AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

The term schizoaffective disorder was coined by Dr. Jacob Kasanin in 1933. Schizoaffective disorder is a perplexing mental illness distinguished by a combination of symptoms of a thought disorder or other psychotic symptoms such as hallucinations or delusions (schizophrenia component) and those of a mood disorder (depressive or manic component). The coupling of symptoms from these divergent spectrums makes treating patients who are schizoaffective difficult.

Schizoaffective disorder is defined using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria or by International Classification of Diseases, Tenth Revision (ICD-10) coding. Schizoaffective disorder has features of both schizophrenia, including hallucinations, delusions, and distorted thinking, and a mood component, such as depression or mania.

The diagnosis is made when the patient has features of both illnesses but does not strictly meet diagnostic criteria for either schizophrenia or a mood disorder alone. Unfortunately, determining if a patient has 2 separate illnesses (schizophrenia or a mood disorder), a combination of illnesses (schizophrenia and a mood disorder), or perhaps even a distinct and separate illness apart from schizophrenia or a mood disorder is difficult. Making the diagnosis of schizoaffective disorder can be difficult because it encompasses 2 other diagnostic entities, namely schizophrenia and mood disorders. An accurate diagnosis is made when the patient meets criteria for major depressive disorder or mania while also meeting the criteria for schizophrenia. Moreover, the patient must have psychosis for at least 2 weeks without a mood disorder.

Men with schizoaffective disorder tend to exhibit antisocial personality traits. The age of onset is later for women than for men, and the exact etiology and epidemiology is unclear because of limited research in this area. Patients with schizoaffective disorder are thought to have a better prognosis than that of patients with schizophrenia. Treatment consists of both pharmacotherapy and psychotherapy.

Pathophysiology

Although the exact etiology of schizoaffective disorder is unknown, it may involve the balance of dopamine and serotonin in the brain.¹ Others believe that it may be due to in utero exposure to viruses, malnutrition, or even birth complications.

Frequency

United States

The lifetime prevalence of schizoaffective disorder is thought to be approximately 0.32%², with a range of 0.5-0.8%³. This rate is only an estimate because no studies have been performed.

International

The international prevalence rates are difficult to determine because the diagnostic criteria have changed over the last few years.

Mortality/Morbidity

The prognosis for patients with schizoaffective disorder is thought to lie between that of patients with schizophrenia and that of patients with a mood disorder. That is, the prognosis is better with schizoaffective disorder than with schizophrenic disorder but worse than with a mood disorder alone.

• Individuals with the bipolar subtype are thought to have a prognosis similar to those with bipolar type I, whereas the prognosis of people with the depressive subtype is thought to be similar to that of people with schizophrenia. Overall, determination of the prognosis is difficult.
• The incidence of suicide is estimated at 10% (Williams, 1998). Also consider difference in suicide attempts among different ethnic groups. Caucasian individuals have a higher rate of suicide than African Americans. Persons who immigrated to a country have higher suicide rates then people born in that country. In regards to gender, women attempt suicide more than men, but men complete suicide more often.¹
• Schizoaffective disorder affects more women than men, but this appears to be influenced the fact that more women are in the depressive subtype as compared with the bipolar subtype.
• A poor prognosis in patients with schizoaffective disorder is generally associated with a poor premorbid history, an insidious onset, no precipitating factors, a predominant psychosis, negative symptoms, an early onset, an unremitting course, or their having a family member with schizophrenia.

Race

No race-based difference in diagnosis is observed.

Sex

Schizoaffective disorder is more common in women than in men. Men with schizoaffective disorder tend to exhibit antisocial traits and behavior in contrast to other personality traits. In addition, the age of onset is later for women than for men, and the exact etiology and epidemiology is unclear because of limited research in this area.

Age

Young people with schizoaffective disorder tend to have a diagnosis with the bipolar subtype, whereas older people tend to have the depressive subtype.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Diagnostic criteria for schizoaffective disorder are as follows:⁴
  
  
  • An uninterrupted period of illness occurs during which a major depressive episode, a manic episode, or a mixed episode occurs with symptoms that meet criterion A for schizophrenia. The major depressive episode must include criterion A1, ie, depressed mood.
  • During the same period of illness, delusions or hallucinations occur for at least 2 weeks, in the absence of prominent mood symptoms.
  • Symptoms that meet the criteria for mood episodes are present for a substantial portion of the total active and residual periods of illness.
  • The disturbance is not due to the direct physiologic effects of a substance (eg, illicit drugs, medications) 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.

Physical

Obtain a complete medical history, and perform a complete mental status examination, physical examination, and neurologic examination to assist with the evaluation and rule out other disease processes.

Although the mental status examination varies for each patient, examples of items to assess are listed below. Because of the variability of the presentation of the disorder, any or all symptoms of schizophrenia, bipolar disorder, or major depressive disorder may manifest depending on the presenting subtype.

• Appearance - Ranges from well-groomed to disheveled
• Eye contact - Appropriate, increased, or decreased
• Facial expression - Neutral, angry, euphoric, sad
• Motor - Possible psychomotor agitation or retardation
• Cooperativeness - May cooperate or may be uncooperative
• Mood - Euthymic, depressed, or manic
• Affect - Ranges from appropriate to flat
• Speech - Ranges from poverty to flight of ideas or pressured
• Suicidal ideation - May or may not be present. Remember that individuals with this disorder have a lifetime risk for suicide, which is significant. Inquiring about suicidal ideation at each visit is always important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent. "Do you have any thoughts of wanting to harm or kill yourself?" "Do you have any thoughts that you would be better off dead?" If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views suicide to determine if a suicidal gesture or act is ego-syntonic or ego-dystonic. Next, determine if the patient will contract for safety. 
• Homicidal ideation - May or may not be present. Inquiring about homicidal ideation or intent during each patient interview is also important. Ask the following types of questions to help determine homicidal ideation or intent. "Do you have any thoughts of wanting to hurt anyone?" "Do you have any feelings or thoughts that you wish someone were dead?" If the reply to one of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how he or she plans to control these feelings if they occur again.
• Orientation - To elicit responses concerning orientation (ie, person, place, time, situation), ask the patient questions, as follows. "What is your full name?" "Do you know where you are?" "What is the month, date, year, day of the week, and time?" "Do you know why you are here?"
• Consciousness - Levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness.
• Concentration and attention - Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as serial 7s. Next, ask the patient to spell the word world forward and backward.
• Reading and writing - Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, "Close your eyes."). The part of the MMSE evaluates the patient's ability to sequence.
• Memory - To evaluate a patient's memory, have him or her respond to the following prompts. For remote memory, "What was the name of your first grade teacher?" For recent memory, "What did you eat for dinner last night?" For immediate memory, "Repeat these 3 words: pen, chair, flag." Tell the patient to remember these words. Then, after 5 minutes, have the patient repeat the words.
• Delusions - Any type possible (eg, paranoid, thought insertion or withdrawal, grandiose, bizarre, to name a few)
• Hallucinations - Any type possible (most common is auditory, least common is gustatory)
• Insight - Range varies
• Judgment - Range varies

Causes

Although the cause of schizoaffective disorder is unknown, the cause may be similar to schizophrenia nature versus nurture. To date, no specific genetic markers have been identified. Environmental causes of malnutrition, viral infections, or complication at birth may play a role. Finally, abnormalities of the neurotransmitters serotonin, norepinephrine, and/or dopamine could all have a role in this disorder. More research is needed to fully elucidate the causes of schizoaffective disorder.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Steroid use
Temporal lobe epilepsy
Complex partial seizure disorder
Neurosyphilis
Thyroid problems
Alcohol abuse or dependence
Metabolic syndrome
Delirium
Narcolepsy

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Sequential multiple analysis
• Complete blood cell count
• Rapid plasma reagent
• Test of thyroid-stimulating hormone or thyroid function tests
• Urine drug screen
• Urine pregnancy test
• Urinalysis
• Lipid panel
• HIV test

Imaging Studies

• If the patient's neurologic findings are abnormal, CT or MRI rule out any suspected intracranial pathology may be appropriate.

Other Tests

• Perform psychological testing to assist with diagnosis (eg, Structured Clinical Interview for Axis I DSM-IV Disorders [SCID-1]).
• Several scales are available for rating the severity of disease in patients with schizophrenia or schizoaffective disorder.
• • These scales may be useful in assessing the patient's progress (eg, Positive and Negative Symptom Scale for Schizophrenia [PANSS]).
  • These scales include those for positive and negative symptoms and many for depression and bipolar rating (eg, Hamilton depression scale, Young mania scale). These tools can be used for baseline and outcome measurements.
  • The cut down, annoyed, guilty, and eye opener (CAGE) Questionnaire is useful to inquire about alcohol consumption in patients with schizoaffective disorder.
• Perform electroencephalography, if indicated.

Histologic Findings

Findings include decreased amounts of cortical gray matter and increased fluid-filled spaces.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• If patients are suicidal, homicidal, or gravely disabled, admit them to an inpatient psychiatric unit. Inpatient treatment is mandatory for patients who are dangerous to themselves or others and for patients who cannot take care of themselves.
• Patients who have schizoaffective disorder can greatly benefit from psychotherapy and well as psychoeducational programs.
• • They should receive therapy that involves their families, develops their social skills, and focuses on cognitive rehabilitation.
  • Psychotherapies should include supportive therapy and assertive community therapy in addition to individual and group forms of therapy and rehabilitation programs.
• Family involvement is needed in the treatment of this particular disorder.
• Treatment includes education about the disorder and its treatment, family assistance in compliance with medications and appointments, and maintenance of structured daily activities (ie, schedule of daily events) for the patient.

Consultations

• Consult a neurologist to rule out neurological disease.

Diet

• No specific diet is recommended for patients with schizoaffective disorder.

Activity

• Restrict activity if patients represent a danger to themselves or to others or if they are gravely disabled. Otherwise, encourage patients who are schizoaffective to continue their normal routines and strengthen their social skills whenever possible.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Several medications are used to treat schizoaffective disorder. Agent selection depends on whether the depressive or manic subtype is present. Early treatment with medication along with good premorbid function often improves outcomes. In the depressive subtype, combinations of antidepressants (eg, sertraline, fluoxetine) plus an antipsychotic (eg, haloperidol, risperidone, olanzapine) are used. In refractory cases, clozapine has been used as an antipsychotic agent. In the manic subtype, combinations of mood stabilizers (eg, lithium, carbamazepine, divalproex) plus an antipsychotic are used. Of the many medications and combinations available to treat schizoaffective disorder, a few are reviewed below.

Drug Category: Antipsychotics

These agents ameliorate psychosis and aggressive behavior.

Drug Category: Antidepressants

These agents decrease aggression and treat the underlying illness.

Selective serotonin reuptake inhibitors (SSRIs) are greatly preferred over the other classes of antidepressants. Because the adverse-effect profile of SSRIs is less prominent than the profiles of other drugs, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when one treats a child or adolescent with a mood disorder.

Physicians are advised to be aware of the following information and to use appropriate caution when they consider treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of depressive illness. After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

Drug Category: Mood Stabilizer

These drugs stabilize mood associated with bipolar disorder.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients may require further inpatient care if they represent a danger to themselves or to others or if they are gravely disabled.

Further Outpatient Care

• For best results, patients require medication and therapy.

In/Out Patient Meds

• When an inpatient who has schizoaffective disorder makes the transition to being an outpatient, stressing the importance of medication compliance is crucial.
• Patients with schizoaffective disorder often lack judgment and insight into their illness. They commonly refuse to continue the medications started in the hospital after they are discharged. Noncompliance can also be due to adverse effects of the medication, such as sedation and weight gain.
• Patients with schizoaffective disorder begin to feel better as a result of their medications and believe that they no longer need to take them. This thinking leads to the discontinuation of medication and results in the patient returning to the hospital within the next several weeks or so.
• If possible, select once-daily or long-acting medications, such as decanoate injections, to help with patient compliance.
• Also discuss compliance with a family member. Always discuss all the risks, benefits, adverse effects, and alternatives of each medication with the patient and family.
• Obtain written informed consent before starting medication therapy.

Transfer

• Medical surgical hospital, if needed
• Residential or group home, if needed

Complications

• Noncompliance with medications is a complication of therapy.
• Expressed emotions must be reduced in all areas of a patient's life, including stress-reduction techniques employed to prevent relapse and possible rehospitalization.

Prognosis

• The prognosis lies somewhere between that associated with schizophrenia and that associated with a mood disorder.

Patient Education

• Patients should be educated about the following:
• • Social skills training
  • Medication compliance
  • Reducing expressed emotions
  • Cognitive rehabilitation
  • Family therapy
• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Schizophrenia.
• Family education should involve reduction of expressed emotions, criticism, hostility, or over protection of the patient, which may led to decreases in relapse of this illness.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Be familiar with local mental health laws.
• If patients with schizoaffective disorder represent a danger to self or others or are gravely disabled and are unwilling to seek help on a formal voluntary basis, they may need to be committed for further evaluation and treatment.
• If noncompliance with medications is an issue, one may seek a court order to force the patient to take medications (eg, in lieu of rehospitalization), which may help increase medication compliance.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: May 18, 2007