Gin S. Malhi: A critical analysis of concepts in psychiatry.

Gin S.Malhi and Erica Bell: Schizoaffective disorder in not "SAD" just bad


Aitor Castillo’s comment


         When reading the 2019 paper by Gin Malhi and Erica Bell, at first glance I had the feeling it was related to Seasonal Affective Disorder (SAD) - actually a specifier for Bipolar and Related Disorders in DSM-5 - but the authors were dealing indeed with another class of SAD, a much more controversial issue: Schizoaffective Disorder (SAD).        

         Then, I was impressed to learn that 17.5% of patients diagnosed with a psychotic illness in Australia had a Schizoaffective Disorder diagnosis; I was also certainly shocked by the data showing that Bipolar Disorder has this same prevalence there. Both numbers seem extraordinarily high.

         Malhi and Bell raise some reasonable hypotheses to explain why this diagnosis is made regardless that “many clinicians are not convinced that it is a valid disorder.” Then they move on to analyze, in a very didactic way, what are the criteria for Schizoaffective Disorder in both DSM and ICD systems.

         At this point, I want to refer to Nasser Ghaemi´s concepts in what he describes as “the conundrum of Schizoaffective Disorder” (Ghaemi 2008). He presents five models of this condition that appear relevant for this discussion:

1. A separate illness

2. An intermediate form on the continuum of psychosis

3. Comorbidity of Schizophrenia and Affective Disorders

4. A more severe variant of Bipolar Disorder

5. A less severe variant of Schizophrenia

         Specifically, he concludes that from a genetic point of view, all genetic studies consistently demonstrate that Schizoaffective Disorder is not a separate illness, a point that apparently could be in concordance with the author’s considerations in their paper. Molecular genetic studies support the hypothesis of overlapping genetic influences on Bipolar Disorder and psychotic disorders. Some of the regions with the strongest linkage evidence for Schizophrenia are also among the regions most strongly linked to Bipolar Disorder (Smoller 2008). More over, the risk for Schizoaffective Disorder may be increased among individuals who have a first-degree relative with Schizophrenia, Bipolar Disorder or Schizoaffective Disorder (American Psychiatric Association 2013).

         Finally, Malhi and Bell propose that changing the D of disorder for the D of dysfunction would be a pragmatic solution to aide clinicians in by-passing prescription legislation. Personally, I think this would be a kind of semantic make-up because the concept of disorder is pretty similar to (if not the same as) dysfunction. According to Campbell´s Psychiatric Dictionary (1989), many words have been used to refer to conditions whose definitions are unsatisfactory (i.e., disease, disorder, illness, dysfunction, reaction, disturbance, etc). As a matter of fact, DSM-I used the term reaction reflecting Adolf Meyer´s psychobiological approach (American Psychiatric Association 2000). DSM-II was similar to DSM-I but eliminated the term reaction. After all, saying that the use of the word dysfunction “would allow the acronym SAD to remain” appears somewhat naive to me.



American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. DSM-5. American Psychiatric Publishing. Washington, DC, 2013.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. DSM-IV-TR. American Psychiatric Association, Washington, DC, 2000.

Campbell R. Psychiatric Dictionary. Sixth Edition. Oxford University Press. New York, 1989.

Ghaemi N: Mood Disorders. Second Edition. Lippincott Williams & Wilkins. Philadelphia, 2008.

Malhi G, Bell E. Fake Views: Schizoaffective Disorder is not ‘SAD’, just bad. Australian and New Zealand Journal of Psychiatry 2019: 53(5):481-4.

Smoller J. Genetics of Mood and Anxiety Disorders. In: Smoller J, Sheidley B, Tsuang M, editors. Psychiatric Genetics. Applications in Clinical Practice. American Psychiatric Publishing. Washington, DC, 2008.


August 13, 2020