Schizoaffective Disorder

Schizoaffective disorder is a mental disorder that is marked by 2 components: a psychotic component (hallucinations or delusions) and a mood component (mania or depression). Patients must therefore meet the diagnostic criteria for both major mood disorder and schizophrenia. Confirming the timing of symptoms is the key to successfully diagnosing this disorder, which is often misdiagnosed. The treatment regimen consists of psychotherapy as well as pharmacotherapy with antipsychotics, antidepressants, and mood stabilizers, similar to the approaches used for schizophrenia and mood disorders.

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Overview

Definition

Schizoaffective disorder is a complex mental disorder that includes 2 components:

  • Psychotic component (hallucinations, delusions, disorganized speech or behavior)
  • Mood component (mania or depression)

Classification

Based on the mood symptoms, there are 2 subtypes:

  • Depressive type: no active or past manic phase
  • Bipolar type: active manic phase or history of manic phase

Epidemiology

  • Lifetime prevalence: 0.32%
  • Women are more commonly affected than men.
  • Young patients tend to have the bipolar subtype.
  • Older patients tend to have the depressive subtype.

Pathophysiology

  • The exact pathophysiology is still unknown.
  • Initially assumed to be a subtype of schizophrenia
  • The disorder may be caused by abnormalities in 1 of the following:
    • Imbalance in brain neurotransmitters: 
      • Serotonin
      • Norepinephrine
      • Dopamine
    • Structural brain abnormalities:
      • Reduced hippocampal volumes 
      • Thalamic abnormalities
      • White matter abnormalities
  • Risk factors:
    • 1st-degree relative with schizoaffective disorder, schizophrenia, or bipolar disorder
    • Stressful or traumatic life events
    • Drug consumption

Diagnosis

DSM-V diagnostic criteria

Diagnostic criteria include the following:

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or unusual behavior
  • Negative symptoms:
    • Flat affect
    • Avolition
    • Anhedonia
    • Poor attention
    • Alogia
  • History of 1 major mood episode (mania or depression) 
  • History of 1 episode of psychotic symptoms (hallucinations or delusions) without mood symptoms
  • Substance use and other medical conditions as causes for the symptoms must be excluded.

Further considerations

It is important to distinguish schizoaffective disorder from mood disorders with psychotic features:

  • Psychotic symptoms must be present without mood symptoms for an episode lasting at least 2 weeks.
  • Mood symptoms are usually still present for the majority of the course of illness.
  • Schizoaffective disorder: Psychotic symptoms can be present without mood symptoms.
  • Mood disorders with psychotic features: Psychotic symptoms can be present only during mood symptoms.

Management and Complications

Psychotherapy

Psychotherapy and psychoeducation have proven to be helpful.

Pharmacotherapy

The pharmacologic therapy utilized depends on the disease subtype:

  • Depressive type: antipsychotic + antidepressant (selective serotonin reuptake inhibitor (SSRI)) → (note: use antidepressants carefully due to risk of increased psychotic/manic symptoms)
  • Bipolar type: antipsychotic + mood stabilizer (lithium, valproic acid)

Complications

  • Suicide or suicide attempts 
  • Social isolation
  • Unemployment, poverty, homelessness
  • Further health problems
  • Anxiety disorders
  • Alcohol or other substance use disorders

Differential Diagnosis

  • Mood disorders with psychotic features: depression or mania with psychotic features (hallucinations, delusions) that occur only during the mood episode. In schizoaffective disorder, patients must experience a period of at least 2 weeks in which they experience psychotic features without the presence of any mood symptoms. 
  • Schizophrenia: a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. Schizophrenia is associated with a decline in both cognitive and social functioning. Treatment includes antipsychotics in conjunction with behavioral therapy. Schizoaffective disorder is differentiated by a major mood disorder (manic or depressive) that is present for the majority of the illness. Unlike in schizophrenia, schizoaffective disorder does not require a 6-month period of prodromal symptoms to be diagnosed. 

References

  1. Wy TJP, Saadabadi A. Schizoaffective Disorder. (2020). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/
  2. Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 7, Schizophrenia spectrum and other psychotic disorders, pages 300-346. Philadelphia, PA: Lippincott Williams and Wilkins.
  3. Mojtabai, R. (2021). Brief psychotic disorder. UpToDate. Retrieved March 18, 2021, from https://www.uptodate.com/contents/brief-psychotic-disorder
  4. National Alliance on Mental Illness. Schizoaffective Disorder. Retrieved June 14, 2021, from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-Disorder

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