- Email: [email protected]
First-episode schizophreniform disorder: comparisons with first-episode schizophrenia
Schizophrenia Research 46 (2000) 31–34 www.elsevier.com/locate/schres
First-episode schizophreniform disorder: comparisons with first-episode schizophrenia Carlos A. ZarateJr. a,b, *, Mauricio Tohenb,c, Michelle L. Land a a Bipolar and Psychotic Disorders Program, University of Massachusetts Medical School, Worcester, MA 01655, USA b The International Consortium for Bipolar Disorder Research and the Harvard–McLean First Psychosis Project: Consolidated Department of Psychiatry and Neuroscience Program, Harvard Medical School and Department of Epidemiology, Harvard School of Public Health, Boston, and the Bipolar & Psychotic Disorders Program, McLean Hospital, Belmont, MA 02178, USA c Lilly Research Laboratories, Indianapolis, IN, USA Received 2 November 1999; accepted 24 January 2000
Abstract Background: Schizophreniform disorder remains poorly understood and has been reported probably to be a heterogeneous group of psychotic disorders. Method: This study compared first-episode schizophreniform disorder (N=12) and schizophrenia (N=18) patients. The authors propose that schizophreniform disorder has a different type of onset and outcome than schizophrenia. Patients were given extensive assessments at initial evaluation, 6 month follow-up, and 24 month follow-up. Comparisons between the two groups were made on type of onset, demographic, clinical ratings and outcome variables. Results: Patients with schizophreniform disorder compared to patients with schizophrenia were more likely to have an acute onset (P=0.003), and have recovered by 6 months (P=0.03). However, there were no differences in outcome at 24 months. Furthermore, all schizophreniform cases except for two were re-diagnosed at 24 months as having schizophrenia. Conclusions: The findings suggest that the initial differences of schizophreniform disorder compared to schizophrenia were not apparent at 24 months follow-up. Schizophreniform disorder did not emerge as a highly distinctive and stable form of psychosis that merits a diagnostic classification separate from schizophrenia. © 2000 Elsevier Science B.V. All rights reserved. Keywords: Epidemiology; Outcome; Psychosis; Schizophrenia; Schizophreniform
1. Introduction The term ‘Schizophreniform psychosis’ was originally coined by Langfeldt in 1939 (Langfeldt, 1939). His purpose in doing so was to identify a group of ‘good prognosis’ schizophrenic patients. * Corresponding author. Present address: Bipolar and Psychotic Disorders Program, University of Massachusetts Medical School, 361 Plantation Street, Worcester, MA 01655, USA. Tel.: +1-508-856-5315; fax: +1-508-856-4854. E-mail address: [email protected] (C.A. Zarate)
The original concept of schizophreniform disorder has received little attention and has since undergone many diagnostic revisions. A recent review of the existing literature on schizophreniform disorder by Strakowski (1994) suggests that the term be abolished, and that these patients should instead receive a provisional diagnosis of psychotic disorder not otherwise specified until additional clinical information becomes available. In the same review, based on four outcome studies (Coryell and Tsuang, 1982; Beiser et al., 1989; Makanjuola and Adedapo, 1987; Marengo et al.,
0920-9964/00/$ - see front matter © 2000 Elsevier Science B.V. All rights reserved. PII: S0 9 2 0 -9 9 6 4 ( 0 0 ) 0 0 03 1 - 1
32
C.A. Zarate Jr. et al. / Schizophrenia Research 46 (2000) 31–34
1991), he concluded that patients with schizophreniform disorder were more likely to have a good outcome than patients with schizophrenia. The outcome studies on schizophreniform disorder to date are few and have limitations, some of which are the inclusion of patients at different stages of their illness, selection bias in sampling and assigning diagnosis retrospectively. To examine whether patients with schizophreniform disorder are a more distinctive group than those with schizophrenia, we compared these two groups. We hypothesized that the patients with schizophreniform disorder would differ significantly from those with schizophrenia.
2. Methods Subjects were drawn from the McLean FirstEpisode Psychosis Study, the methods of which have been described elsewhere ( Tohen et al., 1992, 1996, 2000). Briefly, the study is a prospective, naturalistic follow-up study involving patients who were admitted for their first lifetime hospitalization for a first-episode of psychosis. The present report is based on the first 24 months of follow-up of 30 adults with a DSM-IV schizophrenia or schizophreniform disorder diagnosis. Diagnosis initially followed DSM-III-R criteria (1989–1994), updated in 1998 to meet DSM-IV criteria, and followed DSM-IV since 1994 (American Psychiatric Association, 1994). DSM Axis I diagnoses were determined using the Structured Clinical Interview for DSM-III-R, Patient Edition (SCID-P; Spitzer et al., 1988) at baseline and at 24 month follow-up. The follow-up SCID diagnosis was obtained by a second rater, blind to the baseline SCID diagnosis. Subjects were at least 18 years old and provided written informed consent. Patients with evidence of organic mood syndrome, dementia, or IQ less than 70 were excluded. Those who met the inclusion criteria after an initial screening were invited to participate in the study. All treatment was determined clinically and was not controlled by the investigators. Patients were given an initial evaluation by the study interviewers, then followed up at 6 and 24 months.
Comparisons between patients with schizophreniform disorder and schizophrenia were made on type of onset, demographics, an expanded 36-item version of the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham, 1962; Tohen et al., 2000) and outcome variables. Operational criteria of recovery were based on features that initially established a DSM-III-R diagnosis, rated weekly on a severity scale from 1 to 7, that followed the definitions of the Clinical Global Impressions scale (CGI, Guy, 1976; Tohen et al., 1992, 2000). In addition, specific operational criteria for recovery, for schizophrenia and schizophreniform disorder, were: no DSM-III-R ‘A’ criteria rated >2, and fewer than three criteria rated ≥2. Furthermore, a minimum period of 8 weeks of the above criteria had to be completed for a subject to be considered ‘recovered’. Type of onset was classified as acute, sub-chronic, or chronic based on the duration (months) of the psychotic symptoms before first hospitalization; and were 1–3 months, 4–6 months, and >6 months, respectively. Information on the duration of psychotic symptoms prior to the first hospitalization was obtained from all sources of information, including the patient and family members. Categorical variables were compared by using the chi-square test or two-tailed Fisher’s exact test when expected cell sizes were less than five, and continuous variables were analyzed with the Wilcoxon rank sum test. P<0.05 was set as the level of statistical significance.
3. Results Among the 301 patients with psychoses, 12 (3.98%) met DSM-IV criteria for schizophreniform disorder and 18 (5.98%) for schizophrenia. Twenty-two (73%) patients were available at 24 months follow-up. There were no differences in demographic, clinical characteristics, BPRS total and subscale scores, comorbid psychiatric and medical disorders, length of stay, and days to recovery (Table 1). Patients diagnosed with schizophreniform disorder were more likely to have an acute onset of symptoms (x2=11.7, df=2, P=0.003), and more likely to have recovered by 6 months (x2=4.5, df=1, P=0.033)
33
C.A. Zarate Jr. et al. / Schizophrenia Research 46 (2000) 31–34 Table 1 Demographic and clinical characteristics of 30 patients with first-episode schizophreniform disorder vs. schizophreniaa Variable
Schizophreniform (n=12)
Schizophrenia (n=18)
P
Age, years (mean±S.D.) Male, N (%) Caucasian, N (%) Education, N (%) Less than high school High School College or more Unemployed, N (%) Type of onset, N (%) Acute Subacute Chronic BPRS total score (mean±S.D.) Psychoactive substance abuse, N (%) Comorbid psychiatric disorder, N (%) Comorbid medical disorder, N (%) Length of stay (mean±S.D.) Reasons for not participating at 24 month follow-up, N (%) Refusal to participate Lost to follow-up Recovery at 6 months, N (%)c Recovery at 24 months, N (%)e Days to recovery (mean±S.D.) Rediagnosis at 24 months, N (%)
25.3 ±6.1 7 (58.3) 8 (66.7)
28.9 ±10.9 12 (66.7) 15 (83.3)
NS NS NS NS
4 5 3 1
5 9 4 0
(33) (42) (25) (8.3)
(28) (50) (22) (0)
NS
6 (50.0) 3 (25.0) 3 (25.0) 68.6±19.0 1 (9.1) 2 (18.2) 3 (27.3) 30.7±19.0
0 (0) 6 (33.3) 12 (66.7) 61.8±33.0 1 (5.9) 5 (29.4) 5 (29.4) 41.8±47.3
0.003b NS NS NS NS NS NS NS
2 (16.7) 1 (8.3) 9 (81.8) 10 (100.0) 66.2±67.8 9 (100)f
4 (22.2) 1 (5.6) 6 (40.0) 9 (75.0) 58.8±52.1 0 (0)
NS NS 0.03d NS NS 0.0001
a Type of onset was classified as acute, sub-chronic, or chronic based on the duration (months) of the psychotic symptoms before first hospitalization; and were 1–3 months, 4–6 months, and >6 months, respectively. b x2=11.7, df=2, P=0.003. c Diagnoses: schizophreniform (N=11) and schizophrenia (N=15). d x2=4.5, df=1, P=0.033. e Diagnoses: schizophreniform (N=10) and schizophrenia (N=12). f Fisher’s test, P=0.0001.
compared to patients diagnosed with schizophrenia. However, there were no significant differences in recovery rates between both groups at 24 months follow-up. Furthermore, all patients with schizophreniform disorder were re-diagnosed at 24 months follow-up compared to none of the schizophrenia patients [9 of 9 (100%) versus 0 of 13 (0%); P= 0.001; Fisher’s exact test]. Seventy-eight percent (N=7) of patients with schizophreniform disorder were re-diagnosed with schizophrenia and 22.2% (N=2) with schizoaffective disorder, depressive type.
4. Discussion Contrary to our hypothesis, we did not find any significant differences in the long-term outcome
between patients initially diagnosed with schizophreniform disorder and those patients diagnosed with schizophrenia. The present study suggests that even though there are initial differences in patients with first-episode schizophreniform disorder compared to patients with schizophrenia (type of onset and 6 month recovery rates), the differences were not apparent at 24 months follow-up. Schizophreniform disorder emerged as a highly unstable diagnostic category. We agree with Strakowski (1994) that schizophreniform disorder is a highly unstable diagnosis. In our study, all cases except for two were re-diagnosed at 24 month follow-up as having schizophrenia, suggesting that the diagnosis of schizophreniform disorder has no diagnostic value. The other two cases were
34
C.A. Zarate Jr. et al. / Schizophrenia Research 46 (2000) 31–34
re-diagnosed as having schizoaffective disorder depressed type, a diagnosis (based on family history) that has been reported to be closer to schizophrenia than affective psychosis ( Kendler et al., 1986). The long-term outcome of schizophreniform disorder in our study was indistinguishable at 24 months from patients with schizophrenia, further suggesting that the diagnosis of schizophreniform disorder has no prognostic value. 4.1. Potential methodologic limitations The number of cases of first-episode schizophreniform and schizophrenia were modest. However, all of these cases were drawn from a large, representative, and thoroughly diagnosed group of patients with psychoses at baseline and at 2 years follow-up. The rate of schizophreniform disorder in the present study (4.0%) was similar to that reported in another first-episode project (3.2%) ( Kendler et al., 1986). Furthermore, the rate for recovery at 24 months follow for schizophrenic patients (75%) was comparable to that (80%) reported another first-episode schizophrenia study (Lieberman et al., 1993). These data suggest that schizophreniform disorder does not have distinctive features, and that the criteria of DSM-III-R/IV are of limited usefulness in the diagnostic classification of these cases. We propose that patients with schizophreniform disorder instead be classified as having schizophrenia. Acknowledgement Supported in part by the National Alliance for Research on Schizophrenia and Depression Young Investigator Award (Dr Carlos A. Zarate, Jr.). References American Psychiatric Association, 1994. Diagnostic and Statistical Manual for Mental Disorders (DSM-IV ). fourth ed., American Psychiatric Association, Washington, DC.
Beiser, M., Iacono, W.G., Erickson, D., 1989. Temporal stability in the major mental disorders. In: Robins, L.N., Barrett, J.E. ( Eds.), The Validity of Psychiatric Diagnosis. Raven Press, New York. Coryell, W., Tsuang, M.T., 1982. DSM-III schizophreniform disorder. Arch. Gen. Psychiatry 39, 66–69. Guy, N., 1976. ECDEU Assessment Manual for Psychopharmacology. US Department of Health Education and Welfare, Washington, DC. Kendler, K.S., Gruenberg, A.M., Tsuang, M.T., 1986. A DSMIII family study of the nonschizophrenic psychotic disorders. Am. J. Psychiatry 143, 1098–1105. Langfeldt, G., 1939. The Schizophreniform States. Munksgaard, Copenhagen. Lieberman, J., Jody, D., Geisler, S., Syzmanski, S., Alvir, J., Woerner, M., 1993. Time course and biological predictors of treatment response in first-episode schizophrenia. Arch. Gen. Psychiatry 50 (5), 369–376. Makanjuola, R.O.A., Adedapo, S.A., 1987. The DSM-III concepts of schizophrenic disorder and schizophreniform disorder: a clinical and prognostic evaluation. Br. J. Psychiatry 151, 611–618. Marengo, J.T., Harrow, M., Westermeyer, J.F., 1991. Early longitudinal course of acute–chronic and paranoid– undifferentiated schizophrenia subtypes and schizophreniform disorder. J. Abnorm. Psychol. 100, 600–603. Overall, J.E., Gorham, D.R., 1962. The Brief Psychiatric Rating Scale. Psychol. Rep. 10, 799–812. Spitzer, R.L., Williams, J.B.W., Gibbon, M., First, M.D., 1988. Structured Clinical Interview for DSM-III-R — Patient Version (SCID-P). New York State Psychiatric Institute, Biometrics Research, New York. Strakowski, S.M., 1994. Diagnostic validity of schizophreniform disorder. Am. J. Psychiatry 151, 815–824. Tohen, M., Hennen, J., Zarate, C.A., Baldessarini, R., Strakowski, S., Stoll, A., Faedda, G., Suppes, T., Gebre-Medhin, P., Cohen, B., 2000. The McLean First Episode Project: Two-year syndromal and functional recovery in 219 cases of major affective disorders with psychotic features. Am. J. Psychiatry 157, 3–11. Tohen, M., Stoll, A.L., Strakowski, S.M., Faedda, G.L., Mayer, P.V., Goodwin, D.C., Kolbrener, M.L., Madigan, A.M., 1992. The McLean first-episode psychosis project: six-month recovery and recurrence outcome. Schizophr. Bull. 18, 273–282. Tohen, M., Zarate, C.A., Zarate, S.B., Gebre-Medhin, P., Pike, S., 1996. The McLean/Harvard first-episode mania project: pharmacologic treatment and outcome. Psychiatr. Ann. 26, 444–448.
First-episode schizophreniform disorder: comparisons with first-episode schizophrenia Carlos A. ZarateJr. a,b, *, Mauricio Tohenb,c, Michelle L. Land a a Bipolar and Psychotic Disorders Program, University of Massachusetts Medical School, Worcester, MA 01655, USA b The International Consortium for Bipolar Disorder Research and the Harvard–McLean First Psychosis Project: Consolidated Department of Psychiatry and Neuroscience Program, Harvard Medical School and Department of Epidemiology, Harvard School of Public Health, Boston, and the Bipolar & Psychotic Disorders Program, McLean Hospital, Belmont, MA 02178, USA c Lilly Research Laboratories, Indianapolis, IN, USA Received 2 November 1999; accepted 24 January 2000
Abstract Background: Schizophreniform disorder remains poorly understood and has been reported probably to be a heterogeneous group of psychotic disorders. Method: This study compared first-episode schizophreniform disorder (N=12) and schizophrenia (N=18) patients. The authors propose that schizophreniform disorder has a different type of onset and outcome than schizophrenia. Patients were given extensive assessments at initial evaluation, 6 month follow-up, and 24 month follow-up. Comparisons between the two groups were made on type of onset, demographic, clinical ratings and outcome variables. Results: Patients with schizophreniform disorder compared to patients with schizophrenia were more likely to have an acute onset (P=0.003), and have recovered by 6 months (P=0.03). However, there were no differences in outcome at 24 months. Furthermore, all schizophreniform cases except for two were re-diagnosed at 24 months as having schizophrenia. Conclusions: The findings suggest that the initial differences of schizophreniform disorder compared to schizophrenia were not apparent at 24 months follow-up. Schizophreniform disorder did not emerge as a highly distinctive and stable form of psychosis that merits a diagnostic classification separate from schizophrenia. © 2000 Elsevier Science B.V. All rights reserved. Keywords: Epidemiology; Outcome; Psychosis; Schizophrenia; Schizophreniform
1. Introduction The term ‘Schizophreniform psychosis’ was originally coined by Langfeldt in 1939 (Langfeldt, 1939). His purpose in doing so was to identify a group of ‘good prognosis’ schizophrenic patients. * Corresponding author. Present address: Bipolar and Psychotic Disorders Program, University of Massachusetts Medical School, 361 Plantation Street, Worcester, MA 01655, USA. Tel.: +1-508-856-5315; fax: +1-508-856-4854. E-mail address: [email protected] (C.A. Zarate)
The original concept of schizophreniform disorder has received little attention and has since undergone many diagnostic revisions. A recent review of the existing literature on schizophreniform disorder by Strakowski (1994) suggests that the term be abolished, and that these patients should instead receive a provisional diagnosis of psychotic disorder not otherwise specified until additional clinical information becomes available. In the same review, based on four outcome studies (Coryell and Tsuang, 1982; Beiser et al., 1989; Makanjuola and Adedapo, 1987; Marengo et al.,
0920-9964/00/$ - see front matter © 2000 Elsevier Science B.V. All rights reserved. PII: S0 9 2 0 -9 9 6 4 ( 0 0 ) 0 0 03 1 - 1
32
C.A. Zarate Jr. et al. / Schizophrenia Research 46 (2000) 31–34
1991), he concluded that patients with schizophreniform disorder were more likely to have a good outcome than patients with schizophrenia. The outcome studies on schizophreniform disorder to date are few and have limitations, some of which are the inclusion of patients at different stages of their illness, selection bias in sampling and assigning diagnosis retrospectively. To examine whether patients with schizophreniform disorder are a more distinctive group than those with schizophrenia, we compared these two groups. We hypothesized that the patients with schizophreniform disorder would differ significantly from those with schizophrenia.
2. Methods Subjects were drawn from the McLean FirstEpisode Psychosis Study, the methods of which have been described elsewhere ( Tohen et al., 1992, 1996, 2000). Briefly, the study is a prospective, naturalistic follow-up study involving patients who were admitted for their first lifetime hospitalization for a first-episode of psychosis. The present report is based on the first 24 months of follow-up of 30 adults with a DSM-IV schizophrenia or schizophreniform disorder diagnosis. Diagnosis initially followed DSM-III-R criteria (1989–1994), updated in 1998 to meet DSM-IV criteria, and followed DSM-IV since 1994 (American Psychiatric Association, 1994). DSM Axis I diagnoses were determined using the Structured Clinical Interview for DSM-III-R, Patient Edition (SCID-P; Spitzer et al., 1988) at baseline and at 24 month follow-up. The follow-up SCID diagnosis was obtained by a second rater, blind to the baseline SCID diagnosis. Subjects were at least 18 years old and provided written informed consent. Patients with evidence of organic mood syndrome, dementia, or IQ less than 70 were excluded. Those who met the inclusion criteria after an initial screening were invited to participate in the study. All treatment was determined clinically and was not controlled by the investigators. Patients were given an initial evaluation by the study interviewers, then followed up at 6 and 24 months.
Comparisons between patients with schizophreniform disorder and schizophrenia were made on type of onset, demographics, an expanded 36-item version of the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham, 1962; Tohen et al., 2000) and outcome variables. Operational criteria of recovery were based on features that initially established a DSM-III-R diagnosis, rated weekly on a severity scale from 1 to 7, that followed the definitions of the Clinical Global Impressions scale (CGI, Guy, 1976; Tohen et al., 1992, 2000). In addition, specific operational criteria for recovery, for schizophrenia and schizophreniform disorder, were: no DSM-III-R ‘A’ criteria rated >2, and fewer than three criteria rated ≥2. Furthermore, a minimum period of 8 weeks of the above criteria had to be completed for a subject to be considered ‘recovered’. Type of onset was classified as acute, sub-chronic, or chronic based on the duration (months) of the psychotic symptoms before first hospitalization; and were 1–3 months, 4–6 months, and >6 months, respectively. Information on the duration of psychotic symptoms prior to the first hospitalization was obtained from all sources of information, including the patient and family members. Categorical variables were compared by using the chi-square test or two-tailed Fisher’s exact test when expected cell sizes were less than five, and continuous variables were analyzed with the Wilcoxon rank sum test. P<0.05 was set as the level of statistical significance.
3. Results Among the 301 patients with psychoses, 12 (3.98%) met DSM-IV criteria for schizophreniform disorder and 18 (5.98%) for schizophrenia. Twenty-two (73%) patients were available at 24 months follow-up. There were no differences in demographic, clinical characteristics, BPRS total and subscale scores, comorbid psychiatric and medical disorders, length of stay, and days to recovery (Table 1). Patients diagnosed with schizophreniform disorder were more likely to have an acute onset of symptoms (x2=11.7, df=2, P=0.003), and more likely to have recovered by 6 months (x2=4.5, df=1, P=0.033)
33
C.A. Zarate Jr. et al. / Schizophrenia Research 46 (2000) 31–34 Table 1 Demographic and clinical characteristics of 30 patients with first-episode schizophreniform disorder vs. schizophreniaa Variable
Schizophreniform (n=12)
Schizophrenia (n=18)
P
Age, years (mean±S.D.) Male, N (%) Caucasian, N (%) Education, N (%) Less than high school High School College or more Unemployed, N (%) Type of onset, N (%) Acute Subacute Chronic BPRS total score (mean±S.D.) Psychoactive substance abuse, N (%) Comorbid psychiatric disorder, N (%) Comorbid medical disorder, N (%) Length of stay (mean±S.D.) Reasons for not participating at 24 month follow-up, N (%) Refusal to participate Lost to follow-up Recovery at 6 months, N (%)c Recovery at 24 months, N (%)e Days to recovery (mean±S.D.) Rediagnosis at 24 months, N (%)
25.3 ±6.1 7 (58.3) 8 (66.7)
28.9 ±10.9 12 (66.7) 15 (83.3)
NS NS NS NS
4 5 3 1
5 9 4 0
(33) (42) (25) (8.3)
(28) (50) (22) (0)
NS
6 (50.0) 3 (25.0) 3 (25.0) 68.6±19.0 1 (9.1) 2 (18.2) 3 (27.3) 30.7±19.0
0 (0) 6 (33.3) 12 (66.7) 61.8±33.0 1 (5.9) 5 (29.4) 5 (29.4) 41.8±47.3
0.003b NS NS NS NS NS NS NS
2 (16.7) 1 (8.3) 9 (81.8) 10 (100.0) 66.2±67.8 9 (100)f
4 (22.2) 1 (5.6) 6 (40.0) 9 (75.0) 58.8±52.1 0 (0)
NS NS 0.03d NS NS 0.0001
a Type of onset was classified as acute, sub-chronic, or chronic based on the duration (months) of the psychotic symptoms before first hospitalization; and were 1–3 months, 4–6 months, and >6 months, respectively. b x2=11.7, df=2, P=0.003. c Diagnoses: schizophreniform (N=11) and schizophrenia (N=15). d x2=4.5, df=1, P=0.033. e Diagnoses: schizophreniform (N=10) and schizophrenia (N=12). f Fisher’s test, P=0.0001.
compared to patients diagnosed with schizophrenia. However, there were no significant differences in recovery rates between both groups at 24 months follow-up. Furthermore, all patients with schizophreniform disorder were re-diagnosed at 24 months follow-up compared to none of the schizophrenia patients [9 of 9 (100%) versus 0 of 13 (0%); P= 0.001; Fisher’s exact test]. Seventy-eight percent (N=7) of patients with schizophreniform disorder were re-diagnosed with schizophrenia and 22.2% (N=2) with schizoaffective disorder, depressive type.
4. Discussion Contrary to our hypothesis, we did not find any significant differences in the long-term outcome
between patients initially diagnosed with schizophreniform disorder and those patients diagnosed with schizophrenia. The present study suggests that even though there are initial differences in patients with first-episode schizophreniform disorder compared to patients with schizophrenia (type of onset and 6 month recovery rates), the differences were not apparent at 24 months follow-up. Schizophreniform disorder emerged as a highly unstable diagnostic category. We agree with Strakowski (1994) that schizophreniform disorder is a highly unstable diagnosis. In our study, all cases except for two were re-diagnosed at 24 month follow-up as having schizophrenia, suggesting that the diagnosis of schizophreniform disorder has no diagnostic value. The other two cases were
34
C.A. Zarate Jr. et al. / Schizophrenia Research 46 (2000) 31–34
re-diagnosed as having schizoaffective disorder depressed type, a diagnosis (based on family history) that has been reported to be closer to schizophrenia than affective psychosis ( Kendler et al., 1986). The long-term outcome of schizophreniform disorder in our study was indistinguishable at 24 months from patients with schizophrenia, further suggesting that the diagnosis of schizophreniform disorder has no prognostic value. 4.1. Potential methodologic limitations The number of cases of first-episode schizophreniform and schizophrenia were modest. However, all of these cases were drawn from a large, representative, and thoroughly diagnosed group of patients with psychoses at baseline and at 2 years follow-up. The rate of schizophreniform disorder in the present study (4.0%) was similar to that reported in another first-episode project (3.2%) ( Kendler et al., 1986). Furthermore, the rate for recovery at 24 months follow for schizophrenic patients (75%) was comparable to that (80%) reported another first-episode schizophrenia study (Lieberman et al., 1993). These data suggest that schizophreniform disorder does not have distinctive features, and that the criteria of DSM-III-R/IV are of limited usefulness in the diagnostic classification of these cases. We propose that patients with schizophreniform disorder instead be classified as having schizophrenia. Acknowledgement Supported in part by the National Alliance for Research on Schizophrenia and Depression Young Investigator Award (Dr Carlos A. Zarate, Jr.). References American Psychiatric Association, 1994. Diagnostic and Statistical Manual for Mental Disorders (DSM-IV ). fourth ed., American Psychiatric Association, Washington, DC.
Beiser, M., Iacono, W.G., Erickson, D., 1989. Temporal stability in the major mental disorders. In: Robins, L.N., Barrett, J.E. ( Eds.), The Validity of Psychiatric Diagnosis. Raven Press, New York. Coryell, W., Tsuang, M.T., 1982. DSM-III schizophreniform disorder. Arch. Gen. Psychiatry 39, 66–69. Guy, N., 1976. ECDEU Assessment Manual for Psychopharmacology. US Department of Health Education and Welfare, Washington, DC. Kendler, K.S., Gruenberg, A.M., Tsuang, M.T., 1986. A DSMIII family study of the nonschizophrenic psychotic disorders. Am. J. Psychiatry 143, 1098–1105. Langfeldt, G., 1939. The Schizophreniform States. Munksgaard, Copenhagen. Lieberman, J., Jody, D., Geisler, S., Syzmanski, S., Alvir, J., Woerner, M., 1993. Time course and biological predictors of treatment response in first-episode schizophrenia. Arch. Gen. Psychiatry 50 (5), 369–376. Makanjuola, R.O.A., Adedapo, S.A., 1987. The DSM-III concepts of schizophrenic disorder and schizophreniform disorder: a clinical and prognostic evaluation. Br. J. Psychiatry 151, 611–618. Marengo, J.T., Harrow, M., Westermeyer, J.F., 1991. Early longitudinal course of acute–chronic and paranoid– undifferentiated schizophrenia subtypes and schizophreniform disorder. J. Abnorm. Psychol. 100, 600–603. Overall, J.E., Gorham, D.R., 1962. The Brief Psychiatric Rating Scale. Psychol. Rep. 10, 799–812. Spitzer, R.L., Williams, J.B.W., Gibbon, M., First, M.D., 1988. Structured Clinical Interview for DSM-III-R — Patient Version (SCID-P). New York State Psychiatric Institute, Biometrics Research, New York. Strakowski, S.M., 1994. Diagnostic validity of schizophreniform disorder. Am. J. Psychiatry 151, 815–824. Tohen, M., Hennen, J., Zarate, C.A., Baldessarini, R., Strakowski, S., Stoll, A., Faedda, G., Suppes, T., Gebre-Medhin, P., Cohen, B., 2000. The McLean First Episode Project: Two-year syndromal and functional recovery in 219 cases of major affective disorders with psychotic features. Am. J. Psychiatry 157, 3–11. Tohen, M., Stoll, A.L., Strakowski, S.M., Faedda, G.L., Mayer, P.V., Goodwin, D.C., Kolbrener, M.L., Madigan, A.M., 1992. The McLean first-episode psychosis project: six-month recovery and recurrence outcome. Schizophr. Bull. 18, 273–282. Tohen, M., Zarate, C.A., Zarate, S.B., Gebre-Medhin, P., Pike, S., 1996. The McLean/Harvard first-episode mania project: pharmacologic treatment and outcome. Psychiatr. Ann. 26, 444–448.