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 episodic disorders where mood and schizophrenic symptoms are both present but a diagnosis of schizophrenia, depressive or bipolar disorder is not warranted.[1][1] The disorder usually begins in early adulthood and is rarely diagnosed in childhood (prior to age 13). Schizoaffective disorder may be 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.

Schizoaffective disorder is classified by the ICD into five types: manic, depressive, mixed (manic and depressive), other and unspecified. Generally 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 used. A specific type of psychosocial rehabilitation known as psychiatric rehabilitation can improve the prognosis.[citation needed]

Some people diagnosed with schizoaffective disorder may be diagnosed with comorbid conditions, including substance abuse.[citation needed]

The diagnosis was introduced in 1933.[2]


[edit] 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 and psychosis. Psychosis is defined by delusions and/or hallucinations. Individuals with the disorder experience psychotic symptoms at the same time as (but more 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 depression with psychotic features and schizophrenia.

The main similarity between schizoaffective disorder and 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.

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, when in reality they are not. Individuals may therefore feel paranoid. 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. Things may look or sound different. Individuals may also experience strange sensations. 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.

Comorbid or co-occuring 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. Individuals with schizoaffective disorder may withdraw socially and become isolated.

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 lack of impulse control.

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

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 much, most or even all of their functionality.

The physiology of patients diagnosed with schizoaffective disorder is similar to but not identical to that of those diagnosed with schizophrenia.[3]

[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 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.

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), lack of concentration or 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:

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

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 patients, 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. That is, the disorder appears to exist on a continuum in-between schizophrenia and severe bipolar disorder and severe recurrent unipolar depression. Thus in a subgroup of patients with schizoaffective disorder, the illness appears to be comorbid (or co-occurring) schizophrenia and mood disorder. 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. [2]

[edit] Street Drugs

Use of street drugs (including LSD, methamphetamine and marijuana/hash/cannabis) has been linked with significantly increased probability of developing schizophrenia spectrum disorders (of which schizoaffective disorder is part) in over 30 scientific studies over the past 20 years. A 2007 meta-analysis estimated that cannabis use is statistically associated with a dose-dependent increase in risk of development of psychotic disorders, including schizoaffective disorder.[citation needed]

One study included in the meta-analysis interviewed 50,000 members of the Swedish Army about their drug consumption and followed up with them later in life. Those who were heavy users of cannabis at age 18 were over 6 times more likely to be diagnosed with schizophrenia spectrum disorders over the next 15 years than those who did not take it. Others studies found that younger, heavier cannabis users have worse outcomes in terms of psychotic illness later in life.[citation needed]

[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 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.

[edit] 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 more neuroleptic medications are usually prescribed. Examples of neuroleptic medications include the following:

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

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 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 individuals with depressive symptoms, an antidepressant (usually Prozac or other SSRIs) will be prescribed with a neuroleptic. The anticonvulsant Lamictal is also now 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 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.

[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 will vary 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 Jacob Kasanin in 1933[6] to describe a more episodic psychotic illness with predominant affective symptoms, that was termed a good-prognosis schizophrenia.[7]

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.[8]

Some have disputed the idea that the term "schizoaffective disorder" refers to a well defined condition, and have recommended that the term be removed from future versions of the DSM.[9]

[edit] References

  1. ^ schizoaffective disorder at Dorland's Medical Dictionary
  2. ^ Lake CR, Hurwitz N (July 2007). "Schizoaffective disorder merges schizophrenia and bipolar disorders as one disease--there is no schizoaffective disorder". Curr Opin Psychiatry 20 (4): 365–79. doi:10.1097/YCO.0b013e3281a305ab. PMID 17551352. 
  3. ^ Martin LF, Hall MH, Ross RG, Zerbe G, Freedman R, Olincy A (December 2007). "Physiology of schizophrenia, bipolar disorder, and schizoaffective disorder". Am J Psychiatry 164 (12): 1900–6. doi:10.1176/appi.ajp.2007.06010017. PMID 18056246. 
  4. ^ a b Keks NA, Ingham M, Khan A, Karcher K (August 2007). "Long-acting injectable risperidone v. olanzapine tablets for schizophrenia or schizoaffective disorder. Randomised, controlled, open-label study". Br J Psychiatry 191: 131–9. doi:10.1192/bjp.bp.105.017020. PMID 17666497. 
  5. ^ Flynn J, Grieger TA, Benedek DM (January 2002). "Pharmacologic treatment of hospitalized patients with schizoaffective disorder". Psychiatr Serv 53 (1): 94–6. PMID 11773657. 
  6. ^ Lake CR, Hurwitz N (August 2006). "Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders". Psychiatry Res 143 (2-3): 255–87. doi:10.1016/j.psychres.2005.08.012. PMID 16857267. 
  7. ^ Goodwin & Jamison. p102
  8. ^ Goodwin & Jamison. p96
  9. ^ Malhi GS, Green M, Fagiolini A, Peselow ED, Kumari V (February 2008). "Schizoaffective disorder: diagnostic issues and future recommendations". Bipolar Disord 10 (1 Pt 2): 215–30. doi:10.1111/j.1399-5618.2007.00564.x. PMID 18199238. 

[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. 
  • 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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