broadly defined schizoaffective psychoses as possibly being phenotypical variations or expressions of genetic interforms between schizophrenia and affective psychoses.

The role of gender in understanding the familial transmission of schizoaffective disorder

The purpose of this study was to test the effect of gender on the familial risk for schizophrenia and affective disorders in probands with schizoaffective disorder. The sample consisted of 42 DSM-III schizoaffective probands and 149 first-degree relatives from the retrospective cohort family studies, the Iowa 500 and non-500. Survival analysis estimated differences in morbidity risks, analysed by sex of proband and of relative. Findings showed that, among probands, relatives of females had significantly higher rates of schizophrenia and unipolar disorder than relatives of males. Further, among relatives, males were at significantly higher risk for schizophrenia spectrum disorders than females. Results were similar when probands were subdivided into their primary symptom patterns, that is 'mainly schizophrenic' or 'mainly affective', as well as by 'schizoaffective, depressed' or 'schizoaffective, manic'. Implications for the taxonomy of schizoaffective disorder suggest a stronger relationship with schizophrenia, although the relationship with affective disorder remains unclear.

A review of schizoaffective disorder: I. Current concepts

This paper reviews recent literature on schizoaffective disorder. Research studies of diagnosis, clinical course and outcome and family history are evaluated. It is concluded that schizoaffective disorder is a heterogeneous category which includes patients with bipolar disorder, schizophrenia, a genetically distinct psychosis and a genetic disposition to both schizophrenia and bipolar disorder.

The expression of bipolar affective disorders in brain injured patients

OBJECTIVE

A prospective study was designed to investigate the varied presentations of major affective disorders in patients with organic brain disease.

METHOD

Patients admitted to our neuropsychiatry service, with affective and behavioral disturbances, and known neurological disorders, were classified, on phenomenological grounds, into the following groups: 1) elated mania; 2) irritable mania; 3) affective lability with periods of irritability, but without other symptoms pathognomonic for mania; and 4) intermittent psychosis with absent or ambiguous mood changes.

RESULTS

A majority of patients in all four groups responded to pharmacotherapy with anti-cycling agents.

CONCLUSIONS

It is proposed that these groups represent different expressions of mania in brain injured persons, and that these expressions range through a spectrum of phenomenology, included elated mania, irritable mania, episodic psychosis and explosive organic personality disorder. The DSM-III-R classification of these disorders, and approaches to their clinical management, are discussed.

Schizoaffective disorder: a dimensional approach

The current categorical approach has not proved successful in resolving the problem of classifying patients with both affective and schizophrenic features. A dimensional approach is suggested; postulating two interacting factors; "dissociotaxia", a neurointegrative abnormality; and "hyperactivation", an abnormality in activation regulation. The latter factor can convert dissociotaxia to associative dyscontrol and produce mixed schizoaffective features. Clinical-phenomenological, prognostic, genetic-familial, treatment response and biological evidence is reconsidered from this standpoint; and the preferability of the dimensional approach is suggested, both for understanding the underlying psychopathology, and for constructing a different classification system, extensible to other areas of psychiatry.

Controversies and consistencies in psychiatric genetics

The methodology in psychiatric genetics, including family studies, twin studies, and adoption strategies, developed during the last 70 years to a high degree of perfection, has established beyond doubt the heritability of the major psychoses, the schizophrenic and manic-depressive disorders. In spite of recent refinements, including twin-family-study strategies, dual mating strategies, and advanced mathematical models and statistics the mode of inheritance is still undetermined. Evidence for heterogeneity in both schizophrenia and manic-depressive psychosis has been brought up leading to new approaches in diagnostic delimitations. However, the final solution of this issue probably has to await the finding of a genetic marker, for which recent advances in molecular biology as seen in Huntington's disease may give some hope.

Is 'schizophrenia, schizo-affective type' a useful diagnosis? Ten years experience from Danish psychiatric hospitals

During the period 1 April 1970 to 31 March 1980, 1,039 admissions (592 males and 447 females) with the main diagnosis schizophrenia, schizo-affective type, were registered in Danish psychiatric hospitals. Based on the Danish Central Psychiatric Register, 114 patients first admitted to psychiatric hospitals in the period 1970 to 1978 with the main diagnosis schizophrenia, schizo-affective type in at least one admission are described. The results show a continued increase in the use of the diagnosis, but the variation in the use both in different psychiatric hospitals and in patients' admission histories is striking. The question, whether the diagnosis is useful in this way, is discussed, and a proposal for a different international classification of schizo-affective psychoses is given.

Relatives of unipolar and bipolar patients have normal pursuit

Impaired smooth pursuit eye movements are significantly less prevalent among the first-degree relatives of patients who have major affective disorders than among the first-degree relatives of schizophrenics. The distribution of normal and abnormal smooth pursuit among the relatives of unipolar and bipolar patients does not differ from that of normal individuals having no family history of major psychosis. Smooth pursuit impairment is thus specific to relatives of schizophrenic patients and is not characteristic of relatives of patients with major affective disorders.

[Operationalized diagnosis of schizoaffective and cycloid psychoses]

Case histories of 128 patients suffering from functional psychoses were evaluated. The operational definitions for schizoaffective psychoses (SAP) of Kendell, Welner, Spitzer (RDC) and Feighner were applied. Of the 30 cases of SAP based on ICD 8 (295.7), Kendell's criteria were fulfilled in 97% Welner's in 77%, Spitzer's in 70% and Feighner's in 30%. The highly sensitive criteria of Kendell are best qualified for delineating the schizoaffective (sa) syndroms, but have the disadvantage of not requiring a time limitation when examining the longitudinal course of the illness. In this respect, the Welner criteria which also demonstrate high sensitivity were found to be more appropriate for the disease concept of the ICD 8. When using the schizoaffective criteria, a striking overlap was found with catatonic schizophrenia (Kendell and Welner diagnosed 33% as sa), paranoid schizophrenia (Spitzer 39%, Kendell and Welner 28%) and mania (Kendell and Welner 50% sa diagnoses). Of the SAP only 30% satisfied Perris' criteria for cycloid psychoses. Except for catatonic schizophrenia (47% overlap), the cycloid psychoses could be well distinguished from the other psychoses. cycloid psychoses therefore should not form a subgroup of the SAP. Kendell's criteria were found to be best qualified for the determination of the schizoaffective group. A higher specificity of the disease concept SAP may be achieved if we use time limitations such as Welner's. To avoid placing cycloid psychoses in the SAP category, the Perris criteria should be applied. Because of their high specificity, the criteria of Feighner and Spitzer were found to be inappropriate. In DSM-III the definition of "psychotic disorders not elsewhere classified" is weak. It lacks an operational definition for SAP so that DSM-III was not used for this investigation. In order to obtain a more homogeneous population not only in the schizoaffective group, but also in both of the two major psychoses, we find it legitimate to maintain the schizoaffective group and, at the same time, recognize the exceptional position of cycloid psychoses as separate groups.

Changes of diagnosis to manic-depressive illness

In a cohort of patients with an operationally confirmed diagnosis of mania, half of the patients had received a previous diagnosis of schizophrenia, and over one third of the patients had received a diagnosis of personality disorder. Retrospective analysis of case-notes, using operational criteria based on DSM-III, found that manic-depressive illness was more likely to have been the correct previous diagnosis.

Acute psychotic reactions in Caribbean-born patients

A prospective study of patients with religious delusions identified 24 West Indian and West African patients. Those who had none of Schneider's first-rank symptoms of schizophrenia (principally West Indians) differed from those who did by virtue of early religious commitment, life-long religious experiences, an acute admission precipitated by social events, a greater chance of having their diagnosis changed, less than 10 different PSE syndromes, the absence of 'twentieth-century' delusions, and the presentation of malevolent witchcraft as the sole explanation of the episode. It is suggested that this group can usefully be considered as demonstrating an acute psychotic reaction of the type previously described in Africa and the Caribbean.

The temporo-spatial context. A neglected aspect of the depressive response

This study deals with the role of time or space factors in bringing about depressive disorders. Anniversaries, dates or sensory perceptions associated with a depressive experience are seen to act as cues which can automatically unchain a depressive response at a later occasion. In a series of 53 patients suffering with different types of depressive disorders, a group of 18 (one third) were identified as presenting this kind of response. Clinical illustrations and descriptive characteristics are presented, together with an attempt at explantation of some of the mechanisms involved.

Relationship between schizoaffective illness and affective disorders or schizophrenia. Morbidity risk and genetic transmission

Schizoaffective illness has either been linked to schizophrenia and to affective disorders, or it has been considered to be as separate entity. Family and linkage studies can provide data regarding genetic factors in the aetiology of schizoaffective illness. Morbidity risks for affective illnesses and schizophrenia were estimated in the first-degree relatives of schizoaffective probands as compared to matched controls (bipolars, unipolars and schizophrenics). Linkage studies with X-chromosome markers (protanopia and deuteranopia) were also performed in informative families. Our genetic results indicate that schizoaffective illness is a heterogeneous entity. This syndrome appears to be primarily related to the affective disorders, but there may be a subgroup linked to the schizophrenic spectrum disorders. Our studies also indicate that some schizoaffective syndromes may be transmitted through the X-chromosome, a pattern previously demonstrated in some families with bipolar manic-depressive illness.

Manic patients with schizophrenic or paranoid symptoms

A study of 32 patients meeting criteria for 'schizomanic' psychosis is described. These psychoses account for about 1% of hospital admissions. Very few first-degree relatives had either schizophrenia or mania. Lithium seemed an effective treatment. Twenty-four patients made a full recovery, and the series as a whole was closer to manic depressive psychosis than schizophrenia on all outcome measures. Some diagnosis clues are suggested to help the clinician to recognize the patients with a poor prognosis. These findings are in line with other studies, and suggest that most of these patients should be regarded as manic. This conclusion should lead to some revision of present ideas on the incidence and diagnosis of mania.

The atypical psychoses

The psychiatric literature contains numerous accounts of psychoses found worldwide that do not fit classic definitions of schizophrenia, manic-depression, or organic brain syndrome. These vaguely defined 'atypical psychoses' are under scrutiny because of growing knowledge and more rigorous methodology in descriptive and cross-cultural psychiatry. The authors trace the history of atypical psychosis concepts from the contributions of Kraepelin, Jaspers, and Freud to contemporary European and Anglo-American viewpoints. Studies of the atypical psychoses are reviewed in the light of current validation methods in psychiatry. Several methodologic problems plague this area: inadequate definitions, etiologic prejudice, poor premorbid and follow-up assessment, as well as certain naive notions about psychopathology in different cultures. Consequently, knowledge of atypical psychosis is limited and largely impractical. The authors suggest several possibilities for interpreting present and future evidence about these disorders and certain strategies for future studies.

Schizophrenic psychology, associative learning and the role of forebrain dopamine

It is suggested that schizophrenic thinking can be explained as a lowering of levels of significance for acceptance of conclusions based on inductive logic. The formal similarity between inductive logic and operant, or classical conditioning is pointed out. It is thus possible to explain the therapeutic effects of neuroleptic drugs by referring to the effect of these, and related drugs, and of lesions of ascending dopamine pathways, on acquisition of conditioned responses. It is tentatively suggested that recognition of association of related features of the environment, whether in humans or animals occurs in the basal ganglia by a dopamine dependent process. A role is suggested for neocortical noradrenaline in consolidaton of newly acquired associations. Implications and tests of this hypothesis are discussed.

Agitated psychotic depression associated with severe hypomanic episodes: a rare syndrome

The authors present detailed clinical and follow-up data on 12 patients with agitated psychotic depressions who developed serious hypomanic or manic episodes. In six patients, each type of affective episode seemed to merge into the others, while in the other patients there was always a clear temporal distinction between each type of episode. The authors suggest that the older ages of their patients may have contributed to the syndrome. They also offer several possible theoretical explanations: the patients 1) had mixed affective states and were trapped in the "switch" state from depression to mania, 2) inherited both unipolar and bipolar diseases, 3) represent a subgroup of bipolar patients, and 4) were schizoaffective.