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drphalaksh

schizoaffective  diagnosis of convinience?

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recently we considered putting someone of clozapine then realised that he did not have a diagnosis of schizophrenia but schizoaffective

then otherday we though we should put someone on mood stabiliser again he had a diagnosis of schizoaffective disorder

i wonder what people do to get around these so called guidelines

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We have a man who is 'schizoaffective' doing really well on Clozapine.

Daft question - why can't someone who is schizoaffective be on both an antipsychotic and a mood stabilser?

Obviously avoid clozapine and carbemazepine (cue Paper 3 groans!) but the guidelines are just that - GUIDElines. Look at the evidence base but tailor your treatment to an individual.

NICE sometimes makes inDUHviduals of good psychiatrists!

F_S

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You are a doctor. You are therefore legally empowered to prescribe ANY drug at ANY dose for ANY condition to ANY patient. What you also have to do is be able to justify it if it is not a drug licensed at that dose, for that condition, or in that patient group. I agree with Freudians' sentiments.

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clozapine is licensed for schizophrenia and not schizoaffective. a few years ago when i was an sho my consultant asked me to contact the CPMS to start someone with a diagnosis of schizoaffective disorder on clozapine and CPMS said that it would have to be done off license. the consultant said ok. the CPMS said they wouldn't agree. i don't know if things have changed now. i'm pretty sure it's easier to do now. there is also some evidence for the effectiveness of clozapine in bipolar disorder - though i don't know of any bipolar patients on it.

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Daft question - why can't someone who is schizoaffective be on both an antipsychotic and a mood stabilser?

there is nothing to say they can't be. in fact that would be a common treatment strategy for people with schizoaffective disorder.

Obviously avoid clozapine and carbemazepine (cue Paper 3 groans!)

actually, patients can be on both together.  carbamazepine is apparantly not an absolute contraindication, but there are apparantly the other problem to be aware of is that blood levels become innaccurate for some reason, i can't remember what the reason is though.

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but the guidelines are just that - GUIDElines. Look at the evidence base but tailor your treatment to an individual.

NICE sometimes makes inDUHviduals of good psychiatrists!

F_S

actually, as i understand it the nice schizophrenia guidelines apply to schizophrenia spectrum which includes schizoaffective disorder, cos that's what the trials the guidelines are based on.  so don't blame the guidelines. the schizophrenia guidelines also mention augmentation of antipsychotics with mood stabilisers (and other drugs), but don't make recommendations because that was outside of the scope of the guidelines. if you read the scope, you'll see what areas the guideline was commisioned to cover.

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not exaclty what the topic was about, but i thought the title of the topic was going to be an intereting discussion about the diagnosis of schizoaffective disorder.

it's an interesting diagnostic category i think.

the rates seem to vary dramatically depending in who makes the diagnosis eg

1) i've been at case conferences where some people have argued strongly that the diagnosis should be schizoaffective disorder in someone who appeared to have a classical schizophrenic episode and then two years later had a manic episode with no psychotic symptoms.

2) as a trainee one of my supervising consultants almost never diagnosed schizophrenia and had huge numbers of patients diagnosed with schizoaffective disorder. they argued that people i thought had schizophrenia actually had schizoaffective disorder as they seemed quite depressed at some points.

3) at another point in my training i worked for a consultant who diagnosed most patients as having schizomania rather than schizophrenia because of odd behaviour, sleep disturbance, etc, that i considered to be secondary to their psychotic symptoms.

4) i've worked with someone else who gave everyone with any psychotic symptoms in the context of mood disturbance the diagnosis of schizoaffective disorder, whereas some of them may have been depressed or manic with psychotic symptoms.

5) the idea of two totally different conditions (schizophrenia and bipolar disorder) with a third somewhere in the middle (schizoaffective) with a prognosis and genetics somewhere between the two seems to me to demonstrate very clearly that our classification systems/understanding of mental illness is flawed.

so, anyway, schizoaffective diagnosis of convenience..... who knows.

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why isnt clozapine used for schizoaffective disorder anyone? It seems counter intuitive.. as its obviously licensed for schizophrenia and can be used in bipolar affective disorder..

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Nice one J...

I worked with a consultant... who said... Schizoaffective is a diagnosis that lazy people give...

The patient has either schizophrenia or bipolar disorder...

According to DSM IV...

A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode (2 weeks), a Manic Episode (1 week), or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia (ie atleast 2 symptoms out of delusions/ halln/ catatonia/ negative/ disorganisation).

Note: The Major Depressive Episode must include Criterion A1: depressed mood.

B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms (so one must know where the mood episode ends and the psychosis begins).

C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness (substantial being defined as atleast 20% of the total duration of illness - ie 2 months of frank mania in a person with 10 yrs of schiz is not SA).

D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Taking all this into consideration... it is very difficult to reach a diagnosis of Schizoaffective disorder in reality... because we may not have the proper longitudinal history... to give them a diagnosis of SA..

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why isnt clozapine used for schizoaffective disorder anyone? It seems counter intuitive.. as its obviously licensed for schizophrenia and can be used in bipolar affective disorder..

why not used?

1) it's not licensed, so technically it can be prescribed with the prescribing doc taking full personal responsibility for consequences and having to justify why they used an unlicensed treatment if there are negative consequences. the fact that there is evidence for it's effectiveness in treatment resistant bipolar and in schizoaffective disorder may mean that it's use would be justified, but

2) in the past the cpms made it difficult by not agreeing to let it be used in unlicensed indications, which effectively meant that if you wanted to use it off license you had to lie to the cpms about diagnosis. not something that many people would want to do because if things went wrong and there was a subseuent investigation you could probably justify your reason for prescribing, but would have to admit lying to the cpms which would probably be considered a bad thing to have done and would not be a good career move.

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One of the consultants I worked with argued that the presentation of Schizophrenia may vary across the genders and that females are prone to develop a more mood prominent presentation of Schizophrenia. He had on his patients list quite a few females with chronic Schizophrenia who would prominently present with mood symptoms when unwell. (Evidence strength D)

What complicates this already muddied pool is the understanding that about 1/3 of patients with bipolar disorder can present with frank first rank symptoms. Characteristically, most of those female patients labelled with Schizophrenia did not show any evidence of cognitive decline associated with the chronicity of the illness.

So, is it time to review their diagnoses? In that case, are they suffeing with BPAD or Schizoaffective or Schizophrenia?

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I agree with you, Dorian. I found it very difficult to make a diagnosis of Schizoaffective disorder based on DSM -IV, given the clauses that you have rightly pointed out. It is not easy with ICD-10 either. ICD -10 would require the illness to be episodic like mood disorders. If you think about cases receiving a diganosis of Schizoaffective, they are more likely to have a prolonged period of continous illness rather than episodic cours. In fact, it was easy to exclude this diagnosis in cases presented in Journal Club (the diagnosis would be subject to an extensive debate with groups for and against specific diagnosis) when i did my training back home. As you have said, one must know the longitudinal history with no gaps to make that diagnosis. Very very few would meet that criteria. Many psychotic patients who sometimes present with increased arousal or become depressed secondary to psychotic symptoms will receive a label.  

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I dont think its as simple as it sounds , noc.

Cognitive decline is not a requisite feature of schizophrenia. There is a good proportion of patients with schizophrenia who do not show cognitive decline at all. So to conclude that intact cognition would exclude schizophrenia would be erroneous. Again there are studies to show cognitive deficits in bipolar.

There are more questions than answers, i guess. And the problem is with the diagnostic system, IMHO.

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