Outcome in Schizoaffective Disorders: A Critical Review and Reevaluation of the Literature

Transcription

1 VOL. 10, NO. 1, 1984 Outcome in Schizoaffective Disorders: A Critical Review and Reevaluation of the Literature by Martin Harrow and Linda S. Grossman Abstract A review of a number of major studies of the outcome of schizoaffective disorders, focusing on how schizoaffective disorders should be viewed diagnostically, is presented. An analysis is made of various research methods used, including prospective, retrospective, and prognostic approaches. Results of the analysis suggest that prospective studies are more valuable. The research results on outcome question the thesis that schizoaffective disorders are only affective disorders. Overall, the mixed results reveal that the outcome of schizoaffective disorders is poorer than that of affective disorders and better than that of schizophrenia. Since outcome is one type of validating criterion which can be used for establishing diagnostic categories, the results question aspects of the DSM-IH system of categorizing schizoaffective disorders. We suggest that moodincongruent psychotic symptoms either influence outcome negatively or are associated with other features which influence outcome negatively. Ever since Kraepelin (1919) first proposed the division of psychotic disorders into dementia praecox (schizophrenia) and manic-depressive (affective) insanity, the classification of patients having symptoms typical of both disorders has been a problem (Klerman and Barrett 1973). A major attempt to solve this problem is the notion of schizoaffective disorder, first introduced by Kasanin in 1933 and still in use today. Yet this diagnostic category has itself provoked debate, and the research undertaken to support or question its status shows conflicting results. The current article reviews the literature on posthospital adjustment and outcome in schizoaffective patients. The term schizoaffective reflects the influence of Kraepelin's nosological bifurcation, and the argument in the literature following Kasanin's (1933) introduction of the category has focused on the relationship of this disorder to schizophrenia and to affective disorders. Schizoaffective disorder, when accepted as a legitimate diagnostic category, has been called a variant of schizophrenia (American Psychiatric Association 1968; Kolb 1968; Detre and Jarecki 1971; Lehmann 1975); a variant of affective disorders (Kant 1941; Clayton, Rodin, and Winokur 1968; Klein and Davis 1969; Fowler et al. 1972; McCabe et al. 1972); a category which occupies a position between schizophrenia and affective disorders (Cobb 1948; Holmboe and Astrup 1957; Leonhard 1961; Stephens 1972; Penis 1974; Procci 1976); or a part of a continuum including them (Fish 1962; Redlich and Freedman 1966; Beck 1967). Some investigators have argued that although schizoaffective disorder is a mixture of symptom types which cannot be distinguished cross-sectionally during the acute phase, longitudinal examinations would reveal these patients either to have schizophrenia or affective disorder (Levenstein, Klein, and Pollack 1966; Batchelor 1969; Slater and Roth 1969; Croughan, Welner, and Robins 1974). The disparity of views on the classification of patients with mixed schizophrenic and affective symptoms is reflected in the changes in different editions of the official diagnostic systems endorsed by the Reprint requests should be sent to Dr. Harrow at the Psychosomatic and Psychiatric Institute, Michael Reese Hospital, 29th and Ellis Ave., Chicago, IL

2 68 SCHIZOPHRENIA BULLETIN American Psychiatric Association. The DSM-II (American Psychiatric Association 1968) classified schizoaffective disorder as a subtype of schizophrenia, while the DSM-1II (American Psychiatric Association 1980) imposed criteria which have shifted most patients with both schizophrenic and affective disorders into the affective category (Silverstein et al. 1982). One modern diagnostic system in which schizoaffective disorder is sharply separated from other psychoses, and most clearly defined, is the Research Diagnostic Criteria (RDC) (Spitzer, Endicott, and Robins 1978). Even when strict diagnostic criteria are used to classify patients, however, all diagnostic systems thus far devised are imperfect. At present, clinical diagnoses are primarily based on symptomatology (since this information is most typically available to the clinician), despite the widespread agreement that accurate differential diagnosis requires a broader base of information than a cross-sectional assessment of symptoms alone can provided Symptom-based diagnostic systems are fallible because symptoms specified as pathognomonic signs of one disorder can also be found in some patients with other disorders (Carpenter and Strauss 1974; Strauss and Carpenter 1974; Hawk, Carpenter, and Strauss 1975; Harrow and Quinlan 1977; Silverstein and Harrow 1978, 1981; Harrow et al. 1982). If schizoaffective disorder is considered to be a nosological entity, then the final validation of this diagnostic construct should be based upon more than the symptom complex alone, a requirement equally necessary for the diagnostic constructs of schizophrenia and affective disorders. Several investigators have written recent articles which discuss the requirements for criteria adequate to the establishment of valid diagnostic categories (Klerman 1971; Feighner et al. 1972; Winokur 1973; Welner, Croughan, and Robins 1974; Procci 1976). These writers agree that in addition to symptoms, a number of other factors should be considered, including response to treatment, family history and genetic studies, clinical course, and short- and long-term outcome. Much research has focused on the specificity of schizoaffective disorder with reference to these criteria. Methodological Considerations and Definitions of Schizoaffective Disorders One reason for the controversy about the conceptualization of schizoaffective disorder is that studies designed to evaluate its nosological validity have differed radically from each other in the techniques they used. Most theorists agree that the identification of a characteristic longterm course and outcome is one major validating criterion for the diagnostic category of schizoaffective disorder (Procci 1976), but the longterm outcome research on schizoaffective disorder has used such a heterogeneous set of research methodologies and instruments that meaningful comparisons and generalizations are difficult to make. One central difference among outcome studies is the use of retrospective as opposed to prospective techniques. In retrospective outcome research, decisions about which patients to study and measurements of basic characteristics of the patients are made after the patients have left the clinical (usually inpatient) setting. The purpose of these studies is to correlate qualities which the records suggest were present during the premorbid or morbid phases of illness with indices of recovery and continued or episodic pathology. The accuracy and reliability of this information, which was not collected for the specific purposes of an outcome study, are necessarily suspect. It is also possible that such studies may produce results inadvertently biased by the collection of data about the past which is based on researchers' knowledge of later outcome. Hospital records, for example, are commonly used sources of information in outcome research, in both retrospective and prospective studies. The quality of information available from hospital records can vary widely, depending on the original clinician's degree of thoroughness and accuracy of observing and recording. Other sources of information, such as patients' or family members' recollections, can be even more dubious. Many of these problems can be eliminated in prospective research designs, in which schizoaffective patients are identified during their. hospitalizations. Prospective designs permit systematic inquiry and observation of patients during hospitalization concerning variables which can be used in the subsequent outcome research; then the patients are followed up for later outcome evaluation. Diagnostic validity can be enhanced if, in addition to the standard clinical evaluations, patients are also interviewed thoroughly and systematically through the use of a standardized research interview, such as the Schedule for Affective Disorders and Schizophrenia (SADS) (Spitzer and Endicott 1978). To clarify the limits of generalizability, the diagnostic criteria in a study should be specifically stated. Another problem in evaluating the.outcome research for schizoaffective disorder is the lack of specific criteria for improvement. In some outcome

3 VOL. 10, NO. 1, research, global assessments such as "recovered" or "unimproved" fail to delimit patients' strengths in functioning in specific areas, as well as patients' specific deficits. Outcome indices which specify types of improvement in addition to global measures have been developed (Strauss and Carpenter 1972, 1974; Bromet, Harrow, and Kasl 1974; Harrow, Bromet, and Quinlan 1974). These indices provide information on patients' specific degree of recovery and on different areas of outcome for example, social adjustment and instrumental work functioning. Such instruments Have been particularly helpful in investigating schizoaffective disorder's putative status as intermediate between poor-outcome schizophrenia and relatively goodoutcome affective disorders. Another factor which may influence outcome in research on schizoaffective disorder is the difference in the patient samples which are compared to schizoaffective patients. In particular, patients' chronicity of illness before the index hospitalization, if not matched across samples, could strongly influence outcome results. For example, if only 2 weeks of symptoms are required for schizoaffective or affective disorders, but 6 months of symptoms are required for schizophrenia, as in the DSM-III, the schizophrenic patients, unlike the other diagnostic groups, may already have begun to show a chronic, deteriorating course of illness. A further difficulty in evaluating the research on the long-term course and outcome of schizoaffective disorder is the variation in the concept of schizoaffective illness. Two distinctly different concepts have been used: (1) schizophrenic patients who during the premorbid and morbid phases have "good prognosis" characteristics or schizophrenic patients who have favorable long-term outcomes, and (2) patients who, during their illnesses, have mixed schizophrenic and affective syndromes. The definition based on patients who have mixed affective and schizophrenic syndromes is preferable for a number of reasons. There are several major problems with the definition based on good prognostic features or long-term outcome. Long-term outcome is an impractical datum for clinicians working with schizoaffective patients, since they must make daily decisions about these patients. Obviously, clinicians cannot delay a diagnostic decision while awaiting information about patients' posthospital adjustment years later. The use of "good prognosis" characteristics to define schizoaffective patients can pose other difficulties as well, since the accuracy of these characteristics as predictors of outcome is still an open question. Many prognostic studies have analyzed groups of variables and found that most of these variables, when assessed alone, do not have strong predictive power. They become somewhat more powerful when combined (Vaillant 1964; Stephens, Astrup, and Mangrum 1966; Stephens 1972, 1978). But even at their best, the classical prognostic indices predict subsequent outcome for some, but not all, schizophrenic patients. Recent evidence has suggested that the classical prognostic indicators may not be so accurate as once believed (Welner et al. 1977; Bland, Parker, and Orn 1978; Carpenter, Bartko, and Strauss 1978; Vaillant 1978b; Gift et al. 1980). Among the strongest predictors of outcome have been those which assessed variables which may be related to longitudinal course, such as acute vs. insidious onset of illness (Strauss and Carpenter 1972, 1974, 1977, 1978). This finding could suggest that the prognostic items which some investigators have reported to produce significant results may have appeared to be accurate predictors because they were qualities which characterized patients who had previously begun to deteriorate. In these cases, patients' previous downhill functioning is being used to predict subsequent downhill functioning. The definition of schizoaffective patients as those with mixed schizophrenic and affective syndromes offers clear advantages. It does not depend on waiting for future information in order to assign a diagnosis, and it does not involve tautological conceptualization. In addition, it provides an important focus for empirical and clinical attention on schizoaffective patients. This definition cues both clinicians and researchers to a major nosological and theoretical question: how to classify and treat patients with mixed schizophrenic and affective syndromes. This question is an important one because it is now apparent that there are many more patients who receive diagnoses of schizoaffective disorder than previously was the case (Baldessarini 1970; Morrison 1974). Detailed diagnostic criteria for the concept of schizoaffective disorder based on mixed schizophrenic and affective symptoms, such as those in the RDC, have only recently become available. In a number of cases before the focus on mixed syndromes, affective symptoms were not described for schizophrenic patients because observers were not alerted to their potential importance. In addition, from the 1930s through the 1950s, the most intensive research and analysis was conducted with chronic state hospital patients. Fewer of these patients present mixed

4 90 SCHIZOPHRENIA BULLETIN affective and schizophrenic syndromes. Younger, acute psychotic patients were relatively uncommon in those samples. More recently, there have been a number of proposals that schizoaffective disorders are more appropriately categorized as a type of affective disorder (Clayton, Rodin, and Winokur 1968; McCabe et al. 1971; Cohen et al. 1972; Sovner and McHugh 1976; Tsuang, Dempsey, and Rauscher 1976; Tsuang et al. 1977; Pope and Lipinski 1978). This hypothesis may or may not be accurate. In either case, the research undertaken to support it or to substantiate alternate hypotheses has advanced knowledge and theory about diagnostic classification and about the potential overlap between different types of syndromes. For the purpose of this discussion, we have divided the review of empirical studies of schizoaffective outcome into three major groups of studies. The first of these groups involves studies of the potential relationship between schizophrenics with "good prognostic indicators" and subsequent outcome in schizophrenic disorders. Patients with good prognostic features have been viewed by some as having schizoaffective disorders (Procci 1976). The second group of studies involves retrospective evaluations of outcome in schizoaffective patients, and the third group involves prospective evaluations of outcome in schizoaffective patients. Studies of Affective Symptoms and Other "Good Prognostic Features" as Predictors of Outcome in Schizophrenia Although a concept of schizoaffective illness based on the patients' presenting a mixture of affective and schizophrenic symptoms has the advantage of posing fewer potential methodological problems, other definitions of schizoaffective disorder have frequently been used in research. The majority of these studies have focused on the prognostic significance of affective symptoms and other good prognostic features in patients viewed as being schizophrenic. Thus, much research in this area has been based on the use of the classical prognostic variables to differentiate groups of atypical schizophrenics, many of whom may be presumed to meet modern criteria for schizoaffective disorders. These studies examine the individual and collective prognostic value of affective symptoms and other possible features of schizophrenia. This research approach has received much of its impetus from the investigations of Vaillant and Stephens, initiated in the 1960s and continuing into the present. Vaillant (1964) used both retrospective and prospective techniques to report data from a 10-year retrospective followback sample of 72 schizophrenic patients, and a 1- to 2-year prospective followup sample of 103 schizophrenic patients. Bleulerian diagnostic criteria were used. For the retrospective sample, diagnoses and ratings of prognostic variables were rated from patients' previous hospital chart information. For the prospective sample, data on outcome and clinical course were collected from treating psychiatrists, and from telephone or personal followup interviews with patients or their relatives. Outcome was evaluated globally, and included assessment of employment, rehospitalization, and social adjustment. The characteristics that Vaillant used to predict remission were acute onset, precipitating factors, depression, nonschizoid premorbid adjustment, preoccupation with death, absence of heredity for schizophrenia, and presence of heredity for affective disorder. These variables, and adequate intellectual ability, marriage, and guilt, used by other major investigators, are referred to in this review as the classical prognostic variables. They have formed an important series of variables subject to much attention in research on prognosis and outcome (Vaillant 1964; Astrup and Noreik 1966; Stephens, Astrup, and Mangrum 1966; McCabe et al. 1972; Strauss and Carpenter 1972, 1974; Bromet, Harrow, and Kasl 1974; Stephens 1978; Strauss and Carpenter 1978; Vaillant 1978a, 1978b). All prognostic variables studied by Vaillant except preoccupation with death were present significantly more often in patients whose illnesses remitted over time. However, approximately 70 percent of the patients failed to show complete recovery. Vaillant noted that the individual prognostic indicators did not predict outcome as effectively as a combination of the variables, and he emphasized that the prognostic indicators were additive. He formed an index based on the combination of his six prognostic variables, and proposed that if more than two of these criteria were not met, patients' recovery would seem statistically unlikely. In a later study, Vaillant (1978b) reassessed the same patients 10 years after their original followups. He reported that approximately 40 percent of the original sample of remitted schizophrenic patients showed a negative outcome 10 years later. Affective symptoms, as well as the other prognostic variables, failed to differentiate schizophrenic patients who continued to show good outcome during the second interval

5 VOL. 10, NO. 1, from those who relapsed. This is an extremely important set of studies, since it explores in detail, over a longer period of time, a sample of patients for whom the prognostic variables were originally successful in predicting outcome. Vaillant's 1978 report is one of several studies conducted in the last 10 years which have found that the classical prognostic variables may be of limited value (Welner et al. 1977; Bland, Parker, and Orn 1978; Carpenter, Bartko, and Strauss 1978; Gift et al. 1980). Vaillant suggests as one possible interpretation of his data that remission and diagnosis may be thought of as two separate dimensions in psychotic patients. Stephens and associates (Stephens and Astmp 1963; Stephens, Astrup, and Mangrum 1966, 1967; Stephens 1972, 1978) have explored the relationship of prognosis and outcome in schizophrenia, and have constructed a prognostic scale to differentiate schizophrenic patients with good outcomes from those with poor ones. This scale was derived from data on 206 patients followed up after fewer than 10 years and cross-validated on 143 patients followed up after more than 10 years. A score of 5 or more on this scale predicted good outcome, and a score of 4 or below predicted poor outcome. Six of the prognostic items on this scale were also considered important by Vaillant (1964). These items were acute onset, precipitating factors, good premorbid social adjustment, presence of depression or confusion, absence of schizophrenic heredity, and heredity positive for affective disorders. To this list Stephens added: good premorbid work history, marriage, guilt, and adequate intellectual ability. Stephens found that cross-sectional assessment of affective symptoms was not very effective in predicting outcome. Thus, blunted affect assessed at the time of hospitalization did not successfully predict outcome in the patient group followed up after at least 10 years; hypomanic symptoms and depressive heredity were also not very successful in differentiating between the two outcome groups in either of the samples. These results challenge the predictive utility of affective symptoms during hospitalization. However, a number of other investigators, using retrospective or prospective followup assessment techniques to study the long-term course of psychopathology, have provided evidence suggesting that the presence of affective symptoms does correlate with good outcome (Holmboe and Astrup 1957; Astrup, Fossum, and Holmboe 1959; Astrup and Noreik 1966; McCabe et al. 1972). "Good prognosis" schizophrenia has been characterized by a number of features, among which is the presence of affective symptoms during the acute stages of illness (McCabe et al. 1972; Tsuang, Dempsey, and Rauscher 1976), as well as by such symptoms in the families of patients (Vaillant 1964; Astrup and Noreik 1966; Fowler et al. 1972). For example, McCabe et al. (1972) reported a cross-sectional study in which they divided schizophrenic patients into categories of good and poor prognoses, and assessed the clinical symptoms of each group, using systematic interviewingtechniques. "Good prognosis" schizophrenics had a more acute onset and better premorbid functioning than "poor prognosis" schizophrenics. The authors found that individual depressive and manic symptoms and visual hallucinations characterized the good prognosis group, while other types of hallucinations, delusions, and thought disorder, all of which are usually associated with schizophrenia, failed to distinguish the groups. The authors concluded that good prognosis schizophrenia shows a strong clinical relationship to affective disorders. Research on the prognostic value of mixed affective and schizophrenic symptoms and of prognostic features is by no means uniform. Gift et al. (1980) presented evidence, based on a carefully designed prospective 2-year followup study, which failed to confirm the results of McCabe et al. (1972). Using outcome measures of rehospitalization, symptoms, and social and occupational functioning, they found that affective symptoms had minimal prognostic value, while psychotic symptoms strongly predicted unfavorable outcome. These authors explained the findings as the product of their careful methods, which were designed to eliminate contamination caused in many earlier studies by inappropriate or nonrepresentative sampling procedures, unsystematic collection of data about patients' acute symptomatology, and unreliable diagnostic procedures. This study used a sample of first-admission patients who were studied prospectively, a type of sample which may be more representative of psychopathology in the general population. Patients' acute symptoms were assessed in this study by systematic interviews, rather than by chart evaluation, the method commonly used in retrospective research. Hence these assessments were probably more accurate than those of many other studies. Evidence in agreement with this study has also been presented by Carpenter et al. (1978), by Noreik et al. (1972), and by Vaillant (1978). In a series of studies on schizophrenic (including schizoaffective) patients conducted during the 1970s, Strauss and Carpenter (1972, 1974)

6 92 SCHIZOPHRENIA BULLETIN have proposed a different way of viewing outcome and prognosis in schizophrenia. These authors suggest that separate areas of outcome dysfunction represent linked opensystems, each of which is affected in part by the others, and also by other factors which are more specific to it alone, not only for schizophrenic patients, but also for nonschizophrenic psychotic patients. The authors devised and validated an outcome rating instrument which separates rehospitalization, social adjustment, employment, and symptoms, and which also provides a global rating of overall outcome in the summed scores of each outcome variable. They presented data on a sample of schizophrenic patients who were systematically interviewed for symptomatology during hospitalization, and followed up 2 (1972) and 5 (1975) years after entering the study. Diagnoses were based on DSM-II descriptions. Sixty-eight patients were included in the 5-year study. The authors found that schizophrenic symptoms as delineated by Langfeldt (1937) and Schneider (1959) all failed to predict outcome. Bromet, Harrow, and Kasl (1974) tested the prognostic utility of the factors identified by Vaillant and Stephens in a prospective 1-year followup study of outcome in process and reactive schizophrenic and nonschizophrenic patients. The results indicated that premorbid and morbid factors associated with the distinction between process and reactive schizophrenics, and associated with the classical prognostic indicators, showed trends toward predicting outcome in schizophrenic patients, although many of these positive correlations did not achieve statistical significance. The same premorbid and morbid variables were generally not predictive of outcome for the nonschizophrenic patients, though some positive correlations did occur. In this study, the relationship between outcome and the classical prognostic indicators, as well as the process-reactive dimension, was not so uniformly high as theories based on the processreactive distinction would have predicted. It was also noted that different factors may predict outcome for schizophrenic as opposed to nonschizophrenic patients, although the results in this area were not definitive. In general, recent research on prognostic variables in schizophrenia has begun to find more mixed results on the predictive power of a number of the individual prognostic variables once considered to be reliable predictors of outcome in schizophrenia. The presence of a feature such as depressed or manic mood has predicted schizophrenic outcome in some studies, but a number of recent studies have provided mixed or negative evidence on this question. Those variables which predict outcome best are not single items, but constellations of many items which predict outcome only if they occur together. The strongest predictors are longitudinal rather than cross-sectional. The cun-ent review has suggested that prognosis, like diagnosis, is fallible. No prognostic scheme yet devised is perfect, or even uniformly supported by followup data. Retrospective Studies As can be seen, a large number of studies have investigated the efficacy of prognostic indicators such as affective or schizophrenic symptoms, and other prognostic indicators, to predict subsequent outcome. Fewer studies have been conducted which examine the outcome of patients who fit the criteria of some modern definitions of schizoaffective disorders having a combination of both affective and schizophrenic syndromes during the acute phase. Six such studies using a retrospective research design are summarized in table 1. Some of these individual studies collected large amounts of data which were used as the basis of a number of separate reports. Thus, some of the studies outlined below can be viewed as a series of studies, rather than as only one study. Croughan, Welner, and Robins (1974), in a retrospective chart evaluation of 266 patients with schizoaffective disorders or related disorders (i.e., schizophreniform psychosis or atypical schizophrenia), divided patients into two types: those who in addition to thought or behavior disorders also had sufficient affective symptoms to meet Feighner's criteria (Feighner et al. 1972) for depression or mania, and those who did not have sufficient affective symptoms. In this study, thought disorder was viewed as including delusional ideation. The group of patients with both schizophrenic and affective symptoms would meet modern diagnostic criteria for schizoaffective disorders. No significant differences were observed on age of onset, age at first hospitalization, number of previous hospitalizations, length of illness, acuteness of onset, or presence of confusional symptoms between the two groups of patients. The vast majority of patients from both groups had a chronic, continuous course of illness, with delusions of persecution being the most common symptom. In a comparison of the type of symptoms accounting for the chronic course, a significant difference was found. The patients with schizophrenic plus affective symptoms had chronic affectivt symptoms, while patients with

7 Table 1. Retrospective studies of schizoaffective outcome o Study Croughan, Welner, & Robins (1974) Welner et al. (1977) Subjects 266 patients diagnosed as schizoaffective, schizophreniform, or atypical schizophrenia. Patients were divided according to severity of their schizophrenic or affective disorder symptoms 114 patients diagnosed as schizoaffective or a related psychosis. In chronic group: mean years of illness before Index = 5.8. These patients were free of psychotic symptoms 71% of time between onset of illness & index admission Diagnostic criteria Information from charts. 255 signs & symptoms & 137 demographic variables. Used clinical research criteria cited In article Used authors' clinical. research criteria Follow-back period 4-8 years 8-9 years Indices of outcome Course of Illness & symptoms (1) Job performance (2) Marital adjustment (3) Social adjustment Results and conclusions No significant difference In (1) age of onset, (2) age at first hospltalization, (3) number of previous hospitallzations, (4) length of Illness, or (5) presence of confuslonal symptoms. Most schizoaffectives had a chronic continuous course. Delusions of persecution most common for all patients. Conclusion: Patients were divided into 3 groups, seen as paranoid schizophrenia, affective disorder, and a group which may be a variant of schizophrenia or of affective disorder, or distinct from both (1) 71% of schizoaffective patients had a chronic course, 10% episodic, & 19% considered Indeterminate, although they were asymptomatic. (2) Thought & behavior disorders accounted for chronic course In 28%. (3) Thought & behavior disorders plus affective symptoms accounted for chronic course in 56%. (4) Affective symptoms accounted for chronic course in 16%. (5) Patients whose chronic course was due to affective symptoms did not deteriorate less than other patients z o

8 en o i M o TJ I 3) m CD c Table 1. Retrospective studies of schizoaffectlve outcome Continued Study Subjects 52 schlzoaffective- manic type, 41 schlzo phrenlcs, 34 manlcs Pope et al. (1980) Morrison et al. (1973) 315 schlzophreniform, 225 unipolar affectives, 100 bipolar. affectives, 200 schizophrenics Diagnostic criteria Information from charts. RDC used. For schizophrenia, 6 months' duration of schizophrenic symptoms or signs of deterioration required, instead of RDC's 2-week requirement Information from charts. Feighner criteria used. Special requirements outlined for schlzophreniform Follow-back period Indices of outcome 1 Vi-5 years Best levels of social, occupational, & global functioning, & lowest level of residual symptoms for follow-back period 10 years Recovered vs. nonrecovered Results and conclusions (1) On all 4 outcome indices, schizophrenics had worse outcome than schizoaffectlve-manics or manlcs. (2) First-rank symptoms or moodincongruent psychotic symptoms were not of diagnostic or prognostic significance. Conclusion: Schizoaffectlve-manic type is distinguishable from schizophrenia, but not from mania. Schizoaffectivemanlc Is not a valid diagnostic category. Schizoaffective-manlcs should be classified as manlcs (1) 22% of schizoaffectives recovered, compared to 8% of schizophrenics and 54-59% of bipolar & unipolar affectives. (2) The slope of recovery in the schizophreniform patients in first 2Vi years is similar to affectives, but thereafter similar to schizophrenics. Conclusions: Schizophreniform may represent a mixture of patients, some with process schizophrenia, others with affective disorders Tsuang, Dempsey, & Rauscher (1976) 85 atypical schizophrenics (VJ postpartum psychoses) 200 schizophrenics, 100 bipolar manlcs, 225 bipolar depressives Information from charts. Feighner criteria used. Special requirements outlined for atypical schizophrenia years Recovered vs. nonrecovered (1) Atypical schizophrenia showed no resemblance to schizophrenia, but did not differ from affective disorder. 44% of atypical schizophrenics recovered;

9 o Tsuang & Dempsey (1979) 85 schlzoaffectlves, 200 schizophrenics, 100 manlcs, 225 depresslves, 160 surgical control subjects Information from charts. Felghner criteria used. Special requirements outlined for schlzoaffectlves years 3-polnt rating scale (goodfalr-poor) of marital, residential, psychiatric, & occupational functioning 8% of schizophrenics recovered; & 54% of affective disorders recovered. (2) Atypical schizophrenics had more precipitants; Vs were post-partum psychoses. (3) Atypical schizophrenics had higher incidence of family history of affective disorder than schizophrenia. Conclusions: Atypical schizophrenics have more in common with bipolars than with unlpolars or mixed. Atypical schizophrenics may be young bipolars. Diagnosis should not be based solely on symptoms (1) Schizoaffectives were better than schizophrenics on marital & residential, but not on occupational or psychiatric status. (2) Schizoaffectives were worse than manics on psychiatric status but not on marital, residential, or occupational status. (3) Schizoaffectives were worse than depressives on occupational and psychiatric status, but not on marital or residential status. (4) On global rating of outcome, schlzoaffectlves fell between schizophrenic and affective. Conclusions: Schlzoaffective outcome Is generally better than schizophrenic and worse than affective, & different from both. Schlzcaffectlve disorder may comprise a heterogeneous group of patients

10 96 SCHIZOPHRENIA BULLETIN schizophrenic but no affective symptoms had chronic thought and behavior disorders. The authors concluded that the latter group, though originally diagnosed in their study as schizoaffective, should be seen as paranoid schizophrenic. The other group was viewed as having a disorder which might be a variant of schizophrenia, a variant of affective disorder, or a psychosis distinct from both of these. In order to evaluate the various ways which they suggested of classifying schizoaffective disorder, the authors conducted a second 8- to 9-year retrospective study of 114 patients with schizoaffective and related psychoses (Welner et al. 1977). No comparison groups were used in this follow-back study. Diagnoses were based on hospital records, and assigned according to research criteria presented in the article. The patients had been sick for a mean length of 5.8 years before index admission; however, they had been totally free of any psychotic symptoms for a mean length of 71 percent of the period between onset of illness and index admission. The authors again found that the majority of schizoaffective patients (71 percent) had a chronic course of illness with evidence of deterioration. Of the 81 patients originally diagnosed as schizoaffective who had a chronic course of illness, schizophrenic symptoms were found at followup in 28 percent (with delusions of persecution most common); affective symptoms were found in 16 percent; mixed symptoms were found at followup in 56 percent of these schizoaffective patients. No patients with episodic courses showed any signs of deterioration, while 81 percent of the patients with chronic courses showed evidence of deterioration. The amount, the type, and the chronicity of affective symptomatology all lacked any predictive validity for course or outcome of illness. The authors suggest that when schizophrenic and affective symptoms are present in a psychosis, the psychosis should be regarded as schizophrenia because the chronic course of illness and marked deterioration found in such illness are more characteristic of schizophrenia than of affective disorders. In a more recent retrospective follow-back study which assessed patients years after index hospitalization. Pope et al. (1980) compared 52 schizoaffective, manic type patients with 41 schizophrenic and 34 manic patients. Diagnoses, based on the information available in patients' index hospital records, were assigned according to the RDC (Spitzer, Endicott, and Robins 1978), with the exception that inclusion criteria for schizophrenia required symptoms to have been present for 6 months (as in the DSM-III), rather than 2 weeks (as in the RDC). This more "narrow" criterion was imposed in order to maximize the difference between groups, although it may also have biased the selection of schizophrenics to those whose course of illness had already become chronic. It was not required that the schizoaffective patients have an illness that had already begun to become chronic. A further methodological consideration which should be noted is that in this study long-term outcome indices were rated by clinicians who were aware of patients' diagnoses. Thus, it is possible that the ratings could have been influenced by the authors' theoretical point of view. All four outcome indices demonstrated that outcome of the schizoaffective patients could not be distinguished from that of the manic patients; both groups had significantly better outcomes than did schizophrenic patients. The authors concluded that schizoaffective disorder, manic type is not a valid diagnostic entity since it cannot be distinguished from mania, and that first-rank symptoms or mood-incongruent psychotic symptoms are of no demonstrable diagnostic or prognostic significance. The follow-back studies of schizoaffective patients with the longest periods of retrospective outcome evaluation have been those of the "Iowa 500" (Morrison et al. 1973; Tsuang, Dempsey, and Rauscher 1976; Tsuang and Dempsey 1979), which used large samples of patients over 30- to 40-year periods. These studies may demonstrate the importance of methodological considerations, because their results differed according to which methods the authors used. In the first study conducted on the "Iowa 500" sample, Morrison et al. (1973) evaluated outcome in 315 patients with schizophreniform disorder, compared to 200 strictly diagnosed schizophrenic patients, 225 patients with unipolar affective disorders, and 100 with bipolar affective disorders. Patients were diagnosed as schizophreniform if they had chart diagnoses of schizophrenia but did not meet research require/nents for schizophrenia or. affective disorder, or had either previous remitting episodes of illness or the presence of affective symptoms at the time of index admission. Diagnoses were based on hospital chart information. Patients were followed up retrospectively at 2-year intervals for 10 years, and were rated globally on 4-point scales ranging from "well" to "deteriorated." The results indicated that after 10 years, 22 percent of the patients with schizophreniform disorder were recovered, compared with 8 percent

11 VOL. 10, NO. 1, of the patients with schizophrenia, 54 percent of the patients with bipolar affective disorders, and 59 percent of those with unipolar depression. The slope of recovery in patients with schizophreniform disorder in the first 2.5 years was similar to that of patients with affective disorders. When the followup period was extended to 5.5 years, however, the slope of recovery in schizophreniform patients was extremely similar to that of schizophrenic patients. The authors concluded that schizophreniform disorder may comprise a mixture of patients, some of whom have process schizophrenia, and others an illness more closely allied to the affective disorders. In two later studies arising from the "Iowa 500" sample (Tsuang, Dempsey, and Rauscher 1976; Tsuang and Dempsey 1979), 85 schizoaffective patients were compared with 200 schizophrenics and 325 patients with primary affective disorders. Diagnoses were based on hospital records, and were assigned according to the Feighner criteria (Feighner et al. 1972), which included a 6-month requirement of illness for a diagnosis of schizophrenia (i.e., the schizophrenic patients in these studies were relatively chronic, similar to those classified as schizophrenic by the DSM-III). The requirements for "atypical psychosis" were the same as for the schizophreniform patients from the previous study: that patients had chart diagnoses of schizophrenia, did not meet requirements for affective disorder or schizophrenia, and had either a previous remitting episode of illness or the presence of affective symptoms at the time of their index admission. In the second study, information to evaluate outcome was collected through personal interviews with many of the patients, although apparently with some patients, evaluations had to be based on less systematic information. Patients were rated on a 3-point scale on indices of overall outcome in the second study, and in addition on separate scales designed to assess marital, residential, psychiatric, and occupational functioning in the third study. On a global index of outcome, schizoaffective patients had significantly better outcome than did schizophrenic patients, and did not differ from the patients with affective disorder. On each of the specific outcome indices, however, the percentage of good ratings for schizoaffective patients fell between those for schizophrenic and manic patients. Schizoaffective patients showed significantly better outcomes than did schizophrenic patients on marital and residential functioning. They did not show better outcomes on their scores from the occupational or psychiatric scales. Schizoaffective patients were significantly worse than manic patients only in psychiatric status, but not in marital, residential, or occupational status. Thus in the second study, which used only chart information and a global measurement, schizoaffective outcome did not differ from that of affective disorders in most areas of adjustment. In the third study, which used broader sources of information and more detailed outcome indices, schizoaffective outcome was better than that of schizophrenia, worse than that of affective disorder, and different from both. Among the retrospective studies of schizoaffective outcome, those of the "Iowa 500" sample are among the best in regard to several characteristics. These studies are especially praiseworthy for their sophisticated diagnostic techniques, and for the large percentage of patients on whom the investigators were able to collect followup information. However, these studies are retrospective, and some doubt arises about the accuracy of the followup information given by others about patients who were dead at the time of followup, and about the accuracy of information collected on other patients from relatives or other informants who described the patients' lives 10 to 20 years retrospectively. Despite the excellent case records that these studies used, which were written with care when the patients were in the hospital years ago, there is still some doubt about how uniformly accurate some of these original hospital charts were, and the question arises whether great care was taken for each of the many charts over a number of years. Because of potential methodological constraints such as these, although the retrospective research of the "Iowa 500" makes a clear contribution, prospective outcome research offers potential methodological advantages. Overall, the results from the retrospective studies reviewed here are mixed. One of the six major outcome studies could suggest that schizoaffective disorder should be considered a variant of schizophrenia, since schizoaffective patients' outcome was as poor as that of schizophrenic patients (Welner et al. 1977); two of the six studies could suggest that schizoaffective disorder should be viewed as a variant of affective disorders, since schizoaffective patients' outcome was as good as those of patients with affective disorders (Tsuang, Dempsey, and Rauscher 1976; Pope et al. 1980). The other three of the six studies presented more equivocal evidence. One of these latter three retrospective studies was inconclusive (Croughan, Welner, and Robins 1974). A second study suggested that schizoaffective disorders should be

12 98 SCHIZOPHRENIA BULLETIN viewed as occupying a category intermediate between the other two disorders, since schizoaffective patients' outcome was better than that of schizophrenics, but worse than that of patients with affective disorders (Tsuang and Dempsey 1979). The third study (Morrison et al. 1973) suggested that during the first 2Vi years, outcome in schizoaffective patients is more similar to that in affective patients, after which point it is more similar to that in schizophrenic patients. As we have noted earlier, although the retrospective studies reviewed in this section have made clear contributions, methodological problems may limit the usefulness of their contribution. For this reason, prospective outcome research seems even more profitable for enhancing knowledge about outcome in schizoaffective disorders. (0 O CO CO «c 5 a. o o Si IT. = s 6 0) *~ N ffi ID»J > 1 c o w 2 m «lilt CD ^ O Q. m ^ «5 E o. CO CO O o _ g; I CD «- > CO E-s O ^ Q. «$?"<» o o 0) & -a C CD 5. S o ^ O C CD 3 <2 CO CD CD 8 5 o o to CO CD a. O Q. S: T3 CO to u i S Q. Q. E Ho 3 i U (3 o= CO CD > CO, 6 A f; «I 8 I 8 Si S 7^ ~ -C _ a) O) "t; m ao - e 6 g «z 3 <= 2 co co * s CD c ^ CD > p <g S s: II 3 - "" c o -o >. o "E _ O 1J a * CD o = o T5» O CO -C Q. 13 CO CD > CO Q. 3 O >; CD - * f E a g o i Sw Prospective Studies The research reviewed in this section involves investigations of schizoaffective patients selected and studied during hospitalization as part of a prospective research design, who were subsequently followed up (table 2). Unlike the retrospective studies reviewed in the preceding section, the current prospective studies avoid some of the potential methodological problems outlined earlier. Clark and Mallet (1963) conducted a prospective followup study of 18 schizoaffective patients and compared outcome for this group with that for 86 schizophrenic and 82 depressive patients. These patients were diagnosed by clinical consensus at hospital case conferences, and followed up for 3 years by postal questionnaires. Patients were under 30 years old when first assessed and had a mean number of 1.7 previous hospitalizations. Outcome indices o o e 1o (0 (0 I Q. s CM.a 1 co CO CD c o CD C CO CD 0 c S O S en. CD CO > o c ll co U U CD CO CO "O (D CD CM T- oo co CO CD CO CO O T3 c CD LLJ c CO o N c = 2 -c ffl» *? O 5 ofl m JZ C uoo T3 ^ DC C CO. -x CO CO CO sill o s CN i_ H C «OdJjCOQ co c Q_ UJ to on H E - 1 ^- J_ >» ^ a. O Q. to O O ^0 -^ g» e *i2 o o -2 o ^_ c ^ O" CD 5 = Q "S o < DC O "O Q. CO CD Q. CD co m? I o m

13 z o Post (1971) 29 elderly schlzoaffectlves schlzoaffectlvedepressed Used author's criteria which Included firstrank symptoms 1-7Vi years tlonal functioning; (4) Overall discriminant function score; (5) Followup diagnosis Compared global outcome of schlzoaffective patients to 100 elderly depresslves & paraphrenlcs analysis and canonical variate analysis, authors found no outcome variables distinguished between the schizophrenic and affective poles. Mode of onset, family history of schizophrenia or affective disorder, premorbid personality, work record, & symptoms, duration predicted outcome. Authors suggest that schlzoaffectlve-depressed Is not a useful clinical category because It does not describe a homogeneous group 4% of schizoaffectives remained symptom-free, compared to 26% of depressives and 57% of paraphrenlcs. Author suggests that schizoaffectlve should be considered a syndrome characterized by schizophrenia and affective disorder symptoms, potentiated by physical & cerebral disorders, aging, and emotional stress Angst, Felder, & Lohmeyer (1980) 150 schlzoaffectlves, 95 bipolar affectlves World Health Organization 18 years retrospectively & 13 years prospectively (1) Frequency of relapse; (2) Length of episode; (3) Residual symptoms; (4) Length of last relapse-free interval; (5) Degree of remission (1) Schlzoaffectlves had fewer relapses than bipolars. (2) The 2 groups were equal In length of episode. (3) Residual symptoms were observed In 57% of schizoaffectives, compared to 24% of affectlves. (4) Schlzoaffectlves had longer relapse-free intervals. (5) Schizoaffectives showed full remission less frequently than affectlves

14 in a i N O "D I 3J m z CD C 3 z Table 2. Prospective studies of schizoaffective outcome Continued g Study Grossman et al. (in pres3) Subjects 39 schlzoaffectives, 47 schizophrenics, 33 manlcs, 48 major depressives Diagnostic criteria RDC Followup period 1 year Indices of outcome Used 2 global indices, & separate indices of psychotic symptoms, rehospitalizatlon, work, & social functioning Results and conclusions (1) On both global indices, schizoaffectlves did not differ from schizophrenics, and both had worse outcome than affectlves. (2) No differences In outcome between schizoaffectlves mainly schizophrenic & schizoaffectives mainly affective, or between schlzoaffectivedepressed and schizoaffective manic. (3) Rehospitallzatlon and psychotic symptoms did not separate the diagnostic groups. (4) Schizoaffectlves and affectlves had better work functioning than schizophrenics. (5) Schizoaffectives and schizophrenics had poorer social functioning than affectives. (6) Regardless of whether schizoaffectives and affectives are viewed as the same syndrome, the presence of mood-incongruent psychotic symptoms is associated with poorer outcome

15 VOL. 10, NO. 1, were symptomatology and history of rehospitalization. The results indicated that schizoaffective patients' outcomes were between those of schizophrenic and depressive patients on the rate of rehospitalization and the percentage of patients who reported experiencing mild to moderate symptoms, and of those who reported remaining symptom free during the followup period. The authors concluded that schizoaffective disorders have an outcome which is intermediate between that of schizophrenia and depression. Two methodological considerations should be pointed out in connection with this study. It did not use specific, reliable diagnostic or assessment techniques, and so its generalizability to other schizoaffective samples may be difficult to estimate. In addition, the postal questionnaires which were used may not contain complete information, as the authors point out, especially in cases where patients describe themselves as symptom free; in some cases, these patients and their families may have become habituated to and tolerant of the patients' symptoms. In prospective outcome research conducted by Strauss and Carpenter and associates (1972, 1974) reported earlier in the section of this review covering prognostic research, Hawk, Carpenter, and Strauss (1975) compared their schizoaffective sample, originally included as part of their schizophrenic sample, to the rest of their schizophrenic sample. The outcome of the 14 schizoaffective patients they studied was not different from that of the schizophrenic patients. The only variable which did discriminate patients of different diagnostic types was the presence of schizophrenic symptoms, regardless of the subtype of "schizophrenia." That is, in contrast to the patients with schizophrenic symptoms (including schizoaffective patients), none of the nonschizophrenic patients at followup were in the worst outcome category. There was, however, considerable overlap between schizophrenic and nonschizophrenic patients in the good outcome categories. This study suggests that schizoaffective patients cannot be distinguished from schizophrenic patients by outcome scores, and that both groups may be different from nonschizophrenic patients. We should note that Strauss and Carpenter included six patients with bipolar affective disorders in their comparison group of nonschizophrenic patients. Furthermore, neither affective symptoms nor classical schizophrenic symptoms during the acute stage of illness were able to distinguish schizophrenic patients with good outcome from those with poor outcome. Since the criteria used by Hawk, Carpenter, and Strauss for schizoaffective disorder were those of the DSM-ll, some patients from among this sample may have had only affective features, rather than a full affective syndrome. Thus, their results indicating similarities in outcome between schizoaffective and schizophrenic patients cannot be considered definitive. Brockington and associates (Brockington, Kendell, and Wainwright 1980; Brockington, Wainwright, and Kendell 1980) have reported prospective followup data on two groups of schizoaffective patients diagnosed as "schizomanics" or "schizodepressives"; that is, patients with a mixture of schizophrenic and manic or depressive symptoms. Diagnoses were derived from the Present State Examination (PSE) (Wing, Cooper, and Sartorius 1974), which was administered during index hospitalization and then again 1 to 4 years later during the followup assessment. Diagnoses were assigned according to the authors' criteria, which were very broad. Patients were also diagnosed according to the RDC as well as nine other operational definitions of schizoaffective disorder. Of the 32 schizomanic patients, 8 met RDC requirements for a diagnosis of schizoaffective disorder, manic type. Of the 76 schizodepressive patients, 60 met RDC requirements for a diagnosis of schizoaffective disorder, depressed type. Schizomanic and schizodepressive patients were compared to patients with schizophrenic and affective disorders (Brockington, Kendell, and Leff 1978). Outcome indices included the degree of recovery from index admission, percentage of time spent in hospitals, level of social/occupational functioning, and a global measure of overall functioning. The results differed for the two schizoaffective groups. Schizomanic patients had outcomes which did not differ from those of the patients with affective disorders, and which were better than those of schizophrenic patients in all outcome areas. The authors suggest that schizomania should be considered a variant of affective disorder. Schizodepressive patients, in contrast, had outcomes which were intermediate between schizophrenic patients and patients with affective disorder, with a high proportion of schizodepressive patients having a chronic deteriorating course. The variance scores were smaller for schizodepressive patients, especially for the percentage of time spent in hospitals. The authors interpret this finding as indicating that schizodepressive criteria exclude the most severely handicapped schizophrenic patients and the mildest depressives.

16 102 SCHIZOPHRENIA BULLETIN The authors used discriminant function analysis and canonical variate analysis, which are methods of maximizing the separation of groups, and failed to show any line of demarcation between the schizophrenic and affective poles. They found an almost random distribution, with large groups of typical schizophrenic and typical affective patients, and an equally large number of patients with intermediate status. The authors noted that outcome variables did not enable even schizophrenic and affective subgroups to be distinguished from each other. Depressive symptoms were found to be weak predictors of outcome. The presence of schizophrenic symptoms in the absence of affective symptoms, however, predicted poor outcome. The authors concluded that schizodepressive patients are a very heterogeneous group, and that schizoaffective disorder, depressed type is not a useful clinical category. Post (1971), using somewhat atypical samples, investigated 29 elderly schizoaffective patients diagnosed according to his own criteria, which required first-rank symptoms for schizophrenia. All of these patients were over 60 years of age at index hospitalization. He followed up these patients for years. He compared outcome, as measured by the number of patients who remained symptom free, with that in a group of 100 elderly depressive and paraphrenic patients (Post 1962, 1966), although he noted that the schizoaffective groups were not strictly comparable to the other two groups because of differences in the conditions of long-term observation and treatment. The results indicated that 4 percent of the schizoaffective patients remained symptom free, compared to 26 percent of the depressive and 57 percent of the paraphrenic patients. The sample of paraphrenic patients, however, was limited to those patients who cooperated with phenothiazine therapy. Post suggested that schizoaffective patients had a less favorable course than elderly depressive or paraphrenic patients maintained on phenothiazines. He posited that schizoaffective disorder should not be viewed as a separate illness, but rather as a syndrome in which biological anomalies associated both with schizophrenia and affective disorders are potentiated by physical and cerebral disorders, aging, and emotional stresses. A recent followup study by Angst, Felder, and Lohmeyer (1980) has used both retrospective and prospective techniques to compare 150 schizoaffective patients with bipolar manic-depressive patients for an average of 27 years (retrospectively for 18 years and prospectively for 13 years). Schizoaffective patients were defined by the diagnostic criteria of the World Health Organization (1977). Data were collected by telephone and mail correspondence with patients and their relatives and physicians, as well as by assessment of outpatient and hospital records. Episodes of relapse were defined as occurring when treatment was required, when patients felt ill, or when their relatives reported suffering because of the patients' changed behavior. The reliability of these estimates depended on information obtained from patients and their relatives (and patients' and relatives' tolerance of patients' symptoms), and possibly on patients' differential responses to treatment. The results indicated that on two indices, frequency of relapse and length of relapse-free intervals, schizoaffective outcome was more favorable than that of bipolar affective disorders. Schizoaffective patients had fewer relapses and longer relapse-free intervals than did affectively disordered patients. On two other indices, the degree of remission and residual states of psychopathology, schizoaffective patients had poorer outcomes than did patients with affective disorders. More residual psychopathology was observed in the schizoaffective patients than in the patients with affective disorders, and schizoaffective patients more frequently showed "partial" as opposed to "full" remission. Length of episode was equal for the two groups. In a recent study we conducted a prospective, 1-year followup of the posthospital adjustment of schizoaffective patients, as compared to that of schizophrenic and affectively disordered patients (Grossman et al., in press). The research used samples of patients from the Chicago Followup Study (patients followed up from the Michael Reese Hospital and the Illinois Psychiatric Institute) (Harrow, Silverstein, and Marengo 1983; Harrow and Quinlan, in press), and the University of Chicago Mental Health Clinical Research Center (patients followed up from the Illinois Psychiatric Institute). The 167 patients who were studied were assessed initially during hospitalization and then personally followed up. The Schedule for Affective Disorders and Schizophrenia (SADS) (Spitzer and Endicott 1978) and other structured interviews were used to derive RDC diagnoses. The research attempted to answer the question of whether the overall outcome in schizoaffective patients was more similar to that of affectively disordered patients or of schizophrenic patients. The results indicated that on the two global measures of posthospital adjustment used, both the schizo-

17 VOL. 10, NO. 1, affective and the schizophrenic patients showed significantly poorer outcomes than did patients with affective disorders. The majority of schizoaffective patients showed intermediate levels of functioning, with substantial psychopathology in some individual areas of adjustment and adequate functioning in other areas. In this respect, the schizoaffective patients differed from both other groups, since neither the schizophrenic nor the affectively disordered group showed a large percentage of patients functioning at an intermediate level. Only a very small percentage of schizoaffective patients showed a very favorable outcome, which was a pattern similar to that of the schizophrenic patients, and different from that of patients with affective disorders. However, a smaller percentage of the schizoaffective patients and the patients with affective disorders showed the very poor outcome which was characteristic of many of the schizophrenic patients, and in this way the schizoaffective and affectively disordered patients were similar. The schizoaffective patients were more similar to patients with affective disorders in having lower levels of psychotic symptoms and better subsequent work functioning than the schizophrenics. However, the schizoaffective patients were more similar to the schizophrenic patients in that both groups had more rehospitalizations and poorer social functioning than the patients with affective disorders. We concluded that schizoaffective patients did not show the same outcome pattern as patients with either affective disorders or schizophrenia, showing poorer outcomes than patients with affective disorders and better outcomes than schizophrenics. We also concluded that the presence of mood-incongruent psychotic symptoms is in general associated with poorer outcomes. Overall, the results from the prospective studies, like those from the retrospective studies, are mixed. Of the research reviewed here, one study found evidence that the outcome of patients with schizoaffective disorder,' manic type is indistinguishable from that of patients with bipolar affective disorder (Brockington, Kendell, and Wain Wright 1980). Five studies found evidence indicating that the outcome of patients with schizoaffective disorder can be distinguished from that of patients with affective disorders. In summary, the evidence from these methodologically stronger prospective studies suggests that the posthospital adjustment of schizoaffective patients may be poorer than that of patients with affective disorders. Reevaluation of the Evidence on the Prognostic Importance of Schizophrenic and Affective Symptoms Much research and current theory about schizoaffective outcome has been based on the thesis that affective symptoms during hospitalization are predictive of good later adjustment, and that schizophrenic symptoms are not so effective as predictors (McCabe et al. 1972; Pope and Lipinski 1978; Pope et al. 1980). It would seem worthwhile to reconsider this thesis in light of the research reviewed above. A careful analysis would be of particular value, because this thesis has had considerable influence on theories about major diagnostic issues. Thus, views about the outcome of patients with affective and schizophrenic symptoms may have been prominent in shaping diagnostic theory about schizoaffective patients, especially since the DSM-III deemphasizes the importance of schizoaffective disorders and does not provide specific criteria for this category. The view that the presence of affective symptoms, but not schizophrenic symptoms, predicts posthospital adjustment is inaccurate when it is applied to a broad range of patients or to the general population. A study which used a full range of people, including normals, would show psychotic symptoms to be highly predictive of outcome, since normals, who typically do not have psychotic symptoms, would usually have relatively good long-term adjustment, with few or no hospitalizations or major symptoms of psychopathology. The view is accurate mainly in research using restricted samples that are limited only to schizophrenic patients, since it is not dear that grossly psychotic schizophrenic patients have poorer outcomes than do moderately psychotic schizophrenic patients. This type of inconclusive result, however, is found in many studies which use restricted samples. In a similar manner, the severity of affective symptoms may be ; nonspecific in predicting posthospital adjustment within samples restricted to patients who already have affective disorders. Some theorists have proposed that many schizophrenic symptoms appear in nonschizophrenic patients, and hence are not specific to schizophrenia. This argument is true but misleading, since almost no symptom is limited to any single type of mental disorder. Individual affective and psychotic symptoms appear in a variety of types of psychopathology. Some theorists have suggested that there are many manic-depressive patients with schizophrenic symptoms. Considered in reverse,

18 104 SCHIZOPHRENIA BULLETIN just as affectively disordered patients with both affective disorders and psychotic symptoms are sometimes miscategorized as cases of schizophrenia, it is possible that some schizophrenic patients who have depressive symptoms may be miscategorized as cases of affective disorder. Just as there are no final diagnostic criteria for schizophrenia, one cannot be sure that current criteria for affective disorder are correct in every detail. Every system of classifying patients imposes artificial criteria. Many seemingly psychotic manic-depressive patients fit the depression category well; a few may be schizophrenic patients. Recent emphasis on similarities between schizoaffective patients and patients with affective disorders has pointed out more clearly certain features which could suggest that some or many schizoaffective disorders are a type of affective disorder. These arguments about schizoaffective disorders' being affective disorders are not completely invalid, though the evidence on the posthospital adjustment of these patients is mixed, and the issue at present is an unresolved one which deserves further research. Implications of Outcome Data for Formulations About the Classifications of Schizoaffective Disorders To summarize the results of the current review, the research on clinical course and outcome leaves open the issue of whether schizoaffective disorders should be classified as belonging with affective disorders, with schizophrenia, or as a separate disorder. If we use outcome as one criterion to determine the classification of schizoaffective disorders, then we find the results do not fit neatly into any of the simpler formulations. We have reviewed retrospective studies which offer interesting data of some value, but which have methodological difficulties. In these studies we found mixed evidence concerning the major hypothesis that schizoaffective disorders produce outcomes similar to those produced by affective disorders, but there was at least some evidence supporting this hypothesis (Tsuang, Dempsey, and Rauscher 1976; Pope et al. 1980). We have also reviewed methodologically stronger prospective studies, and again we found mixed evidence, but the majority of studies suggested that outcome in schizoaffective disorders shows some differences from that in affective disorders (Clark and Mallet 1963; Tsuang and Dempsey 1979; Angst, Felder, and Lohmeyer 1980; Grossman et al., in press). Considered together, the results of both the retrospective and prospective studies suggest that outcome in schizoaffective disorders differs from that in affective disorders, although some data showing similarities in clinical course between schizoaffective and affective disorders still leave the question unresolved. In considering the older hypothesis that schizoaffective disorders are a variant of schizophrenia, we again found differences between schizophrenic and schizoaffective patients' outcomes (Pop* et al. 1980; Tsuang, Dempsey, and Rauscher 1976), although there were select studies showing similarities in outcome between these two groups (Morrison et al. 1973; Croughan, Welner, and Robins 1974; Welner et al. 1977). There is a suggestion by a few investigators that schizoaffective disorders, manic type, may be variants of affective disorders, but that many schizoaffective disorders, depressed type, are not variants of affective disorders (Brockington, Kendell, and Wainwright 1980; Brockington, Wainwright, and Kendell 1980). This innovative hypothesis still awaits further support, but it is an interesting possi^ bility worthy of future attention. Overall, the outcome data can be summarized as suggesting that the outcome of schizoaffective disorder is not identical to that of affective disorders, or of schizophrenia. It is possible that they either represent separate disorders or that other factors, such as the presence of both schizophrenic and affective symptoms, lead to or are associated with factors which lead to clinical courses different from those of affective disorders or schizophrenia. The results, many of which indicated mixed or intermediate outcomes for schizoaffective patients, bear directly on theories about the nature of schizoaffective disorders and about the outcome of schizoaffective patients. If the literature reviewed here, with its many findings of intermediate outcomes for schizoaffective patients, is used as a basis for theorizing about the nature of schizoaffective disorder, at least four interpretations are possible. These four interpretations differ from that implied in the DSM-lll, that the great majority of schizoaffective disorders are a variant of affective disorders. Thus, if outcome is used as one criterion for classification, it could be proposed that patients labeled as "schizoaffective" represent a mixture of two kinds of patients, some with schizophrenia "and others with affective disorders. Aspects of the series of studies reviewed here indicating that some schizoaffective patients show outcomes similar to those of affectively disordered patients could support this alternative, although there are other

19 VOL. 10, NO. 1, aspects of the literature which do not neatly fit this model. A second alternative to the DSM-III model is that patients with a combination of schizoaffective and affective syndromes do have affective disorders, but that the presence of particular types of psychotic symptoms (especially mood-incongruent psychotic symptoms) introduces an additional, partially independent factor which is important for outcome. Once patients have mood-incongruent psychotic symptoms for a sustained period, or show the tendency to become psychotic, the patients' clinical course, their self-images, and the way they are treated by their families and society can be adversely influenced. Psychotic symptoms may either directly influence outcome, or they may be associated with, or a consequence of, other underlying factors which influence outcome. According to this view, affective patients and schizoaffective patients have the same affective syndromes, or the same illness, but the presence of mood-incongruent psychotic features, such as those found in schizoaffective disorders, introduces an additional disruptive psychopathological characteristic which drastically influences phenomenology and outcome in a negative way. A third interpretation of the research reviewed is that schizoaffective disorders are not merely a mixture of patients belonging in one or the other of these two diagnostic groups, nor a simple variant of affective disorders. This third alternative to the DSM-1H outlook is that schizoaffective illness may be a separate disorder. This view could be supported by many of the studies indicating that schizoaffective patients show intermediate outcomes, with neither the large number of very poor outcomes found in schizophrenics, nor so large a percentage of good outcomes as found in patients with affective disorders. A fourth possibility involves the view that in our current state of knowledge, it is not possible to divide the major psychoses into different disease states. Even though diagnosis has clear value in helping to organize our thinking about a diverse range of patients with psychopathology, it is merely a means of dividing patients into categories or groups according to some prominent but not decisive variables. In this view, the divisions so made do not automatically coincide with the underlying factors, still unknown, which determine disordered patient behavior and mental illness. More important than the patients' particular constellation of symptoms may be their biological constitutions, responses to treatment, personality characteristics, environmental influences, and other factors. According to this model, when patients show the tendency to become psychotic, the vulnerability to psychosis has implications concerning their biological and psychological resources, and concerning their clinical course and outcome. This model, which may be a promising one, bears some similarity to the views of Vaillant, Bowers, and Strauss and Carpenter, who have suggested looking at diagnosis and outcome in nontraditional ways (Strauss 1973; Strauss and Carpenter 1974; Bowers 1975; Vaillant 1978a). These four interpretations of the research reviewed here have some similarities because they are all based on the thesis that mood-incongruent psychotic symptoms are important features of a disorder, and that they change the immediate clinical picture and also have prognostic significance for patients' subsequent adjustment and outcome. A number of potential models have been discussed, with the second and fourth alternatives described above appearing the most promising to us. However, regardless of which model one adopts, the majority of the research reviewed here would seem to indicate that the presence of certain types of moodincongruent psychotic symptoms at hospitalization is often a bad sign for later outcome for schizoaffective patients who have both schizophrenic and affective syndromes. References American Psychiatric Association. DSM-II: Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: The Association, American Psychiatric Association. DSM-I11: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: The Association, Angst, J.; Felder, W.; and Lohmeyer, B. Course of schizoaffective psychoses: Results of a follow-up study. Schizophrenia Bulletin, 6: , Astrup, C; Fossum, A.; and Holmboe, R. A follow-up study of 270 patients with acute affective psychoses. Ada Psychiatrica Scandinavica, Suppl. 135:1-65, Astrup, C, and Noreik, K. Functional Psychoses: Diagnostic and Prognostic Models. Springfield, IL: Charles C Thomas, Baldessarini, R.J. Frequency of diagnosis of schizophrenia versus affective disorders from 1944 to American Journal of Psychiatry, 127: , Batchelor, I.R.C. Henderson and Gillespie's Textbook of Psychiatry. 10th ed. London: Oxford University Press, 1969.