Schizoaffective Disorder Clinical Presentation

  • Author: Guy E Brannon, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Feb 16, 2012
 

History

Obtain a complete medical history. Diagnostic criteria for schizoaffective disorder are as follows[16] :

  • An uninterrupted period of illness occurs during which a major depressive episode, a manic episode, or a mixed episode occurs with symptoms that meet criterion A for schizophrenia. The major depressive episode must include criterion A1 (ie, depressed mood).
  • During the same period of illness, delusions or hallucinations occur for at least 2 weeks, in the absence of prominent mood symptoms.
  • Symptoms that meet the criteria for mood episodes are present for a substantial portion of the total active and residual periods of illness.
  • The disturbance is not due to the direct physiologic effects of a substance (eg, illicit drugs, medications) or a general medical condition.
  • 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 episodes).
  • The depressive type is diagnosed if the disturbance includes only major depressive episodes.

Severity scales

Several scales are available for rating the severity of disease in patients with schizophrenia or schizoaffective disorder.

These scales include those for positive and negative symptoms (eg, Positive and Negative Symptom Scale for Schizophrenia [PANSS][17] ) and many for depression and bipolar rating (eg, Hamilton depression scale, Young mania scale). Such tools can be used for baseline and outcome measurements and may be useful in assessing the patient’s progress.

The cut down, annoyed, guilty, and eye opener (CAGE) Questionnaire is useful to inquire about alcohol consumption in patients with schizoaffective disorder.[18]

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Physical Examination

In addition to obtaining a medical history, perform a complete mental status examination, physical examination, and neurologic examination to assist with the evaluation and rule out other disease processes.

Although the mental status examination varies for each patient, there are a number of items that are commonly assessed in most patients with possible schizoaffective disorder. Because of the variability of the presentation of this disorder, any or all symptoms of schizophrenia, bipolar disorder, or major depressive disorder may manifest, depending on the presenting subtype, as follows:

  • 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 elicit responses concerning orientation (ie, person, place, time, situation), ask the patient questions, as follows. “What is your full name?” “Do you know where you are?” “What is the month, date, year, day of the week, and time?” “Do you know why you are here?”
  • Consciousness - levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness.
  • Concentration and attention - Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as serial 7s. Next, ask the patient to spell the word world forward and backward.
  • Reading and writing - Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, “Close your eyes.”). The part of the MMSE evaluates the patient’s ability to sequence.
  • Memory - To evaluate a patient’s memory, have him or her respond to the following prompts. For remote memory, “What was the name of your first grade teacher?” For recent memory, “What did you eat for dinner last night?” For immediate memory, “Repeat these 3 words: pen, chair, flag.” Tell the patient to remember these words. Then, after 5 minutes, have the patient repeat the words.
  • 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)
  • Insight - Range varies
  • Judgment - Range varies

Inquiring about suicidal ideation at each visit is always important, because individuals with schizoaffective disorder have a significant lifetime risk for suicide. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent: “Do you have any thoughts of wanting to harm or kill yourself?” and ”Do you have any thoughts that you would be better off dead?”

If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views suicide to determine if a suicidal gesture or act is ego-syntonic or ego-dystonic. Next, determine if the patient will contract for safety.

Inquiring about homicidal ideation or intent during each patient interview is also important. Ask the following types of questions to help determine homicidal ideation or intent: “Do you have any thoughts of wanting to hurt anyone?” and “Do you have any feelings or thoughts that you wish someone were dead?” If the reply to 1 of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how he or she plans to control these feelings if they occur again.

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Contributor Information and Disclosures
Author

Guy E Brannon, MD  Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Guy E Brannon, MD is a member of the following medical societies: American Medical Association, American Medical Writers Association, American Psychiatric Association, American Society of Addiction Medicine, Association of Clinical Research Professionals, Louisiana State Medical Society, and Southern Medical Association

Disclosure: AstraZeneca Grant/research funds Other; Janssen Grant/research funds Other; Pfizer Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Eli Lilly Grant/research funds Other; Forrest Grant/research funds Other

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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