Psychiatric diagnosis is a funny process – even with the operational criteria in DSM and ICD. There are so many things that affect the way one thinks about it. I was confronted with one of those things recently, with a patient for whom I've made the diagnosis of schizophrenia. On the basis of phenomenology and history, it was (and is) clear to me that schizophrenia is the most appropriate diagnosis. While there have been some symptoms of mood disturbance of one sort and another, they've not been to the level, or of such a nature, that they have turned me away from schizophrenia towards mood disorder.
As a quick aside, while I don't entirely dismiss "schizoaffective disorder", I … well I kind of do. It is a diagnosis that is most often mis-applied, in a sloppy fashion, because a patient has a mix of symptoms that are somewhat difficult to tease apart. In this specific case, I have not thought that schizoaffective disorder was a justifiable diagnosis (unsurprisingly, if you don't meet the requirements for a mood disorder, you don't make it to schizoaffective disorder).
And we're back…
So with what have I been confronted? With the fact that this person no longer has any symptoms. That's what. And we are so conditioned to see schizophrenia as unremittingly awful that our immediate response to someone doing that well is to question that we could be dealing with a schizophrenia. "Maybe it's really a mood disorder…"
Even though we know that in fact mood disorders, just as schizophrenias, can indeed have functional decline and chronic or residual symptoms. And even though we know that schizophrenia has a variable outcome, with a group doing very poorly, a group doing ok, and lo and behold a group doing well.
Anyway, I'm sticking with schizophrenia, because symptomatic remission now doesn't invalidate the earlier phenomenology – or most particularly, the history. I just think it's interesting that someone doing well makes us* question the diagnosis. Yes we should be open to questioning and revisiting diagnoses, but this isn't really enough of a reason. It's a manifestation of the nihilistic and hopeless view we often maintain about schizophrenia. Sadly it is an illness that sometimes has an awful outcome – but that's not always the case, and we seem to have trouble recognising that.
And that has to have an effect on how able we are to provide hope to someone newly diagnosed with schizophrenia….
(* not just me; I've often heard it said, when discussing someone with schizophrenia who's functioning well: "it can't be schizophrenia, they must have schizoaffective disorder" or similar.)