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definitions - Schizoaffective disorder

Schizoaffective Disorder (n.)

1.(MeSH)Disorders in which there is a loss of ego boundaries or a gross impairment in reality testing with delusions or prominent hallucinations. (From DSM-IV, 1994)

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synonyms - Schizoaffective disorder

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Schizoaffective disorder, depressive type


Schizoaffective disorder, manic type


Schizoaffective disorder, mixed type


Schizoaffective disorder, unspecified


Wikipedia

Schizoaffective disorder

                   
Schizoaffective disorder
Classification and external resources
ICD-10 F25
ICD-9 295.70
OMIM 181500
MeSH D011618

Schizoaffective disorder is a psychiatric diagnosis that describes a mental disorder characterized by recurring abnormal mood and psychotic components. The mood component may be elevated or depressed, or simultaneously elevated and depressed (mixed episode), and these abnormal mood components alternate with, or occur together with, distortions in perception. For a diagnosis of schizoaffective disorder to be valid, there must be a period of at least two weeks of psychosis without mood disorder, and these symptoms cannot be due to medication(s), substance use or another medical condition.[1][2]

Schizoaffective disorder most commonly affects cognition and emotion. Distortions in perception and disordered cognition, such as auditory hallucinations, delusions, paranoia and/or disorganized speech and thinking with significant social and occupational dysfunction are typical. The division into depressive and bipolar types is based on whether the individual has ever had a manic, hypomanic or mixed episode. Symptoms usually begin in early adulthood; diagnosis prior to age 13 is rare.

Schizoaffective disorder belongs to the "schizophrenia spectrum and other psychotic disorders"[3] proposed by the DSM-5 Workgroup, which includes schizophrenia, schizotypal personality disorder, schizophreniform disorder, brief psychotic disorder, delusional disorder, substance-induced psychotic disorder, both psychotic and catatonic disorders associated with a general medical condition, both unspecified psychotic and catatonic disorders and other unspecified psychotic disorder.[4] This spectrum of psychotic disorders is comparable to the bipolar spectrum in bipolar disorder. Each named disorder on this continuum shares symptoms with the others, and some professionals (including the working group for the DSM-5) contend that the boundaries are so unclear that separate diagnostic labels are not necessarily warranted.

Contents

  Overview

The lifetime prevalence of the disorder is probably less than 1 percent, in the range of 0.5 to 0.8 percent.[5] Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizoaffective disorder currently exists, though extensive evidence exists for abnormalities in the metabolism of tetrahydrobiopterin (BH4), dopamine, and glutamate in people with schizophrenia and schizoaffective disorders. As a group, individuals with schizoaffective disorder have a more favorable prognosis than those with schizophrenia, but a worse prognosis than those with other mood disorders.[6]

Genetics, early environment, neurobiology, psychological and social processes are important contributory factors. Some recreational and prescription drugs may cause or worsen symptoms. Current research is focused on the role of neurobiology, but no single organic cause has been found.

The mainstay of current treatment is antipsychotic medication combined with mood stabilizer medication or antidepressant medication, or both. Psychotherapy, vocational therapy and social/psychiatric rehabilitation are also important for recovery. In cases where there is risk to self and others, brief involuntary hospitalization may be necessary.[7]

People with schizoaffective disorder are likely to have comorbid conditions, including anxiety disorders and substance abuse. Social problems such as long-term unemployment, poverty and homelessness are common. The average life expectancy of people with the disorder is shorter than those without, due to increased physical health problems and a higher suicide rate.

The diagnosis was introduced in 1933[8] and will be moderately amended[9][10] in the next iteration of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) because current diagnostic criteria are unreliable. The DSM-5 changes are intended to increase reliability and to reduce the frequency with which the diagnosis is used. The DSM-5 is scheduled to be published in May 2013.[11][12]

  Signs and symptoms

Late adolescence and early adulthood are the peak years for the onset of schizoaffective disorder, although it has been very rarely diagnosed in childhood.

Schizoaffective disorder is a mental illness characterized by recurring episodes of mood disorder and psychosis. Psychosis is defined by paranoia, delusions and hallucinations. Mood disorders are defined by discrete periods of clinical depression, mixed episodes and manic episodes. Individuals with the disorder may experience psychotic symptoms before, during or (commonly) after their depressive, mixed or manic episodes.

As schizoaffective disorder is presently defined, at some point during the lifetime course of the illness, psychosis must occur continuously for at least two-weeks without any mood disorder symptoms, and the symptoms must not be caused by medication(s), substance use or another medical condition.

Since the illness symptoms are similar to other disorders with prominent mood and psychotic symptoms like bipolar disorder with psychotic features and recurrent depression with psychotic features, the illness tends to be difficult to diagnose. It can be misdiagnosed as schizophrenia also, even though mood episodes have been thought to be absent or much less prominent in schizophrenia than in schizoaffective disorder. Given the difficulty of distinguishing these differences, an accurate and reliable schizoaffective disorder diagnosis usually requires an extended period of observation and treatment.

Untreated, the individual with schizoaffective disorder may experience delusions. It should be noted that delusions in schizoaffective disorder are acute manifestations of an active psychosis and are not personality traits; that is, they go away when the psychosis subsides. Manifestations of delusions include the individual being convinced that he or she is Jesus or the Antichrist, has some special purpose or destiny (such as to save the world), or is being monitored, watched or persecuted by something (commonly government agencies), when in reality they often are not. Individuals may also feel extremely paranoid. Other delusions may include the belief that an external force is controlling the individual's thought processes. (See thought insertion.)

Hallucinations involving all five senses can also occur in untreated or undertreated schizoaffective disorder. That is, the individual may see, hear, smell, feel or taste things that aren't there. For example, the individual may see overt visual hallucinations such as monsters, the devil or more subtle ones such as shadowy apparitions. Individuals may hear voices or, in some cases, music[citation needed]. Things may look or sound differently. Individuals may also experience strange sensations. These hallucinations may worsen when the individual is intoxicated.

The untreated individual may quickly change their mind about their romantic partner, friends or family if they hear something negative being said about them; as a result they may attack or, conversely, isolate themselves from the person or group until they regain normal thoughts.

These abnormal thoughts may result in behaviors that are unusual for the individual during asymptomatic periods. An example of unusual behaviors occurring as a result of an active illness period could be, for example, the individual lying compulsively or stealing impulsively and hiding the theft from family or friends. The individual may not rationally realize their actions, until after beginning treatment, and may then be shocked to realize what they did.

Comorbid or co-occurring anxiety disorders may also play a role in the subjective experience of schizoaffective disorder and thus may shape the individual's delusional thought content. For example, the individual may feel anxious, have trouble swallowing, and then believe that outside forces are controlling their throat functions. They may also suffer from various phobias which may also manifest as delusions.

There may be a decline in work or school functioning during episodes of illness. As stated above, individuals with schizoaffective disorder may withdraw socially and become isolated.

The untreated individual may sleep too much or, conversely, be unable to sleep.

Difficulties with executive function may also be a problem for individuals with schizoaffective disorder. This may include difficulties with concentration, attention, logical reasoning and impulse control.

Without treatment, the individual with schizoaffective disorder may further worsen in their abnormal emotions and delusional thought processes.

With comprehensive treatment, many individuals with schizoaffective disorder may recover much, most or even all of their functionality.

  Diagnosis

Diagnosis is based on the observed behavior of an individual while ill by a mental health professional, the self-reported experiences of the individual as well as abnormalities in behavior reported by family members, friends or co-workers to a psychiatrist, psychiatric nurse, social worker, psychologist or mental health counselor in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

As discussed above, there are several psychiatric illnesses which may present with a similar range of psychotic symptoms; these include bipolar disorder with psychotic features, major depression with psychotic features, schizophrenia, drug intoxication, brief drug-induced psychosis, and schizophreniform disorder. These disorders need to be ruled out before a firm diagnosis of schizoaffective disorder can be made.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizoaffective disorder, tests should be carried out to exclude medical illnesses which rarely may be associated with psychotic symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. It is important to rule out a delirium which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying medical illness.

Further blood tests are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, thyroid function if lithium has previously been taken to rule out hypothyroidism, liver function tests if chlorpromazine has been prescribed, and CPK levels to exclude neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

The most widely-used criteria for diagnosing schizoaffective disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR.

  DSM-IV-TR criteria

The following are the revised criteria for a diagnosis of schizoaffective disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR):[2]

  1. Two (or more) of the following symptoms are present for the majority of a one-month period (or a shorter period of time if symptoms improved with treatment):
    • delusions
    • hallucinations
    • disorganized speech (e.g., frequent derailment or incoherence) which is a manifestation of formal thought disorder
    • grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior
    • negative symptoms—e.g., affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), avolition (lack or decline in motivation), anhedonia (lack or decline in ability to experience pleasure), social withdrawal (sometimes called social anhedonia). Negative symptoms refers to symptoms that are not present or that are diminished in the affected individual but are usually found in healthy persons.[13]
    If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the individual's actions or of hearing two or more voices conversing with each other, only that symptom is required to meet criterion A above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication and at some time during the illness there is either one, two or all three of the following:
  2. During the illness, delusions or hallucinations were present for a minimum of two weeks, without major mood symptoms.
  3. For a substantial part of the overall duration of both the active and residual period of the illness, symptoms meeting criteria for a mood episode are present.
  4. Symptoms are not caused by drug abuse, medication (including antidepressant or sleeping medication) or another medical condition.

  Subtypes

Two subtypes of schizoaffective disorder exist and may be noted in a diagnosis based on the mood component of the disorder:

  Bipolar type

if the disturbance includes

Major depressive episodes usually, but not always, also occur in the bipolar subtype, however they are not required for DSM-IV diagnosis.

  Depressive type

The depressive type is noted when the disturbance includes major depressive episodes exclusively.

This subtype applies if major depressive episodes only (and no manic or mixed episodes) are part of the presentation.

  Controversies and research directions

Citing poor interrater reliability, among other problems, some psychiatrists have totally contested the concept of schizoaffective disorder as a distinct and separate disorder.[14][15] The categorical distinction between mood disorders and schizophrenia, known as the Kraepelinian dichotomy, has also been challenged by data from genetic epidemiology.[16] Consequently, some researchers have disputed that the term "schizoaffective disorder" refers to a well defined condition, and have recommended that the term be removed from or amended in future diagnostic manuals.[17]

In April 2009, the DSM-5 Psychotic Disorders Work Group headed by psychiatrist William T. Carpenter of the University of Maryland, College Park School of Medicine, reported that they will be "developing new criteria for schizoaffective disorder to improve reliability and face validity," and that they will be "determining whether the dimensional assessment of mood will justify a recommendation to drop schizoaffective disorder as a diagnostic category."[11] Speaking at the May 2009 annual conference of the American Psychiatric Association, Carpenter said,

"We had hoped to get rid of schizoaffective [disorder] as a diagnostic category because we don't think it's valid and we don't think it's reliable. On the other hand, we think it's absolutely indispensable to clinical practice."[12]

  Cause

Although the causes of schizoaffective disorder are unknown, it is suspected that this diagnosis represents a heterogeneous group of individuals, some with aberrant forms of schizophrenia and some with very serious forms of mood disorders. There is little evidence that schizoaffective disorder is a distinct variety of psychotic illness. Consequently, the disorder appears to be comorbid or (co-occurring) schizophrenia and mood disorder. Schizoaffective disorder thus appears to exist on a continuum in-between schizophrenia and severe bipolar disorder and severe recurrent unipolar depression. It follows then that the etiology is probably more similar to that of schizophrenia in some cases and more similar to severe mood disorders in other cases.

Many different genes may be contributing to the genetic risk of acquiring this illness. In addition, many different biological and environmental factors are believed to interact with the person's genes in ways which can increase or decrease the person's risk for developing schizoaffective disorder. Schizophrenia spectrum disorders (of which schizoaffective disorder is a part) have been marginally linked to advanced paternal age at the time of conception, a known cause of genetic mutations.[18]

The physiology of patients diagnosed with schizoaffective disorder appears to be similar but not identical to that of those diagnosed with schizophrenia and severe bipolar disorder.[19]

  Substance abuse

A clear causal connection between drug use and psychotic spectrum disorders, including schizoaffective disorder, has been difficult to prove. In the specific case of marijuana or cannabis, however, evidence is mounting that it can play a role in the development and morbidity of psychotic disorders, including schizoaffective disorder.[20][21] For example, a 2007 meta-analysis showed that cannabis use is statistically associated with a dose-dependent increase in risk of development of psychotic disorders, including schizoaffective disorder.[20] Moreover, a 2005 meta-analysis found that cannabis use is a significant independent risk factor for developing psychotic symptoms and psychosis.[21] Finally, a 2009 Yale study stated that it is clear

"that in individuals with an established psychotic disorder, cannabinoids can exacerbate symptoms, trigger relapse, and have negative consequences on the course of the illness."[22]

On the other hand, a 2008 meta-analysis concluded: "Confidence that most associations reported were specifically due to cannabis is low. Despite clinical opinion, it remains important to establish whether cannabis is harmful, what outcomes are particularly susceptible, and how such effects are mediated."[23] For example, despite increases in cannabis consumption in the 1960s and 1970s in western society, rates of psychotic disorders have remained generally relatively stable.[24][25][26]

There is little evidence to suggest that other drugs including alcohol cause schizoaffective disorder, or that psychotic individuals choose specific drugs to self-medicate; there is some support for the theory that they use drugs to cope with unpleasant states such as depression, anxiety, boredom and loneliness.[27] However, regarding psychosis itself, it is well understood that methamphetamine and cocaine use can result in methamphetamine or cocaine-induced psychosis which presents very similar symptomatology and may persist even when users remain abstinent.[28] Alcohol-induced psychosis can also persist during abstinence, though it appears to do so at a lower rate.[29][30][31]

  Management

Treatment for schizoaffective disorder consists of a combination of medicine, psychotherapy and psychosocial rehabilitation focused on symptom management and recovery.

A licensed psychiatrist will prescribe (usually combinations of) medicine aimed at reducing the patient's symptoms. Each person responds differently to medication, so there is usually a period of trial and error of medications, guided by both the psychiatrist's clinical experience and the patient's feedback to the psychiatrist about side effects and symptom reduction.

The only FDA-approved medication for schizoaffective disorder is paliperidone (Invega), which is an antipsychotic. In actual clinical practice, however, all types of antipsychotics are used with patient choice of medication usually based on how effective they are at both reducing symptoms and causing the least side effects.

For manic symptoms, an antipsychotic may be prescribed along with a mood stabilizer. Examples of mood stabilizers are:

In schizoaffective individuals with manic symptoms, combining lithium, carbamazepine, or valproate with an antipsychotic has been shown to be superior to antipsychotics alone. Lithium-antipsychotic combinations, however, may produce severe extrapyramidal reactions or confusion in some patients. When lithium is not effective or well-tolerated in manic individuals with schizoaffective disorder, Tegretol or Depakote are frequently used. Granulocytopenia may occur during the first few weeks of carbamazepine treatment causing a substantial decrease in antipsychotic blood levels due to hepatic enzyme induction. Valproate can, in rare cases, cause liver toxicity and platelet dysfunction. Calcium channel blockers such as verapamil may also be an effective treatment for manic symptoms but are seldom prescribed for this purpose. The degree of benefit for an individual should be considered carefully, as each of these medications carries its own risks.

For depression, an antipsychotic may be prescribed with an antidepressant. Examples of antidepressants are:

  • SSRI antidepressants (Prozac and Zoloft among others). An important precautionary note when using antidepressants: Some individuals with schizoaffective disorder may become psychotic and/or manic when taking only an antidepressant (antidepressant medication without antipsychotic medication) or when using high doses of antidepressant medication relative to their antipsychotic medication.[33][34] In addition, the SNRI antidepressants and Wellbutrin tend not to be prescribed in schizoaffective disorder because they may cause mixed episode symptoms and induce psychosis, respectively.
  • Lamotrigine is a mood stabilizer (from the anticonvulsant class of medications) which has antidepressant properties. Lamotrigine has gained prominence in treating depressed schizoaffective individuals, because antidepressants can increase the risk of mood cycling, mania and/or psychosis in some individuals.
  • When antidepressants and/or lamotrigine do not relieve depression or cause undesirable side effects, electroconvulsive therapy (ECT) or repeated transcranial magnetic stimulation (rTMS) are additional options.

Benzodiazepines such as Ativan and Klonopin are effective adjunctive treatment agents for reducing irritability and anxiety during acute mania, and sometimes during maintenance medication therapy, but long-term use can result in dependency.

Often a sleeping pill will be prescribed initially to allow the individual rest from his or her anxiety, delusions or hallucinations. However, long-term use of sleeping medications can cause dependence and can also cause delusions and hallucinations, thereby exacerbating psychosis.

Self-management techniques, including participating in internet forums, are sometimes used by individuals with schizoaffective disorder. These self-management techniques are part of the self-help movement which hasn't yet been extensively researched by mental health professionals.[35][36][37]

  Complications

Complications are similar to those for schizophrenia and major mood disorders. These include:

  • Problems following medical treatment and therapy.
  • Use of unsanctioned drugs in an attempt to self-medicate.
  • Short-term side effects and problems arising from long-term use of prescribed medications, including drug interactions.
  • Problems resulting from manic behavior (for example: spending sprees, sexual indiscretion, criminal activity).
  • Suicidal behavior due to depressive and/or psychotic symptoms.

  Epidemiology

Estimates of the prevalence of schizoaffective disorder vary widely, but schizoaffective manic patients appear to comprise 3-5% of psychiatric admissions to typical clinical centers. At one point it was widely believed that schizoaffective disorder was associated with increased risk of mood disorders in relatives. This may have been because of the number of patients with psychotic mood disorders who were included in schizoaffective study populations.

The current diagnostic criteria define a group of individuals with a mixed genetic picture. They are more likely to have schizophrenic relatives than individuals with mood disorders but more likely to have relatives with mood disorders than individuals with schizophrenia.

  History

The term schizoaffective psychosis was introduced by the American psychiatrist Jacob Kasanin in 1933[38] to describe an episodic psychotic illness with predominant affective symptoms, that was thought at the time to be a good-prognosis schizophrenia.[39] Kasanin's concept of the illness was influenced by the psychoanalytic teachings of Adolf Meyer and Kasanin postulated that schizoaffective psychosis was caused by "emotional conflicts" of a "mainly sexual nature" and that psychoanalysis "would help prevent the recurrence of such attacks."[40] He based his description on a case study of nine individuals.[40]

Other psychiatrists, before and after Kasanin, have made scientific observations of schizoaffective disorder based on assumptions of a biological and genetic etiology of the illness. In 1863, German psychiatrist Karl Kahlbaum (1828–1899) described schizoaffective disorders as a separate group in his vesania typica circularis.[41] Kahlbaum distinguished between cross-sectional and longitudinal observations. (Cross-sectional refers to observation of a single, specific episode of the illness, for example, one episode of psychotic depression; while longitudinal refers to long-term observation of many distinct episodes [similar or different] often occurring over the span of years.) In 1920, psychiatrist Emil Kraepelin (1856–1926), the founder of contemporary scientific psychiatry, observed a "great number" of cases that had characteristics of both groups of psychoses that he originally posited were two distinct and separate illnesses, dementia praecox (now called schizophrenia) and manic depressive insanity (now called bipolar disorder and recurrent depression).[40]

Kraeplin acknowledged that "there are many overlaps in this area", that is, the area between schizophrenia and severe mood disorders.[42] In 1959, psychiatrist Kurt Schneider (1887–1967) can be said to have been the first to begin to conceptualize the different forms that schizoaffective disorders can take since he observed "concurrent and sequential types".[40] (The concurrent type of illness he referred to is a longitudinal course of illness with episodes of mood disorder and psychosis occurring predominantly at the same time; while his sequential type refers to a longitudinal course predominantly marked by alternating mood and psychotic episodes.)[41] Schneider described schizoaffective disorders as "cases in-between" the traditional Kraepelinian dichotomy of schizophrenia and mood disorders.[41]

The historical phenomenological observation that schizoaffective disorder is an overlap of schizophrenia and severe mood disorders has more recently been assumed to be explained by genes for both illnesses being present in individuals with schizoaffective disorder. In support of this assumption, recent research shows that schizophrenia and severe mood disorders appear to share common genes and polygenic variations also.[16][43][44][45][46]

Schizoaffective disorder was included as a subtype of schizophrenia in DSM-I and DSM-II, though research showed a schizophrenic cluster of symptoms in individuals with a family history of mood disorders whose illness course, other symptoms and treatment outcome were otherwise more akin to bipolar disorder than to schizophrenia. DSM-III placed schizoaffective disorder in "Psychotic Disorders Not Otherwise Specified" before being formally recognized in DSM-III-R.[47] DSM-III-R included its own diagnostic criteria as well as the subtypes, bipolar and depressive.[47] In DSM-IV, published in 1994, schizoaffective disorders belonged to the category "Other Psychotic Disorders" and included almost the same criteria and the same subtypes of illness as DSM-III-R, with the addition of mixed bipolar symptomatology.[48]

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  35. ^ http://psychcentral.com/disorders/sx4t.htm#self
  36. ^ http://www.mifellowship.org/sites/default/files/pdfs/3.%20Health%20Self-Management/3.2%20Dr%20Lawn%27s%20presentation.pdf
  37. ^ http://www.mentalhealthforum.net/forum/forumdisplay.php?136-Schizoaffective-Forum
  38. ^ Lake CR, Hurwitz N (August 2006). "Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders". Psychiatry Research 143 (2-3): 255–87. DOI:10.1016/j.psychres.2005.08.012. PMID 16857267. 
  39. ^ Goodwin & Jamison. p. 102
  40. ^ a b c d Goodwin & Marneros. p. 190
  41. ^ a b c Goodwin & Marneros. p189
  42. ^ Marneros & Akiskal. pp. 3-4
  43. ^ Van Snellenberg JX, de Candia T (July 2009). "Meta-analytic evidence for familial coaggregation of schizophrenia and bipolar disorder". Arch. Gen. Psychiatry 66 (7): 748–55. DOI:10.1001/archgenpsychiatry.2009.64. PMID 19581566. 
  44. ^ "Schizophrenia and bipolar disorder may share genetic origins". Harv Ment Health Lett 25 (12): 7. June 2009. PMID 19582944. 
  45. ^ Purcell SM, Wray NR, Stone JL, et al. (July 2009). "Common polygenic variation contributes to risk of schizophrenia and bipolar disorder". Nature 460 (7256): 748–52. DOI:10.1038/nature08185. PMID 19571811. 
  46. ^ Potash JB, Bienvenu OJ (June 2009). "Neuropsychiatric disorders: Shared genetics of bipolar disorder and schizophrenia". Nat Rev Neurol 5 (6): 299–300. DOI:10.1038/nrneurol.2009.71. PMID 19498428. 
  47. ^ a b Goodwin & Jamison. p. 96
  48. ^ Goodwin & Marneros. p. 192

  Cited texts

  • Marneros A, Akiskal, HS (2007). The Overlap of Schizophrenic and Affective Spectra. New York: Cambridge University Press. ISBN 0-521-85858-5. 
  • Goodwin FK, Jamison KR (2007). Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press. ISBN 0-19-513579-2. 
  • Kaplan HI, Saddock VA (2007). Synopsis of Psychiatry. New York: Lippincott, Williams & Wilkins. ISBN 978-0-7817-7327-0. 
  • Murray WH (2006). Schizoaffective Disorders: New Research. New York: Nova Science Publishers, Inc. ISBN 1-60021-030-9. 
  • Goodwin FK, Marneros, A (2005). Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms. New York: Cambridge University Press. ISBN 0-521-83517-8. 
  • Moore DP, Jefferson JW. Handbook of Medical Psychiatry. 2nd ed. St. Louis, Mo: Mosby; 2004:126-127.
  • Goetz, CG. Textbook of Clinical Neurology. 2nd ed. St. Louis, Mo: WB Saunders; 2003: 48.
   
               

 

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