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Original Investigation |

Boundaries of Schizoaffective Disorder:  Revisiting Kraepelin

Roman Kotov, PhD1; Shirley H. Leong, PhD2; Ramin Mojtabai, MD, PhD, MPH3; Ann C. Eckardt Erlanger, PsyD4; Laura J. Fochtmann, MD1; Eduardo Constantino, MD1; Gabrielle A. Carlson, MD1; Evelyn J. Bromet, PhD1
[+] Author Affiliations
1Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, New York
2Department of Psychiatry, University of Pennsylvania, Philadelphia
3Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
4Department of Cardiology and Comprehensive Care, New York University, New York
JAMA Psychiatry. 2013;70(12):1276-1286. doi:10.1001/jamapsychiatry.2013.2350.
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Importance  Established nosology identifies schizoaffective disorder as a distinct category with boundaries separating it from mood disorders with psychosis and from schizophrenia. Alternative models argue for a single boundary distinguishing mood disorders with psychosis from schizophrenia (kraepelinian dichotomy) or a continuous spectrum from affective to nonaffective psychosis.

Objective  To identify natural boundaries within psychotic disorders by evaluating associations between symptom course and long-term outcome.

Design, Setting, and Participants  The Suffolk County Mental Health Project cohort consists of first-admission patients with psychosis recruited from all inpatient units of Suffolk County, New York (72% response rate). In an inception cohort design, participants were monitored closely for 4 years after admission, and their symptom course was charted for 526 individuals; 10-year outcome was obtained for 413.

Main Outcomes and Measures  Global Assessment of Functioning (GAF) and other consensus ratings of study psychiatrists.

Results  We used nonlinear modeling (locally weighted scatterplot smoothing and spline regression) to examine links between 4-year symptom variables (ratio of nonaffective psychosis to mood disturbance, duration of mania/hypomania, depression, and psychosis) and 10-year outcomes. Nonaffective psychosis ratio exhibited a sharp discontinuity—10 days or more of psychosis outside mood episodes predicted an 11-point decrement in GAF—consistent with the kraepelinian dichotomy. Duration of mania/hypomania showed 2 discontinuities demarcating 3 groups: mania absent, episodic mania, and chronic mania (manic/hypomanic >1 year). The episodic group had a better outcome compared with the mania absent and chronic mania groups (12-point and 8-point difference on GAF). Duration of depression and psychosis had linear associations with worse outcome.

Conclusions and Relevance  Our data support the kraepelinian dichotomy, although the study requires replication. A boundary between schizoaffective disorder and schizophrenia was not observed, which casts further doubt on schizoaffective diagnosis. Co-occurring schizophrenia and mood disorder may be better coded as separate diagnoses, an approach that could simplify diagnosis, improve its reliability, and align it with the natural taxonomy.

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Figure 1.
Locally Weighted Scatterplot–Smoothed Curves for Global Assessment of Functioning (GAF) and 4 Predictors

Dashed lines are 95% confidence band around the curve.

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Figure 2.
Curves for the Best-Fitting Spline Models for Each Outcome

Outcome expected at each level of symptom is shown. GAF indicates Global Assessment of Functioning; GAF-F, Global Assessment of Functional Performance; GAS, Global Assessment of Symptoms; and SADS, Schedule for Affective Disorders and Schizophrenia.

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