Schizoaffective disorder

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

Schizoaffective disorder is a psychiatric diagnosis. It describes an illness that is defined by recurring episodes of mood disorder and psychosis.^[1][2] The disorder usually begins in early adulthood and is rarely diagnosed in childhood (prior to age 13). Despite the greater variety of symptoms, the illness course is more episodic and has an overall more favorable outcome (prognosis) than schizophrenia.

The American Psychiatric Association classifies schizoaffective disorder into two types: bipolar and depressive. The ICD classifies it into five types: manic, depressive, mixed (manic and depressive), other and unspecified. Generally, using the ICD classification, the mixed type has a better prognosis than the depressive type.^{[citation needed]}

The mainstay of treatment is pharmacotherapy with an antipsychotic and an antidepressant and/or mood stabilizer. Psychotherapy, vocational and social rehabilitation are also important for recovery. A specific type of psychosocial rehabilitation known as psychiatric rehabilitation may improve the individual's chances at recovery.^{[citation needed]}

Some individuals diagnosed with schizoaffective disorder may be diagnosed with comorbid conditions, including substance abuse.

The diagnosis was introduced in 1933.^[3]

Contents 1 Signs and symptoms 2 Diagnosis 2.1 DSM-IV-TR criteria 2.2 Subtypes 2.3 Bipolar type 2.4 Depressive type 3 Etiology and pathogenesis 3.1 Drug abuse 4 Epidemiology 5 Treatment 6 Prognosis 7 Complications 8 History 9 References 9.1 Cited texts

[edit] Signs and symptoms

Late adolescence and early adulthood are the peak years for the onset of schizoaffective disorder, although it has been diagnosed (very rarely) in childhood. These are critical periods in a person's social and vocational development which can be severely disrupted by disease onset.

Schizoaffective disorder is a mental illness characterized by recurring episodes of mood disorder and psychosis. Psychosis is defined by paranoia, delusions and/or hallucinations. Mood disorders are defined as discrete periods of clinical depression, mixed and/or manic episodes. Individuals with the disorder may experience psychotic symptoms before, during or (commonly) after their depressive, mixed and/or manic episodes.

The illness tends to be difficult to diagnose since the symptoms are similar to other disorders with prominent psychotic symptoms like bipolar disorder with psychotic features, major depressive disorder with psychotic features and schizophrenia.

The main similarity between schizoaffective disorder, bipolar disorder with psychotic features, and major depressive disorder with psychotic features, is that in all three disorders psychosis occurs during mood episodes. By contrast, in schizoaffective disorder, psychosis must also occur during periods without mood symptoms. In schizophrenia, mood episodes tend be absent or much less prominent than schizoaffective disorder. Since these distinctions can be difficult to detect, a firm diagnosis of schizoaffective disorder may thus require an extended period of observation and treatment.

Untreated, the individual with schizoaffective disorder may experience delusions. It should be noted that delusions in schizoaffective disorder are acute manifestations of an active psychosis and are not personality traits; that is, they go away when the psychosis subsides. Manifestations of delusions include the individual being convinced that he or she is Jesus or the Antichrist, has some special purpose or destiny (such as to save the world), or is being monitored, watched or persecuted by something (commonly governmental agencies), when in reality they are not. Individuals may also feel extremely paranoid. Other delusions may include the belief that an external force is controlling the individual's thought processes. (See thought insertion.)

Hallucinations involving all five senses can also occur in untreated schizoaffective disorder. That is, the individual may see, hear, smell, feel or taste things that aren't there. For example, the individual may see overt visual hallucinations such as monsters, the devil or more subtle ones such as shadowy apparitions. Individuals may hear voices or, in some cases, music. Things may look or sound different. Individuals may also experience strange sensations. These hallucinations may worsen when the individual is intoxicated.

The untreated individual may quickly change their mind about their romantic partner, friends or family if they hear something negative being said about them; as a result they may attack or, conversely, isolate themself from the person or group until they regain normal thoughts, which usually takes treatment and time.

Comorbid or co-occurring anxiety disorders may also play a role in the subjective experience of schizoaffective disorder and thus may shape the individual's delusional thought content. For example, the individual may feel anxious, have trouble swallowing, and then believe that outside forces are controlling their throat functions. They may also suffer from various phobias which may also manifest as delusions.

There may be a decline in work or school functioning during episodes of illness. As stated above, individuals with schizoaffective disorder may withdraw socially and become isolated.

The untreated individual may sleep too much, or (more often) be unable to sleep.

Difficulties with thinking known as "cognitive deficits" may also be a problem for individuals with schizoaffective disorder. This may include difficulties with concentration, attention, logical reasoning and impulse control.

Without treatment, the individual with schizoaffective disorder may further worsen in their delusional thought processes and become further alienated from people and society.

With comprehensive treatment, many individuals with schizoaffective disorder may recover much, most or even all of their functionality.

[edit] Diagnosis

Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers to a psychiatrist, psychiatric nurse, social worker or clinical psychologist in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

As discussed above, there are several psychiatric illnesses which may present with a similar range of psychotic symptoms; these include bipolar disorder with psychotic features, major depression with psychotic features, schizophrenia, drug intoxication, brief drug-induced psychosis, and schizophreniform disorder. These disorders need to be ruled out before a firm diagnosis of schizoaffective disorder can be made.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizoaffective disorder, tests are 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.

Investigations are not generally repeated for relapse unless there is a specific medical indication. 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.

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:

[edit] DSM-IV-TR criteria

The following are the revised criteria for a diagnosis of schizoaffective disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR):

A. Two (or more) of the following symptoms are present for the majority of a one-month period (or a shorter period of time if symptoms got better with treatment):

• delusions
• hallucinations
• disorganized speech (e.g., frequent derailment or incoherence) which is a manifestation of formal thought disorder
• grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior
• negative symptoms—e.g., affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), avolition (lack or decline in motivation), anhedonia (lack or decline in ability to experience pleasure), social withdrawal (sometimes called social anhedonia). It should be noted that negative symptoms are different from symptoms of depression.

If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required to meet criterion A above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication.

AND at some time during the illness there is either one, two or all three of the following:

• major depressive episode
• manic episode
• mixed episode

B. During the same period of illness, there have been delusions or hallucinations for at least two weeks in the absence of prominent mood symptoms.

C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

[edit] Subtypes

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

[edit] Bipolar type

if the disturbance includes

• a manic episode
• a mixed episode

Major depressive episodes usually, but not always, also occur in the bipolar subtype, however they are not required for DSM IV diagnosis.

[edit] Depressive type

The depressive type is noted when the disturbance includes major depressive episodes exclusively.

This subtype applies if major depressive episodes only (and no manic or mixed episodes) are part of the presentation.

[edit] Etiology and pathogenesis

Although the causes of schizoaffective disorder are unknown, it is suspected that this 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 common cause of mutations.^[4]

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.^[5]

[edit] Drug abuse

A clear causal connection between drug use and psychotic spectrum disorders, including schizoaffective disorder, has been difficult to prove. The two most often used explanations for this are "substance use causes schizoaffective disorder" and "substance use is a consequence of schizoaffective disorder", and they both may be correct.^[6] A 2007 meta-analysis estimated that cannabis use is statistically associated with a dose-dependent increase in risk of development of psychotic disorders, including schizoaffecive disorder.^[7] 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.^[8] 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.^[9]

[edit] Epidemiology

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.

[edit] Treatment

Treatment for schizoaffective disorder consists of a combination of medicine, psychotherapy and psychosocial rehabilitation focused on recovery. Not all treatment services focus on recovery, however, so a recovery-oriented program may need to be sought out.

A licensed psychiatrist will prescribe (usually combinations of) medicine for the individual. Each person responds differently to medication. Common medicines used to treat schizoaffective disorder are listed below.

For psychotic symptoms, one or more neuroleptic medications are usually prescribed. Examples of neuroleptic medications include the following:

• Olanzapine (Zyprexa)^[10]
• Risperidone (Risperdal)^[10]
• Quetiapine (Seroquel)
• Aripiprazole (Abilify)
• Ziprasidone (Geodon)

For manic symptoms, mood stabilizer medications may be prescribed along with a neuroleptic. Examples are:

• Lithium salt (Lithium)
• Valproate semisodium (Depakote ER)^[11]
• Carbamazepine (Tegretol)

For depression, antidepressant medications may be prescribed along with a neuroleptic. Examples are:

• Prozac (or other SSRI antidepressants)
• Lamictal (a mood stabilizer with antidepressant properties)

In schizoaffective individuals with manic symptoms, combining lithium, carbamazepine, or valproate with a neuroleptic has been shown to be superior to neuroleptics alone. Lithium-neuroleptic combinations, however, may produce severe extrapyramidal reactions or confusion in some patients.

When lithium is not effective or well tolerated in manic individuals with schizoaffective disorder, Tegretol or Depakote are frequently used. Granulocytopenia can occur during the first few weeks of carbamazepine treatment, and neuroleptic blood levels may be decreased substantially due to hepatic enzyme induction. Valproate can, in rare cases, cause liver toxicity and platelet dysfunction. Calcium channel blockers such as verapamil may also be an effective treatment for manic symptoms but are seldom prescribed for that purpose. The degree of benefit for an individual patient should be considered carefully, as each of these medications carries its own risks.

Benzodiazepines such as Ativan and Klonopin are effective adjunctive treatment agents for acute manic symptoms, but long-term use may result in dependency.

In schizoaffective individuals with depressive symptoms, an antidepressant (usually Prozac or other SSRIs) will be prescribed with a neuroleptic. The SNRI antidepressants and Wellbutrin tend not to be prescribed in schizoaffective disorder because they may cause mixed episode symptoms and induce psychosis, respectively. The anticonvulsant Lamictal is also used in treating depressed schizoaffective individuals.

Often a sleeping pill will be prescribed initially to allow the individual rest from his or her anxiety, delusions or hallucinations. Long-term use of sleeping medications can, however, cause dependence and can also cause delusions and hallucinations thereby exacerbating psychosis.

Nutritional supplements and lifestyle changes are both being studied to augment existing treatments as well. Frequently co-occurring conditions such as mitochondrial dysfunctions, adrenal fatigue, sleep disorders, and diabetes are the targets of nutritional and lifestyle changes. Omega-3 fatty acid supplementation is used as a nutritional aid for many mental disorders including schizoaffective disorder. Some depressed schizoaffective individuals use 5-HTP, an amino acid and precursor to serotonin, in place of SSRI antidepressants to avoid side associated side effects. Other supplements with antidepressant properties, St John's Wort and SAM-e, however, may cause adverse reactions of mixed-state symptoms or psychosis in depressed schizoaffective individuals.

[edit] Prognosis

People with schizoaffective disorder generally have a better outlook than those with schizophrenia, and about the same or worse outlook (depressive subtype having the least favorable outlook) as those with bipolar disorder. It is important to note that individual outcomes may be more favorable than those cited above since these prognoses are based on statistical averages of large groups of patients.

As with any chronic illness, compliance with medication is important, especially since more than one medication is often prescribed. Psychiatric rehabilitation plays an important part in maximizing the individual's chances at recovery, which may result in a better prognosis.

[edit] Complications

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)
• Suicidal behavior due to depressive or psychotic symptoms

[edit] History

The term schizoaffective psychosis was coined by the American psychiatrist John Kasanin in 1933^[12] to describe a more episodic psychotic illness with predominant affective symptoms, that was termed a good-prognosis schizophrenia.^[13]

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 the manic phase of a bipolar disorder. DSM III placed schizoaffective disorder in psychotic disorders Not Otherwise Specified before being formally recognized in DSM III-R.^[14]

Some have disputed that the term "schizoaffective disorder" refers to a well defined condition, and have recommended that the term be removed from or amended in future versions of the DSM.^[15]

[edit] References

[edit] Cited texts

• 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. 

• 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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v • d • e Mood disorder: Bipolar disorder History Emil Kraepelin · Karl Leonhard · John Cade Symptoms Anhedonia · Delusion · Dysphoria · Emotional dysregulation · Hallucination · Hypersomnia · Hypomania · Insomnia · Major depressive episode · Mania · Mixed state · Psychosis · Racing thoughts · Rapid cycling · Suicidal ideation Spectrum Bipolar I · Bipolar II · Cyclothymia · Dysthymia · Major depressive disorder · Schizoaffective disorder Treatment Anticonvulsants Carbamazepine · Gabapentin · Lamotrigine · Oxcarbazepine · Topiramate · Valproic acid (Sodium valproate, Valproate semisodium) Other mood stabilizers Lithium pharmacology (Lithium carbonate, Lithium citrate, Lithium sulfate) · Antipsychotics Non-pharmaceutical Clinical psychology · Electroconvulsive therapy · Involuntary commitment · Light therapy · Psychotherapy · Transcranial magnetic stimulation Related Affective spectrum · List of people affected by bipolar disorder · Bipolar disorder in children