266 Schizoaffective Disorder (295.70)
DSM-IV-TR criteria
- A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.
- B. During the same period of illness, there have been delusions or hallucinations for at least 2 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., drug abuse, medication) or a general medical condition.
- The bipolar type is diagnosed if the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes).
- The depressive type is diagnosed if the disturbance includes only major depressive episodes.
Subtypes
- Bipolar Type (Schizomanic): if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes). Many but not all studies find that Schizomania is closer to Bipolar Disorder than to classic Schizophrenia. The family histories of Schizomanic patients are generally loaded with mood disorders and not with Schizophrenia. They frequently respond to mood stabilizers. Their prognosis is reasonably good—similar to that of Bipolar Disorder and not to Schizophrenia.
- Depressive Type (Schizodepressive): if the disturbance only includes Major Depressive Episodes. Schizodepression is probably closer to classic Schizophrenia. Families of patients with Schizodepression show significant genetic loading for Schizophrenia and not as much for Bipolar Disorder; generally, these patients respond better to anti-psychotics than to mood stabilizers. Their prognosis is not as good as that of mood disordered patients and is much closer to that of Schizophrenic patients.
- Chronic and Nonchronic forms: For Schizomania and Schizodepression, patients whose symptoms are more chronic and less episodic have worse prognoses.
Associated features
- There may be poor occupational functioning, a restricted range of social contact, difficulties with self-care, and increased risk of suicide associated with Schizoaffective Disorder. Anosognosia (i.e., poor insight) is also common in Schizoaffective Disorder, and individuals with Schizoaffective Disorder may be at increased risk for later developing episodes of pure Mood Disorder, Schizophrenia, or Schizophreniform Disorder. There may be associated Alcohol and other Substance-Related Disorders.
- Elevated risk for suicidal behavior among individuals with Schizoaffective Disorder is associated with history of suicidal behavior, severity of suicide ideation and fewer reasons for living, presence and severity of depression, long duration of untreated psychosis, number of hospitalizations in the prior 36 months, more frequent prescription of typical (vs. atypical) antipsychotic agents, and history of abuse or dependence on nicotine or other substances.
Child vs. adult presentation
- Schizoaffective Disorder, Bipolar Type, may be more common in young adults, whereas Schizoaffective Disorder, Depressive Type, may be more common in older adults.
- Schizoaffective Disorder usually starts in early adulthood.
- Rarely is it diagnosed before age 13.
Gender and cultural differences in presentation
The incidence of Schizoaffective Disorder is higher in women than in men, which is mostly accounted for by an increased incidence among women of the Depressive Type.
Schizophrenic Disorders are more prevalent among individuals with lower Social Economic Status. The lower the SES, the more prevalent the Schizophrenic Disorders appear to be.
Little research has occurred examining which cultural factors, if any, both increase and decrease the risk of developing a Schizophrenic Disorder. Although, Schizophrenic Disorders appear to occur less often in what we consider to be third-world, or less industrially developed, countries.
Epidemiology
The prevalence rate for Schizoaffective disorder widely varies. Studies do show that Schizoaffective Manic patients appear to comprise 3-5% of psychiatric admissions to typical clinical centers.
Etiology
There is no single causal factor, a certain causal sequence of events, or one entity (genetic or otherwise) in the etiology of Schizoaffective Disorder. Although the exact etiology of Schizoaffective disorder is unknown, it may involve the balance of dopamine and serotonin in the brain. Others believe that it may be due to in-utero exposure to viruses, malnutrition, or even birth complications.
There is substantial evidence that there is an increased risk for Schizophrenia in first-degree biological relatives of individuals with Schizoaffective Disorder. Most studies show that relatives of individuals with Schizoaffective Disorder are at increased risk for Mood Disorders. As a group, Schizoaffective patients have family histories with increased genetic loading for both Schizophrenia and Mood Disorders.
The prognosis for Schizoaffective Disorder tends to be better than that for Schizophrenia and worse than that for Mood Disorders. The presence of precipitating events or stressors is associated with a better prognosis.
Differential Diagnosis
Substance-Induced Psychotic Disorder and Substance-Induced Delirium are distinguished from Schizoaffective Disorder by the fact that a substance is judged to be etiologically related to the symptoms.
Distinguishing Schizoaffective Disorder from Schizophrenia: In Schizoaffective Disorder, there must be a mood episode that is concurrent with the active-phase symptoms of Schizophrenia, mood symptoms must be present for a substantial portion of the total duration of the disturbance, and delusions or hallucinations must be present for at least 2 weeks in the absence of prominent mood symptoms. In contrast, mood symptoms in Schizophrenia have a duration that is brief, occur only during the prodromal or residual phases, or do not meet full criteria for a mood episode.
Distinguishing Schizoaffective Disorder from Mood Disorder with Psychotic Features: If psychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is Mood Disorder with Psychotic Features. In Schizoaffective Disorder, symptoms should not be counted toward a mood episode if they are clearly the result of symptoms of Schizophrenia. Criterion A for Schizoaffective Disorder, the Major Depressive Episode must include pervasive depressed mood.
Mood disturbances, especially depression, commonly develop during the course of Delusional Disorder. However, such presentations do not meet criteria for Schizoaffective Disorder because the psychotic symptoms in Delusional Disorder are restricted to non-bizarre delusions and therefore do not meet Criterion A for Schizoaffective Disorder.
Schizoaffective Disorder and Schizophrenia: because the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, the appropriate diagnosis for an individual episode of illness may change from Schizoaffective Disorder to Schizophrenia. The diagnosis may also change for different episodes of illness separated by a period of recovery. If psychotic symptoms and affective symptoms always overlap, the person is diagnosed with an affective disorder, whereas if psychotic symptoms are present some of the time, in the absence of an affective syndrome, the person meets criteria for either Schizoaffective Disorder or Schizophrenia. Schizoaffective Disorder is diagnosed if the mood symptoms are prolonged
Empirically supported treatments
Schizoaffective patients respond better to lithium than do schizophrenics, but not as well as Bipolar patients.
Electroconvulsive therapy (ECT) is indicated for Schizoaffective disorder that has an acute onset, presence of hallucinations or delusions, and acute and severe mania, and that has been found to be non-responsive to psychotropic medications. However, some studies find that ECT is not productive in reducing hallucinations or delusions.
There is no cure for Schizoaffective Disorder. However, the most effective approach toward treating the Schizophrenic Disorders seems to be a combination of pharmaceutical, behavioral, cognitive, and family therapy, with the use of anti-psychotic medications seen as the primary treatment modality.
Pharmacotherapy with an antidepressant, an antipsychotic, and/or mood stabilizer is also a mainstream treatment. In quite a few instances, effective treatment modalities will work on attempting to rid the individual of hallucinations, delusions, and disorganized aspects of behavior, or at the very least, attempt to lessen these symptoms.
Even so, many individuals will relapse, even if their treatment is maintained.
Common medicines for neuroleptic symptoms are Olanzapine, Risperidone, Quetiapine, Aripiprazole, and Ziprasidone. Mood stabilizer medications examples are Lithium salt, Valproate semisodium, and Carbamazepine.
