Treatment of Schizo-affective
Disorder
G. Michael Dempsey, Ming T. Tsuang, Andrea Struss, and Ana Dvoredsky-Wortsman
T
HE TERM schizo-affective was first introduced by Kasanin;’ it describes patients who exhibit both schizophrenic and affective symptoms. DSM-II2 lists schizo-affective disorder as a subtype of schizophrenia, and traditionally schizo-affective patients have been diagnosed as schizophrenics who exhibit affective features concomitantly with their underlying and primary schizophrenic symptoms. Family studies by Angst3 and PerTis reinforce the traditional concept of schizo-affective disorder as a variant of schizophrenia. A similar theory explains that schizo-affective patients exhibit typical schizophrenic symptoms while ill; but once well, they have a remitting clinical course such as is seen in affective disorder.5 However, the possibility that schizo-affective disorder is a variant of affective disorder is also supported by recent studies. Clayton et aL6 followed up 39 schizoaffective patients and their families. Eighty-five percent of the patients were either well or not schizophrenic after I to 2 years, and 54% had a family history of affective disorder. Cohen et al.’ found that the concordance rate for schizoaffective disorder in monozygotic male twins was significantly higher than that for schizophrenia, while the concordance rate for affective disorder was not significantly different from that for schizo-affective disorder. Tsuangs found that the mean age of onset for sib pairs concordant for schizo-affective disorder was not significantly different from that for sib pairs concordant for affective disorder, but was significantly different from that for sib pairs concordant for schizophrenia. This finding suggests that, in terms of mean age of onset, schizoaffective disorder is closer to affective disorder than to schizophrenia. McCabe et aLs conducted a blind family study for good-prognosis and poor-prognosis schizophrenics, using diagnostic criteria for the good-prognosis group similar to those commonly used for schizo-affective disorder. The good-prognosis schizophrenics had a significant incidence of affective disorder among their relatives, while a higher incidence of schizophrenia was found in the families of poorprognosis schizophrenics. These investigations suggest that schizo-affective disorder is a variant of affective disorder. Another possibility is that schizo-affective disorder may be a separate entity. Mitsuda’O studied “atypical psychoses” that exhibited the clinical features used to describe schizo-affective disorder. He found significantly more cases of atypical psychosis in families of atypical psychotics, whereas the pedigrees of schizophrenics reveal no cases of atypical psychoses, and the pedigrees of From the Department of Psychiatry. University offowa College of Medicine. Iowa City. Iowa.
G. M. Dempsey, ,M.D.: ChiefResident; M. T. Tsuang, M.D., Ph.D.; Associate Professorand ChieJ StaflPsychiarrist. I:ast Ward Inpatifnt Service, Psychopathic Hospital; A. Struss, M.D.: First-Year Resident; A. Dvordsky-Wortsman, M.D.; Second-Year Resident; University of Iowa College of Medicine. Supported in part by Iowa Mental Health Research Fund (#T-905, and USPHS grant I-ROIMH24189-01. Reprints mav be obtainedfrom Dr. T.yuang, 500 Newton Road, Iowa City, Iowa 52242. ~_’1975 by Grune & Stratton. Inc. Comprehensive Psychiatry. Vol. 16. No. 1 fJenuary/February).
1975
55
DEMPSEY
56
ET AL.
atypical psychotics reveal no cases of schizophrenia. Mitsuda concluded that atypical psychosis (schizo-affective) is genetically distinct from schizophrenia and is not a subtype of affective disorder, although there is some overlapping family history for atypical and affective cases. Mitsuda’s data for atypical psychosis showed that schizophrenic and atypical traits did not exist separately on maternal and paternal sides, thus eliminating the concept of a combined genotype. Walinder” studied an 18-year-old schizo-affective proband whose paternal pedigree revealed 10 relatives with schizo-affective disorder, but no cases of schizophrenia or affective disorder per se. 011erenshaw12 computed the expected risk for a person in the general population having both schizophrenia and affective disorder as 0.135% which was significantly lower than the 9% risk observed. This suggests that schizo-affective disorder may be an independent illness. On the basis of the available literature it is not possible to definitely establish the position of schizo-affective disorder in the nosology of mental illness: it may be a variant of schizophrenia, as traditionally believed; it may be a variant of affective disorder; or it may be an independent illness. Instead of classifying schizo-affective disorder as a subtype of schizophrenia, Tsuang13 has proposed that for future research purposes it should be regarded as a separate category with three subtypes: an affective type, a schizophrenic type, and an undifferentiated type. Although a definite classification of schizo-affective disorder is necessary for future research, the clinician is faced with the immediate concern of treatment for schizo-affective patients. Should schizo-affective patients receive therapy as schizophrenics, as affective patients, or should some combination of treatments for schizophrenic and affective patients be employed? A review of the available literature provides some guidelines for making this decision. It has been reported that atypical cases showing both schizophrenic and affective features responded very well to electroconvulsive therapy. 14-*6Lithium is another method of treatment that has been shown to be effective for both the affective and the schizophrenic components of schizo-affective illness,“*” though less effective than phenothiazines in treating highly active schizo-affectives,‘* This suggests that treatment for schizo-affective patients corresponds more closely to treatment for affective patients than that for schizophrenics. Indeed, in our experience we have found that patients exhibiting schizo-affective features have benefited from ECT, lithium, or phenothiazines at an initial acute phase of the illness. The following five case histories are examples of the types of patients who respond to such treatment. CASE
HISTORIES
Case 1 A 17-year-old white female had had three psychiatric admissions since age 14, each of 2 to 3 months duration, with clear remissions between episodes. The first admission was for a depressive episode and suicide attempt, the second for antisocial behavior and sexual promiscuity, and the third for an acute psychotic illness characterized by inappropriate, silly affect, formal thought disorder, and paranoid delusions without clear manic or depressive symptoms. The family history was positive for affective disorder and alcoholism for both paternal and maternal relatives. Mental status on admission revealed perplexity, although the patient was oriented. Bizarre seductive gesturing, inappropriate silly affect, and tangential disjointed speech were noted. She admitted to somatic passivity, voices com-
TREATMENT
menting.
OF SCHIZO-AFFECTIVE
and many
delusional
doses of phenothiazines status
returned
schizophrenia:
to
normal
within type.
A lo-year-old chotic
black
behavior
nations
perceptions.
were ineffective.
schizo-affective
after
delusions the patient
broadcasting.
subjective
feelings
symptoms
(elated
could
came
prominent,
phenothiazines
mood,
other
medication.
and entering.
The
final
to hospital
A previous
in discharge
both schizophrenic
schizophrenia.
symptoms
type of illness.
such as flight
symptoms
of death.
disappeared
for halluci-
Throughout
(ideas of influence, He also
presented
of ideas, circumstantial and marked
tapered.
The patient’s
behavior
male student
was admitted
to the ward
a course
became
his
thought
of people as devils)
sex drive).
He was then given
was
because of his psy-
admission
and identification
and increased
mental
diagnosis
on phenothiazines.
grandiosity,
High
and the patient’s
speech,
that he was God or an agent of God, and visual hallucinations.
thoughts
were quickly
no
of drug abuse was admitted
the schizophrenic
including
was hebephrenic was instituted,
of change in the environment,
be due to either
treatment,
on
for breaking
exhibited
feelings that he could read minds, phenothiazine
impression carbonate
at age 18 had resulted
and affective that
7 days
male with a history
second hospitalization
symptoms
Initial Lithium
being apprehended
and grandiose
57
DISORDER
defensive of eight
appropriate,
After
features ECT’s,
be-
while
and he was dis-
charged.
An
IR-year-old
havior.
white
He was regarded
hyperactive,
hypertalkative,
he knew more illness.
and, when
a month
paranoid
delusion
was elevated,
with lithium
carbonate only
high
included
doses
in order
reappearance
Family
and use a course
carbonate
of eight
into a
his teachers,
history
with adequate
letters
was negative
ECT’s,
after
thinking
to which
were noticed.
a well-structured
in a plot in which in his stream which
disturbance. which
that
for mental
his father
and tried to phone the F.B.I.
and phenothiazines,
his thought
thinking
blood levels. His symptoms
of symptoms,
he felt he was the victim
to treat
in be-
push of speech and concrete
him. He wrote
lithium
of a sudden change of 2 weeks, developed
who would interrupt
for 1 month,
slight
after
to re-hospitalize
student,
and slept very little.
discharged,
because
who, in a period
his affect was flat, and he showed loose associations
phenothiazines return
He lost weight
was added in which
his treatment
moderately
youngster,
restless
he was readmitted
staff were in collusion mission
irritable,
than they.
He was treated
decreased, Within
as a shy, withdrawn
of thought.
and the
His mood On this ad-
had to be maintained to
in
It
was then
decided
stop
the patient
improved
and was able to
to school.
Case 4 An
I&year-old
white
thought
disorder,
formal
grandiose
delusions.
some antisocial
male had acute onset of psychotic auditory
The patient
traits
including
and visual had always
stealing
He denied drug use in the week prior mother
had a depression
sonality.
On mental
generally
flat
with
visual hallucinations phenothiazines,
lasting
status occasional
ments
he was markedly
improved,
priate.
He has remained
well for 3 months
schizophrenia:
schizo-affective
A 30-year-old
married
had been episodic functioning. paranoid
When or
at age 24, after
grandiose
in school,
Motor
which
activity
was increased:
shake his fist menacingly alone,
and after
was ineffective. six his mental
on lithium
ECT status
carbonate
psychiatric
admission.
her premorbid
he admitted
was instituted.
per-
Affect
was
to auditory
and
of lithium
and
in the air. A trial was normal
and
The patient’s
and tangential.
prophylaxis.
with
hyperactivity,
and he demonstrated
she regained
speech was rapid
After
two treat-
and behavior
Discharge
appro-
diagnosis
was
type.
female
had three
psychiatric
with acute onset, long symptom-free ill,,she
problems
to admission
gesturing,
and urine drug screen was negative.
the patient’s
frequently
and then phenothiazines
1 week prior
bizarre
and drug abuse, but this was his first
6 months
laughter.
and would
had behavior
to admission,
examination
symptoms
hallucinations,
has auditory
delusions,
as well
and visual as affective
admissions intervals,
over the last 7 years.
and return
hallucinations, symptoms.
formal
Her illness
to her premorbid thought
level of
disorder.
She has presented
twice
and with
DEMPSEY
58
ET AL.
depressive symptoms of insomnia, crying spells, morbid ruminations, guilt feelings, and agitation. In each case her illness was refractory to phenothiazines but responsive to ECT’s. At index admission she was grandiose, hyperactive, distractible, and irritable and had decreased sleep. Both parents were alcoholic, and her mother suffered a single depressive episode from which she recovered. Mental status on admission revealed grandiose delusions, distractability, and flat affect punctuated with inappropriate silly laughter. Speech was tangential and disjointed. She admitted to auditory and visual hallucinations. The patient was treated with a course of eight ECT’s, with complete remission of symptoms. She has remained well for 3 months on lithium carbonate maintenance. The final diagnotic impression was schizophrenia: schizo-affective type.
COMMENT
The common features in these five cases demonstrate the pattern of the illness; namely, the patient is young, the onset is acute, there is often a background of drug abuse, the initial schizophrenic features and overactivity respond to phenothiazines, the course is episodic with emerging depressive symptoms, and the family history is strongly positive for psychiatric illness, particularly of alcoholism and depression. Most important, the patients respond favorably to ECT and/or lithium treatment. The case histories presented above are five examples of where an illness traditionally considered to be schizophrenic in nature has been treated effectively on regimens usually employed for affective illnesses. While five cases do not warrant wholesale changes in nosology or clinical treatment, future research in this area entailing longer periods of follow-up and larger samples is certainly indicated. We are presently studying cases of schizo-affective disorder that respond to lithium and/or ECT, following inadequate response to phenothiazines or other treatment, in an attempt to clearly establish the associated clinical features that would strongly indicate that a particular schizo-affective patient seen in the future could be expected to respond to a treatment regimen of lithium and/or ECT. SUMMARY
The classification of schizo-affective disorder is presently ambiguous; it may be a variant of schizophrenia, a variant of affective disorder, or an independent illness. However, treatment of schizo-affective disorder must have definite guidelines in order to be beneficial to patients. Our clinical experience has shown that ECT and/or lithium is effective for schizo-affective patients, and we are collecting more data for future research. REFERENCES I. Kasanin J, Kaufman MR: The acute schizo-affective psychoses. Am J Psychiatry 13:97-126, 1933 2. DSM-II Diagnostic and Statistical Manual of Mental Disorders (ed 2). Washington, D.C., American Psychiatric Association, 1968 3. Angst J: Zur atiologie und nosologie endogener depressiver psychosen. Monogr Gesamtgeb Neurol Psychiatr 112. Berlin, Springer, 1966
4. Perris C: The genetics of affective disorders, in Mendels J (ed): Biological Psychiatry. New York, John Wiley & Sons, 1973 5. Vaillant GE: An historical review of the remitting schizophrenias. J Nerv Ment Dis 138:4856, 1964 6. Clayton PJ, Rodin L, Winokur G: Family history studies: III. Schizo-affective disorder, clinical and genetic factors including a one to two year follow-up. Compr Psychiatry 9:3ll49, 1968
TREATMENT
OF SCHIZO-AFFECTIVE
7. Cohen SM. Martin GA, Pollin W, et al: Relationship of schizo-affective psychosis to manic depressive psychosis and schizophrenia. Arch Gen Psychiatry 26539-545. 1972 8. Tsuang MT: Genetics of affective disorder. Presented at AAAS. San Francisco, Calif., Feb. 27, 1974. To be published in Mendels J (ed): Recent Biological Studies of Depressive Illness. New York, Spectrum Publications 9. McCabe MS, Fowler RC, Cadoret RJ. et al: Familial differences in schizophrenia with
good and poor 332, 1971
prognosis.
Psycho1
Med
1:326-
IO. Mitsuda H: Clinical Genetics in Psychiatry (ed 2). Tokyo, lgaku Shoin, 1967 I I. Walinder J: Recurrent familial psychosis of the schizo-affective Stand 48:274~ 283, 1972
type.
Acta
Psychiatr
12. Ollerenshaw DP: The classification of the functional psychoses. Br J Psychiatry 122:517~ 530, 1973 13. Tsuang MT: disorder’! Presented
59
DISORDER
What is schizo-affective at the New Research
Program of the 127th Psychiatric American Mich.. May 6- IO, 1974
annual meeting of the Association. Detroit,
14. Huston PE, Lecher LM: Manic depressive psychosis. Course when treated and untreated with electric shock. Arch Neurol Psychiatr 60:37-48, 1948 15. Gottlieb JS, Huston PE: Treatment of schizophrenia. A comparison of three methods: Brief psychotherapy, insulin coma, and electric shock. J Nerv Ment Dis Il3:237-246, 1951 16. Kalinowski L, Hippius H: Pharmacological, Convulsive and Other Somatic Treatments in Psychiatry. New York, Grune & Stratton, 1969 17. Dinsmore PR, Ryback R: Lithium in schizo-affective disorders. Dis Nerv Syst 33:771 776, 1972 18. Prien RF, Point P, Coffey EM, et al: A comparison of lithium carbonate and chlorpormazine in the treatment of excited schizo-affectives. Arch Gen Psychiatry 27: 182 -189, 1972
Disorder
G. Michael Dempsey, Ming T. Tsuang, Andrea Struss, and Ana Dvoredsky-Wortsman
T
HE TERM schizo-affective was first introduced by Kasanin;’ it describes patients who exhibit both schizophrenic and affective symptoms. DSM-II2 lists schizo-affective disorder as a subtype of schizophrenia, and traditionally schizo-affective patients have been diagnosed as schizophrenics who exhibit affective features concomitantly with their underlying and primary schizophrenic symptoms. Family studies by Angst3 and PerTis reinforce the traditional concept of schizo-affective disorder as a variant of schizophrenia. A similar theory explains that schizo-affective patients exhibit typical schizophrenic symptoms while ill; but once well, they have a remitting clinical course such as is seen in affective disorder.5 However, the possibility that schizo-affective disorder is a variant of affective disorder is also supported by recent studies. Clayton et aL6 followed up 39 schizoaffective patients and their families. Eighty-five percent of the patients were either well or not schizophrenic after I to 2 years, and 54% had a family history of affective disorder. Cohen et al.’ found that the concordance rate for schizoaffective disorder in monozygotic male twins was significantly higher than that for schizophrenia, while the concordance rate for affective disorder was not significantly different from that for schizo-affective disorder. Tsuangs found that the mean age of onset for sib pairs concordant for schizo-affective disorder was not significantly different from that for sib pairs concordant for affective disorder, but was significantly different from that for sib pairs concordant for schizophrenia. This finding suggests that, in terms of mean age of onset, schizoaffective disorder is closer to affective disorder than to schizophrenia. McCabe et aLs conducted a blind family study for good-prognosis and poor-prognosis schizophrenics, using diagnostic criteria for the good-prognosis group similar to those commonly used for schizo-affective disorder. The good-prognosis schizophrenics had a significant incidence of affective disorder among their relatives, while a higher incidence of schizophrenia was found in the families of poorprognosis schizophrenics. These investigations suggest that schizo-affective disorder is a variant of affective disorder. Another possibility is that schizo-affective disorder may be a separate entity. Mitsuda’O studied “atypical psychoses” that exhibited the clinical features used to describe schizo-affective disorder. He found significantly more cases of atypical psychosis in families of atypical psychotics, whereas the pedigrees of schizophrenics reveal no cases of atypical psychoses, and the pedigrees of From the Department of Psychiatry. University offowa College of Medicine. Iowa City. Iowa.
G. M. Dempsey, ,M.D.: ChiefResident; M. T. Tsuang, M.D., Ph.D.; Associate Professorand ChieJ StaflPsychiarrist. I:ast Ward Inpatifnt Service, Psychopathic Hospital; A. Struss, M.D.: First-Year Resident; A. Dvordsky-Wortsman, M.D.; Second-Year Resident; University of Iowa College of Medicine. Supported in part by Iowa Mental Health Research Fund (#T-905, and USPHS grant I-ROIMH24189-01. Reprints mav be obtainedfrom Dr. T.yuang, 500 Newton Road, Iowa City, Iowa 52242. ~_’1975 by Grune & Stratton. Inc. Comprehensive Psychiatry. Vol. 16. No. 1 fJenuary/February).
1975
55
DEMPSEY
56
ET AL.
atypical psychotics reveal no cases of schizophrenia. Mitsuda concluded that atypical psychosis (schizo-affective) is genetically distinct from schizophrenia and is not a subtype of affective disorder, although there is some overlapping family history for atypical and affective cases. Mitsuda’s data for atypical psychosis showed that schizophrenic and atypical traits did not exist separately on maternal and paternal sides, thus eliminating the concept of a combined genotype. Walinder” studied an 18-year-old schizo-affective proband whose paternal pedigree revealed 10 relatives with schizo-affective disorder, but no cases of schizophrenia or affective disorder per se. 011erenshaw12 computed the expected risk for a person in the general population having both schizophrenia and affective disorder as 0.135% which was significantly lower than the 9% risk observed. This suggests that schizo-affective disorder may be an independent illness. On the basis of the available literature it is not possible to definitely establish the position of schizo-affective disorder in the nosology of mental illness: it may be a variant of schizophrenia, as traditionally believed; it may be a variant of affective disorder; or it may be an independent illness. Instead of classifying schizo-affective disorder as a subtype of schizophrenia, Tsuang13 has proposed that for future research purposes it should be regarded as a separate category with three subtypes: an affective type, a schizophrenic type, and an undifferentiated type. Although a definite classification of schizo-affective disorder is necessary for future research, the clinician is faced with the immediate concern of treatment for schizo-affective patients. Should schizo-affective patients receive therapy as schizophrenics, as affective patients, or should some combination of treatments for schizophrenic and affective patients be employed? A review of the available literature provides some guidelines for making this decision. It has been reported that atypical cases showing both schizophrenic and affective features responded very well to electroconvulsive therapy. 14-*6Lithium is another method of treatment that has been shown to be effective for both the affective and the schizophrenic components of schizo-affective illness,“*” though less effective than phenothiazines in treating highly active schizo-affectives,‘* This suggests that treatment for schizo-affective patients corresponds more closely to treatment for affective patients than that for schizophrenics. Indeed, in our experience we have found that patients exhibiting schizo-affective features have benefited from ECT, lithium, or phenothiazines at an initial acute phase of the illness. The following five case histories are examples of the types of patients who respond to such treatment. CASE
HISTORIES
Case 1 A 17-year-old white female had had three psychiatric admissions since age 14, each of 2 to 3 months duration, with clear remissions between episodes. The first admission was for a depressive episode and suicide attempt, the second for antisocial behavior and sexual promiscuity, and the third for an acute psychotic illness characterized by inappropriate, silly affect, formal thought disorder, and paranoid delusions without clear manic or depressive symptoms. The family history was positive for affective disorder and alcoholism for both paternal and maternal relatives. Mental status on admission revealed perplexity, although the patient was oriented. Bizarre seductive gesturing, inappropriate silly affect, and tangential disjointed speech were noted. She admitted to somatic passivity, voices com-
TREATMENT
menting.
OF SCHIZO-AFFECTIVE
and many
delusional
doses of phenothiazines status
returned
schizophrenia:
to
normal
within type.
A lo-year-old chotic
black
behavior
nations
perceptions.
were ineffective.
schizo-affective
after
delusions the patient
broadcasting.
subjective
feelings
symptoms
(elated
could
came
prominent,
phenothiazines
mood,
other
medication.
and entering.
The
final
to hospital
A previous
in discharge
both schizophrenic
schizophrenia.
symptoms
type of illness.
such as flight
symptoms
of death.
disappeared
for halluci-
Throughout
(ideas of influence, He also
presented
of ideas, circumstantial and marked
tapered.
The patient’s
behavior
male student
was admitted
to the ward
a course
became
his
thought
of people as devils)
sex drive).
He was then given
was
because of his psy-
admission
and identification
and increased
mental
diagnosis
on phenothiazines.
grandiosity,
High
and the patient’s
speech,
that he was God or an agent of God, and visual hallucinations.
thoughts
were quickly
no
of drug abuse was admitted
the schizophrenic
including
was hebephrenic was instituted,
of change in the environment,
be due to either
treatment,
on
for breaking
exhibited
feelings that he could read minds, phenothiazine
impression carbonate
at age 18 had resulted
and affective that
7 days
male with a history
second hospitalization
symptoms
Initial Lithium
being apprehended
and grandiose
57
DISORDER
defensive of eight
appropriate,
After
features ECT’s,
be-
while
and he was dis-
charged.
An
IR-year-old
havior.
white
He was regarded
hyperactive,
hypertalkative,
he knew more illness.
and, when
a month
paranoid
delusion
was elevated,
with lithium
carbonate only
high
included
doses
in order
reappearance
Family
and use a course
carbonate
of eight
into a
his teachers,
history
with adequate
letters
was negative
ECT’s,
after
thinking
to which
were noticed.
a well-structured
in a plot in which in his stream which
disturbance. which
that
for mental
his father
and tried to phone the F.B.I.
and phenothiazines,
his thought
thinking
blood levels. His symptoms
of symptoms,
he felt he was the victim
to treat
in be-
push of speech and concrete
him. He wrote
lithium
of a sudden change of 2 weeks, developed
who would interrupt
for 1 month,
slight
after
to re-hospitalize
student,
and slept very little.
discharged,
because
who, in a period
his affect was flat, and he showed loose associations
phenothiazines return
He lost weight
was added in which
his treatment
moderately
youngster,
restless
he was readmitted
staff were in collusion mission
irritable,
than they.
He was treated
decreased, Within
as a shy, withdrawn
of thought.
and the
His mood On this ad-
had to be maintained to
in
It
was then
decided
stop
the patient
improved
and was able to
to school.
Case 4 An
I&year-old
white
thought
disorder,
formal
grandiose
delusions.
some antisocial
male had acute onset of psychotic auditory
The patient
traits
including
and visual had always
stealing
He denied drug use in the week prior mother
had a depression
sonality.
On mental
generally
flat
with
visual hallucinations phenothiazines,
lasting
status occasional
ments
he was markedly
improved,
priate.
He has remained
well for 3 months
schizophrenia:
schizo-affective
A 30-year-old
married
had been episodic functioning. paranoid
When or
at age 24, after
grandiose
in school,
Motor
which
activity
was increased:
shake his fist menacingly alone,
and after
was ineffective. six his mental
on lithium
ECT status
carbonate
psychiatric
admission.
her premorbid
he admitted
was instituted.
per-
Affect
was
to auditory
and
of lithium
and
in the air. A trial was normal
and
The patient’s
and tangential.
prophylaxis.
with
hyperactivity,
and he demonstrated
she regained
speech was rapid
After
two treat-
and behavior
Discharge
appro-
diagnosis
was
type.
female
had three
psychiatric
with acute onset, long symptom-free ill,,she
problems
to admission
gesturing,
and urine drug screen was negative.
the patient’s
frequently
and then phenothiazines
1 week prior
bizarre
and drug abuse, but this was his first
6 months
laughter.
and would
had behavior
to admission,
examination
symptoms
hallucinations,
has auditory
delusions,
as well
and visual as affective
admissions intervals,
over the last 7 years.
and return
hallucinations, symptoms.
formal
Her illness
to her premorbid thought
level of
disorder.
She has presented
twice
and with
DEMPSEY
58
ET AL.
depressive symptoms of insomnia, crying spells, morbid ruminations, guilt feelings, and agitation. In each case her illness was refractory to phenothiazines but responsive to ECT’s. At index admission she was grandiose, hyperactive, distractible, and irritable and had decreased sleep. Both parents were alcoholic, and her mother suffered a single depressive episode from which she recovered. Mental status on admission revealed grandiose delusions, distractability, and flat affect punctuated with inappropriate silly laughter. Speech was tangential and disjointed. She admitted to auditory and visual hallucinations. The patient was treated with a course of eight ECT’s, with complete remission of symptoms. She has remained well for 3 months on lithium carbonate maintenance. The final diagnotic impression was schizophrenia: schizo-affective type.
COMMENT
The common features in these five cases demonstrate the pattern of the illness; namely, the patient is young, the onset is acute, there is often a background of drug abuse, the initial schizophrenic features and overactivity respond to phenothiazines, the course is episodic with emerging depressive symptoms, and the family history is strongly positive for psychiatric illness, particularly of alcoholism and depression. Most important, the patients respond favorably to ECT and/or lithium treatment. The case histories presented above are five examples of where an illness traditionally considered to be schizophrenic in nature has been treated effectively on regimens usually employed for affective illnesses. While five cases do not warrant wholesale changes in nosology or clinical treatment, future research in this area entailing longer periods of follow-up and larger samples is certainly indicated. We are presently studying cases of schizo-affective disorder that respond to lithium and/or ECT, following inadequate response to phenothiazines or other treatment, in an attempt to clearly establish the associated clinical features that would strongly indicate that a particular schizo-affective patient seen in the future could be expected to respond to a treatment regimen of lithium and/or ECT. SUMMARY
The classification of schizo-affective disorder is presently ambiguous; it may be a variant of schizophrenia, a variant of affective disorder, or an independent illness. However, treatment of schizo-affective disorder must have definite guidelines in order to be beneficial to patients. Our clinical experience has shown that ECT and/or lithium is effective for schizo-affective patients, and we are collecting more data for future research. REFERENCES I. Kasanin J, Kaufman MR: The acute schizo-affective psychoses. Am J Psychiatry 13:97-126, 1933 2. DSM-II Diagnostic and Statistical Manual of Mental Disorders (ed 2). Washington, D.C., American Psychiatric Association, 1968 3. Angst J: Zur atiologie und nosologie endogener depressiver psychosen. Monogr Gesamtgeb Neurol Psychiatr 112. Berlin, Springer, 1966
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TREATMENT
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