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

30 A. Marneros and F. K. GoodwinTable 1.5 Schizoaffective disorders (295.70) according to DSM-IVA. An uninterrupted period of illness during which, at some time, there is a major depressiveepisode, a manic episode, or a mixed episode concurrent with symptoms that meet criterionA for schizophrenia. Note: The major depressive episode must include criterionA1: depressed moodB. During the same period of illness, there have been delusions or hallucinations for at least 2weeks in the absence of prominent mood symptomsC. Symptoms that meet criteria for a mood episode are present for a substantial portion of thetotal duration of the active and residual periods of the illnessD. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug ofabuse, a medication) or a general medical condition.Specify type:Bipolartype:Depressivetype:If the disturbance includes a manic episode (or a mixed episode or a manic or amixed episode and major depressive episodes)If the disturbance only includes major depressive episodesproblem with this is that the beginning of a psychotic episode can rarely be assessedexactly. Every clinician knows that there is usually a gap of many days, weeks, ormonths between the beginning of a psychotic episode and admission to a hospital.Reconstruction of the psychopathological picture, retrospectively, is fraughtwith difficulty. Given the likelihood that the psychotic period would be underestimated,many patients who are really schizoaffective could be diagnosed asschizophrenic or as having psychotic mood disorder.Furthermore, the intensity of both concurrent syndromes can vary enormouslyduring an episode – it seems arbitrary to give chronological priority to the psychoticsymptoms over the mood component. It is curious that DSM-IV rejected Jasper’shierarchical diagnostic principle, which suggested a diagnostic superiority of schizophrenicsymptoms over affective symptoms but, regarding the chronological criterionof the schizoaffective definition, obviously made an exception!Considering what is now known about schizoaffective disorders (see overviewsin Marneros and Tsuang, 1986, 1990; Marneros et al., 1995), we suggest that thedefinition of schizoaffective disorders should contain two components: crosssectionaland longitudinal. The cross-sectional definition should be the definitionof an episode, while the longitudinal definition should be that of a disease ordisorder. The cross-sectional definition of a schizoaffective episode should bebased on the simultaneous occurrence of symptoms of a schizophrenic and amood episode, independent of the chronological manifestation. Thus, we agree