History

The first step in evaluation is to obtain a complete medical history, keeping in mind the diagnostic criteria for schizoaffective disorder.^[4](See Background.)

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

The CAGE (cut down, annoyed, guilty, eye opener) Questionnaire is useful for investigating alcohol consumption in patients with schizoaffective disorder.^[18]

Physical Examination

The next step is to perform a complete mental status examination (MSE), physical examination, and neurologic examination to assist with the evaluation and rule out other disease processes.

Although the MSE varies from patient to patient, there are several 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, or sad
Motor - Possible psychomotor agitation or retardation
Cooperativeness - Patient 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, or situation), ask questions such as “What is your full name?” “Do you know where you are?” “What is the month, date, year, day of the week, and time?” or “Do you know why you are here?”
Consciousness - levels of consciousness are determined by the interviewer and are rated as follows: (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 (so-called 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 him or her to read a sentence (eg, “Close your eyes”); this part of the MMSE evaluates sequencing ability
Memory - Have the patient 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?”; and for immediate memory, “Repeat these 3 words: pen, chair, flag”; tell the patient to remember these words, then, after 5 minutes, have him or her patient repeat them
Delusions - Any type is possible (eg, paranoid, thought insertion or withdrawal, grandiose, or bizarre)
Hallucinations - Any type is possible (most common, auditory; least common, gustatory)
Insight - Range varies
Judgment - Range varies

It is essential to inquire about suicidal ideation at each visit; individuals with schizoaffective disorder have a significant lifetime risk for suicide. In addition, it is important to inquire about past acts of self-harm or violence. To help determine suicidal ideation or intent, ask the following types of questions: “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 patient replies in the positive to any of these questions, 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.

It is also important to inquire about homicidal ideation or intent during each patient interview. To help determine homicidal ideation or intent, ask the following types of questions: “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 patient replies in the positive to any of these questions, ask 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.

Differential Diagnoses

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