Schizoaffective disorder

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Schizoaffective disorder
Classification and external resources
ICD-10 F25
ICD-9 295.70
OMIM 181500
MedlinePlus 000930
MeSH D011618

Schizoaffective disorder is a psychiatric diagnosis that describes a mental disorder characterized by recurring abnormal mood and psychotic components. The mood component may be elevated or depressed (bipolar or depressive subtype), or simultaneously elevated and depressed (mixed episode), and these abnormal mood components alternate with, or occur together with, psychotic symptoms. For a diagnosis of schizoaffective disorder to be valid, according to current DSM criteria (but not ICD-10 criteria), there must be a period of at least two weeks of psychosis without mood disorder, and these symptoms cannot be due to medication(s), substance use or another medical condition.[1][2] In the ICD-10, schizoaffective disorder is seen as episodic, whereas in the DSM-IV it is treated as an uninterrupted illness.[3]

Schizoaffective disorder most commonly affects cognition and emotion. Perceptual disturbances (i.e. hallucinations) and/or disordered thought processes, including delusions and disorganized speech and thinking, occur in conjunction with significant social and occupational dysfunction.[2] The division into depressive and bipolar types is based on whether the individual has ever had a manic, hypomanic or mixed episode. Symptoms usually begin in early adulthood; diagnosis prior to age 13 is rare.

Schizoaffective disorder belongs to the "schizophrenia spectrum and other psychotic disorders"[4] proposed by the DSM-5 Workgroup, which includes schizophrenia, schizotypal personality disorder, schizophreniform disorder, brief psychotic disorder, delusional disorder, substance-induced psychotic disorder, both psychotic and catatonic disorders associated with a general medical condition, both unspecified psychotic and catatonic disorders and other unspecified psychotic disorder.[5] This spectrum of psychotic disorders is comparable to the bipolar spectrum in bipolar disorder. Each named disorder on this continuum shares symptoms with the others, and some professionals, including the working group for the DSM-5, contend that the boundaries are so unclear that separate diagnostic categories are not necessarily warranted.

Contents

Overview [edit]

The lifetime prevalence of the disorder is probably less than 1 percent, in the range of 0.5 to 0.8 percent.[6] Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizoaffective disorder currently exists, though extensive evidence exists for abnormalities in the metabolism of tetrahydrobiopterin (BH4), dopamine, and glutamate in people with schizophrenia and schizoaffective disorders. As a group, individuals with schizoaffective disorder have a more favorable prognosis than those with schizophrenia, but a worse prognosis than those with other mood disorders.[7]

Genetics, early environment, neurobiology, psychological and social processes are important contributory factors. Some recreational and prescription drugs may cause or worsen symptoms. Current research is focused on the role of neurobiology, but no single organic cause has been found.

The mainstay of current treatment is antipsychotic medication combined with mood stabilizer medication or antidepressant medication, or both. Psychotherapy, vocational therapy and social/psychiatric rehabilitation are also important for recovery. In cases where there is risk to self and others, brief involuntary hospitalization may be necessary.[8]

People with schizoaffective disorder are likely to have comorbid conditions, including anxiety disorders and substance abuse. Social problems such as long-term unemployment, poverty and homelessness are common. The average life expectancy of people with the disorder is shorter than those without, due to increased physical health problems and a higher suicide rate.

The diagnosis was introduced in 1933[9] and will be moderately amended[10][11] in the next iteration of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) because current diagnostic criteria are unreliable. The DSM-5 changes are intended to increase reliability and to reduce the frequency with which the diagnosis is used. The DSM-5 is scheduled to be published in May 2013.[12][13]

Signs and symptoms [edit]

As the diagnosis schizoaffective disorder represents an attempt to encompass individuals who have features of both schizophrenia and mood disorders, it does not consist of unique symptoms.[3] Instead, patients experience some combination of symptoms of the two types of disorders. This lack of characteristic symptoms can make diagnosis difficult.

One of the DSM-IV criteria for schizoaffective disorder is that the individual experiences symptoms that meet criterion A for schizophrenia.[2] These symptoms include delusions, hallucinations, disorganized speech or behaviour, and negative symptoms.[2] Delusions and hallucinations are classic psychotic symptoms which involve a disruption in the boundaries between the patient and the outside world.[3] Delusions are false beliefs which are strongly held despite evidence to the contrary.[3] Beliefs should not be considered delusional if they are in keeping with cultural beliefs. The delusional beliefs may or may not reflect mood symptoms (e.g. someone with depressive symptoms may experience delusions of guilt). Hallucinations are disturbances in perception involving any of the five senses, although auditory hallucinations (or "hearing voices") are the most common.[3] Negative symptoms include lack of spontaneous speech, reduced intensity of outward emotional expression, avolition (loss of motivation), and anhedonia, or inability to experience pleasure.[3] Negative symptoms can potentially be quite debilitating.

Mood symptoms can correspond to symptoms of either mania or depression, and tend to be episodic rather than continuous. A mixed episode represents a combination of symptoms of mania and depression at the same time. Symptoms of mania include elevated or irritable mood, grandiosity (inflated self-esteem), agitation, risk-taking behavior, decreased need for sleep, poor concentration, rapid speech, and racing thoughts.[2] Symptoms of depression include low mood, apathy, changes in appetite or weight, disturbances in sleep, changes in motor activity, fatigue, guilt or worthlessness, and suicidal thinking.

Two individuals with schizoaffective disorder may experience quite different symptoms, and any given individual will experience fluctuations in the types and intensity of symptoms he or she experiences. 20-30% of people with schizoaffective disorder have a deteriorating course of illness with persistent psychotic symptoms.[3] However, others may achieve full symptom control.

Diagnosis [edit]

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Diagnosis is based on a mental health clinician's observations of an individual's behavior while the client is experiencing active symptoms. Diagnosis also includes the client's self-reported experiences, as well as abnormalities in behavior reported by family members, friends or co-workers in a clinical assessment. The criteria for diagnosis depend on both the presence and duration of certain signs and symptoms.[14][15]

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizoaffective disorder, tests should be carried out to exclude medical illnesses which rarely may be associated with psychotic symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. It is important to rule out a delirium which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying medical illness.[14][15]

Further blood tests are not generally repeated for relapse unless there is a specific medical indication.[15] These may include serum BSL if olanzapine has previously been prescribed, thyroid function if lithium has previously been taken to rule out hypothyroidism, liver function tests if chlorpromazine has been prescribed, and CPK levels to exclude neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

As discussed above, there are several psychiatric disorders and substance-induced psychoses which may present with a similar range of psychotic symptoms. These include bipolar disorder with psychotic features, major depression with psychotic features, prescribed medication-induced psychosis (including from treatment with antidepressants and/or sleeping medication), schizophrenia and the other schizophrenia spectrum disorders, illicit drug intoxication and brief illicit drug-induced psychosis. Other conditions that cause psychosis need to be ruled out before a working diagnosis of schizoaffective disorder can be made. A firm diagnosis of schizoaffective disorder, using current diagnostic criteria, usually requires a lengthy observation of the illness in patients being treated (often a year or more), because the observed symptoms of psychosis and mood disorder often turn out to be one of the more common conditions listed above.[15]

It can be difficult to reach an accurate diagnosis of schizoaffective disorder, since problems with the reliability and validity of the schizoaffective diagnostic criteria have been well known in the diagnostic research literature for over six years (see Controversies and research directions below). In the context of schizoaffective disorder, problems with reliability mean that mental health professionals observing the same individual with symptoms of schizoaffective disorder often make different diagnoses, due in part to the ambiguity of this disorder's diagnostic criteria. Problems with validity mean that the current schizoaffective disorder diagnostic criteria do not correspond accurately to patients in the real world, whose symptoms and presentations change over time, and many of whom receive a different diagnosis by the end of their treatment. As stated above, the new DSM-5 diagnostic criteria hope to improve the diagnostic reliability and to reduce the frequency with which the diagnosis is used.

The most widely-used criteria for diagnosing schizoaffective disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR.[15]

Subtypes [edit]

Two subtypes of schizoaffective disorder exist and may be noted in a diagnosis based on the mood component of the disorder:

  • Bipolar type, when the disturbance includes a manic episode or a mixed episode, with or without a major depressive episode;
  • Depressive type, when the disturbance includes major depressive episodes exclusively (without manic or mixed episodes).[2]

Controversies and research directions [edit]

The categorical distinction between mood disorders and schizophrenia, known as the Kraepelinian dichotomy, has been challenged by data from genetic epidemiology for over seven years.[16] Some clinical researchers also have concluded that schizoaffective disorder is an intermediate form of psychosis and mood disorder, and that the Kraepelinian dichotomy is mistaken.[17] Furthermore, some diagnostic researchers and clinicians state that the diagnostic term, "schizoaffective disorder," refers to an ambiguously defined condition that leads to diagnoses based on confirmation bias and have recommended that the term be removed from or amended in future diagnostic manuals.[18]

With regard to making a schizoaffective diagnosis on a patient, poor interrater reliability (or agreement among clinicians making the diagnosis), and problems with the validity of the diagnostic criteria, has led some psychiatrists, including leaders in schizoaffective disorder diagnostic research, to conclude that the diagnosis should be removed from future diagnostic criteria.[12][13]

In April 2009, the DSM-5 Psychotic Disorders Work Group headed by psychiatrist William T. Carpenter MD of the University of Maryland, College Park School of Medicine, reported that they will be "developing new criteria for schizoaffective disorder to improve reliability and face validity," and that they will be "determining whether the dimensional assessment of mood will justify a recommendation to drop schizoaffective disorder as a diagnostic category."[12] Speaking to an audience at the May 2009 annual conference of the American Psychiatric Association, Carpenter was quoted in a Medscape article (emphasis added):

"'We had hoped to get rid of schizoaffective [disorder] 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,' he added wryly, drawing a laugh from the audience."[13]

One reason the diagnosis may be indispensable to clinical practice is simply because the diagnosis gives clinicians a placeholder, or working diagnosis, that describes currently observable symptomatology (that may be submitted to patients' health insurance) until a more valid and reliable diagnosis can be reached, which may or may not be ultimately be the schizoaffective disorder diagnosis.

Cause [edit]

Although the causes of schizoaffective disorder are unknown, it is suspected that a valid diagnosis represents a heterogeneous group of individuals, some with aberrant forms of schizophrenia and some with very serious forms of mood disorders. There is little evidence that schizoaffective disorder is a distinct variety of psychotic illness. Consequently, the disorder appears to be comorbid or (co-occurring) schizophrenia and mood disorder. Schizoaffective disorder thus appears to exist on a continuum in-between schizophrenia and severe bipolar disorder and severe recurrent unipolar depression. It follows then that the etiology is probably more similar to that of schizophrenia in some cases and more similar to severe mood disorders in other cases.

Many different genes may be contributing to the genetic risk of acquiring this illness. In addition, many different biological and environmental factors are believed to interact with the person's genes in ways which can increase or decrease the person's risk for developing schizoaffective disorder. Schizophrenia spectrum disorders (of which schizoaffective disorder is a part) have been marginally linked to advanced paternal age at the time of conception, a known cause of genetic mutations, but this link between paternal age and schizoaffective disorder is not robust.[19]

The physiology of patients diagnosed with schizoaffective disorder appears to be similar but not identical to that of those diagnosed with schizophrenia and severe bipolar disorder, but research on the physiology of these disorders is still in its early stages.[20]

Substance abuse [edit]

See also: Dual diagnosis

A clear causal connection between drug use and psychotic spectrum disorders, including schizoaffective disorder, has been difficult to prove. In the specific case of marijuana or cannabis, however, evidence is mounting that it can play a role in the development and morbidity of psychotic disorders, including schizoaffective disorder.[21][22] For example, a 2007 meta-analysis showed that cannabis use is statistically associated with a dose-dependent increase in risk of development of psychotic disorders, including schizoaffective disorder.[21] Moreover, a 2005 meta-analysis found that cannabis use is a significant independent risk factor for developing psychotic symptoms and psychosis.[22] Finally, a 2009 Yale study stated that it is clear

"that in individuals with an established psychotic disorder, cannabinoids can exacerbate symptoms, trigger relapse, and have negative consequences on the course of the illness."[23]

On the other hand, an opposing 2008 meta-analysis concluded: "Confidence that most associations reported were specifically due to cannabis is low. Despite clinical opinion, it remains important to establish whether cannabis is harmful, what outcomes are particularly susceptible, and how such effects are mediated."[24] For example, despite increases in cannabis consumption in the 1960s and 1970s in western society, rates of psychotic disorders have remained generally relatively stable.[25][26][27]

There is little evidence to suggest that other drugs including alcohol cause schizoaffective disorder, or that psychotic individuals choose specific drugs to self-medicate; there is some support for the theory that they use drugs to cope with unpleasant states such as depression, anxiety, boredom and loneliness.[28] However, regarding psychosis itself, it is well understood that methamphetamine and cocaine use can result in methamphetamine or cocaine-induced psychosis which presents very similar symptomatology and may persist even when users remain abstinent.[29] Alcohol-induced psychosis can also persist during abstinence, though it appears to do so at a lower rate.[30][31][32]

Management [edit]

Few medications are approved specifically for use in schizoaffective disorder.[33] Instead, medications are chosen to treat the symptoms rather than the diagnostic label.

Antipsychotic medications are generally required both for acute treatment and the prevention of relapse.[3][34] There is no single antipsychotic of choice in treating schizoaffective disorder, but atypical antipsychotics should be considered because they have mood-stabilizing activity.[3][33] Antipsychotics should be used at the minimum dose necessary to control symptoms.[33] Potential side effects include extrapyramidal symptoms, including tremor, muscle stiffness, and restlessness.[35] Atypical antipsychotics carry a risk of metabolic syndrome, including weight gain, increased blood sugar, and increased blood cholesterol, so regular monitoring of weight and bloodwork should be carried out.[35] Some atypical antipsychotics, such as ziprasidone and aripiprazole, are associated with less risk than others, such as olanzapine.[33][35] Choice of agent will be based on efficacy and tolerability in an individual patient.

In patients with treatment-refractory illness, a clozapine trial should be considered.[3] Clozapine is an atypical antipsychotic that is recognized as being particularly effective when other antipsychotic agents have failed.[35] Clozapine should also be considered in patients with chronic and persistent suicidal thinking and behaviour, as it reduces the risk of suicide in patients with schizoaffective disorder and a history of suicidality.[34] Between 0.5 and 2% of patients taking clozapine may develop a life-threatening complication called agranulocytosis, which is a significant drop in a type of white blood cell.[36] Because of this, patients taking clozapine must have regular monitoring of their blood cell counts.[36]

The bipolar subtype of schizoaffective disorder has been referred to by Stahl[35] as "bipolar 1/2" or "schizobipolar disorder", and as such, the management of mood symptoms is similar to treatment of bipolar disorder. Lithium (medication) or anti-convulsants such as valproic acid,[37] carbamazepine, and lamotrigine are mood stabilizers that can be used in managing the mood symptoms of schizoaffective disorder.[33]

Antidepressants may be used as well for depressive symptoms.[3][33] Care must be taken when using antidepressants due to the risk of triggering mania or psychosis if they are used alone or in high doses.[38][39]

When patients experience anxiety, short term anxiolytic medications can be used.[33] Benzodiazepines, including lorazepam and diazepam, are a type of anxiolytic. Care must be taken when using benzodiazepines due to the risk of tolerance and dependence.[35]

Electroconvulsive therapy, or ECT, may be considered for patients with schizoaffective disorder experiencing severe psychotic symptoms that have not responded to treatment with antipsychotics [34]

Psychosocial treatments are an important part of managing schizoaffective disorder. Supportive psychotherapy and cognitive behavioral therapy are both useful.[33] Intensive case management (ICM) has been shown to reduce hospitalizations, improve adherence to treatment, and improve social functioning.[40] With ICM, clients are assigned a case manager responsible for coordination of care and assisting clients to access supports to address needs in multiple areas related to well-being, including housing. Psychiatric rehabilitation, also known as psychosocial rehabilitation, focuses on community integration and improving quality of life. Principles include hope, respect, empowerment, wellness planning, and recognition of the importance of developing social support networks.[41]

Self-management techniques, including participating in internet forums, are sometimes used by individuals with schizoaffective disorder.[42][43][44]

Complications [edit]

[icon] This section requires expansion. (November 2010)

Complications are similar to those for schizophrenia and major mood disorders. These include:

  • Problems following medical treatment and therapy.
  • Use of unsanctioned drugs in an attempt to self-medicate.
  • Short-term side effects and problems arising from long-term use of prescribed medications, including drug interactions.
  • Problems resulting from manic behavior (for example: spending sprees, sexual indiscretion, criminal activity).
  • Suicidal behavior due to depressive and/or psychotic symptoms.

Epidemiology [edit]

[icon] This section requires expansion. (November 2010)

Estimates of the prevalence of schizoaffective disorder vary widely, but schizoaffective manic patients appear to comprise 3-5% of psychiatric admissions to typical clinical centers. At one point it was widely believed that schizoaffective disorder was associated with increased risk of mood disorders in relatives. This may have been because of the number of patients with psychotic mood disorders who were included in schizoaffective study populations.

The current diagnostic criteria define a group of individuals with a mixed genetic picture. They are more likely to have schizophrenic relatives than individuals with mood disorders but more likely to have relatives with mood disorders than individuals with schizophrenia.

History [edit]

The term schizoaffective psychosis was introduced by the American psychiatrist Jacob Kasanin in 1933[45] to describe an episodic psychotic illness with predominant affective symptoms, that was thought at the time to be a good-prognosis schizophrenia.[46] Kasanin's concept of the illness was influenced by the psychoanalytic teachings of Adolf Meyer and Kasanin postulated that schizoaffective psychosis was caused by "emotional conflicts" of a "mainly sexual nature" and that psychoanalysis "would help prevent the recurrence of such attacks."[47] He based his description on a case study of nine individuals.[47]

Other psychiatrists, before and after Kasanin, have made scientific observations of schizoaffective disorder based on assumptions of a biological and genetic etiology of the illness. In 1863, German psychiatrist Karl Kahlbaum (1828–1899) described schizoaffective disorders as a separate group in his vesania typica circularis.[48] Kahlbaum distinguished between cross-sectional and longitudinal observations. (Cross-sectional refers to observation of a single, specific episode of the illness, for example, one episode of psychotic depression; while longitudinal refers to long-term observation of many distinct episodes [similar or different] often occurring over the span of years.) In 1920, psychiatrist Emil Kraepelin (1856–1926), the founder of contemporary scientific psychiatry, observed a "great number" of cases that had characteristics of both groups of psychoses that he originally posited were two distinct and separate illnesses, dementia praecox (now called schizophrenia) and manic depressive insanity (now called bipolar disorder and recurrent depression).[47]

Kraeplin acknowledged that "there are many overlaps in this area", that is, the area between schizophrenia and severe mood disorders.[49] In 1959, psychiatrist Kurt Schneider (1887–1967) can be said to have been the first to begin to conceptualize the different forms that schizoaffective disorders can take since he observed "concurrent and sequential types".[47] (The concurrent type of illness he referred to is a longitudinal course of illness with episodes of mood disorder and psychosis occurring predominantly at the same time; while his sequential type refers to a longitudinal course predominantly marked by alternating mood and psychotic episodes.)[48] Schneider described schizoaffective disorders as "cases in-between" the traditional Kraepelinian dichotomy of schizophrenia and mood disorders.[48]

The historical phenomenological observation that schizoaffective disorder is an overlap of schizophrenia and severe mood disorders has more recently been assumed to be explained by genes for both illnesses being present in individuals with schizoaffective disorder. In support of this assumption, recent research shows that schizophrenia and severe mood disorders appear to share common genes and polygenic variations also.[16][50][51][52][53]

Schizoaffective disorder was included as a subtype of schizophrenia in DSM-I and DSM-II, though research showed a schizophrenic cluster of symptoms in individuals with a family history of mood disorders whose illness course, other symptoms and treatment outcome were otherwise more akin to bipolar disorder than to schizophrenia. DSM-III placed schizoaffective disorder in "Psychotic Disorders Not Otherwise Specified" before being formally recognized in DSM-III-R.[54] DSM-III-R included its own diagnostic criteria as well as the subtypes, bipolar and depressive.[54] In DSM-IV, published in 1994, schizoaffective disorders belonged to the category "Other Psychotic Disorders" and included almost the same criteria and the same subtypes of illness as DSM-III-R, with the addition of mixed bipolar symptomatology.[55]

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  54. ^ a b Goodwin & Jamison. p. 96
  55. ^ Goodwin & Marneros. p. 192

Cited texts [edit]

  • Marneros A, Akiskal, HS (2007). The Overlap of Schizophrenic and Affective Spectra. New York: Cambridge University Press. ISBN 0-521-85858-5. 
  • Goodwin FK, Jamison KR (2007). Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press. ISBN 0-19-513579-2. 
  • Kaplan HI, Saddock VA (2007). Synopsis of Psychiatry. New York: Lippincott, Williams & Wilkins. ISBN 978-0-7817-7327-0. 
  • Murray WH (2006). Schizoaffective Disorders: New Research. New York: Nova Science Publishers, Inc. ISBN 1-60021-030-9. 
  • Goodwin FK, Marneros, A (2005). Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms. New York: Cambridge University Press. ISBN 0-521-83517-8. 
  • Moore DP, Jefferson JW. Handbook of Medical Psychiatry. 2nd ed. St. Louis, Mo: Mosby; 2004:126-127.
  • Goetz, CG. Textbook of Clinical Neurology. 2nd ed. St. Louis, Mo: WB Saunders; 2003: 48.
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