Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

189 Schizoaffective mixed statesconcepts, and nosological allocations of schizoaffective disorders. The informationthat follows provides a summary of this development.The term ‘‘schizoaffective’’ was introduced in 1933 by the American psychiatristJohn Kasanin in his paper ‘‘The acute schizoaffective psychoses’’, published in theAmerican Journal of Psychiatry, originally presented at the American PsychiatricAssociation annual meeting in Philadelphia the previous year (Kasanin, 1933). Butdescriptions of what was later called schizoaffective disorder are much older. Perhapsthe German psychiatrist Karl Kahlbaum can be considered the first psychiatrist inmodern times to describe schizoaffective disorders as a separate group in vesaniatypica circularis (1863). Kahlbaum applied cross-sectional and longitudinal aspects.Later, Kraepelin recognized a ‘‘great number’’ of cases having the characteristics ofboth groups of psychoses, dementia praecox and manic-depressive insanity. He alsorecognized the existence of such cases, which seriously challenged the clear dichotomybetween schizophrenia and mood disorders (Kraepelin, 1920;seealsoMarnerosand Angst, 2000). Such cases were also recognized by Kurt Schneider, who distinguishedbetween concurrent and sequential types and called them ‘‘cases-in-between’’(Zwischen-Fälle)(Schneider,1959). But John Kasanin gave these ‘‘cases-in-between’’their present name, although the cases described by him are only partly related towhat we today define as schizoaffective disorder. ICD-9 defined schizoaffectivepsychosis (295.7) as a psychosis in which conspicuous manic or depressive symptomsa re mi xed wi th schiz ophre nic symptoms (World H ealth Organi zation, 1968). Thdiagnosis can only be made when affective and schizophrenic symptoms are prominent.How unclear this ICD-9 was can be demonstrated by its synonyms: amongstothers, one finds terms such as ‘‘cycloid psychoses’’ or ‘‘schizophreniform psychoses,affective type,’’ which are nowadays seen as fundamentally different syndromes(Perris, 1986;Pichot,1986;Strömgren, 1986; Marneros and Pillmann, 2004).What we presently define as schizoaffective disorders (for example, the definitionsprovided by the World Health Organization (ICD-8, 1968; ICD-10, 19 91 ) orAmerican Psychiatric Association (DSM-IV, 1994), as well as empirical definitions(Marneros et al., 1986), is much more strongly related to Kurt Schneider’s‘‘cases-in-between’’ than to Kasanin’s ‘‘schizoaffective psychoses.’’Pierre Pichot, who analyzed Kasanin’s concept, observed (1986) that Kasanin’spaper contained three main chapters:1. General considerations are presented regarding the alleged pessimism of theKraepelinian nosology and the specificity of American psychiatry, with AdolfMeyer’s teachings and the psychoanalytic approach being particularly emphasized.Kasanin then suggests the separation (from the ‘‘nuclear constitutionalcases’’ of schizophrenia) of a subgroup of patients defined by special criteria,probably etiologically related to emotional conflicts of a mainly sexual nature.This, in turn, prompts him to suggest that ‘‘psycho-therapy is strongly