Schizoaffective disorder

DiseaseDisorder infobox
Name = Schizoaffective disorder
ICD10 = F25
ICD9 = 295.70
DSM-IV = 295.70

Schizoaffective disorder is a psychiatric diagnosis of neurobiological illness. It describes a condition where symptoms of a mood disorder and symptoms of schizophrenia are both present. A person may manifest impairments in the perception or expression of reality, most commonly in the form of auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking, as well as discrete manic and/or mixed and/or depressive episodes in the context of significant social or occupational dysfunction. The disorder usually begins in early adulthood, although, rarely, it is diagnosed in childhood (prior to age 13). Schizoaffective disorder is more common in women than in men. Despite the greater variety of symptoms, the illness course is more episodic and has an overall more favorable outcome (prognosis) than schizophrenia.

There are two types of schizoaffective disorder: the bipolar type and the depressive type. In general, schizoaffective disorder bipolar type has a better prognosis than the depressive type, which can result in a residual defect with the passing of time.

The mainstay of treatment is pharmacotherapy with an antipsychotic and an antidepressant and/or mood stabilizer. Psychotherapy, vocational and social rehabilitation are also important. A specific type of psychosocial rehabilitation known as psychiatric rehabilitation can improve the prognosis of schizoaffective disorder considerably, although it must be sought out to produce its good effects. In acute cases, where there is risk to self and others, involuntary short-term hospitalization may be necessary.

Some people diagnosed with schizoaffective disorder are likely to be diagnosed with comorbid conditions, including substance abuse.

Children diagnosed with this disorder are highly likely to have other comorbid neurological disorders such as pervasive developmental disorder, autism and learning disabilities.

Signs and symptoms

Late adolescence and early adulthood are the most common peak years for the onset of schizoaffective disorder, although it can be diagnosed more 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 mood swings, delusions and/or hallucinations. Individuals with the disorder experience psychotic symptoms at the same time or sometimes not at the same time as depressions, mixed and/or manic episodes.

It 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 depression with psychotic features and schizophrenia. The main difference between schizoaffective disorder and the other disorders mentioned, is that there is a baseline of psychosis during which mood episodes occur. In the other disorders there is a baseline disorder of mood during which psychosis may occur. A firm diagnosis of schizoaffective disorder thus may require a long period of observation and treatment.

Delusions may manifest as the individual believing he or she is Jesus or the Antichrist, has some special purpose or destiny (such as to save the world), or is being monitored or persecuted by governmental agencies. Other delusions may include the belief that an external force is controlling the individual's thought processes. This delusion is formally called thought insertion.

Hallucinations involving the visual, auditory, olfactory, tactile and gustatory systems may occur. In lay terminology, 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. These hallucinations tend to worsen when the individual is intoxicated.

They may quickly change their minds about their friends or family if they hear something negative being said about them, as a result they may attack or, conversely, back away from the person or group until they regain normal thoughts, which takes treatment and time.

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 some individuals may recover completely.

Anxiety is also a major part of schizoaffective disorder and is often diagnosed in children who grow up to develop the severe mental illness. Patients with this disorder may be afraid of getting hurt, kidnapped, or even being killed. Death may be another fear or phobia for schizoaffective disorder. People with this mental illness may be quick to "jump the gun". They may feel anxious about something negative happening to them, such as assault or abduction. Schizoaffective patients may carry this worry to the point of delusion. However, on the other hand, they may find decision-making very difficult because of their anxiety and cognitive deficits. People with schizoaffective disorder may become extremely preoccupied by certain parts of their body not working. However, they may be perfectly fine in reality. Examples of mechanisms which a schizoaffective sufferer may delude to the point of somatization include swallowing and urination. These fears can arise in the form of somatic delusions. Thus, they may often have phobias. Specific phobias can therefore be a part of schizoaffective disorder. Common simple phobias of this disorder may include animals, insects, injury, death, or even agoraphobia. The fears of animals or insects can arise in the form of visual hallucinations. A specific example includes one who believes that moths are capable of eating humans and are meeting together planning to digest the sufferer. Therefore, he/she would be afraid of them. The patient of this disorder may also see them when they are not really there. Schizoaffective patients may completely imagine getting hurt or watch themselves doing so during an out-of-body experience. Thus, they may confine themselves to the safety of their homes.

Thought-Processing is also a major struggle for schizoaffective patients. This includes forming illogical or unique connections, difficulty with logical reasoning, impulsiveness and the way one perceives the world. Thus, one who suffers from schizoaffective disorder may have a different way of looking at the world. The kinds of impulses they may get include sending completely random emails to people they don't even know, randomly knocking on doors or windows, and disturbing the peace for no apparent reason. The anxiety a schizoaffective patient feels may also affect their ability to control their impulses. Their thought-processing, however, plays an even bigger role since that part of their brain is destroyed.

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 may rarely present 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.

Thought processing problems and anxious-type schizoaffective disorder often go hand-in-hand and is the most common type of schizoaffective disorder.

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:

DSM-IV-TR criteria

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

A. Two (or more) of the following symptoms are present for the majority of a one-month period:

* delusions
* hallucinations
* problems, differences, or uniqueness with thought processing, reasoning, connections, or perception
* disorganized speech (e.g., frequent derailment or incoherence)
* grossly disorganized or catatonic behavior
* negative symptoms (i.e., affective flattening, alogia, or avolition)

Note: Only one of these symptoms is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

AND at some time there is either a

* 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.

Subtypes

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

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.

Depressive type

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

This subtype applies if only major depressive episodes are part of the presentation.

Anxious type

The anxious type is noted when the disturbance includes generalized anxiety, panic, social anxiety, separation anxiety, agoraphobia, specific phobia(s), or obsessive-compulsive tendencies.

Etiology and pathogenesis

Although the causes of schizoaffective disorder are unknown, it is suspected that this diagnosis represents a heterogeneous group of patients, some with aberrant forms of schizophrenia and some with very serious forms of mood disorders. There is little evidence for a distinct variety of psychotic illness. It follows then that the etiology is probably identical to that of schizophrenia in some cases or to mood disorders in others.

Many different genes may be contributing to the genetic risk of acquiring this illness. 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. 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. [http://ajp.psychiatryonline.org/cgi/content/full/159/9/1528]

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 patients with a mixed genetic picture. They are more likely to have schizophrenic relatives than patients with mood disorders but more likely to have relatives with mood disorders than schizophrenic patients.

Treatment

Treatment for schizoaffective disorder consists of a combination of medicine and therapy. A licensed psychiatrist will prescribe (usually combinations of) medicine for the patient. Each person responds differently to medication. Common medicines used to treat schizoaffective disorder are listed below.

For psychotic symptoms, one or a combination of the following neuroleptic medications are usually prescribed:
* Loxapine
* Leponex
* Olanzapine (Zyprexa)
* Risperidone (Risperdal)
* Quetiapine (Seroquel)
* Aripiprazole (Abilify)
* Ziprasidone (Geodon)

For manic symptoms, the following mood stabilizer medications may be prescribed along with a neuroleptic:

* Lithium salt (Lithium)
* Valproate semisodium (Depakote ER)
* Carbamazepine (Tegretol)

For depression, the following anti-depressant medications may be prescribed along with a neuroleptic:

* Prozac
* Effexor
* Cymbalta
* Lamictal (a mood stabilizer with antidepressant properties)

In schizoaffective patients 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 patients 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 increased 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 patients with depressive symptoms, an antidepressant (usually Prozac or other SSRIs) will be prescribed with a neuroleptic. Recently, the anticonvulsant Lamictal has shown promise in treating depressed schizoaffective patients.

Often a sleeping pill will be prescribed initially to allow the patient rest from his or her anxiety or hallucinations.

Nutritional supplements and lifestyle changes are being studied both 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.

Prognosis

People with schizoaffective disorder generally have a better outlook than those with schizophrenia, and about the same or worse outlook (depending on the subtype) than those with bipolar disorder. Individual outcomes will vary however. 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.

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 dependency and polydrug interactions.
* Problems resulting from manic behavior (for example, spending sprees, sexual indiscretion)
* Suicidal behavior due to depressive or psychotic symptoms

History

The term "schizoaffective psychosis" was coined by Jacob Kasanin in 1933 to describe a more episodic psychotic illness with predominant affective symptoms, that was termed a good-prognosis schizophrenia. [Goodwin & Jamison. p102]

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. [Goodwin & Jamison. p96]

References

Cited texts

*cite book |author= Goodwin FK, Jamison KR|title= Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition |year= 2007|publisher= Oxford University Press|location=New York |isbn=0-19-513579-2

*Murray WH. Schizoaffective disorders: new research. Nova Science Publishers, Inc. 2006:1-24, 48-242.

*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.