Schizoaffective disorder

Schizoaffective disorder is a psychiatric diagnosis describing a condition where both the symptoms of mood disorder and schizophrenia are present. A person may manifest impairments in the perception or expression of reality, most commonly manifesting as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking, as well as discrete manic and/or depressive episodes in the context of significant social or occupational dysfunction. The disorder usually begins in early adulthood, and is more common in women. Despite the greater variety of symptoms, the illness course is more episodic and has an overall more favourable outcome than schizophrenia.

There are two sub-types of schizoaffective disorder: the bipolar type and the depressive type. The bipolar type has a better prognosis than the depressive type, which can have a residual defect with the passing of time.

The mainstay of treatment is pharmacotherapy with both mood stabilizer and antipsychotic medications. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, though hospital stays are less frequent and for shorter periods than they were in previous years.

People diagnosed with schizoaffective are likely to be diagnosed with comorbid conditions, including substance abuse.

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Signs and symptoms

Late adolescence and early adulthood are peak years for the onset of schizoaffective disorder. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.

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, followed by secondary signs observed by a psychiatrist, social worker, clinical psychologist or other clinician 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.

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. There are several psychiatric illnesses which may present with a similar range of psychotic symptoms; these include bipolar disorder, schizophrenia, drug intoxication, brief drug-induced psychosis, and schizophreniform disorder.

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 or CPK 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:

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
• 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

Two subtypes of Schizoaffective Disorder may be noted based on the mood component of the disorder:

Bipolar type

if the disturbance includes

• manic episode
• mixed episode
• manic and major depressive episodes
• mixed and major depressive episode

This subtype applies if a manic episode or mixed episode is part of the presentation. Major Depressive Episodes may also occur.

Depressive type

if the disturbance includes major depressive episodes exclusively.

This subtype applies if only Major Depressive Episodes are part of the presentation..

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.

There may be a genetic component, as all conditions on the schizophrenia spectrum have been marginally linked to advanced paternal age at the time of conception, a common cause of mutations. [1]

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

The psychiatric treatment for schizoaffective disorder is a combination of therapy and medicine. A licensed psychiatrist will prescribe different combinations of medicine to the patient in order to find the combination that works. Each person responds differently to medicine.

Common medicines prescribed to treat schizoaffective disorder:

• Depakote ER
• Lithium salts
• Risperdal
• Seroquel
• Abilify
• Geodon

Combining lithium, carbamazepine, or valproate with a neuroleptic has been shown to be superior to neuroleptics alone in schizoaffective patients with manic symptoms. The degree of benefit for an individual patient should be considered carefully, as each of these agents carries an additional set of risks. Lithium-neuroleptic combinations may produce severe extrapyramidal reactions or confusion in some patients. Carbamazepine or valproate are frequently employed when lithium is not effective or well tolerated. 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 cause liver toxicity and platelet dysfunction, although those problems are uncommon. More recently, the anticonvulsants lamotrigine and gabapentin have shown promise in the treatment of manic symptoms, although there have been no systematic studies of their use in schizoaffective disorder at this time. Calcium channel blockers such as verapamil may also be an effective treatment for manic symptoms but are seldom prescribed for that purpose. Benzodiazepines such as lorazepam and clonazepam are effective adjunctive treatment agents for acute manic symptoms, but long-term use may result in dependency.

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

Cannabis

In addition to pharmaceutical medications, some who suffer from schizoaffective disorder have claimed to benefit from medicinal marijuana (cannabis). These claims, however, have not been adequately verified by scientific studies, though recent research has found some support for their beliefs.[2] Additionally, symptoms of paranoia may present in individuals who are experiencing cannabis intoxication. [3] There is not enough evidence to demonstrate a definite link between marijuana use and the development of schizoaffective disorder. Despite this, numerous individual case studies exist in which sufferers of Schizoaffective disorder engaged in cannabis use during their early and formative years, suggesting a tentative correlation between a patient's use of marijuana, marijuana's effect on the developing brain, and a resulting tendency for cannabis users to develop this disorder. [4]

Prognosis

People with schizoaffective disorder generally have a better outlook than those with schizophrenia, and worse than those with bipolar disorder. However, long-term treatment may be necessary and individual outcomes will vary. As with any chronic illness, compliance to medication is important, especially as more than one medication is often prescribed - most commonly an antipsychotic plus mood stabiliser.

Complications

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

• Problems following medical treatment and therapy
• Abuse of drugs in an attempt to self-medicate
• Problems resulting from manic behavior (for example, spending sprees, sexual indiscretions)
• 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, what was termed a good-prognosis schizophrenia.^[1]

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.^[2]

References

Cited texts

• Goodwin FK, Jamison KR (1990). Manic-Depressive Illness. New York: Oxford University Press. ISBN 0-19-503934-3. 

• 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.