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Schizoaffective disorder
Classification & external resources

ICD-10	F25
ICD-9	295.70

Schizoaffective disorder is a psychiatric diagnosis describing a situation where both the symptoms of mood disorder and psychosis are present. The disorder usually begins in early adulthood, and is more common in women.

There are two sub-types of schizoaffective disorder:

bipolar type - Bipolar disorder

Once known as manic-depression, is a psychiatric diagnosis referring to a mental health condition defined by periods of extreme, often inappropriate, and sometimes unpredictable mood states.

Bipolar individuals generally experience mania, hypomania or mixed states alternating with clinical depression and euthymic or normal range of mood over varied periods of time. There are many variations of this disorder. A person with bipolar disorder generally tends to experience more extreme states of mood than other people. Moods can change quickly (many times a day) or last for months. Bipolar individuals tend to have very 'black and white' thinking, where everything in life is either a positive aspect or a negative. Mood patterns of this nature are associated with distress and disruption, and a relatively high risk of suicide. Bipolar disorder is also associated with a variety of cognitive deficits, in particular, difficulty in organizing and planning. The disorder may also skew the ability to judge others' emotion, and alter sense of awareness. paranoid [1]

Bipolar disorder is usually treated with medications and/or therapy or counselling.

As well as being linked to disability, studies have suggested a correlation between creativity and bipolar disorder, although it is unclear what the relationship is between the two.[2][3][4] Studies have also indicated increased striving for, and sometimes obtaining, goals and achievements more generally; in other words, many with bipolar disorder tend to be more driven, extremely goal oriented, and hard working. [5]

depressive - Clinical depression (also called major depressive disorder, or sometimes unipolar when compared with bipolar disorder) is a state of intense sadness, melancholia or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living. Although a low mood or state of dejection that does not affect functioning is often colloquially referred to as depression, clinical depression is a clinical diagnosis and may be different from the everyday meaning of "being depressed." Many people identify the feeling of being depressed as "feeling sad for no reason", or "having no motivation to do anything." One suffering from depression may feel tired, sad, irritable, lazy, unmotivated, and apathetic. Clinical depression is generally acknowledged to be more serious than normal depressed feelings. It often leads to constant negative thinking and sometimes substance abuse.

Without careful assessment, delirium can easily be confused with depression and a number of other psychiatric disorders because many of the signs and symptoms are conditions present in depression, as well as other mental illnesses including dementia and psychosis.[1]

The bipolar type has a better prognosis than the depressive type, which can have a residual defect with the passing of time. Bipolar schizoaffective disorder is more similar to bipolar disorder than schizophrenia. People with bipolar disorder may also suffer from isolated episodes of psychotic symptoms.

Contents 1 Signs and Symptoms 2 Subtypes 3 Etiology & Pathogenesis 4 Epidemiology 5 Treatment 5.1 Cannabis 6 Expectations (prognosis) 7 Complications 8 References

The following are the criteria for a diagnosis of schizoaffective disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):

A. Two (or more) of the following symptoms are present for the majority of a one-month period:

• delusions- A delusion is commonly defined as a fixed false belief and is used in everyday language to describe a belief that is either false, fanciful or derived from deception. In psychiatry, the definition is necessarily more precise and implies that the belief is pathological (the result of an illness or illness process).

Delusions typically occur in the context of neurological or mental illness, although they are not tied to any particular disease and have been found to occur in the context of many pathological states (both physical and mental). However, they are of particular diagnostic importance in psychotic disorders and particularly in schizophrenia.

• hallucinations- A hallucination is a sensory perception experienced in the absence of an external stimulus, as distinct from an illusion, which is a misperception of an external stimulus. Hallucinations may occur in any sensory modality - visual, auditory, olfactory, gustatory, tactile, or proprioceptive (sense of balance and position in space).

• disorganized speech (e.g., frequent derailment or incoherence)
• grossly disorganized or catatonic behavior - Catatonia is a syndrome of psychic and motoric disturbances.
• negative symptoms (i.e., affective flattening - is a general category which includes diminishment of, or absence of, emotional expressiveness. It is sometimes inappropriately equated with blunted or restricted affect. "Blunted" is affect that is present but only with minimal degrees of emotions evident. "Restriction" is a holding back or as in alexithymia. "Restricted" is not as severe as in flattened or blunted affect.

Flat: "I don't know" Blunted: "I'm not sure" Restricted: "I think so"

, alogia, or avolition)

Note: Only one of these symptoms 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.

AND at some time there is either a

• major depressive episode - Major depressive episode is a symptom of a mood disorder. It is characterized by severe, highly persistent depression, which is often manifested by lack of appetite, chronic fatigue, lethargy, and sleep disturbances (somnipathy). The victim may think about suicide, and in fact an increased risk of actual suicide is present.[1]

In addition to the emotional pain endured by those suffering from depression, significant economic costs are associated with depression. In fact, American and Canadian studies have indicated that the costs associated with depression are greater than those associated with hypertension, and equal to those of heart disease, diabetes, and back problems.[2]

• manic episode - Mania is a severe medical condition characterized by extremely elevated mood, energy, and unusual thought patterns. There are several possible causes for mania, but it is most often associated with bipolar disorder, where episodes of mania may cyclically alternate with episodes of clinical depression. Though the elevated mood and energy level typical of mania could be seen as a benefit, mania generally has many undesirable consequences and has the potential to be very destructive. Classic symptoms include rapid speech, racing thoughts, decreased need for sleep, hypersexuality, euphoria, grandiosity, irritability, and increased interest in goal-directed activities. Mild forms of mania, known as hypomania, cause little or no impairment; more severe forms of mania do cause impairment and may even feature grandiose delusions or hallucinations. Mania and hypomania have also been associated with creativity and artistic talent.[1]

• mixed episode - In the context of mental illness, a mixed state (also known as dysphoric mania, agitated depression, or a mixed episode) is a condition during which symptoms of mania and depression occur simultaneously (e.g., agitation, anxiety, fatigue, guilt, impulsiveness, irritability, morbid and/or suicidal ideation, panic, paranoia, pressured speech and rage). Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. One may also feel incredibly frustrated in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states can be the most dangerous period of mood disorders, during which substance abuse, panic disorder, suicide attempts, and other complications increase greatly.

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.

Two subtypes of Schizoaffective Disorder may be noted based on the mood component of the disorder:

Bipolar Type - if the disturbance includes

• manic episode
• mixed episode
• manic and major depressive episodes
• mixed and major depressive episode

This subtype applies if a Manic Episode or Mixed Episode is part of the presentation. Major Depressive Episodes may also occur.

Depressive Type - if the disturbance includes major depressive episodes exclusively.

This subtype applies if only Major Depressive Episodes are part of the presentation.

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 for a distinct variety of psychotic illness. It follows then that the etiology is probably identical to that of schizophrenia in some cases or to mood disorders in others.

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.

The psychiatric treatment for schizoaffective disorder is a combination of therapy and medicine. A licensed psychiatrist will prescribe different combinations of medicine to the patient in order to find the combination that works. Each person responds differently to medicine.

Common medicines prescribed to treat schizoaffective disorder:

• Depakote ER
• Lithium salts
• Risperdal
• Seroquel
• Abilify

Combining lithium, carbamazepine, or valproate with a neuroleptic has been shown to be superior to neuroleptics alone in schizoaffective patients with manic symptoms. The degree of benefit for an individual patient should be considered carefully, as each of these agents carries an additional set of risks. Lithium-neuroleptic combinations may produce severe extrapyramidal reactions or confusion in some patients. Carbamazepine or valproate are frequently employed when lithium is not effective or well tolerated. 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 cause liver toxicity and platelet dysfunction, although those problems are uncommon. More recently, the anticonvulsants lamotrigine and gabapentin have shown promise in the treatment of manic symptoms, although there have been no systematic studies of their use in schizoaffective disorder at this time. Calcium channel blockers such as verapamil may also be an effective treatment for manic symptoms but are seldom prescribed for that purpose. Benzodiazepines such as lorazepam and clonazepam are effective adjunctive treatment agents for acute manic symptoms, but long-term use may result in dependency.

Often a sleeping pill will initially be prescribed to allow the patient rest from his or her anxiety or hallucinations.

In addition to pharmaceutical medications, some who suffer from schizoaffective disorder have claimed to benefit from medicinal marijuana (cannabis) - Medical cannabis refers to the use of the drug Cannabis as a physician recommended herbal therapy, most notably as an antiemetic. The term medical marijuana post-dates the U.S. Marijuana Tax Act of 1937, the effect of which made cannabis prescriptions illegal in the United States.

Due to widespread illegal use of cannabis as a recreational drug its legal or licensed use in medicine is now a controversial issue in most countries.

This claim, however, has not been substantiated by clinical trials and there is no available clinical literature on effective dosage levels.[1] Additionally, psychiatrists report that with patients who are heavy cannabis users, it is often difficult to separate the symptoms of the disorder from those due to the cannabis.[2]

People with schizoaffective disorder have a greater chance of returning to a previous level of functioning than patients with other psychotic disorders. However, long-term treatment may be necessary and individual outcomes will vary.

Complications are similar to those for schizophrenia and major mood disorders. These include:

• Problems following medical treatment and therapy
• Abuse of drugs in an attempt to self-medicate
• Problems resulting from manic behavior (for example, spending sprees, sexual indiscretions)
• Suicidal behavior due to depressive or psychotic symptoms

• 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.