STABILITY AND CHANGE IN THE CLINICAL COURSE OF SCHIZOAFFECTIVE DISORDER

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2013 vol. 117, no. 1 INTERNAL MEDICINE - PEDIATRICS ORIGINAL PAPERS STABILITY AND CHANGE IN THE CLINICAL COURSE OF SCHIZOAFFECTIVE DISORDER Anca Durla 1, M. Ienciu 2, C. Bredicean 2, I. Papava 2, M. Cristanovici 3 1. Satu-Mare County Hospital University of Medicine and Pharmacy Timisoara, Faculty of Medicine 2.Neurosciences Department Timisoara County Emergency Clinical Hospital 3. Psychiatry Trainee STABILITY AND CHANGE IN THE CLINICAL COURSE OF SCHIZOAFFECTIVE DISORDER (Abstract): Schizoaffective disorder currently raises several questions, one of them being related to the stability of the clinical diagnosis over time. The aim of this study is to identify the clinical and evolutional particularities in the longitudinal course of schizoaffective disorder. Material and methods: 44 subjects with a current diagnosis of schizoaffective disorder have been assessed prospectively. Following parameters were an a- lyzed: socio-demographic (age at onset, gender, educational, professional and marital status at onset) and clinical (total duration of evolution, diagnosis at onset, duration of the evol u- tion until the switch to the schizoaffective disorder diagnosis). Results and discussion: Socio-demographic parameters are similar to those in literature and the clinical assessment revealed that schizoaffective disorder is present as a diagnosis along with the longitudinal course of other types of psychosis. Conclusions: Schizoaffective disorder appears as a heterogeneous pathology in terms of the longitudinal course. Keywords: SCHIZOAFFECTIVE DISORDER, DIAGNOSIS STABILITY, LONGITUDINAL COURSE. We have addressed in this study one of the controversial topics of today s psychiatry, namely the concept of schizoaffective disorder (1). Generally, current concerns that regard schizoaffective disorder are linked to the question whether schizoaffective disorder is a nosological entity distinct from schizophrenia or from affective disorders? From a clinical point of view, another question is related to the stability of the diagnosis of schizoaffective disorder in terms of its clinical longitudinal course. The circumscription of schizoaffective disorder varies in scientific literature between the following guidelines: schizoaffective disorder with only schizoaffective episodes, schizoaffective disorder that also presents along with its course schizophrenia episodes, purely delusional episodes or even a combination of both, schizoaffective disorder that has mainly schizophrenia episodes to which schizoaffective episodes are added and schizoaffective disorder that has mainly affective episodes to which schizoaffective episodes are added. Generally, the interferences between schizophrenia, schizoaffective disorder and affective disorders can widely vary and their clarifi- 11

2 Anca Durla et al. cation can be achieved through longitudinal studies. The results of these studies are controversial, varying from results that show that there are differences between these disorders to the ones that show no differences. The aim of this study is to identify clinical and evolutional particularities in the longitudinal course of schizoaffective disorder. One of the specific features of this study is the minimum of 15 years of psychotic pathology evolution of the subjects accepted in this research. MATERIAL AND METHODS The research was conducted on a total of 44 subjects who were admitted for the first time in Timisoara Psychiatric Clinic between 1985 and These subjects have been diagnosed during their first admission with a first episode of psychosis and currently, in the year 2011, have a schizoaffective disorder diagnosis. Since we have considered a clinical population, the sample does not claim to be statistically representative and we have not used random or quota sampling techniques, but we have applied inclusion/exclusion criteria. Inclusion criteria: diagnosis of schizoaffective disorder (F25 according to the ICD-10 criteria) at the assessment, meaning the current diagnosis, at least 15 years of evolution of the pathology from the first episode of psychosis, age under 60 years at assessment, subjects who are able and willing to cooperate with the assessor - we have obtained the informed consent of the subjects that have participated in this study and outpatients of Timisoara Mental Health Centre and of the ambulatory psychiatric surgeries from Timisoara. Exclusion criteria: the presence of other associated psychiatric disorders: mental retardation, alcoholism, personality disorders. We mention that where necessary we have used the conversion tables of ICD 9/ICD 10, because the onset diagnosis was made according to ICD 9. The study sample has been assessed based on the data from the existent research project of Timisoara Psychiatric Clinic, through direct discussions with the subjects but also with the physicians who are regularly seeing the patients in ambulatory. Following parameters were analyzed: social and demographic (age at onset, gender, educational status at onset, professional and marital status at onset) and clinical and evolutionary (total duration of evolution, diagnosis at onset, and duration of the evolution until the switch to the schizoaffective disorder diagnosis). RESULTS For the subjects included in the study the overall average evolution is of 21.5 years (std. dev years), with a minimum of 15 years of evolution and a maximum of 30 years. The diagnostic assessment from the onset was performed using the existing records from our clinic and also with the help of the conversion tables from ICD-9 to ICD-10 diagnosis (fig. 1). Since it is of great interest to determine the average time required for the stabilization of the symptoms and for the framing of the disease into the nosological category of schizoaffective disorder, we took into account the period of time (in years) for the subjects we have investigated, from the onset to the establishment of the schizoaffective disorder diagnosis. Therefore, for establishing the diagnosis of schizoaffective disorder for the subjects included in the study sample 5.98 years (std. dev. 3.23) 12

3 Stability and change in the clinical course ofschizoaffective disorder were needed, with a minimum of 1 year and maximum of 14 years. The average length of time for the change of the diagnosis varies according to the diagnosis at onset (fig. 2). TABLE I Socio-demographic characteristics of the sample Socio-demographic characteristics Schizoaffective disorder sample (N=44) Average age at onset ( std.dev years ) Gender: male 18 female 26 Educational status : 10 grades High school Average years of school Professional status : Employed Unemployed High school/college student Marital status: Married Single Divorced TABLE II The distribution on groups of years of evolution Evolution years Schizoaffective disorder sample at assessment Number Cum.number Percentage Cum.percentage years , , years , , years , , Fig. 1. Distribution of the sample according to the diagnosis at onset Fig. 2. The diagnosis at onset / the average of time for the change of the diagnosis 13

4 Anca Durla et al. DISCUSSION Generally, the assessment of the sociodemographic parameters is similar to that illustrated in the scientific literature (2). The average age at onset is one that corresponds to the young adult period and the gender distribution shows that schizoaffective disorder prevails among female, this is also shown in the majority of the studies (3, 4). To note that the study we conducted has no epidemiological value since we have not used any statistical methodology for the inclusion of the subjects in the sample. The average length of schooling is about the same having a value of 11 years which corresponds to a medium tuition. From the point of view of the profession we observe that most subjects are performing an activity (72.7%), whether they were or they are enrolled in schools (20.4%). Family status shows that most are unmarried (47%) - a predictable percentage since their young age at onset. The evolution course is very long when comparing with most clinical research. It can be observed that most subjects (n=23) have an evolution of 20 to 24 years. Regarding the diagnosis of onset we notice that no subjects had a schizoaffective disorder diagnosis - this diagnosis has been placed somewhere along the course of the disease. The diagnoses palette is diversified, but with the observation that a large number of subjects has a diagnosis of acute and transient psychotic disorder (45.5%), followed by schizophrenia (31.8%). There were also a reduced number of subjects included who experienced at onset an affective pathology (manic or depressive).the average length of time necessary for the change of the diagnosis varies depending on the diagnosis at onset, the shortest being for the subjects who had an affective pathology at onset (4.8 years) and the longest for those with a diagnosis of schizophrenia (6 years). In this research we have also included subjects who had at onset a diagnosis of other psychotic disorders (according to ICD 10) or even of neurosis. For this subgroup the time until the change of the diagnosis was higher (7.5 years). This is however correlated with the diversity of the clinical diagnoses. Schizoaffective disorder is a nosological category for which establishing a diagnosis from onset is rarely possible, more often it is only possible to identify psychotic features and a great variability of psychotic symptoms. The establishment of the diagnosis of schizoaffective disorder is to be made after a period of evolution of the pathology (5). CONCLUSIONS Schizoaffective disorder appears as a heterogeneous pathology in terms of longitudinal course, meaning that most cases that reach this diagnosis also have other diagnoses during their evolution, especially in the period that follows the onset. From the clinical point of view it is important to distinguish between schizoaffective disorder and schizoaffective episode, nuance which is not currently achieved by the diagnostic systems. REFERENCES 1. CheniauxE,Landeira-Fernandez J., Lessa Telles L., et al. Does schizoaffective disorder reallyexist? A systematic review of the studies that compared schizoaffective disorder with schizophrenia or mood disorders, J Affect Disord 2008; 106:

5 Stability and change in the clinical course ofschizoaffective disorder 2. Nardi A.E., Nascimento I., Freire R.C. Demographic and clinical features ofschizoaffective (schizobipolar) disorder a 5-year retrospective study. Support for a bipolar spectrum disorder. J Affect Disord 2005: 89: Williams P.V., McGlashan T.H. Schizoaffective psychosis: I. Comparativelong-term outcome.arch Gen Psychiatry 1987; 44: Benabarre, A., Vieta E., Colom F., Martinez-Aran A., Reinares M., GastoC.,Bipolar disorder, schizoaffective disorder and schizophrenia: epidemiologic, clinical and prognostic differences. EurPsychiatr 2001: 16: Maier W. Do schizoaffective disorders exist at all? ActaPsychiatrScand 2006: 113: NOUTĂȚI NEWS NEW INSIGHT INTO MOLECULAR EPIDEMIOLOGY OF MRSA STRAINS IN ROMANIA A recent study by Székely and co. brings new informations regarding methicillin-resistant Staphylococcus aureus strains (MRSA) circulating in Romania. The authors used pulsedfield gel electrophoresis (PFGE), spa typing and SCCmec typing to describe the clonal relations and virulence profiles of MRSA isolates from patients admitted to intensive care and surgical units, during 2010, in Mures County Emergency Clinical Hospital. The study identified 25 pulsotypes clustering into 4 major clonal groups, named from A to D. The majority of MRSA isolates, included into clonal group A (82%), were associated with the successful HA-MRSA clone, spa type t030, which carried SCCmec type III and enterotoxin A genes. Group B was represented by 15 % of the strains, which were assigned to spa types t127, t015 and t321. These strains harboured SCCmec type IV and enterotoxin genes. Two strains that belonged to spa types t044 and t582 were included into clonal groups C and D, respectively. They were PVL-producing strains (Panton-Valentine leukocidin) and had genes encoding for enterotoxin G and SST-1 (toxic shock syndrome toxin). The remaining two strains were non-typeable by PFGE and belonged to spa type t034, which is characteristic for livestockassociated MRSA (LA-MRSA). These strains were isolated from community onset infections, harboured SCCmec type V and were negative for the searched exotoxins. The study concluded that most MRSA strains were clonally related and suggested an intrahospital origin, but also pointed out the danger of new emerging LA-MRSA strains. (Székely E, Man A, Mare A, Vas KE, Molnár S, Bilca D, et al. Molecular epidemiology and virulence factors of methicillin-resistant Staphylococcus aureus strains in a Romanian university hospital. Rev Rom Med Lab. 2012; 20: ). Teodora Vremeră 15