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| Schizoaffective disorder Classification & external resources | |
| ICD-10 | F25 |
|---|---|
| ICD-9 | 295.70 |
Schizoaffective disorder is a psychiatric diagnosis of a neurobiological nature. It describes a condition where both the symptoms of a mood disorder and schizophrenia are present. A person may manifest impairments in the perception or expression of reality, most commonly manifesting as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking, as well as discrete manic and/or depressive episodes in the context of significant social or occupational dysfunction. The disorder usually begins in early adulthood, although, rarely, it is diagnosed in childhood (prior to age 13). Schizoaffective disorder is more common in women than in men. Despite the greater variety of symptoms, the illness course is more episodic and has an overall more favourable outcome (prognosis) than schizophrenia but worse than mood disorders.
There are two types of schizoaffective disorder: the bipolar type and the depressive type. In general, schizoaffective disorder bipolar type, has a better prognosis than the depressive type, which can result in a residual defect with the passing of time.
The mainstay of treatment is pharmacotherapy with an antipsychotic and an antidepressant or mood stabilizer. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, though hospital stays are less frequent and for shorter periods than they were in previous years.
Some people diagnosed with schizoaffective disorder are likely to be diagnosed with comorbid conditions, including substance abuse.
Children diagnosed with this disorder are highly likey to have other comorbid neurological disorders such as pervasive developmental disorder, autism and learning disabilities.
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Late adolescence and early adulthood are peak years for the onset of schizoaffective disorder, although it can be diagnosed, more rarely, earlier in childhood. These are critical periods in a young adult\'s social and vocational development, and they can be severely disrupted by disease onset.
Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, social worker, clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.
An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizoaffective disorder, tests are carried out to exclude medical illnesses which may rarely present with psychotic symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. It is important to rule out a delirium which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying medical illness. There are several psychiatric illnesses which may present with a similar range of psychotic symptoms; these include bipolar disorder, schizophrenia, drug intoxication, brief drug-induced psychosis, and schizophreniform disorder.
Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, thyroid function if lithium has previously been taken to rule out hypothyroidism, liver function tests if chlorpromazine or CPK to exclude neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.
The most widely used criteria for diagnosing schizoaffective disorder are from the American Psychiatric Association\'s Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR:
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:
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
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:
if the disturbance includes
This subtype applies if a manic episode or mixed episode is part of the presentation. Major Depressive Episodes may also occur.
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.
Many different genes may be contributing to the genetic risk of acquiring this illness. Many different biological and environmental factors are believed to interact to with the person\'s gene\'s increasing or decreasing the person\'s risk. All conditions on the schizophrenia spectrum have been marginally linked to advanced paternal age at the time of conception, a common cause of mutations. [1]
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 optimal psychiatric treatment for schizoaffective disorder is a combination of medicine and therapy. A licensed psychiatrist will prescribe (usually combinations of) medicine for the patient. Each person responds differently to medication. Common medicines used to treat schizoaffective disorder are listed below.
For psychotic symptoms, one or a combination of the following neuroleptic medications are usually prescribed:
For manic symptoms, the following medications may be prescribed along with a neuroleptic:
For depression, the following medications may be prescribed along with a neuroleptic:
In schizoaffective patients with manic symptoms, combining lithium, carbamazepine, or valproate with a neuroleptic has been shown to be superior to neuroleptics alone. Lithium-neuroleptic combinations, however, may produce severe extrapyramidal reactions or confusion in some patients.
When lithium is not effective or well tolerated in manic patients with schizoaffective disorder, Tegretol or Depakote are frequently used. 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, in rare cases, cause liver toxicity and platelet dysfunction. Calcium channel blockers such as verapamil may also be an effective treatment for manic symptoms but are seldom prescribed for that purpose. The degree of benefit for an individual patient should be considered carefully, as each of these medications carries its own risks.
Benzodiazepines such as lorazepam and clonazepam are effective adjunctive treatment agents for acute manic symptoms, but long-term use may result in dependency.
In schizoaffective patients with depressive symptoms, an antidepressant (usually fluoxetine or other SSRIs) will be prescribed with a neuroleptic. The SNRIs and buproprion can exacerbate psychotic symptoms and in general may have a worse side effect profile than the SSRIs in patients with schizoaffective disorder. Recently, the anticonvulsant lamotrigine has shown promise in treating depressed schizoaffective patients.
Often a sleeping pill will initially be prescribed to allow the patient rest from his or her anxiety or hallucinations.
Nutritional supplements and lifestyle changes are being studied to both augment existing treatments as well as to treat often co-morbid conditions such as mitochondrial dysfunctions, adrenal fatigue, sleep disorders, omega-3 fatty acid deficiency and diabetes.
In addition to pharmaceutical medications, some who suffer from schizoaffective disorder claim to benefit from medical marijuana. These claims, however, have not been verified by scientific studies, though a small amount of case studies has found some support for these claims.[2]
Most mental health professionals, however, are against the use of marijuana or other street drugs in patients with schizoaffective disorder because paranoia and other symptoms of psychosis may be exacerbated by marijuana and other street drugs. In point of fact, such patients are usually referred to dual diagnosis treatment facilities which treat both the psychiatric and substance abuse components of the illness.[3]
There is not enough evidence to demonstrate a causal link between marijuana use and the development of schizoaffective disorder. Despite this fact, numerous case studies exist which show that many sufferers of schizoaffective disorder engaged in cannabis use during their early and formative years, suggesting a tentative correlation between a patient\'s use of marijuana, marijuana\'s effect on the developing brain and a resulting tendency for cannabis users to develop schizoaffective disorder. [4]
People with schizoaffective disorder generally have a better outlook than those with schizophrenia, and worse than those with bipolar disorder. However, long-term treatment may be necessary and individual outcomes will vary. As with any chronic illness, compliance to medication is important, especially as more than one medication is often prescribed - most commonly an antipsychotic plus an antidepressant or mood stabilizer.
Complications are similar to those for schizophrenia and major mood disorders. These include:
The term schizoaffective psychosis was coined by Jacob Kasanin in 1933 to describe a more episodic psychotic illness with predominant affective symptoms, what was termed a good-prognosis schizophrenia.Goodwin & Jamison. p102
Schizoaffective disorder was included as a subtype of schizophrenia in DSM I and DSM II, though research showed a schizophrenic cluster of symptoms in individuals with a family history of mood disorders whose illness course, other symptoms and treatment outcome were otherwise more akin to the manic phase of a bipolar disorder. DSM III placed schizoaffective disorder in psychotic disorders Not Otherwise Specified before being formally recognized in DSM III-R.Goodwin & Jamison. p96
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