Stephen M. Strakowski, MD

In patients with psychotic symptoms, why are African-Americans more likely than whites to be diagnosed with schizophrenia? After more than 30 years of debate, some answers—and remedies for the problem—are becoming clear.

In psychiatry, where interpersonal interactions are key to eliciting diagnostic symptoms and signs, there is an intrinsic risk of misinterpretation when clinician and patient are of different cultural, ethnic, or socioeconomic backgrounds. This article analyzes four factors that contribute to misinterpretation and to ethnic misdiagnosis of schizophrenia. Culturally sensitive strategies are offered to avoid diagnostic bias in clinical practice.

SCHIZOPHRENIA MISDIAGNOSIS

Large epidemiologic studies report similar rates of schizophrenia and bipolar disorder in African-American and white populations.¹ Although patients of both races have been wrongly diagnosed with schizophrenia, the pattern is stronger and more persistent in African-Americans.

Box 1

In the 1970s, Simon et al² studied 192 hospitalized patients, of whom all African-Americans and 85% of whites had been identified clinically as having schizophrenia. Using a structured interview, the researchers found that only 40% of the African Americans and 50% of the whites met diagnostic criteria for schizophrenia. African-Americans with mood disorders were found to be at particular risk of schizophrenia misdiagnosis.

In the 1980s, among 76 patients with a clinical diagnosis of schizophrenia, Mukherjee et al³ diagnosed one-half (52%) with bipolar disorder using a structured clinical interview. Schizophrenia misdiagnoses were more common in African-Americans (86%) and Hispanics (83%) than in whites (51%). In particular, African-Americans were most likely to be misdiagnosed with paranoid schizophrenia. African-Americans complained more commonly than whites of auditory hallucinations, which may represent an ethnic difference in symptomatic presentation of psychotic mood disorders.

In the 1990s, colleagues and I conducted two studies—one of 173 patients in a Tennessee psychiatric hospital⁴ and the other of 490 patients in an Ohio psychiatric emergency service⁵—and found yet again that African-Americans were more likely than whites to be diagnosed with schizophrenia. In the hospital study, higher rates of schizophrenia diagnosis were associated with lower rates of mood disorder diagnosis. This inverse relationship implied that African-Americans with mood disorders were being misdiagnosed with schizophrenia.

Men were more likely than women to be diagnosed with schizophrenia, suggesting that African-American men were most likely to be misdiagnosed. When adjustments were made for gender, black women were found to be at higher risk for misdiagnosis than white women.

Lawson et al⁶ extended this research in a population-based study of African-Americans living in Tennessee. They found that African-Americans constituted 16% of the state’s population but 48% of psychiatric inpatients diagnosed with schizophrenia and 37% of psychiatric outpatients.

CONSEQUENCES OF INACCURATE DIAGNOSIS

Differentiating between schizophrenia (Box 1) and a psychotic mood disorder (Box 2) is more than a semantic exercise. Schizophrenia implies a chronic, unremitting, debilitating illness that worsens over time. Though this perception of schizophrenia is not entirely accurate, in clinical practice its diagnosis imparts a bleak prognosis that may lower the clinician’s expectations for the patient.⁷

Schizophrenia misdiagnosis also may lead the psychiatrist to rely excessively on antipsychotics, rather than attempting thymoleptic and psychotherapy trials. Studies suggest that African-American patients are more likely than similar white patients to receive antipsychotics^4,8,9 and less likely to receive psychotherapy.^5,10

Reasons why African-Americans are often misdiagnosed with schizophrenia remain unclear but probably include four contributing factors:

• differences in symptom presentation compared with whites
• failure by clinicians to identify affective symptoms in African-Americans
• minority patients’ wariness when dealing with health services
• and racial stereotyping.

DIFFERENCES IN SYMPTOM EXPRESSION

African-American patients with mood disorders or schizophrenia are more likely than are similar white patients to complain of auditory hallucinations.^11-13 For example, Strakowski et al¹⁴ examined 330 patients with nonaffective and psychotic diagnoses in a study that was used to develop DSM-IV criteria for schizophrenia. Auditory hallucinations were rated as more severe in African-American than in similar white patients.

Box 2

African-American patients also are more likely than whites to exhibit so-called Schneiderian first-rank symptoms of schizophrenia,¹⁵ including:

• delusions of thought broadcasting or insertion
• auditory hallucinations of voices conversing about the patient in the third person.

These symptoms were once used to diagnose schizophrenia, but their lack of specificity has been well documented.^2,16 First-rank symptoms of schizophrenia depend on the specific form of the hallucination or delusion, are likely to be influenced by a patient’s culture, and may be misleading in multicultural populations. Though first-rank symptoms now occupy a minor role in U.S. diagnostic systems, they might continue to sway clinicians—even when using structured diagnostic interviews—to inappropriately diagnose schizophrenia in lieu of affective disorders in minority patients.¹⁵

To extend this finding, our group¹⁶ studied rates and severity of affective and psychotic symptoms—particularly first-rank symptoms—in 100 patients with psychotic mania who met DSM-III-R criteria for bipolar disorder (80%) or schizoaffective disorder, bipolar type (20%) as determined by structured diagnostic interview. No differences in affective symptoms between African-American and white patients were seen. African-Americans were more likely to endorse auditory hallucinations and to report severe auditory hallucinations of voices commenting on their behavior—the only first-rank symptom on which they differed from whites.

Though their affective symptoms were similar, African-Americans were significantly more likely than whites to have been diagnosed with a schizophrenia-spectrum disorder. Because misdiagnosis of African-Americans could not be explained by psychotic symptoms—which were as severe as those of white patients—these findings suggest other mechanisms were at work.

UNIDENTIFIED AFFECTIVE SYMPTOMS

Underidentification of mood disorders in African-American patients may also lead to over-diagnosis of schizophrenia. In a sample of 99 patients, colleagues and I¹⁷ compared clinical diagnoses made in a psychiatric emergency service with those by research investigators using a structured clinical interview. Reasons for diagnostic differences were identified and divided into two categories:

• the same symptoms were recorded but applied differently to diagnostic criteria (criterion variance)
• different information was recorded, which led to diagnostic discrepancies (information variance).

Differences occurred significantly more often in African-American than in white patients, but only information variance was associated with ethnicity. This suggests that clinicians are less likely to elicit appropriate information from African-American than from white psychiatric patients. The fact that researchers obtained this information during diagnostic interviews suggests that the patients could provide it when given appropriate prompts. Specifically, affective symptoms were less likely to be elicited by clinicians than by researchers.

PATIENT WARINESS

Minority patients, when interacting with clinicians of the majority population, may project “protective wariness.”¹⁸ Specific behaviors include hesitancy or reluctance to fully engage with the care provider as a precaution against being exploited or harmed. Cultural misunderstandings¹⁹ and patient concerns about past reports of minorities receiving substandard or unethical health care²⁰ may contribute to this behavior.

Whaley²¹ compared nonpathologic distrust and paranoia in 404 community-living African-Americans and whites. Some were healthy, and some had diagnoses of schizophrenia or depression. African-Americans—particularly those with psychiatric disorders—showed higher levels of distrust than whites. Distrust was also associated with depression in African-Americans but not in whites. Whaley concluded that:

• depressed African-Americans may exhibit more distrust toward clinicians than do whites
• this distrust puts African-Americans at risk of being perceived as paranoid and being misdiagnosed with paranoid schizophrenia.

Table

Remedial actions to avoid ethnic bias in diagnosing schizophrenia

Though Whaley did not report differences in distrust between African-American men and women, others have noted that distrust of health providers may be more common in minority men.¹⁸

RACIAL STEREOTYPING

Compared with similar white men, African-American men with mental disorders are more likely to be:

• referred for mental health care through social and legal—rather than medical—systems and to be involuntarily committed
• perceived as violent—even though controlled research suggests they are not. This misperception can lead to excessive medication and restraints.²²

Differential treatment of African-American men may create a cycle of distrust, hostility, and additional inappropriate treatment. Together, these factors may increase the risk that African-American men will be misdiagnosed with schizophrenia.

Past racism in biomedical and psychiatric practice and research has been documented^23,24 and more recently reviewed by Lawson.¹⁹ Historically, African-Americans were perceived to have a “primitive psychic” nature that was thought to be more susceptible to schizophrenia than depression.¹⁹ Whether these or similar racist stereotypes continue to inject ethnic bias into clinical assessment requires further study.

WHERE DO WE GO FROM HERE?

Although research into methods to eliminate ethnicity bias is sparse, the work reviewed in this article suggests ways that psychiatrists can minimize this problem (Table).

Obtain comprehensive information. Use structured interviews, such as the Structured Clinical Interview for DSM-IV (SCID), and rating scales, such as the Hamilton Depression Scale, which require clinicians to ask about all types of symptoms, particularly affective symptoms.

Review treatment records. Review your practice patterns for evidence of schizophrenia over-diagnosis in African-Americans or other ethnic groups. Examine ethnic differences in legal referrals or use of restraints or seclusion, which may indicate an ethnic bias in how threats are perceived. Only by being aware of bias can one correct it.

Become familiar with cultural and ethnic differences in idioms of distress. Specifically, review research in cultural psychiatry to identify potential differences among cultural groups in how they describe psychiatric symptoms. Talk with colleagues or friends from other cultural groups, and read literature from different ethnic perspectives to increase your cultural sensitivity.

Consult with psychiatrists with expertise in cultural variability of clinical presentation when the diagnosis or threat assessment seems unclear. Consultation is recommended if a patient’s diagnosis is uncertain or if you detect bias in your practice.

These interventions require clinicians to become familiar with psychosocial differences in how patients of various cultural and ethnic groups express psychiatric symptoms. With this understanding, we can better engage wary patients, obtain valid information, and improve clinical practice and patient outcomes.

Finally, psychiatry’s diagnostic systems need to continually address how patient assessment is influenced by ethnicity, culture, gender, and other socio-demographic factors. Studies are needed to examine the contributions of multiple factors—such as symptom differences and stereotyping—that contribute to ethnic-related diagnostic disparities.

Related resources

• Paul AM. Painting insanity black: Why are there more black schizophrenics? Salon.com Dec. 1, 1999. http://www.salon.com/books/it/1999/12/01/schizo/index.html
• Alarcon RD, Westermeyer J, Foulks EF, Ruiz P. Clinical relevance of contemporary cultural psychiatry. J Nerv Ment Dis 1999;187: 465-71.
• Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003;93:200-8.
• Lin KM, Smith MW, Ortiz V. Culture and psychopharmacology. Psychiatr Clin North Am 2001; 24:523-38.

Acknowledgement

Preparation of this manuscript was supported in part by National Institutes of Health grant MH56352.

In patients with psychotic symptoms, why are African-Americans more likely than whites to be diagnosed with schizophrenia? After more than 30 years of debate, some answers—and remedies for the problem—are becoming clear.

In psychiatry, where interpersonal interactions are key to eliciting diagnostic symptoms and signs, there is an intrinsic risk of misinterpretation when clinician and patient are of different cultural, ethnic, or socioeconomic backgrounds. This article analyzes four factors that contribute to misinterpretation and to ethnic misdiagnosis of schizophrenia. Culturally sensitive strategies are offered to avoid diagnostic bias in clinical practice.

SCHIZOPHRENIA MISDIAGNOSIS

Large epidemiologic studies report similar rates of schizophrenia and bipolar disorder in African-American and white populations.¹ Although patients of both races have been wrongly diagnosed with schizophrenia, the pattern is stronger and more persistent in African-Americans.

Box 1

In the 1970s, Simon et al² studied 192 hospitalized patients, of whom all African-Americans and 85% of whites had been identified clinically as having schizophrenia. Using a structured interview, the researchers found that only 40% of the African Americans and 50% of the whites met diagnostic criteria for schizophrenia. African-Americans with mood disorders were found to be at particular risk of schizophrenia misdiagnosis.

In the 1980s, among 76 patients with a clinical diagnosis of schizophrenia, Mukherjee et al³ diagnosed one-half (52%) with bipolar disorder using a structured clinical interview. Schizophrenia misdiagnoses were more common in African-Americans (86%) and Hispanics (83%) than in whites (51%). In particular, African-Americans were most likely to be misdiagnosed with paranoid schizophrenia. African-Americans complained more commonly than whites of auditory hallucinations, which may represent an ethnic difference in symptomatic presentation of psychotic mood disorders.

In the 1990s, colleagues and I conducted two studies—one of 173 patients in a Tennessee psychiatric hospital⁴ and the other of 490 patients in an Ohio psychiatric emergency service⁵—and found yet again that African-Americans were more likely than whites to be diagnosed with schizophrenia. In the hospital study, higher rates of schizophrenia diagnosis were associated with lower rates of mood disorder diagnosis. This inverse relationship implied that African-Americans with mood disorders were being misdiagnosed with schizophrenia.

Men were more likely than women to be diagnosed with schizophrenia, suggesting that African-American men were most likely to be misdiagnosed. When adjustments were made for gender, black women were found to be at higher risk for misdiagnosis than white women.

Lawson et al⁶ extended this research in a population-based study of African-Americans living in Tennessee. They found that African-Americans constituted 16% of the state’s population but 48% of psychiatric inpatients diagnosed with schizophrenia and 37% of psychiatric outpatients.

CONSEQUENCES OF INACCURATE DIAGNOSIS

Differentiating between schizophrenia (Box 1) and a psychotic mood disorder (Box 2) is more than a semantic exercise. Schizophrenia implies a chronic, unremitting, debilitating illness that worsens over time. Though this perception of schizophrenia is not entirely accurate, in clinical practice its diagnosis imparts a bleak prognosis that may lower the clinician’s expectations for the patient.⁷

Schizophrenia misdiagnosis also may lead the psychiatrist to rely excessively on antipsychotics, rather than attempting thymoleptic and psychotherapy trials. Studies suggest that African-American patients are more likely than similar white patients to receive antipsychotics^4,8,9 and less likely to receive psychotherapy.^5,10

Reasons why African-Americans are often misdiagnosed with schizophrenia remain unclear but probably include four contributing factors:

• differences in symptom presentation compared with whites
• failure by clinicians to identify affective symptoms in African-Americans
• minority patients’ wariness when dealing with health services
• and racial stereotyping.

DIFFERENCES IN SYMPTOM EXPRESSION

African-American patients with mood disorders or schizophrenia are more likely than are similar white patients to complain of auditory hallucinations.^11-13 For example, Strakowski et al¹⁴ examined 330 patients with nonaffective and psychotic diagnoses in a study that was used to develop DSM-IV criteria for schizophrenia. Auditory hallucinations were rated as more severe in African-American than in similar white patients.

Box 2

African-American patients also are more likely than whites to exhibit so-called Schneiderian first-rank symptoms of schizophrenia,¹⁵ including:

• delusions of thought broadcasting or insertion
• auditory hallucinations of voices conversing about the patient in the third person.

These symptoms were once used to diagnose schizophrenia, but their lack of specificity has been well documented.^2,16 First-rank symptoms of schizophrenia depend on the specific form of the hallucination or delusion, are likely to be influenced by a patient’s culture, and may be misleading in multicultural populations. Though first-rank symptoms now occupy a minor role in U.S. diagnostic systems, they might continue to sway clinicians—even when using structured diagnostic interviews—to inappropriately diagnose schizophrenia in lieu of affective disorders in minority patients.¹⁵

To extend this finding, our group¹⁶ studied rates and severity of affective and psychotic symptoms—particularly first-rank symptoms—in 100 patients with psychotic mania who met DSM-III-R criteria for bipolar disorder (80%) or schizoaffective disorder, bipolar type (20%) as determined by structured diagnostic interview. No differences in affective symptoms between African-American and white patients were seen. African-Americans were more likely to endorse auditory hallucinations and to report severe auditory hallucinations of voices commenting on their behavior—the only first-rank symptom on which they differed from whites.

Though their affective symptoms were similar, African-Americans were significantly more likely than whites to have been diagnosed with a schizophrenia-spectrum disorder. Because misdiagnosis of African-Americans could not be explained by psychotic symptoms—which were as severe as those of white patients—these findings suggest other mechanisms were at work.

UNIDENTIFIED AFFECTIVE SYMPTOMS

Underidentification of mood disorders in African-American patients may also lead to over-diagnosis of schizophrenia. In a sample of 99 patients, colleagues and I¹⁷ compared clinical diagnoses made in a psychiatric emergency service with those by research investigators using a structured clinical interview. Reasons for diagnostic differences were identified and divided into two categories:

• the same symptoms were recorded but applied differently to diagnostic criteria (criterion variance)
• different information was recorded, which led to diagnostic discrepancies (information variance).

Differences occurred significantly more often in African-American than in white patients, but only information variance was associated with ethnicity. This suggests that clinicians are less likely to elicit appropriate information from African-American than from white psychiatric patients. The fact that researchers obtained this information during diagnostic interviews suggests that the patients could provide it when given appropriate prompts. Specifically, affective symptoms were less likely to be elicited by clinicians than by researchers.

PATIENT WARINESS

Minority patients, when interacting with clinicians of the majority population, may project “protective wariness.”¹⁸ Specific behaviors include hesitancy or reluctance to fully engage with the care provider as a precaution against being exploited or harmed. Cultural misunderstandings¹⁹ and patient concerns about past reports of minorities receiving substandard or unethical health care²⁰ may contribute to this behavior.

Whaley²¹ compared nonpathologic distrust and paranoia in 404 community-living African-Americans and whites. Some were healthy, and some had diagnoses of schizophrenia or depression. African-Americans—particularly those with psychiatric disorders—showed higher levels of distrust than whites. Distrust was also associated with depression in African-Americans but not in whites. Whaley concluded that:

• depressed African-Americans may exhibit more distrust toward clinicians than do whites
• this distrust puts African-Americans at risk of being perceived as paranoid and being misdiagnosed with paranoid schizophrenia.

Table

Remedial actions to avoid ethnic bias in diagnosing schizophrenia

Though Whaley did not report differences in distrust between African-American men and women, others have noted that distrust of health providers may be more common in minority men.¹⁸

RACIAL STEREOTYPING

Compared with similar white men, African-American men with mental disorders are more likely to be:

• referred for mental health care through social and legal—rather than medical—systems and to be involuntarily committed
• perceived as violent—even though controlled research suggests they are not. This misperception can lead to excessive medication and restraints.²²

Differential treatment of African-American men may create a cycle of distrust, hostility, and additional inappropriate treatment. Together, these factors may increase the risk that African-American men will be misdiagnosed with schizophrenia.

Past racism in biomedical and psychiatric practice and research has been documented^23,24 and more recently reviewed by Lawson.¹⁹ Historically, African-Americans were perceived to have a “primitive psychic” nature that was thought to be more susceptible to schizophrenia than depression.¹⁹ Whether these or similar racist stereotypes continue to inject ethnic bias into clinical assessment requires further study.

WHERE DO WE GO FROM HERE?

Although research into methods to eliminate ethnicity bias is sparse, the work reviewed in this article suggests ways that psychiatrists can minimize this problem (Table).

Obtain comprehensive information. Use structured interviews, such as the Structured Clinical Interview for DSM-IV (SCID), and rating scales, such as the Hamilton Depression Scale, which require clinicians to ask about all types of symptoms, particularly affective symptoms.

Review treatment records. Review your practice patterns for evidence of schizophrenia over-diagnosis in African-Americans or other ethnic groups. Examine ethnic differences in legal referrals or use of restraints or seclusion, which may indicate an ethnic bias in how threats are perceived. Only by being aware of bias can one correct it.

Become familiar with cultural and ethnic differences in idioms of distress. Specifically, review research in cultural psychiatry to identify potential differences among cultural groups in how they describe psychiatric symptoms. Talk with colleagues or friends from other cultural groups, and read literature from different ethnic perspectives to increase your cultural sensitivity.

Consult with psychiatrists with expertise in cultural variability of clinical presentation when the diagnosis or threat assessment seems unclear. Consultation is recommended if a patient’s diagnosis is uncertain or if you detect bias in your practice.

These interventions require clinicians to become familiar with psychosocial differences in how patients of various cultural and ethnic groups express psychiatric symptoms. With this understanding, we can better engage wary patients, obtain valid information, and improve clinical practice and patient outcomes.

Finally, psychiatry’s diagnostic systems need to continually address how patient assessment is influenced by ethnicity, culture, gender, and other socio-demographic factors. Studies are needed to examine the contributions of multiple factors—such as symptom differences and stereotyping—that contribute to ethnic-related diagnostic disparities.

Related resources

• Paul AM. Painting insanity black: Why are there more black schizophrenics? Salon.com Dec. 1, 1999. http://www.salon.com/books/it/1999/12/01/schizo/index.html
• Alarcon RD, Westermeyer J, Foulks EF, Ruiz P. Clinical relevance of contemporary cultural psychiatry. J Nerv Ment Dis 1999;187: 465-71.
• Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003;93:200-8.
• Lin KM, Smith MW, Ortiz V. Culture and psychopharmacology. Psychiatr Clin North Am 2001; 24:523-38.

Acknowledgement

Preparation of this manuscript was supported in part by National Institutes of Health grant MH56352.

In patients with psychotic symptoms, why are African-Americans more likely than whites to be diagnosed with schizophrenia? After more than 30 years of debate, some answers—and remedies for the problem—are becoming clear.

In psychiatry, where interpersonal interactions are key to eliciting diagnostic symptoms and signs, there is an intrinsic risk of misinterpretation when clinician and patient are of different cultural, ethnic, or socioeconomic backgrounds. This article analyzes four factors that contribute to misinterpretation and to ethnic misdiagnosis of schizophrenia. Culturally sensitive strategies are offered to avoid diagnostic bias in clinical practice.

SCHIZOPHRENIA MISDIAGNOSIS

Large epidemiologic studies report similar rates of schizophrenia and bipolar disorder in African-American and white populations.¹ Although patients of both races have been wrongly diagnosed with schizophrenia, the pattern is stronger and more persistent in African-Americans.

Box 1

In the 1970s, Simon et al² studied 192 hospitalized patients, of whom all African-Americans and 85% of whites had been identified clinically as having schizophrenia. Using a structured interview, the researchers found that only 40% of the African Americans and 50% of the whites met diagnostic criteria for schizophrenia. African-Americans with mood disorders were found to be at particular risk of schizophrenia misdiagnosis.

In the 1980s, among 76 patients with a clinical diagnosis of schizophrenia, Mukherjee et al³ diagnosed one-half (52%) with bipolar disorder using a structured clinical interview. Schizophrenia misdiagnoses were more common in African-Americans (86%) and Hispanics (83%) than in whites (51%). In particular, African-Americans were most likely to be misdiagnosed with paranoid schizophrenia. African-Americans complained more commonly than whites of auditory hallucinations, which may represent an ethnic difference in symptomatic presentation of psychotic mood disorders.

In the 1990s, colleagues and I conducted two studies—one of 173 patients in a Tennessee psychiatric hospital⁴ and the other of 490 patients in an Ohio psychiatric emergency service⁵—and found yet again that African-Americans were more likely than whites to be diagnosed with schizophrenia. In the hospital study, higher rates of schizophrenia diagnosis were associated with lower rates of mood disorder diagnosis. This inverse relationship implied that African-Americans with mood disorders were being misdiagnosed with schizophrenia.

Men were more likely than women to be diagnosed with schizophrenia, suggesting that African-American men were most likely to be misdiagnosed. When adjustments were made for gender, black women were found to be at higher risk for misdiagnosis than white women.

Lawson et al⁶ extended this research in a population-based study of African-Americans living in Tennessee. They found that African-Americans constituted 16% of the state’s population but 48% of psychiatric inpatients diagnosed with schizophrenia and 37% of psychiatric outpatients.

CONSEQUENCES OF INACCURATE DIAGNOSIS

Differentiating between schizophrenia (Box 1) and a psychotic mood disorder (Box 2) is more than a semantic exercise. Schizophrenia implies a chronic, unremitting, debilitating illness that worsens over time. Though this perception of schizophrenia is not entirely accurate, in clinical practice its diagnosis imparts a bleak prognosis that may lower the clinician’s expectations for the patient.⁷

Schizophrenia misdiagnosis also may lead the psychiatrist to rely excessively on antipsychotics, rather than attempting thymoleptic and psychotherapy trials. Studies suggest that African-American patients are more likely than similar white patients to receive antipsychotics^4,8,9 and less likely to receive psychotherapy.^5,10

Reasons why African-Americans are often misdiagnosed with schizophrenia remain unclear but probably include four contributing factors:

• differences in symptom presentation compared with whites
• failure by clinicians to identify affective symptoms in African-Americans
• minority patients’ wariness when dealing with health services
• and racial stereotyping.

DIFFERENCES IN SYMPTOM EXPRESSION

African-American patients with mood disorders or schizophrenia are more likely than are similar white patients to complain of auditory hallucinations.^11-13 For example, Strakowski et al¹⁴ examined 330 patients with nonaffective and psychotic diagnoses in a study that was used to develop DSM-IV criteria for schizophrenia. Auditory hallucinations were rated as more severe in African-American than in similar white patients.

Box 2

African-American patients also are more likely than whites to exhibit so-called Schneiderian first-rank symptoms of schizophrenia,¹⁵ including:

• delusions of thought broadcasting or insertion
• auditory hallucinations of voices conversing about the patient in the third person.

These symptoms were once used to diagnose schizophrenia, but their lack of specificity has been well documented.^2,16 First-rank symptoms of schizophrenia depend on the specific form of the hallucination or delusion, are likely to be influenced by a patient’s culture, and may be misleading in multicultural populations. Though first-rank symptoms now occupy a minor role in U.S. diagnostic systems, they might continue to sway clinicians—even when using structured diagnostic interviews—to inappropriately diagnose schizophrenia in lieu of affective disorders in minority patients.¹⁵

To extend this finding, our group¹⁶ studied rates and severity of affective and psychotic symptoms—particularly first-rank symptoms—in 100 patients with psychotic mania who met DSM-III-R criteria for bipolar disorder (80%) or schizoaffective disorder, bipolar type (20%) as determined by structured diagnostic interview. No differences in affective symptoms between African-American and white patients were seen. African-Americans were more likely to endorse auditory hallucinations and to report severe auditory hallucinations of voices commenting on their behavior—the only first-rank symptom on which they differed from whites.

Though their affective symptoms were similar, African-Americans were significantly more likely than whites to have been diagnosed with a schizophrenia-spectrum disorder. Because misdiagnosis of African-Americans could not be explained by psychotic symptoms—which were as severe as those of white patients—these findings suggest other mechanisms were at work.

UNIDENTIFIED AFFECTIVE SYMPTOMS

Underidentification of mood disorders in African-American patients may also lead to over-diagnosis of schizophrenia. In a sample of 99 patients, colleagues and I¹⁷ compared clinical diagnoses made in a psychiatric emergency service with those by research investigators using a structured clinical interview. Reasons for diagnostic differences were identified and divided into two categories:

• the same symptoms were recorded but applied differently to diagnostic criteria (criterion variance)
• different information was recorded, which led to diagnostic discrepancies (information variance).

Differences occurred significantly more often in African-American than in white patients, but only information variance was associated with ethnicity. This suggests that clinicians are less likely to elicit appropriate information from African-American than from white psychiatric patients. The fact that researchers obtained this information during diagnostic interviews suggests that the patients could provide it when given appropriate prompts. Specifically, affective symptoms were less likely to be elicited by clinicians than by researchers.

PATIENT WARINESS

Minority patients, when interacting with clinicians of the majority population, may project “protective wariness.”¹⁸ Specific behaviors include hesitancy or reluctance to fully engage with the care provider as a precaution against being exploited or harmed. Cultural misunderstandings¹⁹ and patient concerns about past reports of minorities receiving substandard or unethical health care²⁰ may contribute to this behavior.

Whaley²¹ compared nonpathologic distrust and paranoia in 404 community-living African-Americans and whites. Some were healthy, and some had diagnoses of schizophrenia or depression. African-Americans—particularly those with psychiatric disorders—showed higher levels of distrust than whites. Distrust was also associated with depression in African-Americans but not in whites. Whaley concluded that:

• depressed African-Americans may exhibit more distrust toward clinicians than do whites
• this distrust puts African-Americans at risk of being perceived as paranoid and being misdiagnosed with paranoid schizophrenia.

Table

Remedial actions to avoid ethnic bias in diagnosing schizophrenia

Though Whaley did not report differences in distrust between African-American men and women, others have noted that distrust of health providers may be more common in minority men.¹⁸

RACIAL STEREOTYPING

Compared with similar white men, African-American men with mental disorders are more likely to be:

• referred for mental health care through social and legal—rather than medical—systems and to be involuntarily committed
• perceived as violent—even though controlled research suggests they are not. This misperception can lead to excessive medication and restraints.²²

Differential treatment of African-American men may create a cycle of distrust, hostility, and additional inappropriate treatment. Together, these factors may increase the risk that African-American men will be misdiagnosed with schizophrenia.

Past racism in biomedical and psychiatric practice and research has been documented^23,24 and more recently reviewed by Lawson.¹⁹ Historically, African-Americans were perceived to have a “primitive psychic” nature that was thought to be more susceptible to schizophrenia than depression.¹⁹ Whether these or similar racist stereotypes continue to inject ethnic bias into clinical assessment requires further study.

WHERE DO WE GO FROM HERE?

Although research into methods to eliminate ethnicity bias is sparse, the work reviewed in this article suggests ways that psychiatrists can minimize this problem (Table).

Obtain comprehensive information. Use structured interviews, such as the Structured Clinical Interview for DSM-IV (SCID), and rating scales, such as the Hamilton Depression Scale, which require clinicians to ask about all types of symptoms, particularly affective symptoms.

Review treatment records. Review your practice patterns for evidence of schizophrenia over-diagnosis in African-Americans or other ethnic groups. Examine ethnic differences in legal referrals or use of restraints or seclusion, which may indicate an ethnic bias in how threats are perceived. Only by being aware of bias can one correct it.

Become familiar with cultural and ethnic differences in idioms of distress. Specifically, review research in cultural psychiatry to identify potential differences among cultural groups in how they describe psychiatric symptoms. Talk with colleagues or friends from other cultural groups, and read literature from different ethnic perspectives to increase your cultural sensitivity.

Consult with psychiatrists with expertise in cultural variability of clinical presentation when the diagnosis or threat assessment seems unclear. Consultation is recommended if a patient’s diagnosis is uncertain or if you detect bias in your practice.

These interventions require clinicians to become familiar with psychosocial differences in how patients of various cultural and ethnic groups express psychiatric symptoms. With this understanding, we can better engage wary patients, obtain valid information, and improve clinical practice and patient outcomes.

Finally, psychiatry’s diagnostic systems need to continually address how patient assessment is influenced by ethnicity, culture, gender, and other socio-demographic factors. Studies are needed to examine the contributions of multiple factors—such as symptom differences and stereotyping—that contribute to ethnic-related diagnostic disparities.

Related resources

• Paul AM. Painting insanity black: Why are there more black schizophrenics? Salon.com Dec. 1, 1999. http://www.salon.com/books/it/1999/12/01/schizo/index.html
• Alarcon RD, Westermeyer J, Foulks EF, Ruiz P. Clinical relevance of contemporary cultural psychiatry. J Nerv Ment Dis 1999;187: 465-71.
• Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003;93:200-8.
• Lin KM, Smith MW, Ortiz V. Culture and psychopharmacology. Psychiatr Clin North Am 2001; 24:523-38.

Acknowledgement

Preparation of this manuscript was supported in part by National Institutes of Health grant MH56352.

Psychiatry has used the term “schizoaffective disorder” for more than 60 years, but its specific meaning remains uncertain. Patients who meet its diagnostic criteria typically present with a confusing blend of mood and psychotic symptoms, and we often classify them as being schizoaffective because we don’t know where else to put them.

Much of our difficulty in trying to determine what schizoaffective disorder is can be blamed on insufficient data. We do not know the specific cause of either schizophrenic or mood disorders, and today’s concepts of these broad diagnoses probably encompass multiple etiologies.

Based on the evidence and clinical experience, this article presents:

• the evolution of schizoaffective disorder as a psychiatric diagnosis
• the four main concepts that attempt to explain the disorder’s cause
• and a practical approach for managing these patients’ complicated symptoms.

Origins of schizoaffective disorder

When Jacob Kasanin¹ riginated the term schizoaffective disorder in 1933, psychiatry was struggling to integrate Emil Kraepelin’s and Eugene Bleuler’s two competing and complementary schemes for understanding psychotic disorders.

Kraepelin had proposed that the major psychoses could be divided between dementia praecox and manic-depressive insanity (and to a lesser extent, paraphrenia), based on the presenting symptoms and—importantly—course of illness:²

• Manic-depressive insanity typically included periods of full recovery of mental functions between episodes.
• Dementia praecox was defined by a steady deterioration of mental function and personality from which patients rarely recovered.

Box

This distinction was a landmark in psychiatry but did not offer a specific understanding of the mental or brain dysfunctions underlying these conditions nor a cross-sectional means to diagnose a patient’s condition.

Bleuler was less concerned with predicting course and outcome. Instead, he wished to understand his observations that patients commonly exhibited a disjunction among psychological processes that were integrated in healthy individuals.³ He described the cause of this loss of psychological integration as the “schizophrenias” or, literally, “split mind.” In the schizophrenias, he identified symptoms that seemed to reflect this psychological disjunction, such as flat affect, ambivalence, and splitting of cognition from emotion and behavior.

Because Kraepelin described many of these same symptoms in dementia praecox, clinicians tended to equate the schizophrenias with dementia praecox. However, many more patients with Bleuler’s schizophrenia recovered than did those with Kraepelin’s dementia praecox (essentially by definition). Therefore, some “schizophrenic” patients appeared to meet Kraepelin’s diagnosis of manic-depressive insanity. At this point, Kasanin stepped into the fray with his concept of schizoaffective disorder.

Kasanin’s conceptualization

Kasanin recognized that many patients exhibited a blending of Bleuler’s schizophrenia symptoms with those of Kraepelin’s manic-depressive (affective) illness.¹ Moreover, unlike patients with dementia praecox, these blended patients exhibited:

• good premorbid adjustment
• typically a sudden illness onset with marked emotional turmoil
• few symptoms of withdrawal or passivity
• and a relatively short course with complete recovery.

In reporting these patients and subsequently originating the term “schizoaffective psychosis,” Kasanin tried to identify a homogeneous patient population that could be distinguished from the more broadly conceptualized Bleulerian schizophrenias and the more narrowly defined Kraepelinian categories.

The term “schizoaffective disorder” has evolved from this beginning. Interestingly, most—if not all—of the nine cases reported by Kasanin would be diagnosed with an affective disorder with psychotic features under today’s diagnostic criteria.⁴ Nonetheless, the term “schizoaffective disorder” was adopted by psychiatry (particularly in the United States) and has been used to classify patients who present with features of both schizophrenia and affective illness but cannot be clearly described as having either.

Evolutions from DSM-I to DSM-III

In American nosology, schizoaffective disorder was included as a subtype of schizophrenia in DSM-I (1952)⁵ and DSM-II (1968)⁶ and then reclassified in DSM-III (1980)⁷ as a “psychotic disorder not elsewhere classified.” Remarkably, none of these classifications provided criteria for diagnosing schizoaffective disorder.

Shortly before publication of DSM-III, Robert Spitzer, MD, and colleagues at the New York Neuropsychiatric Institute developed diagnostic criteria for schizoaffective disorder as part of their research diagnostic criteria (RDC).⁸ The RDC separated patients with affective and certain types of psychotic symptoms, suggestive of schizophrenia at that time, into two types—schizoaffective mania and schizoaffective depression—based on the polarity of the mood symptoms.

The psychotic symptoms identified as “schizophrenic” by the RDC were certain first-rank symptoms designated by Kurt Schneider, such as delusions of being controlled or mood-incongruent hallucinations. [Note: In recent studies, neither first-rank symptoms nor other subtypes of psychotic symptoms (moodincongruent delusions or hallucinations) have been shown to specifically identify patients with schizophrenia.^9,10 In fact, no psychotic symptoms are considered pathognomonic for any specific disorder at this time.]

The RDC also introduced the idea that schizoaffective disorder was distinct from psychotic mood disorder in that:

• psychotic symptoms persisted for a specific period (1 week), during which mood symptoms were absent
• and mood and psychotic symptoms overlapped at some time during the course of illness.

These criteria were then adopted with modifications in DSM-III-R,¹¹ which provided the first widely-accepted, well-defined criteria for schizoaffective disorder.

DSM-III-R and DSM-IV

DSM-III-R defined schizoaffective disorder based on relationships between affective syndromes and the criteria for schizophrenia. Specifically, the diagnosis required the presence of a full depressive or manic syndrome while the patient also met criteria for schizophrenia. To distinguish schizoaffective disorder from psychotic mood disorders, DSM-III-R required that psychotic symptoms persist for 2 weeks in the absence of “prominent” mood symptoms.

Unfortunately, “prominent” was not defined, leaving a fair amount of discretion to clinicians and making it difficult to standardize research studies. In addition, the predictive utility of 2 weeks of psychosis has not been strongly validated. In fact, the time span at which psychosis without a mood disorder identifies a new syndrome is not known.

To rule out schizophrenia, the mood syndrome could not have been “brief” relative to the psychosis; again, what “brief” meant was difficult to put into practice. Notably, there was no specific requirement to rule out mood disorders (i.e., that the psychosis was not brief relative to the duration of mood symptoms).

DSM-IV slightly modified these criteria,¹² but their basic flavor from DSM-III-R was retained. Despite their limitations, the diagnostic criteria in DSM-III-R and DSM-IV at least provided clinicians and scientists the means to consistently identify schizoaffective disorder. The diagnostic criteria (Box) are still considered reliable today.¹³

Four concepts of schizoaffective disorder

Relatively few studies of schizoaffective disorder exist, so the diagnosis remains poorly validated. At least four concepts have been developed (Figure).⁴

Concept 1: Schizoaffective disorder is a variant of schizophrenia. Many of the characteristics of schizoaffective disorder that Kasanin first described, such as rapid onset and confusion, were identified as good prognostic indicators in later concepts of schizophrenia. Some family history studies also suggest a link between schizophrenic and schizoaffective disorders.¹⁵

Concept 2: Schizoaffective disorder is a variant of mood disorder. ⁹ Schizoaffective disorder represents a pernicious type of mood disorder in which psychotic symptoms persist and the course of illness is worse than in other variants (although better than in schizophrenia).¹⁶ Family studies are unclear about links between mood and schizoaffective disorders.¹⁷

Figure FOUR CONCEPTS THAT SEEK TO EXPLAIN SCHIZOAFFECTIVE DISORDER

Figure. Four conceptualizations explain schizoaffective disorder as (1) a type of schizophrenia; (2) a type of mood disorder; (3) a heterogeneous combination of patients with schizophrenia, mood disorder, and “real” schizoaffective disorder; and (4) as part of a continuum of psychotic disorders from worst prognosis (schizophrenia) to best prognosis (major depression).Concept 3: Schizoaffective disorder represents a heterogeneous combination of schizophrenia and mood disorder. Specifically, schizoaffective disorder may comprise a group of patients with severe psychotic mood disorders and either good-prognosis schizophrenia or schizophrenia with numerous affective symptoms.

A subgroup of patients with “true” schizoaffective disorder (distinct from schizophrenic or mood disorders) might also exist.¹⁸ As a twist on this idea, others have suggested that schizoaffective disorder, bipolar type is simply a variant of bipolar disorder, whereas schizoaffective disorder, depressed type is more closely akin to schizophrenia. The fact that depression occurs at some time in most patients with schizophrenia supports this view.

Concept 4: Psychotic disorders share a genetic vulnerability and exist on a continuum (from worst to best prognosis) from schizophrenia, to schizoaffective disorder, to psychotic then nonpsychotic bipolar and major depressive disorders.¹⁹

A lack of definitive evidence prevents us from choosing among these concepts; good studies support and discount each possibility.

Patient management

When faced with a patient who meets criteria for schizoaffective disorder, I believe practical considerations can guide treatment. The label “schizoaffective disorder” reminds us to consider treatment of these patients broadly (in contrast, for example, to the label “schizophreniform disorder,” which implies a stronger link to schizophrenia than outcome studies support²¹).

Treat the mood component first. In most patients with schizoaffective disorder, it is difficult to distinguish between diagnoses of schizophrenia or mood disorder. It is prudent to begin by aggressively treating the mood component, because psychotic mood disorders generally respond more favorably to treatment than does schizophrenia. Use mood stabilizers for patients with a history of mania and antidepressants in depressed patients with no history of mania.

As is true for psychotic mood disorders, concurrent administration of an antipsychotic is often warranted. Recent studies strongly suggest that atypical antipsychotics are preferred over traditional neuroleptics to treat psychotic patients in general, and this preference extends to patients with schizoaffective disorder.^4,14,20

Some—if not most—atypical antipsychotics may have mood-stabilizing or antidepressant properties and may permit monotherapy of patients with schizoaffective disorder. Controlled clinical trials have not examined these agents as long-term maintenance therapy for the mood component of schizoaffective disorder, however. Until such studies are completed, many patients may require long-term mood-stabilizer or antidepressant therapy, with or without ongoing antipsychotic treatment.^4,14

The next step. Alternate treatments should be considered for patients in whom trials of atypical antipsychotics have failed, both in combination with thymoleptics and in monotherapy. Conventional antipsychotics, particularly depot formulations, are a reasonable intervention, particularly in schizoaffective patients with minimal mood symptoms.

Clozapine remains a first-line choice for patients with treatment-resistant psychotic disorders and should be considered in patients with treatment-resistant schizoaffective disorder as well.

Conclusion

Patients meeting criteria for schizoaffective disorder typically present with a complex and confusing combination of affective and psychotic symptoms. The diagnosis continues to be applied predominantly to patients who are otherwise difficult to classify, and the diagnostic criteria supporting the presence of a distinct condition remain poorly validated.

Schizoaffective disorder probably defines a heterogeneous group of patients, but—practically speaking—they can often be managed by following algorithms for psychotic mood disorders.^4,13 The most prudent long-term approach seems to be to keep treatment options flexible, with careful attention to managing symptoms as they wax and wane, rather than rigidly fixing on a single medication or type of medication.

Related resources

• National Mental Health Association factsheet on schizoaffective disorder www.nmha.org/infoctr/factsheets/52.cfm
• Reichenberg A, Weiser M, Rabinowitz, J, et al. A population-based cohort study of premorbid intellectual, language, and behavioral functioning in patients with schizophrenia, schizoaffective disorder, and nonpsychotic bipolar disorder. Am J Psychiatry 2002;159(12):2027-35.
• Robinson DG, Woerner, MG, Alvir JM, et al. Predictors of medication discontinuation by patients with first-episode schizophrenia and schizoaffective disorder. Schizophr Res 2002;57(2-3):209-19.

Psychiatry has used the term “schizoaffective disorder” for more than 60 years, but its specific meaning remains uncertain. Patients who meet its diagnostic criteria typically present with a confusing blend of mood and psychotic symptoms, and we often classify them as being schizoaffective because we don’t know where else to put them.

Much of our difficulty in trying to determine what schizoaffective disorder is can be blamed on insufficient data. We do not know the specific cause of either schizophrenic or mood disorders, and today’s concepts of these broad diagnoses probably encompass multiple etiologies.

Based on the evidence and clinical experience, this article presents:

• the evolution of schizoaffective disorder as a psychiatric diagnosis
• the four main concepts that attempt to explain the disorder’s cause
• and a practical approach for managing these patients’ complicated symptoms.

Origins of schizoaffective disorder

When Jacob Kasanin¹ riginated the term schizoaffective disorder in 1933, psychiatry was struggling to integrate Emil Kraepelin’s and Eugene Bleuler’s two competing and complementary schemes for understanding psychotic disorders.

Kraepelin had proposed that the major psychoses could be divided between dementia praecox and manic-depressive insanity (and to a lesser extent, paraphrenia), based on the presenting symptoms and—importantly—course of illness:²

• Manic-depressive insanity typically included periods of full recovery of mental functions between episodes.
• Dementia praecox was defined by a steady deterioration of mental function and personality from which patients rarely recovered.

Box

This distinction was a landmark in psychiatry but did not offer a specific understanding of the mental or brain dysfunctions underlying these conditions nor a cross-sectional means to diagnose a patient’s condition.

Bleuler was less concerned with predicting course and outcome. Instead, he wished to understand his observations that patients commonly exhibited a disjunction among psychological processes that were integrated in healthy individuals.³ He described the cause of this loss of psychological integration as the “schizophrenias” or, literally, “split mind.” In the schizophrenias, he identified symptoms that seemed to reflect this psychological disjunction, such as flat affect, ambivalence, and splitting of cognition from emotion and behavior.

Because Kraepelin described many of these same symptoms in dementia praecox, clinicians tended to equate the schizophrenias with dementia praecox. However, many more patients with Bleuler’s schizophrenia recovered than did those with Kraepelin’s dementia praecox (essentially by definition). Therefore, some “schizophrenic” patients appeared to meet Kraepelin’s diagnosis of manic-depressive insanity. At this point, Kasanin stepped into the fray with his concept of schizoaffective disorder.

Kasanin’s conceptualization

Kasanin recognized that many patients exhibited a blending of Bleuler’s schizophrenia symptoms with those of Kraepelin’s manic-depressive (affective) illness.¹ Moreover, unlike patients with dementia praecox, these blended patients exhibited:

• good premorbid adjustment
• typically a sudden illness onset with marked emotional turmoil
• few symptoms of withdrawal or passivity
• and a relatively short course with complete recovery.

In reporting these patients and subsequently originating the term “schizoaffective psychosis,” Kasanin tried to identify a homogeneous patient population that could be distinguished from the more broadly conceptualized Bleulerian schizophrenias and the more narrowly defined Kraepelinian categories.

The term “schizoaffective disorder” has evolved from this beginning. Interestingly, most—if not all—of the nine cases reported by Kasanin would be diagnosed with an affective disorder with psychotic features under today’s diagnostic criteria.⁴ Nonetheless, the term “schizoaffective disorder” was adopted by psychiatry (particularly in the United States) and has been used to classify patients who present with features of both schizophrenia and affective illness but cannot be clearly described as having either.

Evolutions from DSM-I to DSM-III

In American nosology, schizoaffective disorder was included as a subtype of schizophrenia in DSM-I (1952)⁵ and DSM-II (1968)⁶ and then reclassified in DSM-III (1980)⁷ as a “psychotic disorder not elsewhere classified.” Remarkably, none of these classifications provided criteria for diagnosing schizoaffective disorder.

Shortly before publication of DSM-III, Robert Spitzer, MD, and colleagues at the New York Neuropsychiatric Institute developed diagnostic criteria for schizoaffective disorder as part of their research diagnostic criteria (RDC).⁸ The RDC separated patients with affective and certain types of psychotic symptoms, suggestive of schizophrenia at that time, into two types—schizoaffective mania and schizoaffective depression—based on the polarity of the mood symptoms.

The psychotic symptoms identified as “schizophrenic” by the RDC were certain first-rank symptoms designated by Kurt Schneider, such as delusions of being controlled or mood-incongruent hallucinations. [Note: In recent studies, neither first-rank symptoms nor other subtypes of psychotic symptoms (moodincongruent delusions or hallucinations) have been shown to specifically identify patients with schizophrenia.^9,10 In fact, no psychotic symptoms are considered pathognomonic for any specific disorder at this time.]

The RDC also introduced the idea that schizoaffective disorder was distinct from psychotic mood disorder in that:

• psychotic symptoms persisted for a specific period (1 week), during which mood symptoms were absent
• and mood and psychotic symptoms overlapped at some time during the course of illness.

These criteria were then adopted with modifications in DSM-III-R,¹¹ which provided the first widely-accepted, well-defined criteria for schizoaffective disorder.

DSM-III-R and DSM-IV

DSM-III-R defined schizoaffective disorder based on relationships between affective syndromes and the criteria for schizophrenia. Specifically, the diagnosis required the presence of a full depressive or manic syndrome while the patient also met criteria for schizophrenia. To distinguish schizoaffective disorder from psychotic mood disorders, DSM-III-R required that psychotic symptoms persist for 2 weeks in the absence of “prominent” mood symptoms.

Unfortunately, “prominent” was not defined, leaving a fair amount of discretion to clinicians and making it difficult to standardize research studies. In addition, the predictive utility of 2 weeks of psychosis has not been strongly validated. In fact, the time span at which psychosis without a mood disorder identifies a new syndrome is not known.

To rule out schizophrenia, the mood syndrome could not have been “brief” relative to the psychosis; again, what “brief” meant was difficult to put into practice. Notably, there was no specific requirement to rule out mood disorders (i.e., that the psychosis was not brief relative to the duration of mood symptoms).

DSM-IV slightly modified these criteria,¹² but their basic flavor from DSM-III-R was retained. Despite their limitations, the diagnostic criteria in DSM-III-R and DSM-IV at least provided clinicians and scientists the means to consistently identify schizoaffective disorder. The diagnostic criteria (Box) are still considered reliable today.¹³

Four concepts of schizoaffective disorder

Relatively few studies of schizoaffective disorder exist, so the diagnosis remains poorly validated. At least four concepts have been developed (Figure).⁴

Concept 1: Schizoaffective disorder is a variant of schizophrenia. Many of the characteristics of schizoaffective disorder that Kasanin first described, such as rapid onset and confusion, were identified as good prognostic indicators in later concepts of schizophrenia. Some family history studies also suggest a link between schizophrenic and schizoaffective disorders.¹⁵

Concept 2: Schizoaffective disorder is a variant of mood disorder. ⁹ Schizoaffective disorder represents a pernicious type of mood disorder in which psychotic symptoms persist and the course of illness is worse than in other variants (although better than in schizophrenia).¹⁶ Family studies are unclear about links between mood and schizoaffective disorders.¹⁷

Figure FOUR CONCEPTS THAT SEEK TO EXPLAIN SCHIZOAFFECTIVE DISORDER

Figure. Four conceptualizations explain schizoaffective disorder as (1) a type of schizophrenia; (2) a type of mood disorder; (3) a heterogeneous combination of patients with schizophrenia, mood disorder, and “real” schizoaffective disorder; and (4) as part of a continuum of psychotic disorders from worst prognosis (schizophrenia) to best prognosis (major depression).Concept 3: Schizoaffective disorder represents a heterogeneous combination of schizophrenia and mood disorder. Specifically, schizoaffective disorder may comprise a group of patients with severe psychotic mood disorders and either good-prognosis schizophrenia or schizophrenia with numerous affective symptoms.

A subgroup of patients with “true” schizoaffective disorder (distinct from schizophrenic or mood disorders) might also exist.¹⁸ As a twist on this idea, others have suggested that schizoaffective disorder, bipolar type is simply a variant of bipolar disorder, whereas schizoaffective disorder, depressed type is more closely akin to schizophrenia. The fact that depression occurs at some time in most patients with schizophrenia supports this view.

Concept 4: Psychotic disorders share a genetic vulnerability and exist on a continuum (from worst to best prognosis) from schizophrenia, to schizoaffective disorder, to psychotic then nonpsychotic bipolar and major depressive disorders.¹⁹

A lack of definitive evidence prevents us from choosing among these concepts; good studies support and discount each possibility.

Patient management

When faced with a patient who meets criteria for schizoaffective disorder, I believe practical considerations can guide treatment. The label “schizoaffective disorder” reminds us to consider treatment of these patients broadly (in contrast, for example, to the label “schizophreniform disorder,” which implies a stronger link to schizophrenia than outcome studies support²¹).

Treat the mood component first. In most patients with schizoaffective disorder, it is difficult to distinguish between diagnoses of schizophrenia or mood disorder. It is prudent to begin by aggressively treating the mood component, because psychotic mood disorders generally respond more favorably to treatment than does schizophrenia. Use mood stabilizers for patients with a history of mania and antidepressants in depressed patients with no history of mania.

As is true for psychotic mood disorders, concurrent administration of an antipsychotic is often warranted. Recent studies strongly suggest that atypical antipsychotics are preferred over traditional neuroleptics to treat psychotic patients in general, and this preference extends to patients with schizoaffective disorder.^4,14,20

Some—if not most—atypical antipsychotics may have mood-stabilizing or antidepressant properties and may permit monotherapy of patients with schizoaffective disorder. Controlled clinical trials have not examined these agents as long-term maintenance therapy for the mood component of schizoaffective disorder, however. Until such studies are completed, many patients may require long-term mood-stabilizer or antidepressant therapy, with or without ongoing antipsychotic treatment.^4,14

The next step. Alternate treatments should be considered for patients in whom trials of atypical antipsychotics have failed, both in combination with thymoleptics and in monotherapy. Conventional antipsychotics, particularly depot formulations, are a reasonable intervention, particularly in schizoaffective patients with minimal mood symptoms.

Clozapine remains a first-line choice for patients with treatment-resistant psychotic disorders and should be considered in patients with treatment-resistant schizoaffective disorder as well.

Conclusion

Patients meeting criteria for schizoaffective disorder typically present with a complex and confusing combination of affective and psychotic symptoms. The diagnosis continues to be applied predominantly to patients who are otherwise difficult to classify, and the diagnostic criteria supporting the presence of a distinct condition remain poorly validated.

Schizoaffective disorder probably defines a heterogeneous group of patients, but—practically speaking—they can often be managed by following algorithms for psychotic mood disorders.^4,13 The most prudent long-term approach seems to be to keep treatment options flexible, with careful attention to managing symptoms as they wax and wane, rather than rigidly fixing on a single medication or type of medication.

Related resources

• National Mental Health Association factsheet on schizoaffective disorder www.nmha.org/infoctr/factsheets/52.cfm
• Reichenberg A, Weiser M, Rabinowitz, J, et al. A population-based cohort study of premorbid intellectual, language, and behavioral functioning in patients with schizophrenia, schizoaffective disorder, and nonpsychotic bipolar disorder. Am J Psychiatry 2002;159(12):2027-35.
• Robinson DG, Woerner, MG, Alvir JM, et al. Predictors of medication discontinuation by patients with first-episode schizophrenia and schizoaffective disorder. Schizophr Res 2002;57(2-3):209-19.

Psychiatry has used the term “schizoaffective disorder” for more than 60 years, but its specific meaning remains uncertain. Patients who meet its diagnostic criteria typically present with a confusing blend of mood and psychotic symptoms, and we often classify them as being schizoaffective because we don’t know where else to put them.

Much of our difficulty in trying to determine what schizoaffective disorder is can be blamed on insufficient data. We do not know the specific cause of either schizophrenic or mood disorders, and today’s concepts of these broad diagnoses probably encompass multiple etiologies.

Based on the evidence and clinical experience, this article presents:

• the evolution of schizoaffective disorder as a psychiatric diagnosis
• the four main concepts that attempt to explain the disorder’s cause
• and a practical approach for managing these patients’ complicated symptoms.

Origins of schizoaffective disorder

When Jacob Kasanin¹ riginated the term schizoaffective disorder in 1933, psychiatry was struggling to integrate Emil Kraepelin’s and Eugene Bleuler’s two competing and complementary schemes for understanding psychotic disorders.

Kraepelin had proposed that the major psychoses could be divided between dementia praecox and manic-depressive insanity (and to a lesser extent, paraphrenia), based on the presenting symptoms and—importantly—course of illness:²

• Manic-depressive insanity typically included periods of full recovery of mental functions between episodes.
• Dementia praecox was defined by a steady deterioration of mental function and personality from which patients rarely recovered.

Box

This distinction was a landmark in psychiatry but did not offer a specific understanding of the mental or brain dysfunctions underlying these conditions nor a cross-sectional means to diagnose a patient’s condition.

Bleuler was less concerned with predicting course and outcome. Instead, he wished to understand his observations that patients commonly exhibited a disjunction among psychological processes that were integrated in healthy individuals.³ He described the cause of this loss of psychological integration as the “schizophrenias” or, literally, “split mind.” In the schizophrenias, he identified symptoms that seemed to reflect this psychological disjunction, such as flat affect, ambivalence, and splitting of cognition from emotion and behavior.

Because Kraepelin described many of these same symptoms in dementia praecox, clinicians tended to equate the schizophrenias with dementia praecox. However, many more patients with Bleuler’s schizophrenia recovered than did those with Kraepelin’s dementia praecox (essentially by definition). Therefore, some “schizophrenic” patients appeared to meet Kraepelin’s diagnosis of manic-depressive insanity. At this point, Kasanin stepped into the fray with his concept of schizoaffective disorder.

Kasanin’s conceptualization

Kasanin recognized that many patients exhibited a blending of Bleuler’s schizophrenia symptoms with those of Kraepelin’s manic-depressive (affective) illness.¹ Moreover, unlike patients with dementia praecox, these blended patients exhibited:

• good premorbid adjustment
• typically a sudden illness onset with marked emotional turmoil
• few symptoms of withdrawal or passivity
• and a relatively short course with complete recovery.

In reporting these patients and subsequently originating the term “schizoaffective psychosis,” Kasanin tried to identify a homogeneous patient population that could be distinguished from the more broadly conceptualized Bleulerian schizophrenias and the more narrowly defined Kraepelinian categories.

The term “schizoaffective disorder” has evolved from this beginning. Interestingly, most—if not all—of the nine cases reported by Kasanin would be diagnosed with an affective disorder with psychotic features under today’s diagnostic criteria.⁴ Nonetheless, the term “schizoaffective disorder” was adopted by psychiatry (particularly in the United States) and has been used to classify patients who present with features of both schizophrenia and affective illness but cannot be clearly described as having either.

Evolutions from DSM-I to DSM-III

In American nosology, schizoaffective disorder was included as a subtype of schizophrenia in DSM-I (1952)⁵ and DSM-II (1968)⁶ and then reclassified in DSM-III (1980)⁷ as a “psychotic disorder not elsewhere classified.” Remarkably, none of these classifications provided criteria for diagnosing schizoaffective disorder.

Shortly before publication of DSM-III, Robert Spitzer, MD, and colleagues at the New York Neuropsychiatric Institute developed diagnostic criteria for schizoaffective disorder as part of their research diagnostic criteria (RDC).⁸ The RDC separated patients with affective and certain types of psychotic symptoms, suggestive of schizophrenia at that time, into two types—schizoaffective mania and schizoaffective depression—based on the polarity of the mood symptoms.

The psychotic symptoms identified as “schizophrenic” by the RDC were certain first-rank symptoms designated by Kurt Schneider, such as delusions of being controlled or mood-incongruent hallucinations. [Note: In recent studies, neither first-rank symptoms nor other subtypes of psychotic symptoms (moodincongruent delusions or hallucinations) have been shown to specifically identify patients with schizophrenia.^9,10 In fact, no psychotic symptoms are considered pathognomonic for any specific disorder at this time.]

The RDC also introduced the idea that schizoaffective disorder was distinct from psychotic mood disorder in that:

• psychotic symptoms persisted for a specific period (1 week), during which mood symptoms were absent
• and mood and psychotic symptoms overlapped at some time during the course of illness.

These criteria were then adopted with modifications in DSM-III-R,¹¹ which provided the first widely-accepted, well-defined criteria for schizoaffective disorder.

DSM-III-R and DSM-IV

DSM-III-R defined schizoaffective disorder based on relationships between affective syndromes and the criteria for schizophrenia. Specifically, the diagnosis required the presence of a full depressive or manic syndrome while the patient also met criteria for schizophrenia. To distinguish schizoaffective disorder from psychotic mood disorders, DSM-III-R required that psychotic symptoms persist for 2 weeks in the absence of “prominent” mood symptoms.

Unfortunately, “prominent” was not defined, leaving a fair amount of discretion to clinicians and making it difficult to standardize research studies. In addition, the predictive utility of 2 weeks of psychosis has not been strongly validated. In fact, the time span at which psychosis without a mood disorder identifies a new syndrome is not known.

To rule out schizophrenia, the mood syndrome could not have been “brief” relative to the psychosis; again, what “brief” meant was difficult to put into practice. Notably, there was no specific requirement to rule out mood disorders (i.e., that the psychosis was not brief relative to the duration of mood symptoms).

DSM-IV slightly modified these criteria,¹² but their basic flavor from DSM-III-R was retained. Despite their limitations, the diagnostic criteria in DSM-III-R and DSM-IV at least provided clinicians and scientists the means to consistently identify schizoaffective disorder. The diagnostic criteria (Box) are still considered reliable today.¹³

Four concepts of schizoaffective disorder

Relatively few studies of schizoaffective disorder exist, so the diagnosis remains poorly validated. At least four concepts have been developed (Figure).⁴

Concept 1: Schizoaffective disorder is a variant of schizophrenia. Many of the characteristics of schizoaffective disorder that Kasanin first described, such as rapid onset and confusion, were identified as good prognostic indicators in later concepts of schizophrenia. Some family history studies also suggest a link between schizophrenic and schizoaffective disorders.¹⁵

Concept 2: Schizoaffective disorder is a variant of mood disorder. ⁹ Schizoaffective disorder represents a pernicious type of mood disorder in which psychotic symptoms persist and the course of illness is worse than in other variants (although better than in schizophrenia).¹⁶ Family studies are unclear about links between mood and schizoaffective disorders.¹⁷

Figure FOUR CONCEPTS THAT SEEK TO EXPLAIN SCHIZOAFFECTIVE DISORDER

Figure. Four conceptualizations explain schizoaffective disorder as (1) a type of schizophrenia; (2) a type of mood disorder; (3) a heterogeneous combination of patients with schizophrenia, mood disorder, and “real” schizoaffective disorder; and (4) as part of a continuum of psychotic disorders from worst prognosis (schizophrenia) to best prognosis (major depression).Concept 3: Schizoaffective disorder represents a heterogeneous combination of schizophrenia and mood disorder. Specifically, schizoaffective disorder may comprise a group of patients with severe psychotic mood disorders and either good-prognosis schizophrenia or schizophrenia with numerous affective symptoms.

A subgroup of patients with “true” schizoaffective disorder (distinct from schizophrenic or mood disorders) might also exist.¹⁸ As a twist on this idea, others have suggested that schizoaffective disorder, bipolar type is simply a variant of bipolar disorder, whereas schizoaffective disorder, depressed type is more closely akin to schizophrenia. The fact that depression occurs at some time in most patients with schizophrenia supports this view.

Concept 4: Psychotic disorders share a genetic vulnerability and exist on a continuum (from worst to best prognosis) from schizophrenia, to schizoaffective disorder, to psychotic then nonpsychotic bipolar and major depressive disorders.¹⁹

A lack of definitive evidence prevents us from choosing among these concepts; good studies support and discount each possibility.

Patient management

When faced with a patient who meets criteria for schizoaffective disorder, I believe practical considerations can guide treatment. The label “schizoaffective disorder” reminds us to consider treatment of these patients broadly (in contrast, for example, to the label “schizophreniform disorder,” which implies a stronger link to schizophrenia than outcome studies support²¹).

Treat the mood component first. In most patients with schizoaffective disorder, it is difficult to distinguish between diagnoses of schizophrenia or mood disorder. It is prudent to begin by aggressively treating the mood component, because psychotic mood disorders generally respond more favorably to treatment than does schizophrenia. Use mood stabilizers for patients with a history of mania and antidepressants in depressed patients with no history of mania.

As is true for psychotic mood disorders, concurrent administration of an antipsychotic is often warranted. Recent studies strongly suggest that atypical antipsychotics are preferred over traditional neuroleptics to treat psychotic patients in general, and this preference extends to patients with schizoaffective disorder.^4,14,20

Some—if not most—atypical antipsychotics may have mood-stabilizing or antidepressant properties and may permit monotherapy of patients with schizoaffective disorder. Controlled clinical trials have not examined these agents as long-term maintenance therapy for the mood component of schizoaffective disorder, however. Until such studies are completed, many patients may require long-term mood-stabilizer or antidepressant therapy, with or without ongoing antipsychotic treatment.^4,14

The next step. Alternate treatments should be considered for patients in whom trials of atypical antipsychotics have failed, both in combination with thymoleptics and in monotherapy. Conventional antipsychotics, particularly depot formulations, are a reasonable intervention, particularly in schizoaffective patients with minimal mood symptoms.

Clozapine remains a first-line choice for patients with treatment-resistant psychotic disorders and should be considered in patients with treatment-resistant schizoaffective disorder as well.

Conclusion

Patients meeting criteria for schizoaffective disorder typically present with a complex and confusing combination of affective and psychotic symptoms. The diagnosis continues to be applied predominantly to patients who are otherwise difficult to classify, and the diagnostic criteria supporting the presence of a distinct condition remain poorly validated.

Schizoaffective disorder probably defines a heterogeneous group of patients, but—practically speaking—they can often be managed by following algorithms for psychotic mood disorders.^4,13 The most prudent long-term approach seems to be to keep treatment options flexible, with careful attention to managing symptoms as they wax and wane, rather than rigidly fixing on a single medication or type of medication.

Related resources

• National Mental Health Association factsheet on schizoaffective disorder www.nmha.org/infoctr/factsheets/52.cfm
• Reichenberg A, Weiser M, Rabinowitz, J, et al. A population-based cohort study of premorbid intellectual, language, and behavioral functioning in patients with schizophrenia, schizoaffective disorder, and nonpsychotic bipolar disorder. Am J Psychiatry 2002;159(12):2027-35.
• Robinson DG, Woerner, MG, Alvir JM, et al. Predictors of medication discontinuation by patients with first-episode schizophrenia and schizoaffective disorder. Schizophr Res 2002;57(2-3):209-19.