is schizoaffective a real disorder?

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complaints from @hamstergang & my own interest in the discussion prompted this thread

 

[Mad Jack]

It's a real thing, because one can have both a mood disorder and schizophrenia. It is likely much more rare than currently diagnosed, however- many of the "schizoaffective" patients I saw either were pure schizophrenia, bipolar, or borderline when you dug into their actual symptomatology.

 

[deleted736562]

It has very poor reliability, in the 30s%. That's why DSM 5 aimed for clearer and more stringent criteria so that the diagnosis start meaning something rather than being a dumping ground. Even though it is actually very difficult to diagnose if one goes by the actual criteria, it's still overly diagnosed because of laziness/misunderstandings by so many clinicians.

Whether it's "real" or not, DSM diagnoses in general are very suspect, including much more reliably diagnosed disorders like schizophrenia and bipolar. Even the widely held assumption that schizoaffective leads to intermediate prognosis between schizophrenia and bipolar is not that well supported. This is a very interesting paper that looked at revamping classification of psychotic disorders away from DSM critieria: https://www.ncbi.nlm.nih.gov/pubmed/26651391

 

[erg923]

It's a real thing, because one can have both a mood disorder and schizophrenia.

Well, I think the question is it that, OR is it actually an independent entity/disorder that we call "schizoaffective disorder?"

 

[PistolPete]

One of my attendings in residency didn't believe in it and never diagnosed it, citing that often these patients had borderline personality disorder, schizophrenia or bipolar disorder, and I think he's right. I agree that it's a dumping ground disorder for lazy clinicians.

 

[Mad Jack]

Well, I think the question is it that, OR is it actually an independent entity/disorder that we call "schizoaffective disorder?"

I don't think it's a real diagnosis, personally. I think it's two separate diagnoses that we Voltron together to form the pinnacle of difficult to treat psychopathology.

 

[splik]

It's a real thing, because one can have both a mood disorder and schizophrenia. It is likely much more rare than currently diagnosed, however- many of the "schizoaffective" patients I saw either were pure schizophrenia, bipolar, or borderline when you dug into their actual symptomatology.

you do realize most people with mood symptoms and schizophrenia dont meet criteria for schizophrenia it is very uncommon for someone to meet criteria for schizoaffective disorder.

 

[Mad Jack]

you do realize most people with mood symptoms and schizophrenia dont meet criteria for schizophrenia it is very uncommon for someone to meet criteria for schizoaffective disorder.

I realize that- that was kind of my point. It's something that's out there in the sense that there are a rare subset of people that can fit into these boxes simultaneously. I saw a lot of schizoaffective-labeled patients, only one of which met proper criteria. I mean, I'm no psychiatrist, but one of the big things my attending harped on was misdiagnosis, particularly in the realm of schizoaffective and bipolar disorder.

 

[MacDonaldTriad]

Well, I think the question is it that, OR is it actually an independent entity/disorder that we call "schizoaffective disorder?"

Dr. Ming T. Tsuang spent most of his career looking at this and would say it is separate. Of course that doesn't mean that it isn't a dumping ground for lazy diagnosticians. Historically DSM-III had operational criteria for everything but schizoaffective disorder. That's why we have DSM-III-R. It seems they argued so long about this, they finally had to go ahead and publish the darn thing and then just keep arguing. I'm sure we will still be arguing this for several more decades.

 

[OldPsychDoc]

One of my attendings in residency didn't believe in it and never diagnosed it, citing that often these patients had borderline personality disorder, schizophrenia or bipolar disorder, and I think he's right. I agree that it's a dumping ground disorder for lazy clinicians.

Like "Polysubstance Abuse".
😡

 

[Shikima]

Dr. Ming T. Tsuang spent most of his career looking at this and would say it is separate. Of course that doesn't mean that it isn't a dumping ground for lazy diagnosticians. Historically DSM-III had operational criteria for everything but schizoaffective disorder. That's why we have DSM-III-R. It seems they argued so long about this, they finally had to go ahead and publish the darn thing and then just keep arguing. I'm sure we will still be arguing this for several more decades.

As we elucidate further information about the brain, this will help tease out the diagnosis further.

 

[splik]

i really think youre asking the wrong question here. psychiatric diagnoses are not "real", they are not diseases, they are simply terms of art, social constructs, or ideal types. they do not map onto nature, nor have a biological basis. they simply provide a convenient (or not) short hand for communicating. The problem is the reliability and validity of such labels is questionable, and the schizoaffective label is paradigmatic of the challenge or "carving nature at the joints." Some genetic studies suggest there are genes associated with schizoaffective disorder but not bipolar or schizophrenia. However it seems questionable and highly improbably that this is of consequence if even true.

 

[MacDonaldTriad]

Like "Polysubstance Abuse".
😡

I like this, it is like because it is for lazy clinicians and unlike in that it truly exists for sure.

 

[PistolPete]

I like this, it is like because it is for lazy clinicians and unlike in that it truly exists for sure.

How hard is it to document each substance of abuse? A lot of us just get lazy. And I get it, physicians these days document more and more for less and less patient face time and reimbursement, but that's no excuse.

 

[MrChance2]

We just had a guest lecturer showing that there is tons of genetic overlap between schizophrenia and bipolar. DSM diagnoses are just ways to simply communicate very complex things. Schizoaffective is real but distilling psychosis and mania down to just a few diagnoses isint precise at all. That said these diagnoses exist for communication and to guide treatment and out treatment options are still very limited. Also tangent here, correct me if I'm wrong but I don't think most psychiatrists are like "oh, thank god more DSM diagnoses, I'll finally be able to practice properly." They seem like more of a way to simplistic communication and to appease poorly trained people at insurance companies who try to judge if much better trained physicians are doing their job adequately.

 

[tr]

i really think youre asking the wrong question here. psychiatric diagnoses are not "real", they are not diseases, they are simply terms of art, social constructs, or ideal types. they do not map onto nature, nor have a biological basis. they simply provide a convenient (or not) short hand for communicating. The problem is the reliability and validity of such labels is questionable, and the schizoaffective label is paradigmatic of the challenge or "carving nature at the joints." Some genetic studies suggest there are genes associated with schizoaffective disorder but not bipolar or schizophrenia. However it seems questionable and highly improbably that this is of consequence if even true.

Completely agreed on this.

I would add that I think the DSM nosology is not just a problem with 'carving nature at the joints' but even more so that the sort of box-checking clinical observation approach that spawned the DSM resulted in a real ignorance of where some actual pathophysiological joints could lie.

I hold out hope that the RDoC approach that is being implemented in the research arm will ultimately yield a more pathophysiologically accurate diagnostic framework for clinicians. My suspicion is that will end up looking like a set of 'final common pathways' that could include categories like mania, psychosis, various types of cognitive deficit, etc., with different types of originating pathways/insults that lead there (infectious, autoimmune, various types of psychological and physical trauma, various types of genetic predisposition, etc.).

But yeah, I agree that the question 'is schizoaffective a thing' is misconceived. Mania is clearly a thing, and psychosis is clearly a thing, and you can have both at the same time, and there are a few different ways you could get there. Deciding to put someone with both mania and psychosis in one box vs another based on the length of time they've simultaneously manifested each set of symptoms isn't a reflection of any underlying pathophysiological division.

 

[wolfvgang22]

Interesting discussion.
I wouldn't jump on Psychiatrists too quickly for being lazy, though. Diagnosis is challenging, especially with comorbid personality and social factors, drug abuse, and other psychiatric disorders, not to mention the often overwhelming demands of a busy clinic or psychiatric floor.

 

[Merovinge]

Interesting discussion.
I wouldn't jump on Psychiatrists too quickly for being lazy, though. Diagnosis is challenging, especially with comorbid personality and social factors, drug abuse, and other psychiatric disorders, not to mention the often overwhelming demands of a busy clinic or psychiatric floor.

Agreed. As much fun as it is to write PCP, LSD, THC, EtOH, MDMA, Cocaine, and opioid use disorders separately, particularly when several of those might not meet criteria for use disorder... the temptation to just write polysub is so tempting, like a beautiful siren calling me in.

 

[deleted736562]

Completely agreed on this.

I would add that I think the DSM nosology is not just a problem with 'carving nature at the joints' but even more so that the sort of box-checking clinical observation approach that spawned the DSM resulted in a real ignorance of where some actual pathophysiological joints could lie.

I hold out hope that the RDoC approach that is being implemented in the research arm will ultimately yield a more pathophysiologically accurate diagnostic framework for clinicians. My suspicion is that will end up looking like a set of 'final common pathways' that could include categories like mania, psychosis, various types of cognitive deficit, etc., with different types of originating pathways/insults that lead there (infectious, autoimmune, various types of psychological and physical trauma, various types of genetic predisposition, etc.).

But yeah, I agree that the question 'is schizoaffective a thing' is misconceived. Mania is clearly a thing, and psychosis is clearly a thing, and you can have both at the same time, and there are a few different ways you could get there. Deciding to put someone with both mania and psychosis in one box vs another based on the length of time they've simultaneously manifested each set of symptoms isn't a reflection of any underlying pathophysiological division.

I think that formulation is a little bit misleading though because it assumes that psychiatry is somehow special. In a way all medical diagnoses 'cut nature at the joints'. They are pragmatic, non- ideal human constructs that help guide us in predicting, treating and communicating. There are plenty of examples in medicine of dumping ground diagnoses. Even in the more scientifically based fields, diagnoses like stable vs unstable angina... these are not exact duplicates of natural processes. And let's not go to rheumatology. The science in psych remains so weak that the diagnoses are not very helpful yet.

 

[nexus73]

Diagnosing both schizophrenia and major depressive disorder gives you more medical decision making points for billing purposes.

 

[LasVagus]

One place I feel that the term is misapplied is when it is used to describe a patient with a baseline manageable psychosis who periodically becomes more deeply paranoid, irritable, and aggressive. The assumption is often that the patient's irritability represents a manic-like state, even though it shares no other characteristics with mania and seems to occur exclusively in response to the patient's paranoid perception. I feel like saying, "of course he is irritable and aggressive, he fully believes that we are trying to poison him and he is doing whatever he can to protect himself."

 

[splik]

also there are plenty of people who meet criteria for both bipolar disorder and schizophrenia who do not meet criteria for schizoaffective disorder. I feel like patients are onto something when they think they have "bipolar schizophrenia" lol

 

[clausewitz2]

also there are plenty of people who meet criteria for both bipolar disorder and schizophrenia who do not meet criteria for schizoaffective disorder. I feel like patients are onto something when they think they have "bipolar schizophrenia" lol

...Until perhaps they report that the only medication that has ever worked for it is Xanax.

 

[Gavanshir]

i really think youre asking the wrong question here. psychiatric diagnoses are not "real", they are not diseases, they are simply terms of art, social constructs, or ideal types. they do not map onto nature, nor have a biological basis. they simply provide a convenient (or not) short hand for communicating. The problem is the reliability and validity of such labels is questionable, and the schizoaffective label is paradigmatic of the challenge or "carving nature at the joints." Some genetic studies suggest there are genes associated with schizoaffective disorder but not bipolar or schizophrenia. However it seems questionable and highly improbably that this is of consequence if even true.

Wait, what? Are you saying psychiatric illnesses have no biological basis..? Because that's what I think you said. Around here that's a very controversial statement! Care to elaborate?

 

[splik]

i said psychiatric diagnoses have no biological bases. If we get rid of the label then of course mental experience has a biological basis, but in this regard so-called mental illness is no different than any other aspect of mental life which conventional thinking holds originates in the brain.

 

[smalltownpsych]

i said psychiatric diagnoses have no biological bases. If we get rid of the label then of course mental experience has a biological basis, but in this regard so-called mental illness is no different than any other aspect of mental life which conventional thinking holds originates in the brain.

Do you mean that we don't yet know the biological bases or that the labels we use might not really match up with the biological bases if and when we discover them or even that the biological is not really sufficiently explanatory for mental disorders which are so intertwined with environmental effects. Would love to hear more of your thinking on this.

Oh and to chime in with the schizoaffective disorder dx, my experience has been that patients with this dx from other clinicians are about 70% BPD and about 50% substance use disorders. Some obviously meet both categories and most are not psychotic by any stretch of the definition. Every so often, I also see someone with schizophrenia who tells me they have schizoaffective and they say someone told them it is like schizophrenia but not as bad. From my perspective as a psychotherapist, it would make no difference whatsoever to the treatment to know whether patient met criteria for schizoaffective verses schizophrenia. For me, it is about assessing their current level of psychological functioning and working with patient to improve that functioning regardless of an arbitrary categorical distinction that has such low relaiablity or predictive value. I vote for not a useful diagnostic category which is just short of saying that it is not real.

 

[HarryMTieboutMD]

I'm a little late to this discussion, but it's one of my favorites in psychiatry, so...

The extant literature on "schizoaffective disorder" is a mess, and to SOME extent I agree with Splik that asking "is it real" is not the best question. I think a more refined question is to ask is if the Kraepelinian Dichotomy is the most reliable and valid diagnostic system, despite its glaring imperfections, that we have? Here is I think the best study looking at outcomes (10 year prospective): https://www.ncbi.nlm.nih.gov/pubmed/24089086

The authors declare their results consistent with the Kraepelinian dichotomy and that nonaffective psychosis portends a more unfavorable course. However, they also seem to suggest (like Splik) that SCZ and affective psychoses are NOT mutually exclusive, which, using operational criteria that are merely indexes of the illnesses themselves (Kendler has been writing about this recently), cannot be discerned.

This is why Kraepelin places a strong emphasis on course and issue because people he diagnosed with Dementia Praecox has florid periods of mania and psychosis (some with recovery to baseline functioning) but ultimately ended up with an impaired terminal state, ranging from weak mindedness to profound dementia.

RDocs is not going to better clarify this question because it uses matrices with arbitrary matrices and assumes a "rheostat" model of psychiatric illness, which is not going to lead to anything substantive. The categorical constructs have to remain, but the best way to find biomarkers based on pathophysiology like the rest of medicine) remains unclear

 

[erg923]

I'm a little late to this discussion, but it's one of my favorites in psychiatry, so...

The extant literature on "schizoaffective disorder" is a mess, and to SOME extent I agree with Splik that asking "is it real" is not the best question. I think a more refined question is to ask is if the Kraepelinian Dichotomy is the most reliable and valid diagnostic system, despite its glaring imperfections, that we have? Here is I think the best study looking at outcomes (10 year prospective): https://www.ncbi.nlm.nih.gov/pubmed/24089086

The authors declare their results consistent with the Kraepelinian dichotomy and that nonaffective psychosis portends a more unfavorable course. However, they also seem to suggest (like Splik) that SCZ and affective psychoses are NOT mutually exclusive, which, using operational criteria that are merely indexes of the illnesses themselves (Kendler has been writing about this recently), cannot be discerned.

This is why Kraepelin places a strong emphasis on course and issue because people he diagnosed with Dementia Praecox has florid periods of mania and psychosis (some with recovery to baseline functioning) but ultimately ended up with an impaired terminal state, ranging from weak mindedness to profound dementia.

RDocs is not going to better clarify this question because it uses matrices with arbitrary matrices and assumes a "rheostat" model of psychiatric illness, which is not going to lead to anything substantive. The categorical constructs have to remain, but the best way to find biomarkers based on pathophysiology like the rest of medicine) remains unclear

I 've never heard a normal, nonacademic person use the term "extant." 🙂

 

[smalltownpsych]

I 've never heard a normal, nonacademic person use the term "extant." 🙂

Isn't that sort of redundant? 😉
I do love these discussions though. Guess I fit into the abby-normal category. After all, even though I don't consider myself an academic, I am going to be teaching a class in the fall at the local university.

 

[clausewitz2]

RDocs is not going to better clarify this question because it uses matrices with arbitrary matrices

I think you may have a word. Or, like, ten.

 

[deleted736562]

I believe we need to step away from a categorical to a dimensional perspective of psychiatric illnesses, much like psychologists look at personality structure. Its very clear from practice that patients rarely fit into those tiny little boxes we have called dsm diagnoses and in that sense the kraeplinian dichotomy is not really that helpful. Forcing me to pick between supposedly 3 distinct diagnoses isnt really adding much to the practice and in many cases oversimplifies the approach of many clinicians. We need to understand what are the mechanisms behind symptoms to get anywhere before understanding mechanisms behind a collection of symptoms that we have falsely assumed consist of a si ng le disorder.

 

[HarryMTieboutMD]

I believe we need to step away from a categorical to a dimensional perspective of psychiatric illnesses, much like psychologists look at personality structure. Its very clear from practice that patients rarely fit into those tiny little boxes we have called dsm diagnoses and in that sense the kraeplinian dichotomy is not really that helpful. Forcing me to pick between supposedly 3 distinct diagnoses isnt really adding much to the practice and in many cases oversimplifies the approach of many clinicians. We need to understand what are the mechanisms behind symptoms to get anywhere before understanding mechanisms behind a collection of symptoms that we have falsely assumed consist of a si ng le disorder.

This banality has been echoed for over 100 years (look at what Wernicke and Kleist tried to do). Yes, operationally defined diagnostic categories are imperfect (and DSM 5 is a disaster), but in order for our diagnostic system to be revamped, its replacement has to be better. You are essentially stating the argument for RDocs, which Danny Weinberger easily refutes: https://www.ncbi.nlm.nih.gov/pubmed/26558844

 

[nexus73]

I diagnose everyone with Other Specified Schizophrenia Spectrum and Other Psychotic Disorder, then explain my reasoning why I didn't choose another psychotic disorder diagnosis. Sometimes, when I'm lazy, I diagnose Unspecified Schizophrenia Spectrum and Other Psychotic Disorder, and choose not to explain why I didn't choose another psychotic disorder diagnosis. I do this because the DSM5 makes sense to me.

I also include all my degree initials after my name like a nurse. I'm a certified airline pilot assistant-certified (or APA-C) from U of P.

I just like to.

 

[clausewitz2]

This banality has been echoed for over 100 years (look at what Wernicke and Kleist tried to do). Yes, operationally defined diagnostic categories are imperfect (and DSM 5 is a disaster), but in order for our diagnostic system to be revamped, its replacement has to be better. You are essentially stating the argument for RDocs, which Danny Weinberger easily refutes: https://www.ncbi.nlm.nih.gov/pubmed/26558844

This is an interesting paper, but "refute" suggests establishing that something is logically or factually impossible, which is not at all what this does. Not a fan of the current rdoc proposal, but there is nothing incoherent about making decisions based on categories that more closely resemble clusters in feature-length than on discrete boundaries. Maybe this will ultimately require machine-learning to extract clinically useful clusters, but there is a difference between "humans struggle with this" and "it's a bad idea."


Also the line about psychotropics not benefiting "normal" individuals somehow demonstrating that our diagnostic categories must have bright shining lines is just baffling.

 

[tr]

This banality has been echoed for over 100 years (look at what Wernicke and Kleist tried to do). Yes, operationally defined diagnostic categories are imperfect (and DSM 5 is a disaster), but in order for our diagnostic system to be revamped, its replacement has to be better. You are essentially stating the argument for RDocs, which Danny Weinberger easily refutes: https://www.ncbi.nlm.nih.gov/pubmed/26558844

I don't think those authors have properly understood the purpose of RDoC. It's not a replacement for the DSM; at least not yet. It's a structural framework for filling in the gaps in our knowledge of the pathophysiology of psychiatric disease.

RDoC stands for Research Domain Criteria and that is exactly what it is. It is emphatically not -yet - an alternative clinical diagnostic system, although the ongoing reorganization of the research effort around neurobiologically relevant criteria should ultimately get us there.

 

[HarryMTieboutMD]

This is an interesting paper, but "refute" suggests establishing that something is logically or factually impossible, which is not at all what this does. Not a fan of the current rdoc proposal, but there is nothing incoherent about making decisions based on categories that more closely resemble clusters in feature-length than on discrete boundaries. Maybe this will ultimately require machine-learning to extract clinically useful clusters, but there is a difference between "humans struggle with this" and "it's a bad idea."


Also the line about psychotropics not benefiting "normal" individuals somehow demonstrating that our diagnostic categories must have bright shining lines is just baffling.

Read the paper again.

The theory that an Rdoc classification would be more valid than DSM-5 is readily disproved throughout the entire paper with substantial evidence, encapsulated in the last sentence "[RDoc] is not based on the science it proclaims and it ignores the key clinical reality of sickness vs wellness"

RE categorization- it is the nature of the domains/units (arbitrarily defined) that is the problem and the fact that RDocs suggests some continuum for all measures irrespective of how symptoms are in now normative diagnoses- because the underlying reasons for whatever measures are different. "The assumption that a clinician could successfully treat in a singular fashion all individuals who score high on a negative valence scale or amygdala reactivity or working memory is nonscientific and clinically irresponsible. Indeed, one might argue that RDoC similarities across diverse samples are particularly ill suited to explain why some individuals are sick and how they get better."

" Further, that the major psychotropic drugs have no parallel benefits on normal individuals contradicts the rheostat model of too little or too much of a particular biologic dimension reflecting a continuous range from severely ill to varieties of normality." How is a parallel pharmacophenotypic baffling? While our current diagnostic system attempts to, as Kendler often writes "carve nature at it's joints", and diagnoses by treatment is generally fallacious, we would be remiss to completely pharmacologic response in conceptualizing the illnesses themselves, even if just as a thought experiment.

I don't think those authors have properly understood the purpose of RDoC. It's not a replacement for the DSM; at least not yet. It's a structural framework for filling in the gaps in our knowledge of the pathophysiology of psychiatric disease.

RDoC stands for Research Domain Criteria and that is exactly what it is. It is emphatically not -yet - an alternative clinical diagnostic system, although the ongoing reorganization of the research effort around neurobiologically relevant criteria should ultimately get us there.

When RDoc was initially imagined, the hope was that it would indeed be an alternate diagnostic system, which ended up not being the case. Its current status as a research tool that is now complimentary with phenomenological diagnoses and can assist in making more accurate diagnostic revisions is a more recent descriptor

 

[clausewitz2]

Read the paper again.

The theory that an Rdoc classification would be more valid than DSM-5 is readily disproved throughout the entire paper with substantial evidence, encapsulated in the last sentence "[RDoc] is not based on the science it proclaims and it ignores the key clinical reality of sickness vs wellness"

RE categorization- it is the nature of the domains/units (arbitrarily defined) that is the problem and the fact that RDocs suggests some continuum for all measures irrespective of how symptoms are in now normative diagnoses- because the underlying reasons for whatever measures are different. "The assumption that a clinician could successfully treat in a singular fashion all individuals who score high on a negative valence scale or amygdala reactivity or working memory is nonscientific and clinically irresponsible. Indeed, one might argue that RDoC similarities across diverse samples are particularly ill suited to explain why some individuals are sick and how they get better."

Again, you're not explaining any logical reason why our current clinical experience formally requires discrete categories. All of the effects you are talking about could be generated from a composite score of different scales, especially when you consider that the judgement of whether an individual is sick or not is going to depend on some kind of clinician discrimination function rather than being magically handed down from Olympus. I think a somewhat messy distribution + a sorting function does a better job of modeling how diagnoses end up being made in practice than believing there are a bunch of ideal and separated types that we just have to detect with increasing degrees of precision.

Sure, the medico-legal reality is we have to call someone "sick" or "not sick", but I hope we can avoid mistaking the rationales we present to the system and Leviathan for anything like a true and accurate accounting of what we are really dealing with.

" Further, that the major psychotropic drugs have no parallel benefits on normal individuals contradicts the rheostat model of too little or too much of a particular biologic dimension reflecting a continuous range from severely ill to varieties of normality." How is a parallel pharmacophenotypic baffling? While our current diagnostic system attempts to, as Kendler often writes "carve nature at it's joints", and diagnoses by treatment is generally fallacious, we would be remiss to completely pharmacologic response in conceptualizing the illnesses themselves, even if just as a thought experiment.

The idea that some people respond to medications and some do not and that this might correlate with symptom severity is not the baffling part. The baffling part is making an enormous leap from this fact about the world to "therefore our disorders must be discrete categories and cannot vary in a more continuous fashion." It is very easy to tell a story in which medications might have effects proportional to the distance the center point on any of a number of these scales, in which case people who were "normal" would not have apparent benefits from them but others would see benefits in some proportion to how many SDs away they are. This is literally the first way of conceptualizing it that does not involve discrete categories underlyingly that popped into my head and there are dozens more that would be reasonable. Note that it will still produce people who "respond" and people who don't "respond" without needing there to be two truly different populations.

Talking about disproving or refuting continues to make claims about the epistemic status of this stuff that are very difficult to justify. If I say I have disproved something, it means that I have produced evidence that is totally incommensurate with the statement in question and that I cannot stipulate a possible world in which they are both true.

If, on the other hand, I have merely ginned up a persuasive line of rhetoric or pointed out weak spots of the evidentiary or conceptual base, I have produced a "critique" or an "analysis" or if I am feeling punchy an "attack". I fear these are increasingly nice distinctions that are disappearing in our age of "lol debunked here's a link." I blame the Internet, and of course the young people with their baggy pants and their music nowadays etc. etc.

 

[deleted736562]

Again, you're not explaining any logical reason why our current clinical experience formally requires discrete categories. All of the effects you are talking about could be generated from a composite score of different scales, especially when you consider that the judgement of whether an individual is sick or not is going to depend on some kind of clinician discrimination function rather than being magically handed down from Olympus. I think a somewhat messy distribution + a sorting function does a better job of modeling how diagnoses end up being made in practice than believing there are a bunch of ideal and separated types that we just have to detect with increasing degrees of precision.

The "ideal" and "separated" types may exist as distinct pathophysiological entities (although symptomatology and its direct biological correlates could range across a spectrum). But there's no sense of being so adamant about those entities when pathophysiology is still a big black box in psychiatry. In fact, if one looks at the criteria of schizophrenia, 2 out of 5 very different set of symptoms that happen to occur in so many other contexts and that no one has an idea how they actually correlate together, it's very difficult to see "schizophrenia" as a distinct type.

 

[Igor4sugry]

complaints from @hamstergang & my own interest in the discussion prompted this thread

Schizoaffective disorder Bipolar Type -> the ultimate dumping ground diagnosis.