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Eur Arch Psychiatry Clin Neurosci. 2014 February ; 264(1): 29–34. doi:10.1007/s00406-013-0410-7.

The schizoaffective disorder diagnosis: A conundrum in the

clinical setting
Jo Ellen Wilson1, Hui Nian2, and Stephan Heckers1
1Department of Psychiatry, Vanderbilt University, Nashville, Tennessee, USA
2Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA

Abstract
The term schizoaffective was introduced to describe the co-occurrence of both psychotic and
affective symptoms. Over time, as the diagnosis schizoaffective disorder was added to diagnostic
manuals, significant concerns were raised as to the reliability and clinical utility of the diagnosis.
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We recruited 134 psychiatrically hospitalized subjects who had received a diagnosis of

schizophrenia, schizoaffective disorder or bipolar disorder with psychotic features by their treating
clinician. The subjects were also diagnosed by trained research personnel with the Structured
Clinical Interview of the DSM-IV-TR, employing an explicit time threshold for criterion C of the
schizoaffective disorder diagnosis. We found significant differences between the clinical and
research diagnoses. Clinicians diagnosed 48 patients (36%) with schizophrenia, 50 patients (37%)
with schizoaffective disorder and 36 patients (27%) with psychotic bipolar disorder. In contrast,
researchers diagnosed 64 patients (48%) with schizophrenia, 38 patients (28%) with
schizoaffective disorder and 32 patients (24%) with psychotic bipolar disorder. This was a
statistically significant disagreement between the research and clinical diagnoses (p = 0.003) and
indicates that clinicians choose the less severe diagnosis for psychotic patients. We conclude that a
more stringent criterion C for the schizoaffective disorder diagnosis will address an implicit bias
in clinical practice and will affect the prevalence of the psychotic disorder diagnoses.

Keywords
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schizoaffective disorder; diagnosis; DSM-IV; DSM-5; reliability

Jacob Kasanin introduced the term schizoaffective psychosis to capture the co-occurrence of
both schizophrenia and affective symptoms [13]. He associated the diagnosis with better
premorbid functioning, less severe symptomatology, overall shorter duration of illness and
improved recovery as compared to patients with schizophrenia. In the DSM (Diagnostic and
Statistical Manual of Mental Disorders) I and II, published in 1952 and 1968 respectively,
the term schizoaffective was used to define a subtype of schizophrenia. In the DSM III, the
term schizoaffective was separated from schizophrenia and retained without specific
diagnostic criteria under the category of “psychotic disorder not otherwise classified.” [1].

Corresponding author: Jo Ellen Wilson, Vanderbilt Psychiatric Hospital, 1601 23rd Ave. South, Nashville, TN 37212,
[email protected], 615-936-3555.
The authors declare that they have no conflict of interest.
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In the Research Diagnostic Criteria (RDC, Spitzer 1973), schizoaffective disorder was
distinguished from other psychotic and mood disorders and defined by the co-occurrence of
a major mood episode (major depression or mania) and psychotic symptoms, “suggestive of
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schizophrenia”, which persist for at least 1 week in the absence of major mood
symptomatology [23]. The DSM III-R (1987) introduced the first operationalized diagnostic
criteria for schizoaffective disorder, which required the persistence of psychotic symptoms
in the absence of significant affective illness for at least 2 weeks [2]. In subsequent editions
of the DSM, schizoaffective disorder has been retained as a separate diagnostic entity, but
it’s reliability, clinical utility and reliability has been questioned [10, 15, 16, 22].

DSM-IV-TR lists four diagnostic criteria for Schizoaffective Disorder (A-D). Criterion A
requires that the patient experience psychotic symptoms consistent with criterion A for
schizophrenia and that they co-occur with a major mood episode (major depression, mania
or a mixed state.) Criterion B requires that the patient also experience spsychotic symptoms
in the absence of major mood symptoms, for a period of at least 2 weeks. Criterion C states
that manic or major depressive symptoms must be present for a “substantial portion of the
total duration” of the illness. Finally, Criterion D excludes cases with psychotic and mood
symptoms that can be attributed to substance use or another medical condition [3].
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Criterion C has limited clinical utility and low reliability. Maj et al studied the DSM-IV
schizoaffective disorder criteria and found the lowest inter-rater reliability measures for
criterion C (Cohen’s Kappa = 0.29) and criterion A (Cohen’s kappa = 0.31), with an overall
kappa value for all criteria (A-D) of 0.22 [16]. This reliability measure was significantly
lower than those for mania and major depressive episode (kappa= 0.71 and 0.82,
respectively), which the authors attributed to the ambiguity of the duration requirement [16].
The duration threshold used in the study by Maj et al. was 10% of the present episode, as
suggested by Frances et al [7]. Because of the low diagnostic reliability of schizoaffective
disorder (kappa between 0.08 and 0.54 [12]), it has been suggested that criterion C include
“a quantitative threshold (e.g., 30% as is now implemented in the revised Diagnostic
Interview for Genetic Studies criteria)” [10].

In the present study we compared the schizoaffective disorder diagnoses between 2 groups
of raters, clinicians and researchers, to estimate the effect of a change of criterion Con the
prevalence of the schizoaffective disorder diagnosis.
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Methods
Subjects
We recruited 134 patients who had received a diagnosis of schizophrenia, schizoaffective
disorder or bipolar disorder with psychotic features by their treating clinician at Vanderbilt
Psychiatric Hospital. All participants completed written informed consent after approval of
the study protocol by the Vanderbilt University Institutional Review Board. All subjects
were paid for their participation in the study. All participants were also diagnosed via the
Structural Clinical Interview of the DSM-IV-TR (SCID) [6], which was administered by
trained research personnel, supplemented with review of available clinical records, and final
review by an experienced psychiatrist (S.H.). All subjects were also assessed with three

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symptom rating scales (Positive and Negative Syndrome Scale [14], Young Mania Scale
[27], and Hamilton Rating Scale for Depression [8]). Inclusion criteria included an age
between 18 and 65 and confirmation of a diagnosis of schizophrenia, schizoaffective
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disorder or bipolar disorder with psychotic features on the SCID. Exclusion criteria for all
participants included: serious head injury, serious medical condition (e.g., HIV, cancer),
neurologic disease (e.g., dementia, neuromuscular condition), mental retardation, history of
substance dependence, or substance abuse within the past 3 months of study enrollment.

In an effort to standardize the diagnosis of schizoaffective disorder, subjects were only

assigned a SCID diagnosis of schizoaffective disorder if their mood symptoms met criteria
for a major mood episode (major depression, mania or mixed) that occupied at least 30% of
the total duration of their illness, in line with the recommendations by the revised Diagnostic
Interview for Genetic Studies criteria [19].

Statistical Analysis
Demographics and clinical characteristics of the subjects were presented as frequencies or
Mean±SD. We compared the three different disease groups using chi-square test for
categorical variables and Kruskall-Wallis (trend) test for continuous variables. We used
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Maxwell’s test to examine the overall diagnostic agreement between the clinicians and
researchers, and Bowker’s test to evaluate the asymmetry in the distribution of patients
about which these two rater groups disagree [4, 18, 26]. We classified diagnoses into three
categories: bias by clinicians toward less severe diagnosis, agreement of diagnoses amongst
research team and clinician, and bias by clinician toward more severe diagnosis, and
estimated the probability of each category. 95% confidence intervals of probability estimates
were obtained using bootstrap.

Results
Demographic and Clinical Characteristics
Demographic and clinical characteristics are listed in table 1. The three groups did not differ
in duration of illness (all p > 0.05). All but 15 subjects were medicated at the time of testing
with similar mean chlorpromazine (CPZ) equivalent dosages between schizoaffective
disorder and schizophrenia patients (p = 0.233), however bipolar patients were treated with
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significantly lower mean doses (p < 0.005) than schizophrenia or schizoaffective patients.

Schizophrenia patients had lower estimated IQ, as measured by the Wechsler Test of Adult
Reading (WTAR), than bipolar patients (p=0.056) and but did not differ from
schizoaffective disorder patients (p = 0.386). Schizoaffective disorder patients reported more
depressive symptoms compared to the bipolar disorder subjects (p < 0.005). Both
schizophrenia and schizoaffective disorder patients displayed significantly more positive (p
<0.001 and 0.01), negative (p<0.001 and 0.006) and general psychotic symptoms (p<0.001
for both groups) than the bipolar disorder subjects. The schizophrenia and schizoaffective
disorder patients did not differ in positive or general psychotic symptoms (p = 0.5 and 0.7
respectively), but the schizophrenia subjects did report more negative symptoms than the
schizoaffective disorder subjects (p = 0.013). The schizoaffective disorder patients were

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treated with higher doses of antipsychotic drugs than the bipolar disorder patients (p =
0.001) but there was no difference between schizoaffective disorder and schizophrenia
patients (p = 0.233).
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Diagnostic assessments
We found significant differences between the clinical and research diagnoses in our sample
of 134 psychotic disorder patients (Table 2). Clinicians diagnosed 48 patients (36%) with
schizophrenia, 50 patients (37%) with schizoaffective disorder and 36 patients (27%) with
psychotic bipolar disorder. In contrast, researchers diagnosed 64 patients (48%) with
schizophrenia, 38 patients (28%) with schizoaffective disorder and 32 patients (24%) with
psychotic bipolar disorder. This was a statistically significant disagreement between the
research and clinical diagnoses (Maxwell’s Test, p = 0.003). Additionally, Bowker’s test
indicated that there was significant (p = 0.009) asymmetry between the research and clinical
diagnoses amongst the three diagnostic categories. This is displayed visually in table 2,
where 25 cases are above, but only 9 cases below the symmetry line that indicates diagnostic
concordance.

To further quantify the bias of clinicians favoring a less severe diagnosis, we classified the
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134 diagnoses into agreement by clinicians and researchers (n=100), clinicians choosing a
less severe diagnosis (n=25) and clinicians choosing a more severe diagnosis (n=9). The
probabilities of the diagnosis falling into each of the three categories were 74.6% (95% CI,
57.2% to 82.1%), 18.7% (95% CI, 11.9% to 25.4%) and 6.7% (95% CI, 3% to 11.2%)
respectively. The likelihood of clinicians choosing a less severe diagnosis was significantly
higher (18.7%) than choosing a more severe diagnosis (6.7%).

If the SCID diagnosis is chosen as the gold standard, then clinicians were correct in making
the diagnosis psychotic bipolar disorder in 28 out of 32 cases (88%), schizoaffective
disorder in 30 out of 38 cases (79%) and schizophrenia in 42 out of 64 cases (66%). This
was primarily due to the tendency of clinicians to favor the schizoaffective disorder
diagnosis in patients who met DSM-IV-TR criteria for schizophrenia.

Discussion
Schizoaffective disorder occupies an intermediate position on the continuum of disease
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severity, between schizophrenia and mood disorders, in particular bipolar disorder [5, 24]. In
short-term and long-term outcome studies, schizoaffective disorder patients had a
significantly better prognosis than schizophrenia patients [9, 16]. Long-term outcome for
patients diagnosed with schizoaffective disorder paralleled that of affective disorder patients
[11].

Cheniaux et al concluded that the DSM-IV schizoaffective disorder diagnosis “essentially

represents a provisional diagnosis, employed when a schizophrenia or mood disorder
diagnosis typical course is not yet clearly defined” [5]. Because of the ambiguity in
diagnostic criteria, clinicians tend to prefer assigning a more favorable diagnosis, when both
affective and psychotic symptoms co-exist. This is in line with our results, where clinicians

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tended to prefer a less severe diagnosis18.7% of the time and a more severe diagnosis only
6.7% of the time.
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In a follow-up study of 500 first episode psychosis patients, Salvatore et al. assessed the
stability of initial psychotic disorder diagnoses [21]. Schizoaffective disorder was
considered to be the least stable diagnosis. Although only one patient was given an initial
diagnosis of schizoaffective disorder, at 2-year follow-up 53.6% of the 112 revised
diagnoses were to schizoaffective disorder, which they attributed to “later-appearing
affective features in previously non-affective conditions” [21]. Schwartz et al. assessed the
congruence of initial psychotic disorder diagnoses with 6 month and 24 month follow up
[22]. They found that the most temporally consistent categories were schizophrenia (92%),
bipolar disorder (83%) and major depression (74%), with schizoaffective disorder only
showing a 36% temporal congruency amongst initial and 6-month follow-up diagnoses [22].
Because of findings such as these, Vollmer-Larsen et al, in a recent comparison of ICD-10
and DSM IV criteria for schizoaffective disorder, noted that clinicians “nearly always use
the diagnosis of schizoaffective disorder incorrectly” and called for a moratorium on its use
[25].
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Schizoaffective disorder is one of the least stable DSM-IV-TR diagnoses, mainly due to the
uncertainty in how to apply criterion C, which has allowed for greater flexibility but less
reliability in diagnosing this condition, as compared to other affective and non-affective
psychotic disorders. This was shown in our study population, with clinicians and researchers
agreeing on the diagnosis of schizoaffective disorder slightly more than half of the time, as
compared to a much higher agreement for the other psychotic disorders studied. In our
study, the researchers assigned the diagnosis of schizoaffective disorder only if mood
symptoms, meeting criteria for a major mood episode (major depression, mania or mixed),
occurred for at least 30% of the total duration of their illness. This was in contrast to the
clinicians, who employed a less clearly defined threshold, as captured in DSM-IV-TR with
the phrase “substantial portion”. Furthermore, clinicians assess mood symptoms primarily in
relationship to a current episode, not the lifetime duration of psychotic symptoms. The
vague definition of criterion C leaves it to the clinician when to choose the diagnosis
schizoaffective disorder for patients who meet criteria for schizophrenia and also present
with prominent mood symptoms for at least some time. When given no further guidance to
quantify the relative weight of mood versus psychotic symptoms, clinicians tend to prefer
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schizoaffective disorder to schizophrenia.

Several authors have made recommendations for a revision of schizoaffective disorder

diagnostic criteria [12, 17]. Some have asked for a removal of the category, but it would
leave clinicians with no option to capture prominent mood symptoms in the schizophrenia
spectrum and would discontinue ongoing research efforts that have embraced the
schizoaffective disorder diagnosis [15, 20]. Our results suggest that two changes of criterion
C, i.e., a more explicit duration threshold and lifetime rather than episode-based assessment
of mood symptoms, will change the prevalence of the schizoaffective disorder diagnosis.
Future research needs to establish whether such changes will improve the reliability, clinical
utility and ultimately the validity of the schizoaffective disorder diagnosis.

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Acknowledgments
This study is supported by NIMH grant R01-MH70560 (SH), the Vanderbilt Psychiatric Genotype/Phenotype
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Project, and the Vanderbilt Institute for Clinical and Translational Research (through grant 1-UL-1-RR024975 from
the National Center for Research Resources/NIH).

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Table 1

Demographics and Clinical Characteristics

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Schizophrenia (n = 64) Schizoaffective Disorder (n = 38) Bipolar Disorder with psychotic features
Mean ± SD Mean ± SD (n = 32)
Mean ± SD

Demographics
Age 35.00 ± 11.98 36.84 ± 11.78 33.41 ± 12.7
Gender 18 F/37 M 18 F/20 M 19 F/12 M
WTAR IQ 93.27 ± 16.99 94.31 ± 17.05 99.16 ± 16.2
Education 12.33 ± 2.44 13.08 ± 2.23 13.24 ± 2.73
Clinical Characteristics
Age of onset 19.95 ± 6.42 20.16 ± 5.97 20.94 ± 9.43
Duration of illness 15.00 ± 13 17.06 ± 10.31 12.47 ± 12.25
HAM-D 12.97 ± 10.54 15.84 ± 8.46 10.66 ± 7.63
YMRS 8.83 ± 7.14 10.87 ± 9.89 8.71 ± 10.01
PANSS-positive 21.61 ± 6.49 20.70 ± 6.33 17.03 ± 5.33
PANSS-negative 17.02 ± 7.37 13.84 ± 5.12 10.87 ± 3.51
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PANSS-general 33.57 ± 9 34.32 ± 8.29 27.55 ± 5.28

PANSS-total 72.76 ± 17.13 68.89 ± 15.09 55.35 ± 10.24
Chlorpromazine equivalent 495.71 ± 288.12 589.64 ± 397.88 292.33 ± 314.65

Note: WTAR, Wechsler Test of Adult Reading; HAM-D, Hamilton Rating Scale for Depression; PANSS, Positive and Negative Syndrome Scale;
YMRS, Young Mania Rating Scale; AIMS, Abnormal Involuntary Movement Scale.
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Table 2
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