Practice Essentials
Schizoaffective disorder is a perplexing mental illness that has both features of schizophrenia and features of a mood disorder. The coupling of symptoms from these divergent conditions makes diagnosing and treating schizoaffective patients difficult.
Signs and symptoms
The key signs and symptoms vary depending on whether the individual has the bipolar type (which includes manic or mixed episodes) or the depressive type (which includes major depressive episodes).
See Presentation for more detail.
Diagnosis
The diagnosis of schizoaffective disorder is made when the patient has features of both schizophrenia and a mood disorder but does not strictly meet diagnostic criteria for either alone. Ongoing reevaluation over the course of the illness is important for confirming the diagnosis.
The first step in evaluation is to obtain a complete medical history, keeping in mind the diagnostic criteria for schizoaffective disorder.
The next step is to perform a complete mental status examination (MSE), physical examination, and neurologic examination to assist with the evaluation and rule out other disease processes.
Psychological testing (eg, The Structured Clinical Interview for DSM-5 [SCID-5]) is warranted to assist with diagnosis.
Laboratory studies should be used to rule out organic causes.
Imaging studies that may be helpful include CT, MRI, and EEG.
See Workup for more detail.
Management
Management principles include the following:
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Treatment approaches include both pharmacotherapy and psychotherapy (as well as psychoeducational programs)
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The treatment plan must be individualized for each patient
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Inpatient treatment is mandatory for patients who are dangerous to themselves or others and for patients who cannot take care of themselves
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Transfer to a medical surgical hospital or to a residential or group home should be considered if appropriate
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Smoking cessation and noncompliance with medications are special concerns
Selection of medications to treat schizoaffective disorder depends on whether the depressive or manic subtype is present. In the depressive subtype, combinations of antidepressants (eg, sertraline or fluoxetine) plus an antipsychotic (eg, haloperidol, risperidone, olanzapine, aripiprazole, or ziprasidone) are used. In refractory cases, clozapine has been used as an antipsychotic agent. In the manic subtype, combinations of mood stabilizers (eg, lithium, carbamazepine, and valproic acid) plus an antipsychotic are used.
See Treatment and Medication for more detail.
Background
Schizoaffective disorder can be defined according to either Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), criteria (see below) or International Classification of Diseases, Eleventh Revision (ICD-11) coding. It is a perplexing mental illness that has both features of schizophrenia (eg, hallucinations, delusions, and distorted thinking) and features of a mood disorder (eg, depression or mania). The coupling of symptoms from these divergent spectrums makes diagnosing and treating schizoaffective patients 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 one of the two distinct illnesses (schizophrenia or a mood disorder), a combination of the two illnesses (schizophrenia with a mood disorder), or perhaps even a different illness entirely.
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 patient’s 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 because 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 patients with schizophrenia do. Treatment consists of both pharmacotherapy and psychotherapy.
Diagnostic criteria
DSM-5-TR
The specific DSM-5-TR criteria for schizoaffective disorder are as follows: [4]
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An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with criterion A for schizophrenia; the major depressive episode must include depressed mood
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Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness
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Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness
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The disturbance is not attributable to the effects of a substance (eg, a drug of abuse or a medication) or to another medical condition
Subtypes are defined as bipolar type (if a manic episode is part of the presentation, though major depressive episodes may also occur) and depressive type (if only major depressive episodes are part of the presentation). The presence or absence of catatonia is specified.
Various course specifiers are used, though only if the disorder has been present for at least 1 year and if they do not contradict diagnostic course criteria. These specifiers include the following:
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First episode, currently in acute episode
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First episode, currently in partial remission
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First episode, currently in full remission
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Multiple episodes, currently in acute episode
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Multiple episodes, currently in partial remission
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Multiple episodes, currently in full remission
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Continuous
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Unspecified
Finally, the current severity of the disorder is specified by evaluating the primary symptoms of psychosis and rating their severity on a 5-point scale ranging from 0 (not present) to 4 (present and severe).
ICD-11
The ICD-11 defines schizoaffective disorder as the presence of both prominent mood (affective) and psychotic symptoms, occurring simultaneously or within a few days of each other. [5]
Epidemiology
The frequency of schizoaffective disorder worldwide is difficult to determine, because the diagnostic criteria have changed over the past few years. A Finnish study estimated the lifetime prevalence of schizoaffective disorder to be about 0.32%. [6] A French review cited a range of 0.5–0.8%. [7] These numbers are only estimates; no studies have been performed.
Young people with schizoaffective disorder tend to have the bipolar subtype, whereas older people tend to have the depressive subtype. Overall, the disorder affects more women than men, probably in part because more women have the depressive subtype as opposed to 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 differences in frequency have been observed.
Pathophysiology and Etiology
The exact pathophysiology of schizoaffective disorder is unknown but may involve neurotransmitter imbalances in the brain. [8] Abnormalities of the neurotransmitters serotonin, norepinephrine, and dopamine could play a role in this disorder. Reduced hippocampal volumes, thalamic abnormalities, and white-matter abnormalities have been noted in patients with schizoaffective disorder. [9, 10, 11]
Although the cause of schizoaffective disorder is unknown, it may be similar to that 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.
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 than that of schizophrenia alone but worse than that of 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. [12, 13, 14, 15]
The overall incidence of suicide is estimated to be about 10%. The incidence of suicide attempts varies among different ethnic and social groups. [16, 17] White individuals have a higher rate of suicide than do African Americans. People who immigrated to a country have higher suicide rates than people born in that country do. Women attempt suicide more than men do, but men complete suicide more often. [8]
A poor prognosis in patients with schizoaffective disorder is generally associated with a poor premorbid history, an insidious onset, an absence of precipitating factors, a predominant psychosis, negative symptoms, an early onset, an unremitting course, or having a family member with schizophrenia.
Patient Education
Patients with schizoaffective disorder should be educated about the following:
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Social skills training
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Medication compliance
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Reducing expressed emotions
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Cognitive rehabilitation
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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.
