Schizoaffective Disorder


Article Author:
Tom Joshua Wy


Article Editor:
Abdolreza Saadabadi


Editors In Chief:
Wanda Wright
Cynthia Oster


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/30/2019 9:32:06 AM

Introduction

Schizoaffective disorder is one of the most misdiagnosed psychiatric disorders in clinical practice.[1]  In fact, some researchers have proposed revisions to the diagnostic criteria, and others have suggested removing the diagnosis all together from the DSM-5.[2]  There were significant concerns regarding the reliability and utility of the diagnosis when it was first introduced in the DSM.[2]  The challenges lie within the diagnostic criteria itself since the disorder is part of a spectrum that shares criteria with many other prominent psychiatric disorders found in clinical practice.

Etiology

The term schizoaffective disorder first appeared as a subtype of schizophrenia in the first edition of the DSM.  It eventually became its own diagnosis despite lack of evidence for unique differences in etiology or pathophysiology. Therefore, there have been no conclusive studies on the etiology of the disorder.  However, investigating the potential causes of mood disorders and schizophrenia as individual disorders allows for further discussion.

Some studies show that as high as 50% of people with schizophrenia also have comorbid depression.[3]  The pathogenesis of both mood disorders and schizophrenia is multifactorial and covers a range of risk factors including genetics, social factors, trauma, and stress.[4]  Among people with schizophrenia, there is a possible increased risk for first-degree relatives for schizoaffective disorder and vice-versa; there may be increased risk among individuals for schizoaffective disorder who have a first-degree relative with bipolar disorder, schizophrenia, or schizoaffective disorder.[5]

Epidemiology

The diagnostic criteria for the schizoaffective disorder have been reworded and addended since its inclusion in the DSM, which made it difficult to subsequently conduct appropriate epidemiological studies. Thus, there have been no large-scale studies on the epidemiology, incidence, or prevalence of the schizoaffective disorder.  Research shows that 30% of cases occur between the ages of 25 and 35,[6] and it occurs more frequently in women.[7]  Schizoaffective disorder occurs about one-third as commonly as schizophrenia and the lifetime prevalence appears to be around 0.3%.[5]  Estimates are that schizoaffective disorder comprises 10 to 30% of inpatient admissions for psychosis.[8]

Pathophysiology

The exact pathophysiology of schizoaffective disorder is currently unknown.  Some studies have shown that abnormalities in dopamine, norepinephrine, and serotonin may play a role.[9]  Also, white matter abnormalities in multiple areas of the brain, particularly the right lentiform nucleus, left temporal gyrus and right precuneus are associated with schizophrenia and schizoaffective disorder.[10] Researchers have also found reduced hippocampal volumes and distinct deformations in the medial and lateral thalamic regions in those with schizoaffective disorder in comparison to controls.[11][12]

History and Physical

The first step in evaluation is obtaining a complete medical history while focusing on the diagnostic criteria for schizoaffective disorder.  

The specific DSM-5 criteria for schizoaffective disorder are as follows[1]:

A. An uninterrupted duration of illness during which there is a major mood episode (manic or depressive) in addition to criterion A for schizophrenia; the major depressive episode must include depressed mood.

Criterion A for schizophrenia is as follows[13]:

Two or more of the following presentations, each present for a significant amount of time during a 1-month period (or less if successfully treated).  At least one of these must be from the first three below.

  1. Delusions
  2. Hallucinations
  3. Disorganized speech (e.g., frequent derailment or incoherence).
  4. Grossly disorganized or catatonic behavior
  5. Negative symptoms (i.e., diminished emotional expression or avolition.)

B.  Hallucinations and delusions for two or more weeks in the absence of a major mood episode (manic or depressive) during the entire lifetime duration of the illness.

C.  Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active as well as residual portions of the illness.

D.  The disturbance is not the results of the effects of a substance (e.g., a drug of misuse or a medication) or another underlying medical condition.

The following are specifiers based on the primary mood episode as part of the presentation.

Bipolar type: includes episodes of mania and sometimes major depression.

Depressive type: includes only major depressive episodes.

Please note the patient must meet the criteria for A-D above to be diagnosed with schizoaffective disorder.  It is not enough to symptoms of schizophrenia while meeting the criteria for a major mood episode. Please see differential diagnoses and pearls sections below for more information.

The next step of evaluation is the objective and physical portion.  A thorough mental status examination (MSE), physical examination, and neurologic examination should be completed to aid in ruling out other differential diagnoses.

Evaluation

The following workup is optional and typically not needed to make the diagnosis.  The history and physical are the mainstays of diagnosis. However, some elect to include additional tests, or imaging to aid in the diagnosis such as MRI (magnetic resonance imaging), EEG (electroencephalography) or CT (computed tomography).

Laboratory studies are tailored to the patient’s history, especially for those who have an atypical presentation.

  • Complete blood count (CBC)
  • Lipid panel
  • Urine drug screen
  • Urine pregnancy test
  • Urinalysis
  • Thyroid-stimulating hormone (TSH) level
  • Rapid plasma reagent
  • HIV test

If the patient's neurologic exam is found to be aberrant, performing a brain MRI or CT to rule out any suspected intracranial abnormalities may be considered.

Treatment / Management

The treatment of schizoaffective disorder typically involves both pharmacotherapy and psychotherapy.  The mainstay of most treatment regimens should include an antipsychotic, but the choice of treatment should be tailored to the individual.[14]  A study which reported obtained data on treatment regimens for schizoaffective showed that 93% of patients received an antipsychotic.  20% of patients received a mood-stabilizer in addition to an antipsychotic, while 19% received an antidepressant in along with an antipsychotic.[15]  Prior to initiating treatment, if a patient with schizoaffective disorder is a danger to themselves or others, inpatient hospitalization should be considered; this includes patients who are neglecting activities of daily living or those who are disabled well below their baseline in terms of functioning.

Pharmacotherapy

Antipsychotics: Used to target psychosis and aggressive behavior in schizoaffective disorder.  Other symptoms include delusions, hallucinations, negative symptoms, disorganized speech, and behavior. Most first and second generation antipsychotics block dopamine receptors.  While second-generation antipsychotics have further actions on serotonin receptors. Antipsychotics include, but are not limited to paliperidone (FDA approved for schizoaffective disorder), risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and haloperidol.[16][17][18][19][20]  Clozapine is a consideration for refractory cases, much like in schizophrenia.[18]

Mood-stabilizers: Patients who have periods of distractibility, indiscretion, grandiosity, a flight of ideas, increased goal-directed activity, decreased need for sleep, and who are hyperverbal fall under the bipolar-specifier for schizoaffective disorder.  Consider the use of mood-stabilizers if the patient has a history of manic or hypomanic symptoms. These include medications such as lithium, valproic acid, carbamazepine, oxcarbazepine, and lamotrigine which target mood dysregulation.[21][22][23][24]

Antidepressants:  Used to target depressive symptoms in schizoaffective disorder.  Selective-serotonin reuptake inhibitors (SSRIs) are preferred due to lower risk for adverse drug effects and tolerability when compared to the tricyclic antidepressants, and selective norepinephrine reuptake inhibitors.[25]  SSRIs include fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine.  It is vital to rule out bipolar disorder before starting an antidepressant due to risk for exacerbating a manic episode.[26]  

Psychotherapy

Patients who have schizoaffective disorder can benefit from psychotherapy, as is the case with most mental disorders.

Treatment plans should incorporate individual therapy, family therapy, and psychoeducational programs.  The aim is to develop their social skills and improve cognitive functioning to prevent relapse and possible rehospitalization.[27]  This treatment plan includes education about the disorder, etiology, and treatment.  

Individual therapy: This type of treatment aims to normalize thought processes and better help the patient understand the disorder, to reduce the burden of symptoms. Sessions focus on everyday goals, social interactions, and conflict' this includes social skills training and vocational training.

Family and/or group therapy:  Family involvement is crucial in the treatment of this schizoaffective disorder.[28]  Family education aids in compliance with medications and appointments, and helps provide structure throughout the patient's life given the dynamic nature of the schizoaffective disorder.  Supportive group programs can also help if the patient has been in social isolation and provides a sense of shared experiences among participants.

ECT (Electroconvulsive Therapy)

ECT is usually a last resort treatment.  However, not only has it been used in urgent cases and treatment resistance, but it should also merit consideration in augmentation of current pharmacotherapy.[29]  The most common indicated symptoms are catatonia and aggression.  ECT is safe and effective for most chronically hospitalized patients.[30]

Differential Diagnosis

Due to having criteria that encompass both psychotic and mood symptoms, schizoaffective disorder is easy to mistake for other mental disorders.  Disorders that must be ruled out during the workup of schizoaffective disorder include schizophrenia, major depressive disorder with psychotic features, and bipolar disorder.

Schizophrenia and Schizoaffective Disorder:  There has to be a definite period of at least two weeks in which there are only psychotic symptoms (delusions and hallucinations) without mood symptoms to diagnose schizoaffective disorder.  However, a major mood episode (depression or mania) is present for the majority of the total duration of the illness. Once the psychotic symptoms predominate the majority of the total duration of the illness, the diagnosis leans towards schizophrenia.  Also, schizophrenia requires 6 months of prodromal or residual symptoms; schizoaffective disorder does not require this criterion.

Major Depressive Disorder Psychotic Features and Schizoaffective Disorder:  Patients with major depression with psychotic features (MDD with PF), only experience psychotic features during their mood episodes.  In contrast, schizoaffective requires at least 2 weeks in which there are only psychotic symptoms (delusions and hallucinations) without mood symptoms.  Patients with MDD with PF do not meet criterion A of schizoaffective disorder.

Bipolar Disorder and Schizoaffective Disorder: Similar to the contrasts with MDD w/ PF, patients with bipolar disorder with psychotic features only experience psychotic features (delusions and hallucinations) during a manic episode.  Again, schizoaffective requires a period of at least 2 weeks in which there are only psychotic symptoms without mood symptoms. Psychotic features in bipolar disorder do not meet criterion A of schizoaffective disorder.

Prognosis

Given that the diagnostic criteria of schizoaffective disorder change periodically, prognostic studies have been challenging to conduct.  However, a study by Harrison et al., 2001 on the overall prognosis of those with psychotic illness showed that 50% of cases showed favorable outcomes.[31]  The defined favorable as minimal or no symptoms, and/or employment.  These outcomes were highly reliant on early initiation of treatment and optimized treatment regimens as outlined above.

Complications

Left untreated, schizoaffective disorder has many ramifications in both social functioning and activities of daily living.  These include unemployment, isolation, impaired ability to care for self, etc. Untreated mental disorders have more than just social and functional consequences.  Some studies show that as many as 5% of people with a psychotic illness will commit suicide over their lifetime.[32]  Research has shown that among all completed suicides, ten percent are attributable to those with a psychotic illness.[33]

Pearls and Other Issues

Working through the differential of schizoaffective disorder is often a daunting task, and many clinicians continue to have trouble making the diagnosis.[2]  A few considerations when working through the differential diagnosis include:

  • Observe the criteria for each diagnosis carefully.
  • Do not "fill in blanks" with preconceived notions about the patient's history.  Take what the patient tells you and what family/collateral information tells you when working through a differential.
  • Time frames often give clues towards one specific diagnosis.  Symptom course also plays a role; did mood symptoms or psychotic symptoms come first?  For how long did symptoms last? History-taking is an essential skill that is necessary for all clinicians; it is even more imperative in psychiatry.
  • Criterion B of schizoaffective disorder is key for the following reasons.  One must tease out a 2 week or longer period of just psychotic symptoms in the patient's history.  If one finds that the patient has always had mood symptoms during their entire illness, the diagnosis by definition is not a schizoaffective disorder.  

Enhancing Healthcare Team Outcomes

As with most mental disorders, schizoaffective disorder is best managed by a multidisciplinary team including psychiatric specialty nurses and pharmacists and clinicians that practice close interprofessional communication. [Level V] Pharmacotherapy, psychotherapy, skills training, and vocational training work in tandem to create a holistic treatment plan. In addition to what the information alluded to in previous sections, psychotherapy strongly influences medication compliance.[34]  An ideal treatment course to improve outcomes around patient-centered care may include:

  • Early detection of mental disorder in the primary care setting
  • Referral to a psychiatrist for further evaluation
  • A psychiatrist would stabilize the patient with pharmacotherapy or defer to a clinical psychologist for diagnosis or additional therapy
  • If the patient requires inpatient hospitalization, the nursing staff and case management become crucial in providing optimal patient care

It is critical to determine if the patient is competent to make healthcare decisions on their own - otherwise, a proxy must be a consideration.


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Schizoaffective Disorder - Questions

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A 42-year-old female with a past psychiatric history of major depressive disorder presents to inpatient services voluntarily with her husband. Her husband states that the patient's mood symptoms had been pretty constant for the past couple of years, but subsequently was observed with worsening bizarre behaviors for the past year to the point that the patient is no longer attending to her daily needs. The patient is observed to be internally preoccupied, responding to internal stimuli. The patient also states that she must cleanse herself of all toxins and her husband notes that she has stopped taking her medications. Additionally, he states that the patient has not had depressive symptoms for the past month. Which of the following is the mechanism of action of the primary pharmacologic treatment in this patient?



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A 37-year-old male with a past psychiatric history of major depressive disorder presents to the outpatient clinic with his wife. His wife states that the patient's mood symptoms had been pretty constant for the past couple of months, but recently he has been having auditory hallucinations. The patient is observed to be internally preoccupied, responding to internal stimuli. The patient is looking down throughout most of the interview talking to himself. Which of the additional following symptoms would help make the most likely diagnosis?



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A 65-year-old male with a past psychiatric history of bipolar disorder type one presents to your outpatient clinic with his daughter. His daughter states that the patient's mood symptoms have been well controlled on lithium, but for the past two weeks he has been observed to have auditory hallucinations. The patient is observed to be internally preoccupied, responding to internal stimuli. The patient denies any depressive or manic symptoms since the hallucinations began. If you were to add a medication to his current regimen for the ongoing symptoms, which of the following side effects would need to be monitored?



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A 33-year-old female with a past psychiatric history of remitted major depressive disorder diagnosed a few years ago, was recently admitted to an inpatient psychiatric hospital for paranoid delusions. She and her husband present to the office for follow-up after being discharged after seven days in the hospital. Speaking with the patient and her husband, they endorse that the patient denied having mood symptoms, but instead was having paranoid delusions. She states that for the month leading up to her hospitalization, she believed that scammers were attempting to hack her credit card and she said she could hear the government speaking through the wires in the house. She no longer reports strong feelings of paranoia and auditory hallucinations but still has some delusions that scammers are after her which the husband denies. However, she does state that she has begun to once again have feelings of depression, hopelessness, poor appetite, low energy, poor concentration, and little sleep. Which of the following would be the best pharmacologic regimen for the patient to be on at this time?



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Schizoaffective Disorder - References

References

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