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Schizoaffective Disorder

Background: Schizoaffective disorder is a perplexing mental illness

distinguished by a combination of symptoms of a thought disorder or other
psychotic symptoms such as hallucinations or delusions (schizophrenia
component) and those of a mood disorder (depressive or manic component).
The coupling of symptoms from these divergent spectrums makes treating
patients who are schizoaffective difficult.

Schizoaffective disorder is defined using the Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria
or by International Classification of Diseases, Tenth Revision (ICD-10) coding.
Schizoaffective disorder has features of both schizophrenia, including
hallucinations, delusions, and distorted thinking, and a mood component, such
as depression or mania.

The diagnosis is made when the patient has features of both illnesses but
does not strictly meet diagnostic criteria for either schizophrenia or a mood
disorder alone. Making the diagnosis of schizoaffective disorder can be difficult
because it encompasses 2 other diagnostic entities, namely schizophrenia and
mood disorders. 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.

Men with schizoaffective disorder tend to exhibit antisocial personality

traits. The age of onset is later for women than for men, and the exact etiology
and epidemiology is unclear due to limited research in this area. Schizoaffective
disorder is thought to have a better prognosis than schizophrenia. Treatment
consists of both pharmacotherapy and psychotherapy.

• In the US: The lifetime prevalence of schizoaffective disorder is thought

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to be less than 1%, with a range of 0.5-0.8%. This is only an estimate because
no studies have been performed.

• Internationally: The international prevalence rates are difficult to

determine because the diagnostic criteria have changed over the past few
years. However, estimates range from 2-2.9%.

Race: No difference in diagnosis is observed based on race.

Sex: Schizoaffective disorder is more common in women than in men.

Age: Younger people with schizoaffective disorder tend to have a

diagnosis with the bipolar subtype, whereas older people tend to exhibit the
depressive subtype.

• Diagnostic criteria for schizoaffective disorder are as follows:

o An uninterrupted period of illness occurs during which, at some

time, a major depressive episode, a manic episode, or a mixed episode occurs
concurrent with symptoms that meet criterion A for schizophrenia. The major
depressive episode must include criterion A1, ie, depressed mood.

o During the same period of illness, delusions or hallucinations occur

for at least 2 weeks, in the absence of prominent mood symptoms.

o Symptoms that meet the criteria for mood episodes are present for a
substantial portion of the total duration of the active and residual periods of the
illness.

o The disturbance is not due to the direct physiological effects of a

substance (eg, drug abuse, medications) or a general medical condition.

o 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
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episodes).

o The depressive type is diagnosed if the disturbance includes only

major depressive episodes.

Because of the variability of the presentation of the disorder, any or all

symptoms of schizophrenia, bipolar disorder, or major depressive disorder may
manifest depending on the presenting subtype.

• 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 person, place, or situation is confused

• 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)
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• Insight - Range varies

• Judgment - Range varies

• If patients are suicidal, homicidal, or gravely disabled, admit them to an
inpatient psychiatric unit. Inpatient treatment is mandatory for patients who are
dangerous to themselves or others or for patients who cannot take care of
themselves.

• Patients who are schizoaffective can benefit greatly from psychotherapy.

o They should receive therapy that involves their families, develops

their social skills, and focuses on cognitive rehabilitation.

o Psychotherapies should include supportive therapy and assertive

community therapy in addition to individual and group forms of therapy.

• Family involvement is needed in the treatment of this particular disorder.

• Treatment includes education about the disorder and its treatment, family
assistance in compliance with medications and appointments, and maintenance
of structured daily activities (ie, schedule of daily events) for the patient.

Several medications are used to treat schizoaffective disorder. Agent

selection depends on whether the depressive or manic subtype is present. In
the depressive subtype, combinations of antidepressants (eg, sertraline,
fluoxetine) plus an antipsychotic (eg, haloperidol, risperidone, olanzapine) are
used. In refractory cases, clozapine has been used as an antipsychotic agent.
In the manic subtype, combinations of mood stabilizers (eg, lithium,
carbamazepine, divalproex) plus an antipsychotic are used. Of the many
medications and combinations available to treat schizoaffective disorder, a few
are reviewed below.

Further Inpatient Care:

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• Patients may require further inpatient care if they represent a danger to

themselves or to others or they are gravely disabled.

Further Outpatient Care:

• For best results, patients require medication management and therapy.

o Patients with schizoaffective disorder often lack judgment and

insight into their illness. They commonly refuse to continue the medications
started in the hospital once they are discharged. This also could be due to
adverse effects of the medication, such as sedation and weight gain.

o Patients who are schizoaffective begin to feel better as a result of

their medications and believe that they no longer need to take them. This leads
to the discontinuation of medication and results in the patient returning to the
hospital within the next several weeks or so.

o If possible, select medications that allow once-a-day dosing or those

that are long acting, such as decanoate injections, to help with patient
compliance.

o Also, discuss compliance with a family member. Always discuss all

the risks, benefits, adverse effects, and alternatives of each medication with the
patient and family.