One of the most challenging mental disorders to identify accurately and treat appropriately is schizoaffective disorder. This condition involves both psychotic symptoms and conspicuous, long-enduring, severe symptoms of mood disorder. The cluster of symptoms experienced by persons with schizoaffective disorder can resemble—at various times in its course—bipolar disorder, major depressive episode with psychotic features, or schizophrenia .
The schizoaffective disorder classification is applied when a mental health client meets diagnostic criteria for both schizophrenia and an "affective" (mood) disorder— depression or bipolar disorder . In schizoaffective disorder, the experiencing of mood and psychotic symptoms occurs predominantly simultaneously and the mood disturbance is long lasting. However, periods of experiencing serious psychotic symptoms without serious mood disturbance are also a definitive feature. In bipolar disorder and depression with psychotic features, psychotic symptoms only occur during an active episode of mania or severe clinical depression. Schizoaffective disorder is characterized by periods during which psychotic symptoms are experienced without simultaneous severe mood changes. If the patient is encountered for the first time during such a period of psychotic symptoms in the absence of mood changes, it can appear that the individual has schizophrenia. However, in a person who has psychotic symptoms, the presence of long-standing severe mood disturbance suggests possible schizoaffective disorder if there are also periods of psychotic symptoms without concurrent mood fluctuations.
Schizoaffective disorder is typically identified by a process of lengthy observation and elimination of another diagnostic alternative over a long course of care. Because of the need for longitudinal observation and collection of a wealth of information before an accurate diagnosis is possible, most people with schizoaffective disorder have borne other diagnostic labels prior to the schizoaffective diagnosis (usually, bipolar disorder).
Both psychotic symptoms and mood disorder symptoms are experienced by the individual with schizoaffective disorder. In schizoaffective disorder, at least two of the major symptoms of psychosis are evident in the client. Classic psychotic symptoms can occur during mood disturbances as well as in periods without extreme mood changes. Hallucinations , delusions , and strange bodily movements or lack of movements (catatonic behavior) are all psychotic symptoms that may be observed. Additionally, minimal or peculiar speech, lack of drive to act on one's own behalf, bizarre or primitive (socially inappropriate or immature) behavior, a wooden quality to one's emotions, or near-absent emotionality are also typical psychotic symptoms that may occur. Of course, not all of the possible psychotic symptoms will occur concurrently in a single person with schizoaffective disorder. Importantly, to meet the criteria for the schizoaffective disorder diagnosis, delusions or hallucinations (the most "prototypical" of the psychotic symptoms) must be observed within a fairly lengthy period of time during which there is no form of mood disturbance.
An extremely important and challenging aspect of schizoaffective disorder is that mood problems are prominent. During mood episodes, psychotic features are simultaneously evident. The disruption of mood may be depressive, manic, or take the form of a mixed episode (which includes both depressive and manic features). If only depressed mood occurs, the individual is described as having the depressive subtype of schizoaffective disorder. If mixed episodes or manic episodes are noted, the client is identified as having the bipolar form of schizoaffective disorder.
Causes and symptoms
Because clear identification of schizoaffective disorder has traditionally been challenging, scientists have conducted far less research relating to the disorder than studies relating to schizophrenia or mood disorders. However, there are indications that there is a genetic component to the disorder. Close relatives of persons with schizoaffective disorder have higher rates of both schizophrenia and mood disorder. The disorder most typically strikes in early adulthood; in some cases, there appears to be a major trigger—some form of life stress initiating the occurrence of the symptoms. In cases where there is an identifiable stressor involved, the person tends to have a better outcome than when such is not the case. Some evidence suggests that the bipolar form of schizoaffective disorder is more treatable and yields better outcomes than the depressive form.
RELATIONSHIP TO PERSONALITY DISORDER. Persons with personality disorders appear to be more susceptible to developing psychotic reactions in response to stress. One aspect of personality disorder is that, when life becomes more demanding and difficult than can be tolerated, the individual with personality disorder may lapse into a brief psychotic episode. For some individuals, personality disorder may be a predecessor to the development of schizoaffective disorder. Apparently, a chronic problem of lacking effective adult mechanisms for coping with life becomes an ongoing schizoaffective disorder in some predisposed persons. Persons with preexisting schizotypal, paranoid, schizoid, and borderline personality disorders may be more vulnerable to develop a schizoaffective disorder than the general population.
The Diagnostic and Statistical Manual of Mental Disorders , DSM-IV-TR , produced by the American Psychiatric Association, is used by most mental health professionals in North America and Europe to diagnose mental disorders. The DSM-IV-TR provides these major criteria for schizoaffective disorder:
- • At least two symptoms of psychosis from among the following, present for at least one month: Delusions; hallucinations; disorganized speech (strange, peculiar, difficult to comprehend); disorganized (bizarre or child-like) behavior; catatonic behavior; minimal speech (approaching mutism); lack of drive to act on one's own behalf; a wooden quality to one's emotions, or near-absent emotionality.
- • Delusions or hallucinations have occurred for at least two weeks in the absence of prominent mood symptoms.
- • During a "substantial portion" of the period of active illness, the individual meets criteria for one of the following mood disturbances: Major depressive episode, manic episode , mixed episode.
- • The symptoms are not caused by a biologically active entity such as drugs, alcohol, adverse reaction to a medication, physical injury, or medical illness.
Because of the imprecise nature of the diagnosis, the actual rate of brief schizoaffective disorder in adults is unknown. The proportion of schizoaffective disorder identified in persons undergoing treatment for psychiatric disorders has ranged from 2% to almost 30%, depending on the study cited. More females than males (overall) suffer from schizoaffective disorder. However, similar to gender ratios in clinical depression and bipolar disorder, it seems that there is a much higher ratio of women to men in the depressive subtype whereas the bipolar subtype has a more even gender distribution. Thus, the higher ratio of women overall is primarily caused by the concentration of women within the depressive subtype of schizoaffective disorder.
Even using the DSM-IV-TR criteria, identification of schizoaffective disorder remains difficult and relatively subjective. An unusual condition in this set of diagnostic criteria is the need to weigh the relative prominence of the mood symptoms and to identify a period of psychotic symptoms that occurred without significant mood disturbance. In the various other psychotic disorders, there is frequently a low level of depression accompanying the symptoms. When depressive symptoms are the sole form of mood disturbance, only subjective clinical judgment determines whether there has been sufficient severity or duration of that disturbance to merit the possibility of schizoaffective disorder. An additional complication is the cultural relativity of "psychotic symptoms." If the psychotic-like behaviors shown are expected and valued in the person's culture or religion, and these behaviors occur in a traditionally affirming context such as religious services or meditation , then schizoaffective disorder would not be diagnosed.
As stated, schizoaffective disorder is typically identified by a process of lengthy observation and elimination of another diagnostic alternative over a long course of care. A very thorough history of the client's entire past experiences of psychiatric symptoms, mental health treatments, and response to different kinds of medications that have been taken, helps in determining whether that individual is suffering from schizoaffective disorder. Information about current and past experiences is collected in interviews with the client and possibly in discussion with the client's immediate family. Data also may be gathered from earlier medical records with the client's consent. In order to examine the sufferer's ability to concentrate, to remember, to understand his or her situation realistically, and to think logically, the clinician may use a semi-structured interview called a mental status examination. The mental status examination is designed to uncover psychotic or demented thought processes. Psychological assessment instruments, such as the MMPI-2, The Rorschach Inkblot Test, various mood disorder questionnaires, or structured diagnostic interviews, are sometimes used as well to aid in diagnosis. The criteria used by the clinician to classify this constellation of symptoms as schizoaffective disorder are presented in the DSM-IV-TR.
Atypical, novel, or newer-generation antipsychotic medications are very effective in schizoaffective disorder treatment. Examples of atypical or novel antipsychotic medications include risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa). If the patient's psychotic symptoms are acute and accompanied by agitation, a number of different antipsychotics can be used to terminate the flare-up of acute agitated psychosis. Agitation is a state of frantic activity that is often accompanied by anger or marked fearfulness; when in an agitated state, the client is more likely to cause harm to self or others. In agitated psychotic states, the antipsychotic agent haloperidol (Haldol) is often given as an injection, accompanied by other medications that decrease anxiety and slow behavior (often lorazepam , also known as Ativan). At this time, there are no atypical antipsychotics available in an injectable formulation. If the client is not extremely agitated, usually a novel antipsychotic is used, given orally daily, for a lengthier period of time.
In some cases, the antipsychotic medication is not sufficient to overcome the mood disturbance component of the disorder, even though some antipsychotics have thymoleptic (mood-affecting) qualities. Some of the atypical antipsychotic medications are thought to have antidepressant properties, while olanzapine has an FDA approval for the management of acute manic psychosis.
If there is little response to novel antipsychotic monotherapy (treatment with only one medication) an additional compound may be given to target the mood disorder aspect of the illness. The choice of which drug should be added to the medication regimen to decrease mood disorder problems is determined by the subtype of schizoaffective disorder shown by the client. If the client experiences the bipolar form, a mood stabilizer is added, often valproic acid (Depakote), carbamazepine (Tegretol), or lithium (Eskalith or Lithabid). In schizoaffective disorder of the bipolar type, if little response occurs to the usual antipsychotic/mood stabilizer combinations, the mental health consumer may be prescribed clozapine (Clozaril or other generic formulations) which appears to be both anti-psychotic and mood-stabilizing. However, because clozapine has the potential (in a very minute number of cases) to cause lethal alterations in the composition of blood, and because its use requires regular monitoring with recurrent blood testing, it is reserved as a "last-resort" therapy. In cases of the depressive sub-type, psychiatrists may prescribe an antidepressant such as citalopram (Celexa), venlafaxine (Effexor), paroxetine (Paxil), or fluoxetine (Prozac) as an adjunct to the antipsychotic. In certain cases of depressive subtypes, where medications have been ineffective in resolving the extreme mood or where psychosis is so severe as to be life-threatening, electroconvulsive therapy may be utilized. Electroconvulsive therapy has also been shown to be effective in major depressive episode with psychotic features.
Medication is not the only treatment avenue. Supportive psychotherapy and psychoeducation is helpful to decrease the client's fears and to inform the client about the psychiatric illness. Cognitive-behavioral therapy aims to modify the thoughts and behaviors that provoke mood disturbance or prevent full involvement and collaboration in therapy for the mental illness. Psychoeducation and cognitive-behavioral therapy are not effective in lieu of biological therapy, but are enhancing, meaningful components of a "whole-person" approach used in concert with medications for the best possible outcomes.
The prognosis for clients with schizoaffective disorder is largely dependent on the form of the disorder and the presence or absence of a trigger. If there is a major life event as a prompting stressor, or an unusual traumatic experience preceded the occurrence of the disorder, chances for improvement are higher. If there is not a particular triggering event, or if the schizoaffective disorder occurred in an individual with a premorbid personality disorder, the outcome is less likely to be positive. The bipolar form of the disorder may respond better to treatment than the depressive form. Generally, the earlier the disorder is identified and treated, and the fewer lapses from medications, the more positive the outcome.
Given that this disorder appears to have a strong genetic or biologic aspect, society-wide prevention approaches are not likely to be fruitful. However, a promising strategy is to educate physicians, psychologists, and social workers , as well as persons at higher risk for the disorder, about the characteristics and treatability of schizoaffective disorder. Such education of care providers and high-risk individuals would foster early identification and treatment. In schizoaffective disorder, similar to schizophrenia and bipolar disorder, better response is predicted the earlier treatment begins. Because theoretically, severe stressors can be a trigger for this disorder (in some cases), strong social support and immediate post-crisis counseling for severe stress could possibly prevent the development of the disorder in some susceptible persons.
See also Compliance
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.
Fuller, Mark and M. Sajatovic. Drug Information for Mental Health. Hudson, Ohio: Lexi-comp, 2000.
Ferfel D. "Rationale and guidelines for the inpatient treatment of acute psychosis." Journal of Clinical Psychiatry 61, Supplement 14, (2000): 27-32.
Keck, Paul E., S. L. McElroy and Stephan M. Strakowski. "Schizoaffective disorder: role of atypical antipsychotics." Schizophrenia Research 35 (1999): S5-S12.
Levinson, Douglas, C. Umapathy and M. Musthaq. "Treatment of schizoaffective disorder and schizophrenia with mood symptoms." American Journal of Psychiatry 156 (1999): 1138-1148.
Norman, Ross and Laurel A. Townsend. "Cognitive-behavioural therapy for psychosis: A status report." Canadian Journal of Psychiatry 44 (1999): 245-252.
Sajatovic, Martha, Sue Kim Giovanni, Bijan Bastani, Helen Hattab, and Luis F. Ramirez. "Risperidone therapy in treatment refractory acute bipolar and schizoaffective mania." Psychopharmacology Bulletin 32, no. 1 (1996): 55-81.
National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. Telephone: (703) 524-7600. NAMI HelpLine: (800) 950-NAMI (6264). Web site: <www.nami.org> .
National Association for Research on Schizophrenia and Affective Disorders (NARSAD). 60 Cutter Mill Road, Suite 404, Great Neck, NY 11021. Main Line: (516) 829-0091. Infoline: (800) 829-8289. Web site: <www.narsad.org> .
Deborah Rosch Eifert, Ph.D.
Martha Sajatovic, M.D.