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Original Paper
Psychopathology 2010;43:285291
DOI: 10.1159/000318812
Stability of Schizoaffective Disorder in
Correlation with Duration of Follow-Up:
Retrospective Analysis
InbalBrenner
a
AmirKrivoy
a,b
AbrahamWeizman
a,b
TsviFischel
a,b


a
Geha Mental Health Center, Petah-Tikva , and
b
Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv , Israel
the group of patients with stable diagnosis than in the group
of patients whose diagnosis had changed (p = 0.037). Con-
clusions: The diagnostic stability of SAD might be higher
than previously reported. Patients who are diagnosed with
SAD manic subtype have a higher tendency to retain their
diagnosis than patients with other SAD subtypes. The diag-
nostic changes are derived from manifestations of new
symptoms in the course of the disease. Clarification of the
current diagnostic criteria in order to enable a more precise
utilization of the SAD subtype diagnoses is warranted. Study
Limitations: (a) The study design was retrospective and fur-
ther prospective studies are needed to establish our find-
ings; (b) there is a misusage of the SAD subtype definitions,
thus conclusions regarding polarity of SAD and stability of
diagnosis are limited, and (c) the population studied was
comprised of inpatients, therefore generalization to the out-
patient population should be done with caution.
Copyright 2010 S. Karger AG, Basel
Introduction
The term schizoaffective disorder (SAD) was first
coined in 1933 by Kasanin [1] , who recognized the need
for a description for those patients who had schizophren-
ic symptoms as well as affective ones, and could not fit in
Key Words
Schizoaffective disorder Diagnostic stability Bipolar
disorder Affective disorder
Abstract
Background/Aims: Previous studies have indicated that the
validity and reliability of schizoaffective disorder (SAD) diag-
nosis according to the DSM-IV criteria are insufficient, and
that the stability of the diagnosis is poor. However, no study
has examined exclusively the diagnostic stability of SAD. The
aims of this study were to examine the longitudinal stability
of the diagnosis of SAD and SAD subtypes among a large
sample of patients, and to examine demographic and clini-
cal variables as predictors of diagnostic stability. Methods: A
retrospective chart review of 123 inpatients who were ad-
mitted to Geha Mental Health Center between the years
2000 and 2005, and who had been diagnosed with SAD at
some stage of their illness. We compared the group of pa-
tients whose diagnosis of SAD had remained stable and the
group of patients whose diagnosis had changed. Results:
The diagnostic stability for SAD was 73.1%. Diagnostic transi-
tions were mainly from and towards schizophrenia. We
found an association between the SAD bipolar subtype and
higher rates of diagnostic stability. The time that had elapsed
since SAD diagnosis was made was significantly shorter in
Received: January 22, 2009
Accepted after revision: December 10, 2009
Published online: July 15, 2010
Inbal Brenner
Geha Mental Health Center, 1 Helsinki St., PO Box 102
IL49100 Petah Tikva (Israel)
Tel. +972 3 925 8230, Fax +972 3 924 1041
E-Mail inbalbr @ clalit.org.il
2010 S. Karger AG, Basel
02544962/10/04350285$26.00/0
Accessible online at:
www.karger.com/psp
Brenner /Krivoy /Weizman /Fischel

Psychopathology 2010;43:285291 286
the Kraepelin dichotomy of schizophrenia versus manic-
depressive psychosis (later known as bipolar disorder).
The nosology of SAD has gone through many changes
since 1933, reflecting the attempts to define more accu-
rately the disorder. During those years, some considered
SAD as a part of the schizophrenic spectrum [2] , others
as a subtype of affective disorders [3] , and others as an
intermediate condition between the two [46] .
In the DSM-IV-TR, SAD is positioned under the
Schizophrenia and other psychotic disorders section [7] .
The DSM-IV specifies two SAD subtypes: bipolar type
and depressive type. The current concept of SAD has
been regarded as unsatisfactory by the DSM-IV coordi-
nators themselves [8] as well as by others [9, 10] and the
reliability and validity of the DSM criteria were found to
be low [11, 12] . Both the DSM-IV and the ICD-10 [13] lack
a longitudinal aspect in their criteria [9, 11] . In addition
to the complex diagnostic criteria, the clinical signs and
symptoms of SAD are often easy to be confused with pure
schizophrenic or affective symptoms, which make the
differential diagnosis even more challenging.
There are inconsistent findings regarding the course
and prognosis of SAD. Angst et al. [14] found that SAD
and bipolar disorder had more similarities than differ-
ences in their course, and that SAD had a somewhat more
benign course than bipolar disorder, while others showed
that SAD has a worse course and outcome than bipolar
disorder [5, 9] . Findings regarding the impact of SAD
subtype on the course and prognosis are inconsistent as
well, e.g. Marneros et al. [15] found that SAD bipolar type
has a worse outcome than SAD depressive type, while
others claim the contrary [16] .
Therefore, it is not surprising that the stability of SAD
diagnosis was found to be low in several studies. One
study found that the stability of SAD diagnosis was 36%
2 years after the first admission [17] . In another study the
stability rate was 18.6% after 7 years [18] . That is in con-
trast to high stability levels for schizophrenia diagnosis
(9298%) and intermediate-high stability levels for affec-
tive disorders (7893%) in different studies [17, 19, 20] .
The main limitation of the former studies was that they
examined stability of SAD diagnosis after a psychotic ep-
isode and admission. Moreover, the number of the SAD
patients was small (43 SAD patients in the largest sam-
ple), and the studies did not focus specifically on SAD.
The current study examined the stability of the diagnosis
of SAD in a relatively large sample of patients (n = 123).
Other objectives were to examine the diagnostic transi-
tion towards SAD or from SAD to other diagnoses, the
distribution of SAD subtypes (bipolar vs. depressive) and
to assess the correlation between the disorder polarity
and the diagnostic stability. Finally, we examined the dif-
ferences of demographic and clinical variables between
the stable and unstable SAD groups.
Methods and Subjects
In this retrospective study the data of inpatients (aged 1 18
years) that were admitted at least once to the Geha Mental Health
Center between the years 2000 and 2005, and were diagnosed at
some point of their illness as suffering from SAD prior to the
study, was retrieved. All diagnoses in the patients records were
made by senior psychiatrists, and according to the DSM-IV-TR
criteria, following a comprehensive interview according the
guidelines of the SCID [21] . Exclusion criteria were an organic
brain disease or psychosis due to a general medical condition. The
study was approved by the local IRB and the need to get an in-
formed consent was waived.
Files of the patients who met the inclusion criteria were re-
viewed by the same examiners (I.B. and A.K.), who had not made
any of the diagnoses in the patients records, and consensus be-
tween the two examiners was required for the final diagnosis.
Data was collected from all their past and current hospitalizations
(until the year 2005). Data was retrieved from three domains:
(1) Psychiatric diagnoses (as was documented at each admission):
SAD depressive, SAD bipolar, SAD mixed, SAD unspecified,
schizophrenia (SCZ), bipolar disorder (BPD), major depres-
sive disorder (MDD), other psychotic disorders (this category
included the diagnoses: schizophreniform disorder, delusion-
al disorder, brief psychotic disorder, psychotic disorder due to
substance abuse and psychotic disorder not otherwise speci-
fied) and other non-psychotic disorders (this category includ-
ed other axis I diagnoses who were not included in the former
categories). Axis II diagnoses were addressed separately. The
clinical chart of each admission was reviewed by the research
team for a correlation between the diagnosis that was made
and the clinical description and confirmation of diagnosis ac-
cording to DSM-IV-TR criteria.
(2) Demographic data: Gender, number of years of education, du-
ration of follow-up, duration since the diagnosis of SAD was
made, psychopathology in first-degree relatives.
(3) Clinical data: Age at first admission, total number of admis-
sions, history of or current substance abuse, mood stabilizer
therapy, suicide attempts, evidence of violent behavior, nature
of affective episodes (manic, depressive or mixed).
A special questionnaire was built for data collection and stan-
dardization. Initial screening yielded 159 files. Of these, 36 pa-
tients were excluded from the study: 11 files did not hold sufficient
material, and in the other 25 files the diagnosis of SAD was given
only as a possible differential diagnosis or was defined as to rule
out (13 of these patients had by then a diagnosis of SCZ, 6 had
BPD, 5 had MDD, and 1 had another psychotic disorder).
Establishment of Diagnostic Stability
We defined the SAD diagnosis as stable in those patients who
were diagnosed as SAD at some point of their illness, and still had
the SAD diagnosis by the time the study was conducted (i.e. SAD
diagnosis at least at two different time points as well as at the last
Stability of SAD in Correlation with
Duration of Follow-Up
Psychopathology 2010;43:285291 287
admission). Other patients who were diagnosed as SAD and later
had their diagnosis changed were defined as unstable. The overall
stability was defined as the percentage of patients who had the
diagnosis of SAD by the time the data was retrieved.
Study Procedure and Group Comparison
We examined the diagnostic transition towards SAD and from
it by examining the distribution of diagnoses before and after the
diagnosis of SAD was made. We also examined the distribution
of SAD subtypes (bipolar, depressive or mixed) and the distribu-
tion of SAD patients according to the affective course of their ill-
ness (patients were defined as having depressive episodes only,
manic episodes only, both depressive and manic episodes, or un-
specified episodes). Next, in order to define demographic and
clinical variables as predictors of stability of diagnosis, we focused
on the comparison of the two groups of patients, the stable (who
still had the SAD diagnosis) versus the unstable (who had the
SAD diagnosis changed). We then further divided the stable
group into two subgroups: the group who had a stable SAD sub-
type diagnosis (depressive or bipolar) versus the group who had
diagnostic transition between SAD subtypes ( fig.1 ). The variables
were compared, first between the stable and unstable and after-
wards among the three groups. We also compared the first SAD
subtype diagnosis that the patients received in the three groups in
order to examine the association between the disorder polarity (at
the first diagnosis of SAD) and the diagnostic stability.
Statistical Analysis
We used the
2
test or Fishers exact test for comparison of cat-
egorical variables. Associations between variables were assessed
using the Pearson correlation test. The significance threshold for
all analyses was set at p ! 0.05. All results are expressed as mean
8 SD.
Results
Descriptive Characteristics of Sample
The study group was predominantly male (52.8%),
with 11.67 8 2.80 years of education and was first admit-
ted at the age of 25.84 8 9.88 years. The duration of fol-
low-up was 18.68 8 11.1 years, and the number of admis-
sions per patient was 10.6 8 9.35.
Stability of Diagnosis
We divided the patients into four different groups, ac-
cording to their diagnosis (SAD or other) on their first
and last admission ( table 1 ). Group 1 patients are those
who received the SAD diagnosis on their first admission,
and kept it, during the follow-up, till their last admission.
Group 2 patients received a different diagnosis on their
first admission. These patients, who are the majority of
subjects in the study (59%), received the SAD diagnosis at
a later stage of their illness, and kept it till their last ad-
mission. Together these two groups composed the stable
group of patients. Group 3 includes the patients who re-
ceived the SAD diagnosis on their first admission, and
had their diagnosis changed over time. Group 4 includes
those patients who received a different diagnosis on their
first and last admission, but received the SAD diagnosis
at some point in between their first and last admissions.
Together, groups 3 and 4 compose the unstable group of
patients.
The overall stability of SAD diagnosis was defined as
the percentage of stable patients out of the whole sample:
73.1% (90 of 123).
Diagnostic Transitions
73 patients had a diagnostic transition towards SAD.
Half of them received a diagnosis of schizophrenia before
receiving the SAD diagnosis, and only 31.6% had a prior
diagnosis of BPD. Out of the 33 patients who had a diag-
nostic shift from SAD, most had their diagnosis changed
Table 1. D istribution of patients (n = 123) to groups according to
their diagnosis at first and last admission: stable vs. unstable SAD
diagnosis
Group
No.
Diagnosis at
first admission
Diagnosis
at last admission
Patients
n (%)
Stability of
SAD
1 SAD SAD 17 (14) stable
2 other SAD 73 (59) stable
3 SAD other 9 (7) unstable
4
1
other other 24 (20) unstable
1
Patients had been diagnosed as SAD after their first admis-
sion, and the diagnosis was changed later on.
SAD patients
(n = 123)


Stable
(SAD today)
(n = 90)


43
Unstable SAD
subtype

Unstable
(SAD in the past)
(n = 33)




47
Stable SAD subtype
C
o
l
o
r

v
e
r
s
i
o
n

a
v
a
i
l
a
b
l
e

o
n
l
i
n
e
Fig. 1. Patient distribution according to stability of SAD and SAD
subtype diagnoses.
Brenner /Krivoy /Weizman /Fischel

Psychopathology 2010;43:285291 288
to schizophrenia (60.6%), and only 24.2% had a shift to
BPD diagnosis ( table2 ).
SAD Subtypes
For every patient in the sample, we examined which
SAD subtype diagnosis he received when first diagnosed
as SAD. 29% of the patients had a SAD bipolar diagnosis
as a first SAD diagnosis. 17% had a diagnosis of SAD de-
pressive, and 6% had a diagnosis of SAD mixed. Almost
half of the patients (48%) received a SAD diagnosis with-
out specification of the subtype. We also examined the
nature of affective episodes during the time the patient
had a SAD diagnosis. Most of the patients (63%) had
manic episodes at some point of their illness: 33% of the
patients had manic and depressive episodes, and another
30% had only manic episodes. That in contrast to pure
bipolar disorder in which, according to different reports,
there are only 1020% of patients with only manic epi-
sodes [22] . 17% of the patients had only depressive epi-
sodes, and 20% of the patients had unspecified affective
episodes. These episodes might have been mainly schizo-
phrenic, or that their affective polarity was not clear.
Comparison between Stable and Unstable
Demographic and Clinical Variables
While the total duration of follow-up among the sta-
ble and unstable groups was not significantly different,
the duration of follow-up since the diagnosis of SAD was
given, was significantly shorter at the stable group (p =
0.037) ( fig.2 ). Other demographic and clinical variables
were not found to be significantly different between the
two groups, including gender, family psychopathology,
substance abuse, violence, suicidality, total duration of
follow-up and age at first admission ( table3 ).
Comparison between Stable and Unstable
Polarity of SAD
We compared the three groups unstable, unstable in
SAD subtype and stable in SAD subtype in order to ex-
amine a relationship between the SAD polarity and the
diagnosis stability. We found that among the patients
who had a stable subtype diagnosis, the percentage of
Table 2. D iagnostic transitions towards and from SAD
Diagnosis Patients w ho received the diagnosis
n (%)
before SAD after SAD
Schizophrenia 37 (50.7) 20 (60.6)
Bipolar disorder 23 (31.6) 8 (24.2)
Major depressive disorder 5 (6.8) 2 (6.1)
Other psychotic disorders 6 (8.2) 0 (0.0)
Other non-psychotic disorders 2 (2.7) 3 (9.1)
Total 73 (100) 33 (100)
0 5 10 15 20 25
Unstable
(n = 33)
Stable
(n = 90)
Duration of total follow-up (years)
Time of SAD diagnosis
Time of SAD diagnosis
0
5
10
15
20
25
P
a
t
i
e
n
t
s

(
n
)
Unstable Stable at SAD
subtype
Unstable at SAD
subtype
SAD unspecifed
SAD bipolar
SAD depressive
SAD mixed
*
C
o
l
o
r

v
e
r
s
i
o
n

a
v
a
i
l
a
b
l
e

o
n
l
i
n
e
C
o
l
o
r

v
e
r
s
i
o
n

a
v
a
i
l
a
b
l
e

o
n
l
i
n
e
Fig. 2. Comparison of total duration of follow-up, time of SAD
diagnosis and duration of follow-up since SAD diagnosis was giv-
en between stable and unstable groups (black vertical line rep-
resents mean value of time of SAD diagnosis for each group).
Fig. 3. SAD subtype at first diagnosis of SAD as a predictor of di-
agnosis stability. * p = 0.026 (rate of SAD bipolar in the stable at
SAD subtype group, versus the rate of SAD bipolar in the other
groups).
Stability of SAD in Correlation with
Duration of Follow-Up
Psychopathology 2010;43:285291 289
SAD bipolar was high (42.6%). On the contrary, most of
the patients whose diagnosis was unstable (either within
the spectrum of SAD or at the transition towards other
diagnoses) were diagnosed as SAD unspecified and the
percentage of SAD bipolar was significantly lower in
those groups ( fig.3 ).
Discussion
Stability of Diagnosis
In this study, the stability of SAD diagnosis was found
to be 73.1%, which is relatively high compared to former
reports [17, 18] . There are a number of explanations for
this finding: First, the size of the sample in the current
study was larger than the samples in the former studies.
Second, our study was designed and held in the year of
2005, while the former studies took place in the late 1990s.
The option that the DSM-IV diagnoses were not well as-
similated by then cannot be ruled out. A third explana-
tion is that the diagnosis of SAD is an appealing diagno-
sis for clinicians, especially in those cases where the dif-
ferential diagnosis between schizophrenia and bipolar
disorder is not clear-cut. This option was previously pro-
posed by other investigators [3, 23] .
Diagnostic Transitions
Most of the patients had a different diagnosis before
they were diagnosed as SAD. This is not surprising, since
even though the DSM-IV does not require a certain dura-
tion of symptoms for the diagnosis of SAD, the affective
symptoms should be present for a substantial portion of
the total duration of the active and residual periods of the
illness [7] . Out of 73 patients who had different diagnoses
prior to SAD, the majority (50.7%) had a diagnosis of
schizophrenia, and only 31.6% had a previous diagnosis
of bipolar disorder. Other previous diagnoses were rela-
tively rare. The diagnostic shift from SAD towards other
diagnoses was mainly towards schizophrenia as well:
about 60% from the patients who had a diagnostic shift
from SAD to schizophrenia, and only 24.2% to BPD. An-
other interesting finding was that among the 56 patients
who had a first-degree relative with a psychiatric disor-
der, 37% had relatives with schizophrenia and only 29%
had relatives with affective disorders. Together these
findings support the more accepted hypothesis today that
SAD is closer to schizophrenia than to the affective dis-
orders [2, 5, 11, 24] . An alternative explanation to these
findings is that clinicians have a greater tendency to di-
agnose SAD when there is a personal or familial history
of schizophrenia versus a history of affective disorders.
Table 3. D emographic and clinical variables a comparison between stable and unstable groups
Unstable
(n = 33)
Stable
(n = 90)
p
(t test/
2
)
Male/female 18/15 (54.5/45.5) 47/43 (52.2/47.8) 0.841
Psychopathology in family 18 (54.5) 38 (42.2) 0.307
Type of family psychopathology
SCZ
BPD
MDD
SAD
Other/no data
9 (50.0)
1 (5.6)
3 (16.7)
1 (5.6)
4 (22.2)
10 (27.8)
5 (13.9)
7 (19.4)
1 (2.8)
13 (36.1)
0.483
Substance abuse 8 (24.2) 19 (21.1) 0.806
Mood stabilizer therapy 26 (78.8) 78 (86.7) 0.277
Suicidal behavior 19 (57.6) 51 (56.7) 1.000
Violence 21 (63.6) 58 (64.4) 1.000
Total duration of follow-up, years 10.33816.87 19.34811.4 0.279
Time of SAD diagnosis, years 7.6388.46 12.07810.88 0.040
Duration of follow-up since SAD diagnosis, years 9.2486.22 7.2786.53 0.037
Age at first admission, years 25.8489.01 25.8489.49 1.000
Total number of admissions 13.72813.21 9.5687.02 0.092
Education, years 11.6482.31 11.6383.16 0.996
1
Results are expressed as either number and percentage (in parentheses) of patients, or as mean 8 SD.
Brenner /Krivoy /Weizman /Fischel

Psychopathology 2010;43:285291 290
SAD Subtypes
Most of the patients had a manic or manic and depres-
sive mixed symptomatology during the SAD episodes.
This finding is in accordance with data regarding the af-
fective nature of SAD episodes, e.g. Angst et al. [14]
found that 64% of the patients had manic or mixed man-
ic and depressive symptomatology. In our study, only
17% of the patients had pure depressive episodes. We
found a relation between the bipolar subtype of SAD and
higher levels of diagnostic stability: patients who were
diagnosed as SAD bipolar subtype on their first diagno-
sis of SAD had a higher tendency for diagnosis stability
both in SAD diagnosis and in the subtype diagnosis.
On the other hand, patients who were diagnosed as SAD
depressive or SAD unspecified had a greater tendency
for diagnostic transitions, both from SAD to other diag-
noses and between subtypes of SAD. Some limitations
for this conclusion should be made: first, there seems to
be a misusage of the SAD subtypes. The DSM-IV speci-
fies the subtypes in order to describe the whole affective
course of the illness. Therefore, a single manic episode
(with or without depressive episodes) is sufficient for
specifying a patient as a bipolar subtype. In practice, we
found that some patients were diagnosed as SAD bipolar
at one episode, and their diagnosis was changed to SAD
depressive at the sequential depressive episode. This am-
plifies the fact that the subtypes specifications are used,
at least sometimes, for describing the current episode
and not the whole affective course of illness. The sub-
types definitions were already found to be unclear and
confusing in one study [12] and our findings support the
need for a better clarification of the definitions. A second
limitation is that there is a wide use of SAD unspecified
diagnosis. Almost half of the patients were diagnosed as
SAD unspecified at the first diagnosis of SAD, and al-
most a third stayed with that diagnosis in further admis-
sions. These patients might have had episodes with un-
clear affective polarity, or mainly schizophrenic epi-
sodes, and therefore the determination of their SAD
subtype might have been challenging. Another possibil-
ity is that these episodes were mixed, which are known
to be under-diagnosed [25] . However, had they been di-
agnosed as specific subtypes, the overall picture of diag-
nostic stability in relation to SAD polarity could have
been different.
Former studies proposed different findings according
to nature and prognosis of SAD subtypes [15, 16, 26] . It
seems that the confusion according to the subtypes defi-
nitions plays a significant role in the inconsistent find-
ings.
Demographic and Clinical Differences between
Stable and Unstable SAD
In general, we did not find significant differences in
the clinical and demographic variables between the stable
and unstable SAD diagnostic groups. The main different
factor between the groups was a significantly shorter du-
ration of time since the SAD diagnosis was given in the
stable group. It can be assumed that the longer the time
from first SAD diagnosis, the greater the chances are for
a diagnostic transition. This finding is in accord with for-
mer studies, establishing the hypothesis that changes in
the diagnosis are primarily due to new symptoms re-
vealed within the longitudinal course of the illness, and
not due to lack of validity and reliability [9, 17, 19] . This
finding supports the necessity of a longitudinal dimen-
sion in the definition of SAD, an aspect that is currently
lacking in the accepted diagnostic criteria. It should also
be considered that SAD is less a final lifetime diagnosis
but more a transitional diagnosis with relative stability. It
is of note that the course of SADs may be very variable
and it is possible that during the lifetime of the patients
other types of non-SAD episodes may occur.
Conclusions
The stability of diagnosis of SAD might be higher than
formerly reported. Further prospective studies are need-
ed to substantiate our findings. The diagnosis definitions
are problematic, mainly the subtype definitions. Still it
seems that the diagnosis of a bipolar SAD subtype is a
predictor of a diagnostic stability. The main factor for di-
agnostic shifts from SAD is the course of illness over the
years, which emphasizes the need for a longitudinal fol-
low-up in the current diagnostic criteria.
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