Acta Psychiatr Scand 2004: 109: 3037 Printed in UK.

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ACTA PSYCHIATRICA SCANDINAVICA

Fifteen-year follow-up of ICD-10 schizoaective disorders compared with schizophrenia and aective disorders
Ja ger M, Bottlender R, Strauss A, Mo ller H-J. Fifteen-year follow-up of ICD-10 schizoaective disorders compared with schizophrenia and aective disorders. Acta Psychiatr Scand 2004: 109: 3037. Blackwell Munksgaard 2004. Objective: The nosological status of schizoaective disorders is still unclear. The aim of the present study was to compare ICD-10 schizoaective disorders to schizophrenia and aective disorders with respect to the clinical picture and the long-term outcome. Method: Two hundred and forty-one rst-admitted inpatients from the years 19801982 who fullled the ICD-10 criteria for schizophrenia, schizoaective or aective disorders were included. Patients were examined at the time of rst hospitalization and then followed-up after 15 years. Results: With respect to the clinical picture at the time of rst hospitalization ICD-10 schizoaective disorders were distinguishable from both schizophrenia and aective disorders. However, with respect to the long-term outcome ICD-10 schizoaective disorders had a prognosis similar to that of aective disorders. Conclusion: Diering prognosis implies that schizoaective disorders should be distinguished from schizophrenia and suggests their subcategorization under aective disorders.

M. Jger, R. Bottlender, A. Strauss, H.-J. Mller

Department of Psychiatry, Ludwig-MaximiliansUniversity, Munich, Germany

Key words: schizoaffective disorders; schizophrenia; affective disorders; ICD-10; validity; follow-up Markus Jger MD, Psychiatrische Klinik der LudwigMaximilians-Universitt, Nussbaumstrasse 7, D-80336 Mnchen, Germany E-mail: markus.jaeger@psy.med.uni-muenchen.de Accepted for publication June 20, 2003

Introduction

More than 100 years ago, Kraepelin (1) divided functional psychoses into Dementia praecox, which he associated with an unfavourable outcome, and Manic-depressive insanity, which he associated with a favourable one. However, the observation that there are cases with symptoms typical for Dementia praecox but with favourable outcome challenged this dichotomous classication of functional psychoses. For this reason Kraepelins classication was expanded with concepts such as schizophreniform psychosis (2), cycloid psychosis (3, 4), reactive psychosis (5, 6) or schizoaective psychosis (7). The term schizoaffective psychosis was introduced by Kasanin (7), when he described nine patients with a good premorbid functioning, who developed acute psychoses with a mixture of psychotic and aective symptoms but fully recovered after a few months. Robins and Guze (8) proposed a ve-point model in order to establish diagnostic validity: 30

clinical description, laboratory studies, delimitation from other disorders, follow-up studies and family studies. Following this paradigm there were several attempts to operationalize the concept of schizoaective psychoses and to perform empirical investigations with respect to the variables mentioned above. The dierent empirical observations have led to at least four nosological concepts: 1. Schizoaffective disorder is a variant of schizophrenia (9, 10). 2. Schizoaffective disorder is a variant of affective disorders (11, 12). 3. Schizoaffective disorder is an intermediate entity between schizophrenia and affective disorders (1315). 4. There is a continuum of functional psychoses with schizophrenia at the one end and affective psychoses at the other end of the spectrum (16). These conicting ndings may be a result of the dierent methodological approaches (clinical

Fifteen-year follow-up of ICD-10 schizoaective disorders description, follow-up studies, family studies). Furthermore, dierent studies used dierent denitions for schizoaective psychoses, which are not comparable with each other (17). Nevertheless, schizoaective disorders were introduced into modern diagnostic systems: while in DSM-III they had only the state of a remnant category, in DSM-III-R schizoaective disorders were extended to a true entity with specic diagnostic criteria. The ICD-10 also has a separate diagnostic category for schizoaective disorders; this category is part of the group schizophrenia, schizotypical and delusional disorders (18). Nowadays ICD-10 schizoaective disorder is a common diagnosis in European psychiatric hospitals (19). However, there is a lack of empirical investigations for schizoaective disorders according to ICD-10 criteria, in particular comparing this diagnostic category with schizophrenia and aective disorders. Based on a sample of rst-hospitalized patients from 1980 to 1982 with a follow-up assessment after 15 years, the aim of the present study was to examine the four nosological concepts mentioned above with respect to the following questions:
Aims of the study

1. Do patients with an ICD-10 diagnosis of schizoaffective disorders differ from patients with schizophrenia or affective disorders with regard to the cross-sectional clinical picture at the time of rst hospitalization? 2. Do patients who met ICD-10 criteria for a schizoaffective disorder at time of rst hospitalization differ from patients with schizophrenia or affective disorders with regard to the longterm outcome (15 years later)?

diagnostic criteria according to ICD-10 (18). Consensus diagnoses were made by at least two wellexperienced psychiatrists, who were blinded for the results of the follow-up examination. This procedure was made possible by the great amount of detailed information routinely included in the clinical case records of the psychiatric hospital of the Ludwig-Maximilians-University. In total 241 patients, 74 men (mean age: 30.5 years) and 167 women (mean age: 36.1 years), met the ICD-10 criteria for schizoaective disorders (F25), schizophrenia (F20) or aective disorders (F30, F31, F32, F33). From the total sample of 241 patients follow-up information (15 years later) was available from 222 persons. However, a complete follow-up examination was possible in only 155 patients: nine persons refused to provide any follow-up data. Thus, the only information available for these patients was that they are alive. Thirty-three persons were known to be deceased. In 25 persons a complete follow-up examination was impossible for dierent reasons (e.g. permanent stay in foreign country). There were no signicant dierences in age, gender and diagnosis between the samples with complete follow-up data (n 155) and those with incomplete (n 67) or missing (n 19) follow-up data. Thus, a selection bias concerning these variables seems improbable.
Nosological concepts and their observable consequences

Material and methods Selection of patient sample

The sample stems from a clearly dened catchment area (Munich and surroundings) and includes all psychiatric inpatients, who were rst admitted to the psychiatric hospital of the Ludwig-Maximilians-University, Munich, between 1 January 1980 and 31 December 1982, suering from a functional psychosis (ICD-9: 295.x, 296.x, 297.x, 298.x) (20). Subjects were excluded if they had a history of major medical illness, head injury or symptoms of drug or alcohol dependence at the time of psychiatric admission. All patients were rediagnosed on the basis of their clinical case records by applying operational

The four nosological conceptions of schizoaective disorders (see Introduction) are associated with observable consequences that can be tested by empirical investigations: if one considers schizoaffective disorders as an intermediate entity between schizophrenia and aective disorders, one would expect that schizoaective disorders display a clinical picture at rst hospitalization and a longterm outcome dierent from that of schizophrenia and aective disorders. However, the model of a continuum of functional psychoses is associated with the expectation that it is not possible to nd sharp boundaries between the three diagnostic groups, neither concerning the clinical picture at rst hospitalization nor concerning the long-term outcome. While those two conceptions are in contrast to Kraepelins dichotomous classication of functional psychoses, the two remaining models of schizoaective disorders are principally compatible with Kraepelins opinions: if one considers schizoaective disorders as a variant of schizophrenia, an unfavourable long-term outcome similar to schizophrenia would be expected. However, if schizoaective disorders are considered as a 31

 ger et al. Ja variant of aective disorders, one would expect a favourable long-term outcome similar to that of aective disorders. On this background, ICD-10 schizoaective disorders are compared with schizophrenia and aective disorders with respect to the clinical picture at rst hospitalization and the long-term outcome after 15 years. According to Feinstein (21), the rst approach represents an internal and the second one an external validation of diagnostic groups. Validation is internal if one uses parameters that are part of the diagnostic judgement. For an external validation, however, it is necessary to examine diagnostic groups with respect to parameters that are not available at the time of diagnostic judgement, such as information concerning the long-term course.
Comparison of clinical picture at first hospitalization

internal validation of diagnostic groups, because the underlying diagnostic classication (ICD-10 diagnoses at the time of rst hospitalization) is based upon the cross-sectional psychopathological picture.
Comparison of long-term outcome (15 years after first hospitalization)

In order to compare the clinical picture of ICD10 schizoaective disorders with schizophrenia and aective disorders at the time of rst hospitalization, this study refers to the standardized assessment of psychopathological characteristics by using the Association for Methodology and Documentation in Psychiatry (AMDP) system, which was routinely performed on the day of admission. The investigators who made the ICD-10 diagnoses were blinded for the AMDP ratings. The AMDP system was developed in Europe by the AMDP in order to standardize the assessment of psychopathological symptoms, and is a comprehensive rating instrument that includes more than 200 items. It is based on traditional descriptive psychopathology and covers all psychopathological manifestations of functional psychoses (22). Psychopathological rater-trainings were regularly performed to establish a high interrater reliability. Pietzcker et al. (23) extracted several psychopathological syndromes by using the principal component analysis of AMDP ratings. For the purpose of the present study the summary scores of the paranoid-hallucinatory, manic and depressive syndromes (23) and the negative syndrome (24) were calculated. For the comparison of the clinical picture at the time of rst hospitalization schizoaective disorders were divided into the depressive and the manic or mixed type. The former group was compared pairwise with schizophrenia and depressive episodes of aective disorders, the latter group to schizophrenia and manic or mixed episodes of aective disorders. According to the terminology of Feinstein (21), such comparisons represent an 32

In order to compare the outcome of the three diagnostic groups the present study refers to the results of the follow-up examination (15 years after rst hospitalization). Outcome was measured considering the following three domains: global functioning, psychopathological characteristics and social state at time of follow-up examination. Global functioning was recorded by using the Global Assessment Scale (GAS) (25), which includes the global psychopathological status, as well as the global social functioning. This is an internationally well-known single-dimension rating scale for the evaluation of the overall functioning of a subject on a continuum, from severe psychiatric illness (rated 0) to health (rated 100). The GAS has 10 behavioural denitions, one for each 10-point interval. Psychopathological characteristics were assessed at follow-up examination by using the AMDP system as at study entry. Information about social parameters (partnership, employment state) was assessed using the hospitals operationalized documentation system. Concerning these dierent outcome domains patients with ICD-10 schizoaective disorders were compared to those with schizophrenia and those with aective disorders. According to Feinsteins terminology (21), this is a kind of external validation: ICD-10 diagnoses are based upon the information available at the time of rst hospitalization and outcome variables are based on the information from the follow-up examination (15 years later).
Statistical analyses

Statistical analyses were carried out using the SPSS 7.5 Software for Windows. Schizoaective disorders were compared with both schizophrenia and aective disorders. Group dierences for all continuous variables were compared by using the MannWhitney U-test. Group dierences for all categorical variables were evaluated using the chisquare test. For all statistical analyses, a P-value of <0.05 (two-tailed) was considered as statistically signicant.

Fifteen-year follow-up of ICD-10 schizoaective disorders

Results Description of the sample

At the time of rst hospitalization 41 patients (six men and 35 women) met the ICD-10 criteria for schizoaective disorders, 105 patients (46 men and 59 women) those for schizophrenia and 95 patients (22 men and 73 women) those for aective disorders (total sample: n 241). From the 41 patients with schizoaective disorders, 17 met the criteria for schizodepressive and 24 those for schizomanic or mixed subtype. In the sample of aective disorders 77 had depressive episodes and 18 manic or mixed episodes at the time of rst hospitalization. The proportion of female patients in the group with schizoaective disorders (85%) was higher than in the group with schizophrenia (56%) (P 0.001), but quite comparable with the proportion of female patients in the group with aective disorders (77%). However, patients with schizoaective disorders (mean age: 30.0 years; SD: 10.9) were younger than patients with aective disorders (mean age: 42.0 years; SD: 13.8) at the time of rst admission (P < 0.001). However, no signicant dierences were found when schizoaective disorders were compared with manic or mixed episodes of aective disorders (mean age: 34.1 years; SD: 11.0). The comparison between patients with schizoaective disorders and those with schizophrenia (mean age: 29.2 years; SD: 10.5) showed no signicant dierences, too. Fifteen years after rst hospitalization, 33 persons (14% from the original sample) were known to be deceased (natural death or suicide): 19 persons with aective disorders (20%), 13 with
Table 1. ICD-10 schizodepressive disorders compared with schizophrenia and depressive disorders concerning the clinical picture at first hospitalization Paranoid-hallucinatory syndrome Negative syndrome Manic syndrome Depressive syndrome

schizophrenia (12%) and one person with schizoaective disorders (2%). A complete follow-up assessment (15 years after rst hospitalization) was possible in 155 patients (follow-up sample): 30 patients met the ICD-10 criteria for schizoaective disorders, 64 those for schizophrenia and 61 those for aective disorder at the time of rst-hospitalization.
Do patients with an ICD-10 diagnosis of schizoaffective disorders differ from patients with schizophrenia and affective disorders with regard to the cross-sectional clinical picture at the time of first hospitalization?

In the rst step, patients with the schizodepressive subtype of schizoaective disorders (F25.1) were compared to those with schizophrenia (F20) and those with depressive episodes of aective disorders (F31.3,4,5; F32; F33). The comparison of mean values of the total scores of the depressive, manic, paranoid-hallucinatory and negative syndromes at the time of rst hospitalization (admission) revealed the following results (Table 1). Schizodepressive patients showed a signicantly higher mean value in the total score of the depressive syndrome than patients with schizophrenia. Compared with depressive patients they showed a higher mean value in the total score of the paranoid-hallucinatory syndrome and a lower one in the total score of the depressive syndrome. In the second step, patients with schizomanic or mixed type of schizoaective disorders (F25.0,2) were compared to those with schizophrenia (F20) and those with manic or mixed episodes of aective disorders (F30; F31.0,1,2,6) (Table 2). Schizomanic patients showed a signicantly lower mean value in total score of the negative

Schizodepressive disorders (n 17) 11.6 9.0 1.1 10.7 6.0 4.9 1.4 6.4 10.2 9.3 1.9 4.4

Schizophrenia (n 105) 6.7, 5.4, 2.7, 3.8, P P P P 0.441 0.976 0.325 < 0.001

Depressive disorders (n 77) 1.2 7.78 1.0 16.5 2.7, 4.2, 1.9, 6.8, P P P P < 0.001 0.310 0.391 0.005

Values are represented as mean SD.

Table 2. ICD-10 schizomanic disorders compared with schizophrenia and manic disorders concerning the clinical picture at first hospitalization Paranoid-hallucinatory syndrome Negative syndrome Manic syndrome Depressive syndrome

Schizomanic disorders (n 24) 9.3 6.5 6.1 5.0 6.5 4.2 4.4 3.8 10.2 9.3 1.9 4.4

Schizophrenia (n 105) 6.7, 5.4, 2.7, 3.8, P P P P 0.401 0.018 < 0.001 0.467

Manic disorders (n 18) 3.0 4.4 8.7 4.5 4.8, 2.9, 6.0, 3.3, P P P P 0.001 0.064 0.139 0.898

Values are represented as mean SD at the time of admission.

33

 ger et al. Ja syndrome and a higher one in total score of the manic syndrome than patients with schizophrenia. Compared with manic patients they showed a higher mean value in total score of the paranoidhallucinatory syndrome. Taken together, at the time of rst admission patients with ICD-10 schizoaective disorders presented a clinical picture that is distinguishable from both that of schizophrenia and that of aective disorders.
Do patients, who met ICD-10 criteria for a schizoaffective disorder at the time of first hospitalization, differ from patients with schizophrenia or affective disorders with regard to the long-term outcome?

only found in the total scores of the manic and depressive syndromes. No signicant dierences with regard to the long-term outcome (global assessment, social outcome and clinical picture) were found when schizoaective disorders (n 30) were compared with the subgroup of aective disorders with psychotic symptoms (n 17). The same was true for the comparison between patients with schizomanic or mixed subtype (n 17) and those with schizodepressive subtype (n 13). These results will therefore not be presented in detail. Taken together, schizoaective disorders showed a very similar outcome to aective disorders.
Discussion

Based upon the assessment at the follow-up examination (15 years after rst hospitalization), patients who met ICD-10 criteria for a schizoaffective disorder at the time of rst hospitalization were compared to those with schizophrenia or aective disorders concerning global outcome (GAS), psychopathological outcome (paranoidhallucinatory, manic, depressive and negative syndromes) and social outcome (partnership, employment) (Table 3). Because of the small size of the diagnostic groups they were not dierentiated into schizodepressive and schizomanic subtypes. There were signicant dierences between schizoaective disorders and schizophrenia with regard to the mean values of the GAS score, and paranoidhallucinatory, negative and depressive syndromes. The same was true for the proportion of patients with a GAS higher than 60, with a stable partnership and in a regular employment. These results indicate that patients with schizoaective disorders dier from those with schizophrenia because they obviously have a more favourable outcome. When schizoaective disorders were compared with aective disorders signicant dierences were

In the present study, ICD-10 schizoaective disorders were compared with schizophrenia and aective disorders with respect to both the clinical picture at time of rst hospitalization as well as the outcome 15 years after rst hospitalization. These empirical examinations were performed in order to test the following four nosological models: (1) schizoaective disorder is a variant of schizophrenia; (2) schizoaective disorder is a variant of aective disorders; (3) schizoaective disorder is an intermediate entity between schizophrenia and aective disorders; (4) there is a continuum of functional psychoses with schizophrenia at the one end and aective psychoses at the other end of the spectrum.
Clinical picture at first admission

The empirical ndings revealed that it is possible to distinguish ICD-10 schizoaective disorders from both schizophrenia and aective disorders with respect to the clinical picture at the time of rst hospitalization. This is in line with the model of an intermediate position of schizoaective
Table 3. ICD-10 schizoaffective disorders compared with schizophrenia and affective disorders concerning the long-term outcome (follow-up sample)

Schizoaffective disorders (n 30) Global assessment GAS score GAS > 60 Social outcome Stable partnership Regularly employment Clinical picture Paranoid-hallucinatory syndrome Negative syndrome Manic syndrome Depressive syndrome Values are represented as mean SD.

Schizophrenia (n 64)

Affective disorders (n 61)

60.9 20.9 56.7% 56.7% 73.3% 0.6 2.4 1.0 1.9 1.8 2.6 1.5 4.3

45.6 19.7, P < 0.001 15.6%, P < 0.001 29.7%, P 0.012 46.9%, P 0.016 3.7 7.9 0.5 3.8 6.9, 7.3, 0.9, 4.7, P P P P 0.004 < 0.001 0.191 0.002

67.7 18.6, P 0.408 73.8%, P 0.100 65.6%, P 0.409 83.1%, P 0.281 0.2 2.3 0.3 3.3 0.7, 2.7, 0.8, 5.0, P P P P 0.168 0.764 0.011 0.037

34

Fifteen-year follow-up of ICD-10 schizoaective disorders disorders. However, these descriptive ndings are not surprising, because psychopathological dierences are part of the diagnostic criteria for the respective groups in ICD-10. According to Feinstein, this is a kind of internal validation, and all kinds of internal validation are limited because such an approach does not go outside our observed evidence (21) and can lead to circular conclusions. In particular, Feinstein criticized the use of statistical methods like cluster analysis for an internal diagnostic validation because these procedures are arbitrary and depend on mathematical principles that have no direct relationship to clinical reality (21). Although the present results revealed that ICD10 schizoaective disorder is distinguishable from both schizophrenia and aective disorder with regard to the clinical picture, one has to discuss the continuous spectrum model of functional psychoses as suggested by Angst et al. (16). The crucial question is whether there is a continuous transition from schizophrenia to aective disorders or a point of rarity (26) between the dierent diagnostic entities. Therefore, Angst et al. (16) analysed the data of 269 patients, assessed with the AMDP system and the syndrome checklist (SCL), in order to identify homogenous symptomatological subgroups using multidimensional scaling and cluster analysis. They found transitional groups of schizoaective patients and a marked aective symptomatology underlying or superimposing the schizophrenic subgroup, which was interpreted as supporting the continuous spectrum model. However, Feinsteins critical remarks also apply to the cross-sectional study by Angst et al. (16). Furthermore, from a cross-sectional point of view the results of the present study give no direct support to the dichotomous concepts of functional psychoses that consider schizoaective disorders either as a variant of schizophrenia or as a variant of aective disorders. However, in order to test these models it is necessary to follow Kraepelins approach and examine diagnostic groups with regard to the long-term outcome, which is a kind of external validation (21).
Long-term outcome

Results of the follow-up examination revealed that the outcome of ICD-10 schizoaective disorders is very similar to that of aective disorders, but quite dierent from that of schizophrenia. These ndings lend support to the model that ICD-10 schizoaffective disorder is a variant of aective disorders. Similar results were reported by Pope et al. (12), who compared the outcome (11 25 years) of schiz-

omanic patients according to research diagnostic criteria with that of patients suering from schizophrenia or manic or bipolar disorders. Mo ller et al. (27), who compared the outcome (58 years after rst hospitalization) of schizoaective disorders according to RDC and ICD-8 with that of schizophrenia and aective disorders, also found a favourable outcome for both aective and schizoaective disorders. However, these results do not support the second dichotomous model of functional psychoses, which considers schizoaective disorder as a variant of schizophrenia. Conicting ndings were reported by Welner et al. (9) and Tsuang & Coryell (28). Welner et al. (9) followed-up 114 patients diagnosed as having schizoaective and related psychoses. They found that 71% of these patients had a chronic course of illness, 10% an episodic course and 19% were asymptomatic on neuroleptic medication, and concluded that schizoaective psychoses appears to resemble schizophrenia rather than aective disorders. However, there were no control groups of patients with schizophrenia or aective disorders. Furthermore, the 114 patients with schizoaective and related psychoses are not comparable to those with ICD-10 schizoaective disorders, because only less than 60% had enough aective symptoms to meet criteria for depression or mania (29). Tsuang and Coryell (28), who compared outcome (8 year follow-up) of patients with DSM-III-R schizoaffective disorders (n 11) to that of patients with schizophrenia (n 22) or depressive disorders (n 32), also found that DSM-III-R schizoaective disorders have a prognosis resembling that of schizophrenia. However, in contrast to ICD-10 the criteria for schizoaective disorders in DSM-III-R and DSM-IV require the presence of delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms (30). In this context it is important to consider the ndings of Himmelhoch et al. (31), who pointed out that interepisodic thought disorders, i.e. schizophrenic symptoms in-between acute aective episodes, are associated with an unfavourable outcome. Similar results were reported by Brockington et al. (32), who found that the presence of schizophrenic symptoms at some time without depression is an important predictor for a poor outcome. These results can explain the ndings of Welner et al. (9) and those of Tsuang and Coryell (28), because both samples are selected for patients who had thought disorders at some time without prominent aective symptoms. Hence, whenever discussing empirical ndings on schizoaective disorders, it is important to mention the underlying diagnostic criteria. 35

 ger et al. Ja Furthermore, the results of the follow-up examination on ICD-10 schizoaective disorders are in contrast to the two models that challenge Kraepelins dichotomous classication of functional psychoses: the ndings support neither the concept that ICD-10 schizoaective disorder is an intermediate entity between schizophrenia and aective disorders nor the model of a continuous spectrum of functional psychoses. However, rejection of the continuous spectrum model is limited by the fact that the present study compares only the means of the dierent outcome variables without investigating whether there is a continuous transition from schizophrenia to aective disorders or a point of rarity (26) between the diagnostic entities. However, Marneros et al. (14), who compared the long-term course (mean follow-up period: 25.1 years) of 101 schizoaective disorders with 148 schizophrenic and 106 aective disorders according to modied DSM-III criteria, concluded that schizoaective disorders occupy an intermediate position. However, their results revealed that outcome of schizoaective disorders was much more similar to that of aective than to that of schizophrenic disorders, with regard to both psychopathological as well as with regard to psychosocial outcome variables. More recently Harrow et al. (33), who compared the 10-year outcome of schizoaective disorders (n 36) according to RDC with that of schizophrenia (n 70), psychotic aective disorders (n 44) and non-psychotic aective disorders (n 60), concluded that schizoaective outcome was better than schizophrenic outcome and poorer than the outcome of psychotic aective disorders leading to a symptom dimension view of schizoaective course (33). However, similar to Marneros investigation, outcome of schizoaective disorders was more similar to those of aective disorders, in particular to that of psychotic aective disorders, than to that of schizophrenia.
Limitations

detailed and informative and investigators were blinded for results of follow-up examination. Operational diagnostic criteria are commonly applied to clinical case records in this eld of psychiatric research (12, 28). It is not possible to solve the problem of schizoaective disorders unclear nosological state with one single follow-up study. The present study only investigates this question with regard to the clinical picture and the long-term outcome. Following the model of Robins and Guze (8), which was proposed for achieving diagnostic validity, it is necessary to consider not only the results of followup studies but also those of family and laboratory investigations. However, in this eld of psychiatric research there are also many conicting results concerning the nosological state of schizoaective disorders. Nevertheless most family studies like those of Kendler et al. (34) or Maier et al. (35), point to the spectrum model of functional psychoses. In conclusion, the results of the present study reveal that with regard to the clinical picture at the time of rst hospitalization ICD-10 schizoaective disorders are distinguishable from both schizophrenia and aective disorders. However, with respect to the long-term outcome ICD-10 schizoaective disorders are similar to aective disorders. From this point of view the present ndings support Kraepelins dichotomous classication, provided that schizoaective disorders are subsumed to aective disorders. Therefore, the classication of schizoaective disorders as a subcategory of aective disorders, as suggested in the draft versions of ICD-10 has to be taken into consideration. However, it is necessary to perform further investigations (follow-up studies, family studies and laboratory studies) in this eld of psychiatric research.
References
1. Kraepelin E. Psychiatrie, 6th edn. Leipzig: Barth, 1899. 2. Langfeld G. The schizophreniform states. Copenhagen: Munskgaard, 1939. 3. Leonhard K. In: Beckmann H, ed. Die Aufteilung der tiologie, 7th endogenen Psychosen und ihre differenzierte A edn. Stuttgart: Thieme, 1995. 4. Perris C. A study of cycloid psychoses. Acta Psychiatr Scand 1974;253(Suppl.):177. 5. Wimmer A. Psykogene sindssygdomsformer. In: Wimmer A, ed. St. Hans Hospital 18161915. Jubilaeumsskrift, Kobenhavn: GEC Grad Publishers, 1916:85216. mgren E. The development of the concept of reactive 6. Stro psychoses. Psychopathology 1987;20:6267. 7. Kasanin J. The acute schizoaective psychoses. Am J Psychiatry 1933;13:97126. 8. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970;126:983987.

One important methodological limitation of the present study is that statements with regard to further course of illness refer only to patients with complete follow-up data. However, with respect to age, gender and frequency of diagnostic groups, there are no signicant dierences between this sample and the sample with missing or incomplete follow-up data. Thus, a selection bias concerning these variables seems improbable. Furthermore, one can criticize the method of retrospective assessment of diagnoses based upon clinical case records. However, clinical case records were 36

Fifteen-year follow-up of ICD-10 schizoaective disorders

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