The essential feature of Schizoaffective Disorder is an uninterrupted period of illness during which, at some time, there is a Major Depressive, Manic, or Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia (Criterion A). In addition, during the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms (Criterion B). Finally, the mood symptoms are present for a substantial portion of the total duration of the illness (Criterion C). The symptoms must not be due to the direct physiological effects of a substance (e.g., cocaine) or a general medical condition (e.g., hyperthyroidism or temporal lobe epilepsy) (Criterion D). To meet criteria for Schizoaffective Disorder, the essential features must occur within a single uninterrupted period of illness. The phrase "period of illness" as used here refers to a time period during which the individual continues to display active or residual symptoms of psychotic illness. For some individuals, this period of illness may last for years or even decades. A period of illness is considered to have ended when the individual has completely recovered for a significant interval of time and no longer demonstrates any significant symptoms of the disorder.
The phase of the illness with concurrent mood and psychotic symptoms is characterized by the full criteria being met for both the active phase of Schizophrenia (i.e., Criterion A) and for a Major Depressive Episode, a Manic Episode, or a Mixed Episode. The duration of the Major Depressive Episode must be at least 2 weeks; the duration of the Manic or Mixed Episode must be at least 1 week.
Because the psychotic symptoms must have a total duration of at least 1 month to meet Criterion A for Schizophrenia, the minimum duration of a schizoaffective episode is also 1 month. An essential feature of a Major Depressive Episode is the presence of either depressed mood or markedly diminished interest or pleasure. Because loss of interest or pleasure is so common in nonaffective Psychotic Disorders, to meet Criterion A for Schizoaffective Disorder the Major Depressive Episode must include pervasive depressed mood (i.e., the presence of markedly diminished interest or pleasure is not sufficient). The phase of the illness with psychotic symptoms alone is characterized by delusions or hallucinations that last at least 2 weeks. Although some mood symptoms may be present during this phase, they are not prominent. This determination can be difficult and may require longitudinal observation and multiple sources of information.
The symptoms of Schizoaffective Disorder may occur in a variety of temporal patterns. The following is a typical pattern: An individual may have pronounced auditory hallucinations and persecutory delusions for 2 months before the onset of a prominent Major Depressive Episode. The psychotic symptoms and the full Major Depressive Episode are then present for 3 months. Then, the person recovers completely from the Major Depressive Episode, but the psychotic symptoms persist for another month before they too disappear. During this period of illness, the individual's symptoms concurrently met criteria for a Major Depressive Episode and Criterion A for Schizophrenia, and, during this same period of illness, auditory hallucinations and delusions were present both before and after the depressive phase. The total period of illness lasted for about 6 months, with psychotic symptoms alone present during the initial 2 months, both depressive and psychotic symptoms present during the next 3 months, and psychotic symptoms alone present during the last month. In this instance, the duration of the depressive episode was not brief relative to the total duration of the psychotic disturbance, and thus the presentation qualifies for a diagnosis of Schizoaffective Disorder.
Criterion C for Schizoaffective Disorder specifies that mood symptoms that meet criteria for a mood episode must be present for a substantial portion of the entire period of illness. If the mood symptoms are present for only a relatively brief period of time, the diagnosis is Schizophrenia, not Schizoaffective Disorder. In evaluating this criterion, the clinician should determine the proportion of time during the continuous period of psychotic illness (i.e., both active and residual symptoms) in which there were significant mood symptoms accompanying the psychotic symptoms. The operationalization of what is meant by "a substantial portion of time" requires clinical judgment. For example, an individual with a 4-year history of active and residual symptoms of Schizophrenia develops a superimposed Major Depressive Episode that lasts for 5 weeks during which the psychotic symptoms persist. This presentation would not meet the criterion for "a substantial portion of the total duration" because the symptoms that meet criteria for a mood episode occurred for only 5 weeks out of a total of 4 years of disturbance. The diagnosis in this example remains Schizophrenia with the additional diagnosis of Depressive Disorder Not Otherwise Specified to indicate the superimposed Major Depressive Episode.
Two subtypes of Schizoaffective Disorder may be noted based on the mood component of the disorder:
Bipolar Type. This subtype applies if a Manic Episode or Mixed Episode is part of the presentation. Major Depressive Episodes may also occur.
Depressive Type. This subtype applies if only Major Depressive Episodes are part of the presentation.
Symptoms & Signs
For decades there has been controversy about whether patients with admixtures of schizophrenic and mood symptoms were suffering from schizophrenia, an atypical variety of bipolar disorder, or a separate disorder entirely. A number of diagnostic labels have been applied to this group of patients, including (but not limited to) cycloid psychosis, atypical schizophrenia, good-prognosis schizophrenia, and remitting schizophrenia. The term "schizoaffective disorder," originated by Jacob S. Kasanin in 1933, has prevailed, although the boundaries with other disorders are still debated. In modern diagnostic practice, many of these patients are diagnosed as having psychotic mood disorders.
Patients with schizoaffective disorder display psychotic symptoms consistent with the acute phase of schizophrenia, but these symptoms are frequently accompanied by prominent manic or depressive symptomatology. At other times, schizophrenic symptoms unaccompanied by mood symptoms are present. Schizoaffective disorder is further divided into bipolar (history of manic episodes) and depressive types. The DSM-IV criteria for this disorder are shown in Table 19-3.
Natural History & Prognosis
Schizoaffective disorder can present at any age, but it is most commonly first seen in young adulthood. Prognosis can be estimated from the relative prominence of schizophrenic and mood symptoms; more prominent and persistent schizophrenic symptoms are associated with poorer outcome, whereas more frequent and persistent mood symptoms predict more positive outcome. The presence of mood-congruent delusions and hallucinations (eg, the belief by a depressed woman that she has sinned or a manic individual's belief that he or she is the Messiah) predicts better outcome than mood-incongruent psychotic symptoms. Age of onset may also be a factor, as the functional status of adolescents diagnosed with schizoaffective disorder resembles that of schizophrenia more than it does mood disorders.
Etiology & Pathogenesis
Although the causes of schizoaffective disorder are unknown, it is suspected that this diagnosis represents a heterogeneous group of patients, some with atypical forms of schizophrenia and some with very severe 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.
Associated Features and Disorders
There may be poor occupational functioning, a restricted range of social contact, difficulties with self-care, and increased risk of suicide associated with Schizoaffective Disorder. Residual and negative symptoms are usually less severe and less chronic than those seen in Schizophrenia. Anosognosia (i.e., poor insight) is also common in Schizoaffective Disorder, but the deficits in insight may be less severe and pervasive than in Schizophrenia. Individuals with Schizoaffective Disorder may be at increased risk for later developing episodes of pure Mood Disorder (e.g., Major Depressive or Bipolar Disorder) or of Schizophrenia or Schizophreniform Disorder. There may be associated Alcohol and other Substance-Related Disorders. Limited clinical evidence suggests that Schizoaffective Disorder may be preceded by Schizoid, Schizotypal, Borderline, or Paranoid Personality Disorder.
Specific Culture, Age, and Gender Features
For additional discussion of culture, age, and gender factors relevant to evaluating psychotic symptoms, see the text for Schizophrenia, and for a discussion of such factors relevant to diagnosing Mood Disorders. Schizoaffective Disorder, Bipolar Type, may be more common in young adults, whereas Schizoaffective Disorder, Depressive Type, may be more common in older adults. The incidence of Schizoaffective Disorder is higher in women than in men - a difference that is mostly accounted for by an increased incidence among women of the Depressive Type.
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.
Detailed information is lacking, but Schizoaffective Disorder appears to be less common than Schizophrenia.
The typical age at onset of Schizoaffective Disorder is early adulthood, although onset can occur anywhere from adolescence to late in life. The prognosis for Schizoaffective Disorder is somewhat better than the prognosis for Schizophrenia, but considerably worse than the prognosis for Mood Disorders. Substantial occupational and social dysfunction are common. The presence of precipitating events or stressors is associated with a better prognosis. The outcome for Schizoaffective Disorder, Bipolar Type, may be better than that for Schizoaffective Disorder, Depressive Type.
There is substantial evidence that there is an increased risk for Schizophrenia in first-degree biological relatives of individuals with Schizoaffective Disorder. Most studies also show that relatives of individuals with Schizoaffective Disorder are at increased risk for Mood Disorders.
General medical conditions and substance use can present with a combination of psychotic and mood symptoms. Psychotic Disorder Due to a General Medical Condition, a delirium, or a dementia is diagnosed when there is evidence from the history, physical examination, or laboratory tests indicating that the symptoms are the direct physiological consequence of a specific general medical condition. Substance-Induced Psychotic Disorder and Substance-Induced Delirium are distinguished from Schizoaffective Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the symptoms.
Distinguishing Schizoaffective Disorder from Schizophrenia and from Mood Disorder With Psychotic Features is often difficult. In Schizoaffective Disorder, there must be a mood episode that is concurrent with the active-phase symptoms of Schizophrenia, mood symptoms must be present for a substantial portion of the total duration of the disturbance, and delusions or hallucinations must be present for at least 2 weeks in the absence of prominent mood symptoms. In contrast, mood symptoms in Schizophrenia either have a duration that is brief relative to the total duration of the disturbance, occur only during the prodromal or residual phases, or do not meet full criteria for a mood episode. If psychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is Mood Disorder With Psychotic Features. In Schizoaffective Disorder, symptoms should not be counted toward a mood episode if they are clearly the result of symptoms of Schizophrenia (e.g., difficulty sleeping because of disturbing auditory hallucinations, weight loss because food is considered poisoned, difficulty concentrating because of psychotic disorganization). Loss of interest or pleasure is common in nonaffective Psychotic Disorders; therefore, to meet Criterion A for Schizoaffective Disorder, the Major Depressive Episode must include pervasive depressed mood.
Because the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, the appropriate diagnosis for an individual episode of illness may change from Schizoaffective Disorder to Schizophrenia (e.g., a diagnosis of Schizoaffective Disorder for a severe and prominent Major Depressive Episode lasting 3 months during the first 6 months of a chronic psychotic illness would be changed to Schizophrenia if active psychotic or prominent residual symptoms persist over several years without a recurrence of another mood episode). The diagnosis may also change for different episodes of illness separated by a period of recovery. For example, an individual may have an episode of psychotic symptoms that meet Criterion A for Schizophrenia during a Major Depressive Episode, recover fully from this episode, and then later develop 6 weeks of delusions and hallucinations without prominent mood symptoms. The diagnosis in this instance would not be Schizoaffective Disorder because the period of delusions and hallucinations was not continuous with the initial period of disturbance. Instead, the appropriate diagnoses for the first episode would be Mood Disorder With Psychotic Features, In Full Remission, and Schizophreniform Disorder (Provisional) for the current episode.
Mood disturbances, especially depression, commonly develop during the course of Delusional Disorder. However, such presentations do not meet criteria for Schizoaffective Disorder because the psychotic symptoms in Delusional Disorder are restricted to nonbizarre delusions and therefore do not meet Criterion A for Schizoaffective Disorder.
If there is insufficient information concerning the relationship between psychotic and mood symptoms, Psychotic Disorder Not Otherwise Specified may be the most appropriate diagnosis.
Diagnostic criteria for Schizoaffective Disorder
A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.
Note: The Major Depressive Episode must include Criterion A1: depressed mood.
B. During the same period of illness, there have been delusions or hallucinations for at least 2 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.
Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes)
Depressive Type: if the disturbance only includes Major Depressive Episodes
- phototherapy (light therapy) is preferential treatment
- MAO inhibitor or fluoxetine
Most schizoaffective patients require neuroleptic medication, often on a long-term basis, to control psychotic symptoms, as well as treatment for mood symptoms.
Combining lithium, carbamazepine, or valproate with a neuroleptic has been shown to be superior to neuroleptics alone in schizoaffective patients with manic symptoms. The degree of benefit for an individual patient should be considered carefully, as each of these agents carries an additional set of risks. Lithium-neuroleptic combinations may produce severe extrapyramidal reactions or confusion in some patients. Carbamazepine or valproate are frequently employed when lithium is not effective or well tolerated. 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 cause liver toxicity and platelet dysfunction, although those problems are uncommon. More recently, the anticonvulsants lamotrigine and gabapentin have shown promise in the treatment of manic symptoms, although there have been no systematic studies of their use in schizoaffective disorder at this time. Calcium channel blockers such as verapamil may also be an effective treatment for manic symptoms but are seldom prescribed for that purpose. Benzodiazepines such as lorazepam and clonazepam are effective adjunctive treatment agents for acute manic symptoms, but long-term use may result in dependency.
Treatment of the schizoaffective depressed patient has not been studied as well as the schizoaffective patient with mania. Administration of a neuroleptic drug is required, but it is not clear whether adding an antidepressant is beneficial. Preliminary evidence suggests that atypical neuroleptics have antidepressant properties. If so, they would become the preferred choice in these patients. Continued depressive symptoms might necessitate the addition of antidepressant medication. Although the utility of lithium, carbamazepine, or valproate in the treatment of schizoaffective depression has not been clearly established, patients who have histories of manic episodes in the past will need to be on mood stabilizers to minimize the risk of antidepressant-induced switches into mania. Polypharmacy of this type requires monitoring for drug interactions. Manic symptoms can occur when antidepressants are administered, particularly in patients with a prior history of those symptoms, even when a mood stabilizer is being used. Tricyclics are the worst offenders, whereas selective serotonin reuptake inhibitors (SSRIs) and bupropion are less likely to induce mania. Administration of multiple drugs with anticholinergic properties can create toxicity, including delirium. Lower-potency standard neuroleptics such as chlorpromazine and thioridizine, most tricyclic antidepressants and monoamine oxidase (MAO) inhibitors, and agents such as benztropin used to treat drug-induced parkinsonism are common offenders. Of the newer medications, clozapine, the SSRI paroxetine, and the atypical neuroleptic olan-zapine also have anticholinergic activity. Carbamazepine induces hepatic enzymes and may result in increased serum levels of other medications, and some antidepressants, particularly fluoxetine, inhibit metabolism of many drugs through action on the cytochrome P450 system. Thus, dosages of medications may have to be adjusted downward when they are added. Many clinicians are choosing to minimize the drawbacks of polytherapy by using atypical neuroleptics for psychotic symptoms and by choosing newer antidepressants rather than tricyclics. Newer antidepressants are also much safer in overdose, an important consideration in depressed psychotic patients. They may be indicated when there is a history of previous positive response, when other drugs have failed, or when there is a history of manic episodes. Both lithium and heterocyclic antidepressants are effective prophylactic agents in recurrent unipolar depression. Newer drugs are still under study, and their effectiveness in preventing recurrences of schizoaffective depression has not been demonstrated.
Illustrative Case 1
A 65-year-old man of German descent had been hospitalized frequently since his 30s for an illness characterized in part by auditory hallucinations and paranoid delusions. After each hospitalization, he recovered enough to return to his full-time job. On retiring, he took up residence in a downtown hotel while receiving injections of depot fluphenazine. Within a few months he became markedly depressed. A trial of tricyclic antidepressant drugs resulted in a euphoric mood accompanied by pressured speech, insomnia, and poor judgment. The antidepressant medication was discontinued, but the depression returned within a few months, and the patient was hospitalized.
On admission to the hospital, the patient was severely slowed in his movements and speech and walked with a stooped gait. He slept poorly and had little appetite. He insisted that therapeutic efforts were best spent on other patients, because he was a worthless person for whom there was no hope. He wanted to be dead but lacked the initiative or "courage" to commit suicide. There were no delusions or hallucinations apparent, and his speech was well organized and logical. He responded dramatically within 10 days after resumption of the antidepressant drug in a lower dosage. A diagnosis of bipolar disorder was made, and prophylactic lithium treatment was begun. The fluphenazine was discontinued.
Several months later the patient discontinued lithium because of a tremor and began to pace around his hotel, sleeping poorly and eating only one meal daily. He also stopped bathing and shaving. He presented himself again to the hospital in a filthy, dis-heveled state; he was lice ridden and had lost 20 pounds. He was not visibly depressed or elated but was negativistic and turned his head and glared frequently as if responding to a voice. After several days of treatment with moderate doses of haloperidol, he began to respond to questioning by his physician. He denied having been depressed and insisted that nothing was wrong with him. He admitted hearing women singing happy German children's songs and often sang along with them. He also discussed his belief that Jews were attempting to harm him and his grandchildren as retaliation for what the Germans had done to them during World War II. He claimed that he had felt this way for years but often avoided discussing it with his doctors. He described a series of seemingly ordinary incidents that had happened through the years that he felt proved his point.
Illustrative Case 2
A 44-year-old divorced black male presented with a 20-year history of traveling about the country, almost annual psychiatric hospitalizations, and alcohol abuse. The usual diagnosis had been paranoid schizophrenia. Two months before his latest request for inpatient care he had been started on lithium treatment for the first time but discontinued it because of increased urination and dysuria. He also stopped taking the chlorpromazine that had been prescribed. He complained of sleeplessness and weight loss and became loud and belligerent when his need for hospitalization was questioned.
Mental status examination revealed a guarded, somewhat sarcastic, physically thin man who spoke in increasingly loud tones with a considerable degree of pressure and circumstantiality. His behavior on the ward was intrusive and loud, and he slept little. His mood was irritable, and he was frequently pacing, talking, or otherwise active. When questioned about auditory hallucinations, he became extremely defensive and denied hearing voices. He did say, however, that he sometimes picked up information from "the wrong channel" but ignored it. He had gotten "into trouble" in the past when he paid attention to what he had heard.
Treatment was started with lithium. Small doses of haloperidol had to be added temporarily because his pressured, irritable manner caused conflicts with other patients. After 1 week his behavior was considerably subdued, but it became apparent that he was hallucinating. He spent most of the day off the ward in animated conversation with nonexistent persons. At that point serum lithium levels were within the therapeutic range. Addition of haloperidol in standard doses eliminated the hallucinations, but withdrawal of lithium resulted in a return of manic behavior.