Schizoaffective Disorder

Contents

WHAT IS SCHIZOAFFECTIVE DISORDER?

Some psychiatric disorders are very difficult to diagnose accurately. One of the most confusing conditions is schizoaffective disorder.

This relatively rare disorder is defined as "the presence of psychotic symptoms in the absence of mood changes for at least two weeks in a patient who has a mood disorder." The diagnosis is used when an individual does not fit diagnostic standards for either schizophrenia or "affective" (mood) disorders such as depression and bipolar disorder (manic depression).

Some people may have symptoms of both a depressive disorder and schizophrenia at the same time, or they may have symptoms of schizophrenia without mood symptoms.

Many individuals with schizoaffective disorder are originally diagnosed with manic depression. If the person experiences delusions or hallucinations that go away in less than two weeks when the mood is "normal," bipolar disorder may be the proper diagnosis. Someone who experiences psychosis for three or four weeks while in a manic phase does not have schizoaffective disorder.

However, if delusions or hallucinations continue after the mood has stabilized and are accompanied by other symptoms of schizophrenia such as catatonia, paranoia, bizarre behavior, or thought disorders, a diagnosis of schizoaffective disorder may be appropriate. Accurate diagnosis is easier once the acute psychotic episode is under control.

Distinguishing between bipolar disorder and schizophrenia can be particularly difficult in an adolescent, since at that age psychotic features are especially common during manic periods.

Because schizoaffective disorder is so complicated, misdiagnosis is common. Some people may be misdiagnosed as having schizophrenia. Others may be misdiagnosed as having bipolar disorder. And those diagnosed as having schizoaffective disorder may actually have schizophrenia with prominent mood symptoms. Or they may have a mood disorder with symptoms similar to those of schizophrenia.

Top

 

WHAT IS THE TREATMENT FOR THIS DISORDER?

Psychiatrists often treat this disorder with an anti-psychotic medication and lithium, or with carbamazepine (an anticonvulsant medication) and lithium.
As a practical matter, differentiating between schizophrenia, bipolar disorder, and schizoaffective disorder is not absolutely critical, since anti psychotic medication is recommended for all three. If a mood problem is suspected, lithium or an antidepressant should be added.

Top

 

WHAT IS THE PROGNOSIS FOR THOSE WITH THIS DISORDER?

The prognosis for individuals diagnosed with schizoaffective disorder is generally better than for those diagnosed with schizophrenia, but not quite as good for those diagnosed with a mood disorder. (Schizophrenia is a chronic brain disorder interfering with a persons' ability to think clearly, manage emotions, make decisions, and relate to others. Persons with schizophrenia may experience hallucinations and delusions. Mood disorders, including depression and bipolar disorder, are chronic illnesses in which the person's mood may return to "normal" between depressive or manic episodes.) Those with schizoaffective disorder generally respond to lithium better than those with schizophrenia, but not as well as those with mood disorders.

More research is needed to fully understand this illness and why it resists conventional treatment. New medications may be developed to treat this disorder more effectively.

NAMI (©2002)

Top

 

DEFINITIONS

I - DSM-IV Diagnostic Criteria*

DIAGNOSTIC CRITERIA

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.

Note: The Major Depressive Episode must include depressed mood.

Top

 

Criteria For Major Depressive Episode

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

  • depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

  • markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

  • significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

  • insomnia or hypersomnia nearly every day.

  • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

  • fatigue or loss of energy nearly every day.

  • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

  • diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

  • recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

The symptoms do not meet criteria for a Mixed Episode


The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Top

 

Criteria For Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

  • inflated self-esteem or grandiosity.

  • decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

  • more talkative than usual or pressure to keep talking.

  • insomnia or hypersomnia nearly every day.

  • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

  • flight of ideas or subjective experience that thoughts are racing.

  • distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli).

  • increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

  • excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

The symptoms do not meet criteria for a Mixed Episode

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Top

 

Criteria For Mixed Episodes

The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Top

 

Criterion A For Schizophrenia

Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

  • delusions
  • hallucinations
  • disorganized speech (e.g., frequent derailment or incoherence)
  • grossly disorganized or catatonic behavior
  • negative symptoms, i.e., affective flattening, alogia, or avolition

Only one symptom 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.

During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

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.

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.

Specify if:
BIPOLAR TYPE: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes)

DEPRESSIVE TYPE: if the disturbance only includes Major Depressive Episodes

ASSOCIATED FEATURES

  • Learning Problem
  • Hypoactivity
  • Psychotic
  • Euphoric Mood
  • Depressed Mood
  • Somatic/Sexual Dysfunction
  • Hyperactivity
  • Guilt/Obsession
  • Odd/Eccentric/Suspicious Personality
  • Anxious/Fearful/Dependent Personality
  • Dramatic/Erratic/Antisocial Personality

DIFFERENTIAL DIAGNOSIS

Psychotic Disorder Due to a General Medical Condition, a delirium, or a dementia; Substance-Induced Psychotic Disorder; Substance-Induced Delirium; Delusional Disorder; Psychotic Disorder Not Otherwise Specified.

Top

 

II. The ICD-10 Classification of Mental and Behavioral Disorders**

Schizoaffective Disorders

These are episodic disorders in which both affective and schizophrenic symptoms are prominent within the same episode of illness, preferably simultaneously, but at least within a few days of each other. Their relationship to typical mood (affective) disorders and to schizophrenic disorders is uncertain. They are given a separate category because they are too common to be ignored.

Other conditions in which affective symptoms are superimposed upon or form part of a preexisting schizophrenic illness, or in which they coexist or alternate with other types of persistent delusional disorders, are classified under the appropriate category. Mood-incongruent delusions or hallucinations in affective disorders do not by themselves justify a diagnosis of schizoaffective disorder.

Patients who suffer from recurrent schizoaffective episodes, particularly those whose symptoms are of the manic rather than the depressive type, usually make a full recovery and only rarely develop a defect state.

Top

 

Diagnostic Guidelines

A diagnosis of schizoaffective disorder should be made only when both definite schizophrenic and definite affective symptoms are prominent simultaneously, or within a few days of each other, within the same episode of illness, and when, as a consequence of this, the episode of illness does not meet criteria for either schizophrenia or a depressive or manic episode.

The term should not be applied to patients who exhibit schizophrenic symptoms and affective symptoms only in different episodes of illness. It is common, for example, for a schizophrenic patient to present with depressive symptoms in the aftermath of a psychotic episode (see post-schizophrenic depression).

Some patients have recurrent schizoaffective episodes, which may be of the manic or depressive type or a mixture of the two. Others have one or two schizoaffective episodes interspersed between typical episodes of mania or depression. In the former case, schizoaffective disorder is the appropriate diagnosis. In the latter, the occurrence of an occasional schizoaffective episode does not invalidate a diagnosis of bipolar affective disorder or recurrent depressive disorder if the clinical picture is typical in other respects.

Top

 

F25.0 Schizoaffective Disorder, Manic Type

A disorder in which schizophrenic and manic symptoms are both prominent in the same episode of illness. The abnormality of mood usually takes the form of elation, accompanied by increased self-esteem and grandiose ideas, but sometimes excitement or irritability are more obvious and accompanied by aggressive behavior and persecutory ideas. In both cases there is increased energy, overactivity, impaired concentration, and a loss of normal social inhibition.

Delusions of reference, grandeur, or persecution may be present, but other more typically schizophrenic symptoms are required to establish the diagnosis. People may insist, for example, that their thoughts are being broadcast or interfered with, or that alien forces are trying to control them, or they may report hearing voices of varied kinds or express bizarre delusional ideas that are not merely grandiose or persecutory.

Careful questioning is often required to establish that an individual really is experiencing these morbid phenomena, and not merely joking or talking in metaphors. Schizoaffective disorders, manic type, are usually florid psychoses with an acute onset; although behavior is often grossly disturbed, full recovery generally occurs within a few weeks.

Top

 

Diagnostic Guidelines

There must be a prominent elevation of mood, or a less obvious elevation of mood combined with increased irritability or excitement. Within the same episode, at least one and preferably two typically schizophrenic symptoms (as specified for schizophrenia [F20], diagnostic guidelines (a) - (d)) should be clearly present.

This category should be used both for a single schizoaffective episode of the manic type and for a recurrent disorder in which the majority of episodes are schizoaffective, manic type.

Includes:

  • schizoaffective psychosis, manic type
  • schizophreniform psychosis, manic type

Top

 

F25.1 Schizoaffective Disorder, Depressive Type

A disorder in which schizophrenic and depressive symptoms are both prominent in the same episode of illness. Depression of mood is usually accompanied by several characteristic depressive symptoms or behavioral abnormalities such as retardation, insomnia, loss of energy, appetite or weight, reduction of normal interests, impairment of concentration, guilt, feelings of hopelessness, and suicidal thoughts.

At the same time, or within the same episode, other more typically schizophrenic symptoms are present; patients may insist, for example, that their thoughts are being broadcast or interfered with, or that alien forces are trying to control them. They may be convinced that they are being spied upon or plotted against and this is not justified by their own behavior. Voices may be heard that are not merely disparaging or condemnatory but that talk of killing the patient or discuss this behavior between themselves.

Schizoaffective episodes of the depressive type are usually less florid and alarming than schizoaffective episodes of the manic type, but they tend to last longer and the prognosis is less favorable. Although the majority of patients recover completely, some eventually develop a schizophrenic defect.

Top

 

Diagnostic Guidelines

There must be prominent depression, accompanied by at least two characteristic depressive symptoms or associated behavioral abnormalities as listed for depressive episode; within the same episode, at least one and preferably two typically schizophrenic symptoms (as specified for schizophrenia), diagnostic guidelines (a)-(d) should be clearly present.

This category should be used both for a single schizoaffective episode, depressive type, and for a recurrent disorder in which the majority of episodes are schizoaffective, depressive type.

Includes:

  • schizoaffective psychosis, depressive type
  • schizophreniform psychosis, depressive type

 

*Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), published by the American Psychiatric Association, Washington D.C., 1994
**World Health Organization, Geneva, ICD-10 copyright © 1992