The following description of schizoaffective disorder is taken from the educational handouts section of Behavioral Family Therapy for

Psychiatric Disorders by Kim T. Mueser and Shirley M. Glynn, published by New Harbinger Publications, Inc. (www.newharbinger.com). Second edition, 1999:

Schizoaffective disorder is a major psychiatric disorder that is similar to schizophrenia. The disorder can affect all aspects of daily living, including work, social relationships, and self-care skills (such as grooming and hygiene). People with schizoaffective disorder can have a wide variety of symptoms, including problems with their contact with reality (hallucinations and delusions), mood (such as marked depression), low motivation, inability to experience pleasure, and poor attention. The serious nature of the symptoms of this disorder sometimes require clients to be hospitalized at times for treatment. The experience of schizoaffective disorder can be described as similar to "dreaming when you are wide awake"; that is, it can be hard for the person with the disorder to distinguish between reality and fantasy."

You may read about symptoms such as hallucinations, delusions and thought disorder, as well as the symptoms which affect enjoyment and attention in the section Schizophrenia. Symptoms of mania may be found under Bipolar Disorder and depressive symptoms under the section Depression.

You will realize from the description of this condition that a diagnosis may be difficult for a physician to make in the early stages. However, when a person experiences mania, depression and psychotic symptoms over a period of time, Schizoaffective disorder is the preferred diagnosis.

With all serious mental illness there is an ever present risk of suicide. Schizophrenia and bipolar disorder have a similar incidence of 1 in 10 people who have these disorders committing suicide. About 4 in 10 attempt suicide.

schizoaffective disorder is a mental condition that causes both a loss of contact with
reality (psychosis) and mood problems.

Causes, incidence, and risk factors

The exact cause of schizoaffective disorder is unknown. Changes in genes and chemicals in the brain (neurotransmitters) may play a role. Some experts do not believe it is a separate disorder from schizophrenia. Schizoaffective disorder is believed to be less common than schizophrenia and mood disorders. Women may have the condition more often than men. Schizoaffective disorder tends to be rare in children.

Symptoms
The symptoms of schizoaffective disorder are different in each person. Often, people with schizoaffective disorder seek treatment for problems with mood, daily function, or abnormal thoughts. Psychosis and mood problems may occur at the same time, or by themselves. The course of the disorder may involve cycles of severe symptoms followed by improvement. The symptoms of schizoaffective disorder can include: Changes in appetite and energy Disorganized speech that is not logical False beliefs (delusions), such as thinking someone is trying to harm you (paranoia) or thinking that special messages are hidden in common places (delusions of reference) Lack of concern with hygiene or grooming Mood that is either too good, or depressed or irritable

Problems sleeping Problems with concentration Sadness or hopelessness Seeing or hearing things that aren't there (hallucinations) Social isolation Speaking so quickly that others cannot interrupt you

Signs and tests

Your health care provider will do a psychiatric evaluation to find out about your behavior and symptoms. You may be referred to a psychiatrist to confirm the diagnosis. To be diagnosed with schizoaffective disorder, you must have psychotic symptoms during a period of normal mood for at least 2 weeks. The combination of psychotic and mood symptoms in schizoaffective disorder can be seen in other illnesses, such as bipolar disorder. Extreme disturbance in mood is an important part of schizoaffective disorder. Your health care provider should consider and rule out medical, psychiatric, and drug-related conditions that cause psychotic or mood symptoms before making a diagnosis of schizoaffective disorder. For example, psychotic or mood disorder symptoms can occur in people who: Abuse cocaine, amphetamines, or phencyclidine (PCP) Have seizure disorders Take steroid medications

Treatment
Treatment can vary. In general, your health care provider will prescribe medications to improve your mood and treat psychosis. Antipsychotic medications are used to treat psychotic symptoms. Antidepressant medications or "mood stabilizers" may be prescribed to improve mood.

Talk therapy can help with creating plans, solving problems, and maintaining relationships. Group therapy can help with social isolation. Support and work training may be helpful for work skills, relationships, money management, and living situations.

Expectations (prognosis)
People with schizoaffective disorder have a greater chance of going back to their previous level of function than do people with most other psychotic disorders. However, long-term treatment is often needed, and results can vary from person to person.

Complications
Complications are similar to those for schizophrenia and major mood disorders. These include: Abuse of drugs in an attempt to self-medicate Problems following medical treatment and therapy Problems due to manic behavior (for example, spending sprees, overly sexual behavior) Suicidal behavior

Calling your health care provider

Call your health care or mental health provider if you or someone you know is experiencing any of the following: Depression with feelings of hopelessness or helplessness Inability to care for basic personal needs Increase in energy and involvement in risky behavior that is sudden and not normal for you (for instance, going days without sleeping and feeling no need for sleep) Strange or unusual thoughts or perceptions Symptoms that get worse or do not improve with treatment

Thoughts of suicide or of harming others

Schizoaffective Disorder
SYMPTOMS
Schizoaffective Disorder is characterized by the presence of one of the following: Major Depressive Episode (must include depressed mood) Manic Episode Mixed Episode

As well as the presence of at least two of the following symptoms, for at least one month: Delusions Hallucinations Disorganized speech (e.g., frequent derailment or incoherence) Grossly disorganized or catatonic behavior Negative symptoms (e.g., affective flattening, alogia, avolition)

(Only one symptom is required if delusions are bizarre orhallucinations 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.) The occurrence of the delusions or hallucinations must be in the absence of any serious mood symptoms for at least 2 weeks. The mood disorder, however, must be present for a significant minority of the time. The symptoms of this disorder also can not be better explained by the use or abuse of a substance (alcohol, drugs, medications) or a general medical condition (stroke).

Background

Schizoaffective disorder is defined according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria or International Classification of Diseases, Tenth Revision (ICD-10) coding. It is a perplexing mental illness that has both features of schizophrenia, including hallucinations, delusions, and distorted thinking, and features of a mood disorder, such as depression or mania. The coupling of symptoms from these divergent spectrums makes diagnosing and treating patients who are schizoaffective difficult.

The diagnosis is made when the patient has features of both schizophrenia and a mood disorder but does not strictly meet diagnostic criteria for either illness alone. Unfortunately, it is often difficult to determine whether a patient has 2 separate illnesses (schizophrenia or a mood disorder), a combination of illnesses (schizophrenia with a mood disorder), or perhaps even a distinct and separate illness apart from schizophrenia or a mood disorder.

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.

To diagnosis schizoaffective disorder, one must complete the patients history review, medical and psychiatric records, and, if possible, obtain information from family members.[1, 2]

Men with schizoaffective disorder tend to exhibit antisocial personality traits.[3] The age of onset is later for women than for men, and as a consequence of limited research in this area, the exact etiology and epidemiology are unclear. Patients with schizoaffective disorder are thought to have a better prognosis than that of patients with schizophrenia. Treatment consists of both pharmacotherapy and psychotherapy.

Case study

A 50-year-old white man who had been suffering from a psychotic disorder since age 28 years had been treated with antipsychotic medications with good results.

During the patients last medication check, his psychiatrist noticed that he appeared irritated. On further questioning, the patient reported insomnia, rapid speech, distractibility, and grandiosity. He became angry with the psychiatrist for inquiring about auditory and visual hallucinations. The patient was diagnosed with schizoaffective disorder, bipolar type. The psychiatrist initiated treatment with a mood stabilizer, with good results. The patient continued on both the antipsychotic and the mood stabilizer, and this approach was successful.

Go to Emergent Treatment of Schizophrenia, Childhood-Onset Schizophrenia, and Schizophreniform Disorder for complete information on these topics.

References Pathophysiology

The exact pathophysiology of schizoaffective disorder is unknown but may involve imbalance of neurotransmitters in the brain.[4] Abnormalities of the neurotransmitters serotonin, norepinephrine, and dopamine could play a role in this disorder.

In patients with schizoaffective disorder, reduced hippocampal volumes, thalamus, and white matter abnormalities have been noted.

References Etiology

Although the cause of schizoaffective disorder is unknown, it may be similar to the cause of schizophrenia. To date, no specific genetic markers have been identified. In utero exposure to viruses, malnutrition, or even birth complications may play a role. More research is needed to fully elucidate the causes of schizoaffective disorder.

References Epidemiology

The lifetime prevalence of schizoaffective disorder is thought to be approximately 0.32%,[8] with a range of 0.5-0.8%.[9] This rate is only an estimate; no studies have been performed. The international prevalence rates are difficult to determine, because the diagnostic criteria have changed over the last few years.

Young people with schizoaffective disorder tend to have a diagnosis with the bipolar subtype, whereas older people tend to have the depressive subtype. Schizoaffective disorder affects more women than men, but this appears to be influenced by the fact that more women are in the depressive subtype as compared with the bipolar subtype. 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. No race-based difference in diagnosis is observed.

References Prognosis

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 schizophrenia alone 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.[10, 11, 12, 13]

The incidence of suicide is estimated at 10%. Also consider difference in suicide attempts among different ethnic groups.[14, 15] 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.[4]

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.

References Patient Education

Patients should be educated about the following:

Social skills training Medication compliance Reducing expressed emotions Cognitive rehabilitation Family therapy Family education should involve reduction of expressed emotions, criticism, hostility, or overprotection of the patient; such reduction may lead to decreases in relapse rates.

For useful online patient information, visit the following sites:

MayoClinic, Schizoaffective disorder National Alliance on Mental Illness (NAMI), Schizoaffective Disorder MedlinePlus, Schizoaffective disorder References History

Obtain a complete medical history. Diagnostic criteria for schizoaffective disorder are as follows[16] :

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. Severity scales

Several scales are available for rating the severity of disease in patients with schizophrenia or schizoaffective disorder.

These scales include those for positive and negative symptoms (eg, Positive and Negative Symptom Scale for Schizophrenia [PANSS][17] ) and many for depression and bipolar rating (eg, Hamilton depression scale, Young mania scale). Such tools can be used for baseline and outcome measurements and may be useful in assessing the patients progress.

The cut down, annoyed, guilty, and eye opener (CAGE) Questionnaire is useful to inquire about alcohol consumption in patients with schizoaffective disorder.[18]

References Physical Examination

In addition to obtaining a medical history, 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, there are a number of items that are commonly assessed in most patients with possible schizoaffective disorder. Because of the variability of the presentation of this disorder, any or all symptoms of schizophrenia, bipolar disorder, or major depressive disorder may manifest, depending on the presenting subtype, as follows:

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 Homicidal ideation - May or may not be present 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 patients ability to sequence. Memory - To evaluate a patients 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 Inquiring about suicidal ideation at each visit is always important, because individuals with schizoaffective disorder have a significant lifetime risk for suicide. 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? and 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.

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? and Do you have any feelings or thoughts that you wish someone were dead? If the reply to 1 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.