eMedicine Specialties > Psychiatry > Adult

Schizoaffective Disorder

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
Contributor Information and Disclosures

Updated: Jun 3, 2009

Introduction

Background

The term schizoaffective disorder was coined by Dr. Jacob Kasanin in 1933. 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. Unfortunately, determining if a patient has 2 separate illnesses (schizophrenia or a mood disorder), a combination of illnesses (schizophrenia and a mood disorder), or perhaps even a distinct and separate illness apart from schizophrenia or a mood disorder is difficult. 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 because of limited research in this area. Patients with schizoaffective disorder are thought to have a better prognosis than that of patients with schizophrenia. Treatment consists of both pharmacotherapy and psychotherapy.

Pathophysiology

Although the exact etiology of schizoaffective disorder is unknown, it may involve the balance of dopamine and serotonin in the brain.1  Others believe that it may be due to in utero exposure to viruses, malnutrition, or even birth complications.

Frequency

United States

The lifetime prevalence of schizoaffective disorder is thought to be approximately 0.32%2 , with a range of 0.5-0.8%3 . This rate is only an estimate because no studies have been performed.

International

The international prevalence rates are difficult to determine because the diagnostic criteria have changed over the last few years.

Mortality/Morbidity

The prognosis for patients with schizoaffective disorder is thought to lie between that of patients with schizophrenia and that of patients with a mood disorder. That is, the prognosis is better with schizoaffective disorder than with schizophrenic disorder but worse than with a mood disorder alone.

  • Individuals with the bipolar subtype are thought to have a prognosis similar to those with bipolar type I, whereas the prognosis of people with the depressive subtype is thought to be similar to that of people with schizophrenia. Overall, determination of the prognosis is difficult.
  • The incidence of suicide is estimated at 10% (Williams, 1998). Also consider difference in suicide attempts among different ethnic groups. Caucasian individuals have a higher rate of suicide than African Americans. Persons who immigrated to a country have higher suicide rates then people born in that country. In regards to gender, women attempt suicide more than men, but men complete suicide more often.1
  • Schizoaffective disorder affects more women than men, but this appears to be influenced the fact that more women are in the depressive subtype as compared with the bipolar subtype.
  • A poor prognosis in patients with schizoaffective disorder is generally associated with a poor premorbid history, an insidious onset, no precipitating factors, a predominant psychosis, negative symptoms, an early onset, an unremitting course, or their having a family member with schizophrenia.

Race

No race-based difference in diagnosis is observed.

Sex

Schizoaffective disorder is more common in women than in men. Men with schizoaffective disorder tend to exhibit antisocial traits and behavior in contrast to other personality traits. In addition, the age of onset is later for women than for men, and the exact etiology and epidemiology is unclear because of limited research in this area.

Age

Young people with schizoaffective disorder tend to have a diagnosis with the bipolar subtype, whereas older people tend to have the depressive subtype.

Clinical

History

  • Diagnostic criteria for schizoaffective disorder are as follows:4

    • 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.

Physical

Obtain a complete medical history, and 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, examples of items to assess are listed below. 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. Remember that individuals with this disorder have a lifetime risk for suicide, which is significant. Inquiring about suicidal ideation at each visit is always important. 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?" "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. 
  • Homicidal ideation - May or may not be present. 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?" "Do you have any feelings or thoughts that you wish someone were dead?" If the reply to one 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.
  • 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

Causes

Although the cause of schizoaffective disorder is unknown, the cause may be similar to schizophrenia nature versus nurture. To date, no specific genetic markers have been identified. Environmental causes of malnutrition, viral infections, or complication at birth may play a role. Finally, abnormalities of the neurotransmitters serotonin, norepinephrine, and/or dopamine could all have a role in this disorder. More research is needed to fully elucidate the causes of schizoaffective disorder.

More on Schizoaffective Disorder

Overview: Schizoaffective Disorder
Differential Diagnoses & Workup: Schizoaffective Disorder
Treatment & Medication: Schizoaffective Disorder
Follow-up: Schizoaffective Disorder
References
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References

  1. Kaplan HI, Sadock BJ, eds. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. New York, NY: Lippincott Williams & Wilkins; 2003:508-11.

  2. Perälä J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. Jan 2007;64(1):19-28. [Medline].

  3. Azorin JM, Kaladjian A, Fakra E. [Current issues on schizoaffective disorder]. Encephale. May-Jun 2005;31(3):359-65. [Medline].

  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000:319-23.

  5. Addington DE, Pantelis C, Dineen M, et al. Efficacy and tolerability of ziprasidone versus risoeridone in patients with acute exacerbation of schizophrenia or schizoaffective disorder: an 8 week, double blind, multicenter trial. J Clin Psychiatry. 2004;65(12):1624-33. [Medline].

  6. Baethge C. Long-term treatment of schizoaffective disorder: review and recommendations. Pharmacopsychiatry. Mar-Apr 2003;36(2):45-56. [Medline].

  7. Baethge C, Gruschka P, Berghofer A, et al. Prophylaxis of schizoaffective disorder with lithium or carbamazepine: outcome after long-term follow up. J Affective Disord. 2004;79(1-3):43-50. [Medline].

  8. Basu R, Brar JS, Chengappa KN, et al. The prevalence of the metabolic syndrome in pateints with schizoaffective disorder - bipolar type. Bipolar Disord. 2004;6(4):314-8. [Medline].

  9. Bhatia T, Thomas P, Semwal P, Thelma BK, Nimgaonkar VL, Deshpande SN. Differing correlates for suicide attempts among patients with schizophrenia or schizoaffective disorder in India and USA. Schizophr Res. Sep 2006;86(1-3):208-14. [Medline].

  10. Bogan AM, Brown ES, Suppes T. Efficacy of divalproex therapy for schizoaffective disorder. J Clin Psychopharmacol. Oct 2000;20(5):520-2. [Medline].

  11. Brenner CA, Sporns O, Lysaker PH, O'Donnell BF. EEG synchronization to modualted auditory tones in schizophrenia, schizoaffective disorder, and schizotypal personality disorder. Am J Psychiatry. 2003;160(12):2238-40. [Medline].

  12. Brewerton TD. The phenomenology of psychosis associated with complex partial seizure disorder. Ann Clin Psychiatry. Mar 1997;9(1):31-51. [Medline].

  13. Centorrino F, Kelleher JP, Berry JM, et al. Pilot comparison of extented-release and standard preparations of divalproex sodium in patients with bipolar and schizoaffective disorder. Am J Psychiatry. 2003;160(7):1348-50. [Medline]. [Full Text].

  14. Ciapparelli A, Dell''Osso L, Bandettini di Poggio A, et al. Clozapine in treatment-resistant patients with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder: a naturalistic 48-month follow-up study. J Clin Psychiatry. Apr 2003;64(4):451-8. [Medline].

  15. Ciapparelli A, Dell''Osso L, Pini S, et al. Clozapine for treatment-refractory schizophrenia, schizoaffective disorder, and psychotic bipolar disorder: a 24-month naturalistic study. J Clin Psychiatry. May 2000;61(5):329-34. [Medline].

  16. Dietrich DE, Kropp S, Emrich HM. Oxcarbazepine in affective and schizoaffective disorders. Pharmacopsychiatry. Nov 2001;34(6):242-50. [Medline].

  17. Douglass AB. Narcolepsy: differential diagnosis or etiology in some cases of bipolar disorder and schizophrenia?. CNS Spectr. Feb 2003;8(2):120-6. [Medline].

  18. Emsley R, Rabinowitz J, Torreman M,. The factor structure for the Positive and Negative Syndrome Scale (PANSS) in recent-onset psychosis. Schizophr Res. May 1 2003;61(1):47-57. [Medline].

  19. Etter M, Etter JF. Alcohol consuption and the CAGE test in outpatients with schizophrenia or schizoaffective disorder and in the general population. Schizophrenia Bull. 2004;30(4):947-56. [Medline].

  20. Evans JD, Heaton RK, Paulsen JS, et al. Schizoaffective disorder: a form of schizophrenia or affective disorder?. J Clin Psychiatry. Dec 1999;60(12):874-82. [Medline].

  21. Ghaemi SN, Goodwin FK. Use of atypical antipsychotic agents in bipolar and schizoaffective disorders: review of the empirical literature. J Clin Psychopharmacol. Aug 1999;19(4):354-61. [Medline].

  22. Gunasekara NS, Spencer CM, Keating GM. Spotlight on ziprasidone in schizophrenia and schizoaffective disorder. CNS Drugs. 2002;16(9):645-52. [Medline].

  23. Gunasekara NS, Spencer CM, Keating GM. Ziprasidone: a review of its use in schizophrenia and schizoaffective disorder. Drugs. 2002;62(8):1217-51. [Medline].

  24. Gunduz H, Woerner MG, Alvir JM, et al. Obstetric complications in schizophrenia, schizoaffective disorder and normal comparison subjects. Schizophr Res. Dec 21 1999;40(3):237-43. [Medline].

  25. Harrow M, Grossman LS, Herbener ES, Davies EW. Ten-year outcome: patients with schizoaffective disorders, schizophrenia, affective disorders and mood-incongruent psychotic symptoms. Br J Psychiatry. Nov 2000;177:421-6. [Medline].

  26. Hirsch D, Orr G, Kantarovich V, et al. Cushing''s syndrome presenting as a schizophrenia-like psychotic state. Isr J Psychiatry Relat Sci. 2000;37(1):46-50. [Medline].

  27. Kane JM, Carson WH, Saha AR, et al. Efficacy and safety of aripiprazole and haloperidol versus placebo in patients with schizoaffective disorder. J Clin Psychiatry. 2002;63(9):763-71. [Medline].

  28. Kohler CG, Pickholtz J, Ballas C. Neurosyphilis presenting as schizophrenialike psychosis. Neuropsychiatry Neuropsychol Behav Neurol. Oct 2000;13(4):297-302. [Medline].

  29. Lake CR, Hurwitz N. Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders. Psychiatry Res. Aug 30 2006;143(2-3):255-87. [Medline].

  30. Lasser R, Bossie CA, Gharabawi G, et al. Efficacy and safety of long-acting risperidone in stable patients with schizoaffective disorder. J Affect Disord. 2004;83(2-3):262-75. [Medline].

  31. Leucht S, McGrath J, White P, Kissling W. Carbamazepine for schizophrenia and schizoaffective psychoses. Cochrane Database Syst Rev. 2002;(3):CD001258. [Medline].

  32. Levinson DF, Umapathy C, Musthaq M. Treatment of schizoaffective disorder and schizophrenia with mood symptoms. Am J Psychiatry. Aug 1999;156(8):1138-48. [Medline]. [Full Text].

  33. Marneros A. Schizoaffective disorder: clinical aspects, differential diagnosis, and treatment. Curr Psychiatry Rep. 2003;5(3):202-5. [Medline].

  34. McClure RK. The visual backward masking deficit in schizoaffective disorder. Prog Neuropsychopharmacol Biol Psychiatry. Jul 1999;23(5):785-90. [Medline].

  35. McKinnon K, Rosner J. Severe mental illness and HIV-AIDS. New Dir Ment Health Serv. Fall 2000;(87):69-76. [Medline].

  36. Meyer JM, Koro CE. The effects of antipsychotic therapy on serum lipids: a comprehensive review. Schizophr Res. Sep 1 2004;70(1):1-17. [Medline].

  37. Oquendo MA, Ellis SP, Greenwald S, Malone KM, Weissman MM, Mann JJ. Ethnic and sex differences in suicide rates relative to major depression in the United States. Am J Psychiatry. Oct 2001;158(10):1652-8. [Medline].

  38. Perkins D, Lieberman J, Gu H, et al. Predictors of antipsychotic treatment response in patients with first-episode schizophrenia, schizoaffective, and schizophreniform disorders. Br J Psychiatry. 2004;185:18-24. [Medline]. [Full Text].

  39. Pharoah FM, Mari JJ, Streiner D. Family intervention for schizophrenia. Cochrane Database Syst rev. 2003;4:CD000088.

  40. Potkin SG, Saha AR, Kujawa MJ, et al. Aripiprazole, an antipsychotic with a novel mechanism of action, and risperidone vs placebo in patients with schiphrenia and schizoaffective disorder. Arch Gen Psychiatry. 2003;60(7):681-90. [Medline].

  41. Raja M, Azzoni A. Oxcarbazepine vs. valproate in the treatment of mood and schizoaffective disorders. Int J Neuropsychopharmacol. 2003;6(4):409-14. [Medline].

  42. Reid WH, Mason M, Hogan T. Suicide prevention effects associated with clozapine therapy in schizophrenia and schizoaffective disorder. Psychiatr Serv. Aug 1998;49(8):1029-33. [Medline].

  43. Smith TE, Hull JW, Huppert JD, Silverstein SM. Recovery from psychosis in schizophrenia and schizoaffective disorder: symptoms and neurocognitive rate-limiters for the development of social behavior skills. Schizophr Res. 2002;55(3):229-37. [Medline].

  44. Swainston Harrison T, Perry CM. Aripiprazole: a review of its use in schizophrenia and schizoaffective disorder. Drugs. 2004;64(15):1715-36. [Medline].

  45. Swoboda E, Conca A, Konig P, et al. Maintenance electroconvulsive therapy in affective and schizoaffective disorder. Neuropsychobiology. Jan 2001;43(1):23-8. [Medline].

  46. Tran PV, Tollefson GD, Sanger TM, et al. Olanzapine versus haloperidol in the treatment of schizoaffective disorder. Acute and long-term therapy. Br J Psychiatry. Jan 1999;174:15-22. [Medline].

  47. Vieta E, Goikolea JM, Corbella B, et al. Risperidone safety and efficacy in the treatment od bipolar and schizoaffective disorder: results from a 6-month, multicenter, open study. J Clin Psychiatry. 2001;62(10):818-25. [Medline].

  48. Volavka J, Czobor P, Sheitman B, et al. Clozapine, olanzapine, risperidone, and haloperidol in the treatment of patients with chronic schizophrenia and schizoaffective disorder. Am J Psychiatry. 2002;159(2):255-62. [Medline]. [Full Text].

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Further Reading

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Keywords

mental illness, psychosis, mental disorder, hallucinations, delusions, schizophrenia, depression, mania, manic depressive, manic subtype, major depressive disorder, viral infection, malnutrition, birth complications, mood disorder, distorted thinking, bipolar disorder, antisocial personality traits, psychotherapy

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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 Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Janssen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Medical Editor

Ronald C Albucher, MD, Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center
Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University 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.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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