Schizoaffective disorder

From Wikipedia, the free encyclopedia

Schizoaffective disorder
Classification and external resources
ICD-10 F25
ICD-9 295.70

Schizoaffective disorder is a psychiatric diagnosis of a neurobiological illness. It describes a condition where symptoms of a mood disorder and symptoms of schizophrenia are both present. A person may manifest impairments in the perception or expression of reality, most commonly in the form of auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking, as well as discrete manic and/or mixed and/or depressive episodes in the context of significant social or occupational dysfunction. The disorder usually begins in early adulthood, although, rarely, it is diagnosed in childhood (prior to age 13). Schizoaffective disorder is more common in women than in men. Despite the greater variety of symptoms, the illness course is more episodic and has an overall more favorable outcome (prognosis) than schizophrenia but worse than mood disorders.

There are two types of schizoaffective disorder: the bipolar type and the depressive type. In general, schizoaffective disorder bipolar type has a better prognosis than the depressive type, which can result in a residual defect with the passing of time.

The mainstay of treatment is pharmacotherapy with an antipsychotic and an antidepressant or mood stabilizer. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, though hospital stays are less frequent and for shorter periods than they were in previous years.

Some people diagnosed with schizoaffective disorder are likely to be diagnosed with comorbid conditions, including substance abuse.

Children diagnosed with this disorder are highly likely to have other comorbid neurological disorders such as pervasive developmental disorder, autism and learning disabilities.

Contents

[edit] Signs and symptoms

Late adolescence and early adulthood are the most common peak years for the onset of schizoaffective disorder, although it can be diagnosed, more rarely, earlier in childhood. These are critical periods in a person's social and vocational development which can be severely disrupted by disease onset.

Schizoaffective disorder is a mental illness characterized by mood swings and delusions and sometimes hallucinations.

Delusions may manifest as the individual believing he or she is Jesus or the Antichrist. Examples of hallucinations include: Tactile hallucinations such as have chronic burning headaches or of blurry vision. Individuals with the disorder may have trouble distinguishing their own thoughts from reality. Individuals may hear voices that aren't there. They may hear music that is not playing or see shadowy apparitions. These hallucinations may worsen when the individual is intoxicated.

Watching television or a movie may completely change the person's mood to angry or disturbed. The person may have trouble with friendships and romantic relationships. They may not participate in class due to severe social anxiety and asocial behavior. Many schizoaffective individuals are very intelligent and highly literate, however they may often seclude themselves due to paranoia and may mistakenly believe that people are out to hurt them. Traveling may be difficult as the sufferer may be anxious, or feel they are too far from the safety of home.

Without treatment a person may further worsen in their delusional thought processes about people or society. Individuals with schizoaffective disorder may quickly change their minds about their friends or family if they hear or feel something negative being said about them, as a result they will back away from the person or group until they regain normal thoughts, which takes treatment and time. They may feel that people are laughing or talking about them when they aren't. They may hear their name or a negative word being called at them. Individuals with schizoaffective disorder may have trouble making eye contact with people.

Anxiety plays a major role in schizoaffective disorder. In some cases, the patient may tense up, causing him/her to have difficult or painful swallowing. However, when they are checked out by a specialist, there is nothing wrong with them. This is also known as a tactile hallucination where the sufferer may feel food getting caught in the throat, when, in reality, it has already gone down and went down successfully. The same applies for urinating, defecating, and other normal bodily functions. They may each "psychologically" be disrupted to some degree or other by disease onset. But, patients may refuse to believe that for they may not trust the information being used against them. They may believe that they are being lied to about this as well as other things. Trust is a big issue for schizoaffective sufferers as it strongly affects their social interaction. Although, patients with this disorder may have had problems with social interaction for all of their lives. Social skills deficits and anxiety are the two highlights of schizoaffective symptoms.

Other common symptoms may include impulsiveness, obsessive thought, fear of being hurt, panic, organizational difficulties, and/or problems with thought processing. Common impulses a schizoaffective patient may get include knocking on doors, sending inappropriate emails, or sending used and/or stained underwear through the mail. Obsessive thoughts are usually directed towards swallowing, urinating, and defecating. Dogs may also be a common phobia for a schizoaffective patient.

[edit] Diagnosis

Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers to a psychiatrist, psychiatric nurse, social worker or clinical psychologist in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizoaffective disorder, tests are carried out to exclude medical illnesses which may rarely present with psychotic symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. It is important to rule out a delirium which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying medical illness. There are several psychiatric illnesses which may present with a similar range of psychotic symptoms; these include bipolar disorder, schizophrenia, drug intoxication, brief drug-induced psychosis, and schizophreniform disorder.

Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, thyroid function if lithium has previously been taken to rule out hypothyroidism, liver function tests if chlorpromazine or CPK to exclude neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

The most widely-used criteria for diagnosing schizoaffective disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR:

[edit] DSM-IV-TR criteria

The following are the criteria for a diagnosis of schizoaffective disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):

A. Two (or more) of the following symptoms are present for the majority of a one-month period:

Note: Only one of these symptoms is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

AND at some time there is either a

B. During the same period of illness, there have been delusions or hallucinations for at least two 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.

[edit] Subtypes

Two subtypes of Schizoaffective Disorder exist and may be noted in a diagnosis based on the mood component of the disorder:

[edit] Bipolar type

if the disturbance includes

This subtype applies if a manic episode or mixed episode is part of the presentation. Major Depressive Episodes usually, but not always, also occur in the bipolar subtype.

[edit] Depressive type

The depressive type is noted when the disturbance includes major depressive episodes exclusively.

This subtype applies if only major depressive episodes are part of the presentation.

[edit] Etiology and pathogenesis

Although the causes of schizoaffective disorder are unknown, it is suspected that this diagnosis represents a heterogeneous group of patients, some with aberrant forms of schizophrenia and some with very serious 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.

Many different genes may be contributing to the genetic risk of acquiring this illness. Many different biological and environmental factors are believed to interact with the person's genes in ways which can increase or decrease the person's risk. Schizophrenia spectrum disorders (of which schizoaffective disorder is a part) have been marginally linked to advanced paternal age at the time of conception, a common cause of mutations. [1]

[edit] Epidemiology

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.

[edit] Treatment

The optimal psychiatric treatment for schizoaffective disorder is a combination of medicine and therapy. A licensed psychiatrist will prescribe (usually combinations of) medicine for the patient. Each person responds differently to medication. Common medicines used to treat schizoaffective disorder are listed below.

For psychotic symptoms, one or a combination of the following neuroleptic medications are usually prescribed:

For manic symptoms, the following medications may be prescribed along with a neuroleptic:

For depression, the following medications may be prescribed along with a neuroleptic:

In schizoaffective patients with manic symptoms, combining lithium, carbamazepine, or valproate with a neuroleptic has been shown to be superior to neuroleptics alone. Lithium-neuroleptic combinations, however, may produce severe extrapyramidal reactions or confusion in some patients.

When lithium is not effective or well tolerated in manic patients with schizoaffective disorder, Tegretol or Depakote are frequently used. 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, in rare cases, cause liver toxicity and platelet dysfunction. Calcium channel blockers such as verapamil may also be an effective treatment for manic symptoms but are seldom prescribed for that purpose. The degree of benefit for an individual patient should be considered carefully, as each of these medications carries its own risks.

Benzodiazepines such as Ativan and Klonopin are effective adjunctive treatment agents for acute manic symptoms, but long-term use may result in dependency.

In schizoaffective patients with depressive symptoms, an antidepressant (usually Prozac or other SSRIs) will be prescribed with a neuroleptic. Recently, the anticonvulsant Lamictal has shown promise in treating depressed schizoaffective patients.

Often a sleeping pill will initially be prescribed to allow the patient rest from his or her anxiety or hallucinations.

Nutritional supplements and lifestyle changes are being studied both to augment existing treatments as well as treat frequently occurring co-morbid conditions such as mitochondrial dysfunctions, adrenal fatigue, sleep disorders, omega-3 fatty acid deficiency and diabetes.

[edit] Cannabis

New research shows that use of marijuana results in an increased risk for schizophrenia and schizoaffective disorder. [2] The research suggests that a pot smoker is 40 percent more likely to suffer a psychotic episode than a nonsmoker. For people who smoke pot daily for long periods the risk is 200 percent higher. The research concludes that individuals who smoked cannabis or marijuana heavily during their early and formative years are much more likely to develop schizoaffective disorder later on.

Most mental health professionals are against the use of marijuana or other street drugs in patients currently diagnosed with schizoaffective disorder because paranoia and other symptoms of psychosis can be exacerbated by these drugs. In point of fact, such patients are usually referred to dual diagnosis treatment facilities which treat both the psychiatric and substance abuse components of the illness.[3]

[edit] Prognosis

People with schizoaffective disorder generally have better breath and a better outlook than those with schizophrenia, and worse than those with bipolar disorder. Individual outcomes will vary however. As with any chronic illness, compliance with medication is important, especially since more than one medication is often prescribed.

[edit] Complications

Complications are similar to those for schizophrenia and major mood disorders. These include:

  • Problems following medical treatment and therapy
  • Abuse of drugs in an attempt to self-medicate
  • Problems resulting from manic behavior (for example, spending sprees, sexual indiscretions)
  • Suicidal behavior due to depressive or psychotic symptoms

[edit] History

The term schizoaffective psychosis was coined by Jacob Kasanin in 1933 to describe a more episodic psychotic illness with predominant affective symptoms, that was termed a good-prognosis schizophrenia.[1]

Schizoaffective disorder was included as a subtype of schizophrenia in DSM I and DSM II, though research showed a schizophrenic cluster of symptoms in individuals with a family history of mood disorders whose illness course, other symptoms and treatment outcome were otherwise more akin to the manic phase of a bipolar disorder. DSM III placed schizoaffective disorder in psychotic disorders Not Otherwise Specified before being formally recognized in DSM III-R.[2]

[edit] References

  1. ^ Goodwin & Jamison. p102
  2. ^ Goodwin & Jamison. p96

[edit] Cited texts

  • Goodwin FK, Jamison KR (1990). Manic-Depressive Illness. New York: Oxford University Press. ISBN 0-19-503934-3. 
  • Moore DP, Jefferson JW. Handbook of Medical Psychiatry. 2nd ed. St. Louis, Mo: Mosby; 2004:126-127.
  • Goetz, CG. Textbook of Clinical Neurology. 2nd ed. St. Louis, Mo: WB Saunders; 2003: 48.