and their families whether there is a family history of bipolar disorder or psychosis before prescribing these medications. most patients and their families don't know the answer when they are first asked, so time should be allowed for the patient to ask family or relatives, between the session when asked by and a follow-up session. this may increase the wait for a medication slightly, but because some patients are vulnerable, this is a necessary step for to take. i believe that psychiatry as a field has not emphasized this point sufficiently. as a result, some patients have been harmed by the very treatments that were supposed to help them; or to the disgrace of psychiatry, harmed and then misdiagnosed. substance-induced psychosis should also be ruled out. both substance- and medication-induced psychosis can be excluded to a high level of certainty while the person is psychotic, typically in an emergency department, using both a broad spectrum urine toxicology screening, and a full serum toxicology screening (of the blood). some dietary supplements may also induce psychosis or mania, but cannot be ruled out with laboratory tests. so a psychotic person's family, partner, or friends should be asked whether he or she is currently taking any dietary supplements. common mistakes made when diagnosing psychotic patients include: not properly excluding delirium, missing a toxic psychosis by not screening for substances and medications, not appreciating medical abnormalities (e.g., vital signs), not obtaining a medical history and family history, indiscriminate screening without an organizing framework, not asking family or others about dietary supplements, premature diagnostic closure, and not revisiting or questioning the initial diagnostic impression of primary psychiatric disorder. schizoaffective disorder can only be diagnosed among those who have undergone a clinical evaluation with a psychiatrist. the criterion includes mental and physical symptoms such as hallucinations or delusions, and depressive episodes. there are also links to bad hygiene and a troubled social life for those with schizoaffective disorder. research has failed to conclusively demonstrate a positive relationship between schizoaffective disorder and substance abuse. there are several theorized causations for the onset of schizoaffective disorder, including, genetics, general brain function, like chemistry, and structure, and stress. only after these relevant and known causes of psychosis have been ruled out can a psychiatric differential diagnosis be made. a mental health clinician will incorporate family history, observation of a psychotic person's behavior while the person is experiencing active symptoms, to begin a psychiatric differential diagnosis. diagnosis also includes self-reported experiences, as well as behavioral abnormalities reported by family members, friends, or significant others. mistakes in this stage include: not screening for dissociative disorders. dissociative identity disorder and psychotic symptoms in schizoaffective disorder have considerable overlap, yet a different overall treatment approach. dsm-5 criteria the most widely used criteria for diagnosing schizoaffective disorder are from the american psychiatric association's diagnostic and statistical manual of mental disorders-5. the dsm-iv schizoaffective disorder definition was plagued by problems of being inconsistently (or unreliably) used on patients; when the diagnosis is made, it does not stay with most patients over time, and it has questionable diagnostic validity (that is, it does not describe a distinct disorder, nor predict any particular outcome). these problems have been slightly reduced (or "modestly improved") in the dsm-5 according to carpenter. when psychotic symptoms are confined to an episode of mania or depression (with or without mixed features), the diagnosis is that of a "psychotic" mood disorder, namely either psychotic bipolar disorder or psychotic major depression. only when psychotic states persist in a sustained fashion for two weeks or longer without concurrent affective symptoms is the diagnosis schizoaffective disorder, schizophreniform disorder or schizophrenia. the second cardinal guideline in the dsm-5 diagnosis of schizoaffective disorder is one of timeframe. dsm-5 requires two episodes of psychosis (whereas dsm-iv needed only one) to qualify for the schizoaffective disorder diagnosis. as such, it is no longer an "episode diagnosis." the new schizoaffective framework looks at the time from "the psychosis up to the current episode , rather than only defining a single episode with psychotic and mood syndromes." specifically, one of the episodes of psychosis must last a minimum of two weeks without mood disorder symptoms, but the person may be mildly to moderately depressed while psychotic. the other period of psychosis "requires the overlap of mood symptoms with psychotic symptoms to be conspicuous" and last for a greater portion of the disorder. these two changes are intended by the dsm-5 workgroup to accomplish two goals: increase the diagnosis' consistency (or reliability) when it is used; significantly decrease the overall use of the schizoaffective disorder diagnosis. if the schizoaffective diagnosis is used less often, other diagnoses (like psychotic mood disorders and schizophrenia) are likely to be used more often; but this is hypothetical until real-world data arrive. validity problems with the diagnosis remain and await further work in the fields of psychiatric genetics, neuroimaging, and cognitive science that includes the overlapping fields of cognitive, affective, and social neuroscience, which may change the way schizoaffective disorder is conceptualized and defined in future versions of the dsm and icd. comorbidities schizoaffective disorder shares a high level of comorbidity with anxiety disorders, depression, and bipolar disorder. individuals with schizoaffective disorder are also often diagnosed with substance abuse disorder, usually relating to tobacco, marijuana, or alcohol. health care providers indicate the importance of assessing for co-occurring substance use disorders, as multiple diagnoses not only potentially increase negative symptomology, but may also adversely affect the treatment of schizoaffective disorder. types one of three types of schizoaffective disorder may be noted in a diagnosis based on the mood component of the disorder: bipolar type, when the disturbance includes manic episodes, hypomania, or mixed episodes—major depressive episodes also typically occur; depressive type, when the disturbance includes major depressive episodes exclusively—that is, without manic, hypomanic, or mixed episodes. mixed type, when the disturbance includes both manic and depressive symptoms, but psychotic symptoms exist separately from bipolar disorder. problems with dsm-iv schizoaffective disorder the american psychiatric association's dsm-iv criteria for schizoaffective disorder persisted for 19 years (1994–2013). clinicians adequately trained in diagnosis used the schizoaffective diagnosis too often, largely because the criteria were poorly defined, ambiguous, and hard to use (or poorly operationalized). poorly trained clinicians used the diagnosis without making necessary exclusions of common causes of psychosis, including some prescribed psychiatric medications. specialty books written by experts on schizoaffective disorder have existed for over eight years before dsm-5 describing the overuse of the diagnosis. carpenter and the dsm-5 schizoaffective disorders workgroup analyzed data made available to them in 2009, and reported in may 2013 that: a recent review of psychotic disorders from large private insurance and medicare databases in the u.s. found that the diagnosis of dsm-iv schizoaffective disorder was used for about a third of cases with non-affective psychotic disorders. hence, this unreliable and poorly defined diagnosis is clearly overused. as stated above, the dsm-iv schizoaffective disorder diagnosis is very inconsistently used or unreliable. a diagnosis is unreliable when several different mental health professionals observing the same individual make different diagnoses excessively. even when a structured dsm-iv diagnostic interview and best estimate procedures were made by experts in the field that included information from family informants and prior clinical records, reliability was still poor for the dsm-iv schizoaffective diagnosis. the dsm-iv schizoaffective diagnosis is not stable over time either. an initial diagnosis of schizoaffective disorder during time spent at a psychiatric inpatient facility was stable at 6-month and 24-month follow ups for only 36% of patients. by comparison, diagnostic stability was 92% for schizophrenia, 83% for bipolar disorder and 74% for major depression. most patients diagnosed with dsm-iv schizoaffective disorder are later diagnosed with a different disorder, and that disorder is more stable over time than the dsm-iv schizoaffective disorder diagnosis. in april 2009, carpenter and the dsm-5 schizoaffective disorder workgroup reported that they were "developing new criteria for schizoaffective disorder to improve reliability and face validity," and were "determining whether the dimensional assessment of mood justify a recommendation to drop schizoaffective disorder as a diagnostic category." speaking to an audience at the may 2009 annual conference of the american psychiatric association, carpenter said: we had hoped to get rid of schizoaffective as a diagnostic category because we don't think it's valid and we don't think it's reliable. on the other hand, we think it's absolutely indispensable to clinical practice. a major reason why dsm-iv schizoaffective disorder was indispensable to clinical practice is because it offered clinicians a diagnosis for patients with psychosis in the context of mood disorder whose clinical picture, at the time diagnosed, appeared different from dsm-iv "schizophrenia" or "mood disorder with psychotic features". but dsm-iv schizoaffective disorder carries an unnecessarily worse prognosis than a "mood disorder with psychotic features" diagnosis, because long-term data revealed that a significant proportion of dsm-iv schizoaffective disorder patients had 15-year outcomes indistinguishable from patients with mood disorders with or without psychotic features, even though the clinical picture at the time of first diagnosis looked different from both schizophrenia and mood disorders. these problems with the dsm-iv schizoaffective disorder definition result in most people the diagnosis is used on being misdiagnosed; furthermore, outcome studies done 10 years after the diagnosis was released showed that the group of patients defined by the dsm-iv and icd-10 schizoaffective diagnosis had significantly better outcomes than predicted, so the diagnosis carries a misleading and unnecessarily poor prognosis. the dsm-iv criteria for schizoaffective disorder will continue to be used on u.s. board examinations in psychiatry through the end of 2014; established practitioners may continue to use the problematic dsm-iv definition much further into the future also. dsm-5 research directions the new schizoaffective disorder criteria continue to have questionable diagnostic validity. questionable diagnostic validity does not doubt that people with symptoms of psychosis and mood disorder need treatment—psychosis and mood disorder must be treated. instead, questionable diagnostic validity means there are unresolved problems with the way the dsm-5 categorizes and defines schizoaffective disorder. emil kraepelin's dichotomy (c. 1898) continues to influence classification and diagnosis in psychiatry. a core concept in modern psychiatry since dsm-iii was released in 1980, is the categorical separation of mood disorders from schizophrenia, known as the kraepelinian dichotomy. emil kraepelin introduced the idea that schizophrenia was separate from mood disorders after observing patients with symptoms of psychosis and mood disorder, over a century ago, in 1898. this was a time before genetics were known and before any treatments existed for mental illness. the kraepelinian dichotomy was not used for dsm-i and dsm-ii because both manuals were influenced by the dominant psychodynamic psychiatry of the time, but the designers of dsm-iii wanted to use more scientific and biological definitions. consequently, they looked to psychiatry's history and decided to use the kraepelinian dichotomy as a foundation for the classification system. the kraepelinian dichotomy continues to be used in dsm-5 despite having been challenged by data from modern psychiatric genetics for over eight years, and there is now evidence of a significant overlap in the genetics of schizophrenia and bipolar disorder. according to this genetic evidence, the kraepelinian categorical separation of mood disorders from schizophrenia at the foundation of the current classification and diagnostic system is a mistaken false dichotomy. the dichotomy at the foundation of the current system forms the basis for a convoluted schizoaffective disorder definition in dsm-iv that resulted in excessive misdiagnosis. real life schizoaffective disorder patients have significant and enduring symptoms that bridge what are incorrectly assumed to be categorically separate disorders, schizophrenia and bipolar disorder. people with psychotic depression, bipolar disorder with a history of psychosis, and schizophrenia with mood symptoms also have symptoms that bridge psychosis and mood disorders. the categorical diagnostic manuals do not reflect reality in their separation of psychosis (via the schizophrenia diagnosis) from mood disorder, nor do they currently emphasize the actual overlap found in real-life patients. thus, they are likely to continue to introduce either-or conceptual and diagnostic error, by way of confirmation bias into clinicians' mindsets, hindering accurate assessment and treatment. the new definition continues the lack of parsimony of the old definition. simpler, clearer, and more usable definitions of the diagnosis were supported by certain members of the dsm-5 workgroup; these were debated but deemed premature, because more "research needed to establish a new classification system of equal or greater validity" to the