18 - 6A21 Schizoaffective disorder

6A21 Schizoaffective disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders delusions. Auditory hallucinations (e.g. derogatory or accusatory voices that berate the individual for imaginary weaknesses or sins) are more common than visual (e.g. visions of death or destruction) or olfactory (e.g. the smell of rotting flesh) hallucinations. However, in a moderate or severe depressive episode with psychotic symptoms, the psychotic symptoms are confined to the mood episode. Schizophrenia is differentiated from depressive episodes in mood disorders by the occurrence of psychotic and other symptoms that meet the diagnostic requirements of schizophrenia during periods without mood symptoms that meet the diagnostic requirements of a moderate or severe depressive episode. If the diagnostic requirements for both schizophrenia and a moderate or severe depressive episode are met concurrently, and both the psychotic and mood symptoms last for at least 1 month, schizoaffective disorder is the appropriate diagnosis. Boundary with manic or mixed episodes in bipolar type I disorder Psychotic symptoms may occur during manic or mixed episodes in bipolar type I disorder. Though all types of psychotic symptoms are known to occur in manic or mixed episodes, grandiose delusions (e.g. being chosen by God, having special powers or abilities) and persecutory and self-referential delusions (e.g. being conspired against because of one’s special identity or abilities) are among the most common. Experiences of influence, passivity or control (e.g. thought insertion, thought withdrawal or thought broadcasting) may also occur during manic or mixed episodes. Hallucinations are less frequent and commonly accompany delusions of persecution or reference. They are usually auditory (e.g. adulatory voices), and less commonly visual (e.g. visions of deities), somatic or tactile. However, in a manic or mixed episode with psychotic symptoms, the psychotic symptoms are confined to the mood episode. Schizophrenia is differentiated from manic or mixed episodes in bipolar type I disorder by the occurrence of psychotic and other symptoms that meet the diagnostic requirements of schizophrenia during periods without mood symptoms that meet the diagnostic requirements of a manic or mixed episode. If the diagnostic requirements for both schizophrenia and bipolar type I disorder are met concurrently, and both psychotic and mood symptoms last for at least 1 month, schizoaffective disorder is the appropriate diagnosis. Boundary with post-traumatic stress disorder and complex post-traumatic stress disorder In post-traumatic stress disorder and complex post-traumatic stress disorder, severe flashbacks that involve a complete loss of awareness of present surroundings may occur, intrusive images or memories may have a hallucinatory quality, and hypervigilance may reach proportions that appear to be paranoid. However, the diagnoses of post-traumatic stress disorder and complex post-traumatic stress disorder require a history of exposure to an event or series of events (either short- or long-lasting) of an extremely threatening or horrific nature. These diagnoses also require re-experiencing of the traumatic event in the present, in which the event is not just remembered but rather experienced as occurring again in the here and now, and may include loss of awareness and hallucination-like experiences within this specific context. Re-experiencing of traumatic events is not a characteristic feature of schizophrenia. However, post-traumatic stress disorder and schizophrenia frequently co-occur, and both diagnoses should be assigned when the diagnostic requirements for each are met. Schizoaffective disorder Essential (required) features • All diagnostic requirements for schizophrenia are met concurrently with mood symptoms that meet the diagnostic requirements of a moderate or severe depressive episode, a manic episode or a mixed episode. 6A21 Schizophrenia and other primary psychotic disorders | Schizoaffective disorder

171 Schizophrenia and other primary psychotic disorders Note: in making a diagnosis of schizoaffective disorder, depressive episodes must include depressed mood, not just diminished interest or pleasure. • The onsets of the psychotic and mood symptoms are either simultaneous or occur within a few days of one another. • The duration of symptomatic episodes is at least 1 month for both psychotic and mood symptoms. • The symptoms or behaviours are not a manifestation of another medical condition (e.g. a brain tumour), and are not due to the effects of a substance or medication on the central nervous system (e.g. corticosteroids), including withdrawal effects (e.g. from alcohol). Course specifiers for schizoaffective disorder The following specifiers should be applied to identify the course of schizoaffective disorder, including whether the individual currently meets the diagnostic requirements of schizoaffective disorder or is in partial or full remission. Course specifiers are also used to indicate whether the current episode is the first episode of schizoaffective disorder, whether there have been multiple such episodes, or whether symptoms have been continuous over an extended period of time. Schizoaffective disorder, first episode • The first episode specifier should be applied when the current or most recent episode is the first manifestation of the schizoaffective disorder meeting all diagnostic requirements in terms of symptoms and duration. If there has been a previous episode of schizoaffective disorder or schizophrenia, the multiple episodes specifier should be applied. Schizoaffective disorder, first episode, currently symptomatic • All diagnostic requirements for schizoaffective disorder in terms of symptoms and duration are currently met, or have been met within the past month. • There have been no previous episodes of schizophrenia or schizoaffective disorder. Note: if the duration of the episode is more than 1 year, the continuous specifier may be used instead, depending on the clinical situation. Schizoaffective disorder, first episode, in partial remission • The full diagnostic requirements for schizoaffective disorder have not been met within the past month, but some clinically significant symptoms remain, which may or may not be associated with functional impairment. • There have been no previous episodes of schizophrenia or schizoaffective disorder. 6A21.0 6A21.00 6A21.01 Schizophrenia and other primary psychotic disorders | Schizoaffective disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Note: this category may also be used to designate the re-emergence of subthreshold symptoms of schizoaffective disorder following an asymptomatic period in a person who has previously met the diagnostic requirements for schizoaffective disorder. Schizoaffective disorder, first episode, in full remission • The full diagnostic requirements for schizoaffective disorder have not been met within the past month, and no clinically significant symptoms remain. • There have been no previous episodes of schizophrenia or schizoaffective disorder. Schizoaffective disorder, first episode, unspecified Schizoaffective disorder, multiple episodes • The multiple episodes specifier should be applied when there have been a minimum of two episodes meeting all diagnostic requirements of schizoaffective disorder or schizophrenia in terms of symptoms, with a period of partial or full remission between episodes lasting at least 3 months, and the current or most recent episode is schizoaffective disorder. Note that the 1-month duration requirement for the first episode does not necessarily need to be met for subsequent episodes. During the period of remission, the diagnostic requirements of schizoaffective disorder are either only partially fulfilled or absent. Schizoaffective disorder, multiple episodes, currently symptomatic • All symptom requirements for schizoaffective disorder are currently met, or have been met within the past month. Note that the 1-month duration requirement for the first episode does not necessarily need to be met for subsequent episodes. • There have been a minimum of two episodes of schizoaffective disorder or a previous episode of schizophrenia, with a period of partial or full remission between episodes lasting at least 3 months. Schizoaffective disorder, multiple episodes, in partial remission • The full diagnostic requirements for schizoaffective disorder have not been met within the past month, but some clinically significant symptoms remain, which may or may not be associated with functional impairment. • There have been a minimum of two episodes of schizoaffective disorder or a previous episode of schizophrenia, with a period of partial or full remission between episodes lasting at least 3 months. Note: this category may also be used to designate the re-emergence of subthreshold symptoms of schizoaffective disorder following an asymptomatic period. 6A21.02 6A21.0Z 6A21.1 6A21.10 6A21.11 Schizophrenia and other primary psychotic disorders | Schizoaffective disorder

173 Schizophrenia and other primary psychotic disorders Schizoaffective disorder, multiple episodes, in full remission • The full diagnostic requirements for schizoaffective disorder have not been met within the past month, and no clinically significant symptoms remain. • There have been a minimum of two episodes of schizoaffective disorder or a previous episode of schizophrenia, with a period of partial or full remission between episodes lasting at least 3 months. Schizoaffective disorder, multiple episodes, unspecified Schizoaffective disorder, continuous • The continuous specifier should be applied when symptoms fulfilling all diagnostic requirements of schizoaffective disorder have been present for almost all of the course of the disorder during the person’s lifetime since its first onset, with periods of subthreshold symptoms being very brief relative to the overall course. In order to apply this specifier to a first episode, the duration of schizoaffective disorder should be at least 1 year. In that case, the continuous specifier should be applied instead of the first episode specifier. Schizoaffective disorder, continuous, currently symptomatic • All symptom requirements for schizoaffective disorder are currently met, or have been met within the past month. • Symptoms meeting the diagnostic requirements for schizoaffective disorder or schizophrenia have been present for almost all of the course of the disorder during the person’s lifetime since its first onset. • Periods of partial or full remission have been very brief relative to the overall course, and none have lasted for three months or longer. • To apply the continuous specifier to a first episode, symptoms meeting the diagnostic requirements for schizoaffective disorder must have been present for at least 1 year. Schizoaffective disorder, continuous, in partial remission • The full diagnostic requirements for schizoaffective disorder, continuous were previously met but have not been met within the past month. • Some clinically significant symptoms of schizoaffective disorder remain, which may or may not be associated with functional impairment. Note: this category may also be used to designate the re-emergence of subthreshold symptoms of schizoaffective disorder following an asymptomatic period. 6A21.1Z 6A21.2 6A21.20 6A21.21 Schizophrenia and other primary psychotic disorders | Schizoaffective disorder 6A21.12

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Schizoaffective disorder, continuous, in full remission • The full diagnostic requirements for schizoaffective disorder, continuous were previously met but have not been met within the past month. • No clinically significant symptoms of schizoaffective disorder remain. Schizoaffective disorder, continuous, unspecified Other specified schizoaffective disorder Schizoaffective disorder, unspecified Additional clinical features • The onset of schizoaffective disorder may be acute, with serious disturbance apparent within a few days, or insidious, with a gradual development of signs and symptoms. • There is often a history of prior mood episodes and a previous diagnosis of a depressive disorder or a bipolar disorder in individuals with schizoaffective disorder. • A prodromal phase often precedes the onset of psychotic symptoms by weeks or months. The characteristic features of this phase often include loss of interest in work or social activities, neglect of personal appearance or hygiene, inversion of the sleep cycle and attenuated psychotic symptoms, accompanied by negative symptoms, anxiety/agitation or varying degrees of depressive symptoms. • An episodic course with periods of remission is the most common pattern of progression of the disorder. • Schizoaffective disorder is frequently associated with significant distress and significant impairment in personal, family, social, educational, occupational or other important areas of functioning. However, distress and psychosocial impairment are not requirements for a diagnosis of schizoaffective disorder. Boundary with normality (threshold) • Psychotic-like symptoms or unusual subjective experiences may occur in the general population, but these are usually fleeting in nature and are not accompanied by other symptoms of schizophrenia or a deterioration in psychosocial functioning. In schizoaffective 6A21.2Z 6A21.Y 6A21.Z Schizophrenia and other primary psychotic disorders | Schizoaffective disorder 6A21.22

175 Schizophrenia and other primary psychotic disorders disorder, multiple persistent symptoms are present, and are typically accompanied by impairment in cognitive functioning and other psychosocial problems. Course features • Some people with schizoaffective disorder experience exacerbations and remission of symptoms periodically throughout the illness course, whereas others experience a full remission of symptoms between episodes. Developmental presentations • Diagnosis of schizoaffective disorder among children is challenging because the sequence of mood and psychotic symptoms may be difficult for children to describe accurately. • Children who are diagnosed with schizoaffective disorder are the most severely impaired and have the poorest outcomes among all children diagnosed with psychotic disorders. • Schizoaffective disorder with manic episodes is more common among young adults whereas schizoaffective disorder with depressive episodes is more common among older adults. Culture-related features • See the culture-related features section for schizophrenia, all of which also applies to schizoaffective disorder. • In addition. culture may affect the expression of mood symptoms, the use of idioms of distress and illness-related metaphors, and the prominence of certain patterns of moodrelated symptoms. For example, religious or spiritual views about suicidal ideation or behaviour may decrease reporting and increase associated guilt; and shame may be more prominent than guilt in sociocentric societies. Norms for experiencing and articulating mood symptoms psychologically vary by culture, as does the attribution of distress to interpersonal, social, psychological, biological, supernatural or spiritual concerns. • Bodily complaints as somatic expressions of depression may predominate over cognitive mood symptoms due to their greater cultural acceptability as indications of the need for clinical attention. Schizophrenia and other primary psychotic disorders | Schizoaffective disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Sex- and/or gender-related features • Schizoaffective disorder is more prevalent among females – especially schizoaffective disorder with depressive episodes. Boundaries with other disorders and conditions (differential diagnosis) Boundary with schizophrenia The diagnoses of schizophrenia and schizoaffective disorder are intended to apply to the current or most recent episode of the disorder. In other words, a previous diagnosis of schizoaffective disorder does not preclude a diagnosis of schizophrenia, and vice versa. In both schizophrenia and schizoaffective disorder, at least two the characteristic symptoms of schizophrenia are present most of the time for a period of 1 month or more. In schizoaffective disorder, the symptoms of schizophrenia are present concurrently with mood symptoms that meet the full diagnostic requirements of a mood episode and last for at least 1 month, and the onsets of the psychotic and mood symptoms are either simultaneous or occur within a few days of one another. In schizophrenia, co-occurring mood symptoms, if any, either do not persist for as long as 1 month or are not of sufficient severity to meet the requirements of a moderate or severe depressive episode, a manic episode or a mixed episode. (See mood episode descriptions, p. 212.) An episode that initially meets the diagnostic requirements for schizoaffective disorder in which only the mood symptoms remit, so that the duration of psychotic symptoms without mood symptoms is much longer than the duration of concurrent symptoms, may be best characterized as an episode of schizophrenia. Boundary with mood episodes with psychotic symptoms Schizoaffective disorder, schizophrenia, moderate or severe depressive episodes, manic episodes and mixed episodes are all intended to describe the current episode of the disorder. In schizoaffective disorder, the duration and symptom requirements for schizophrenia are fully met during the mood episode. In a depressive disorder with psychotic symptoms or a bipolar type I disorder with psychotic symptoms, psychotic symptoms occur simultaneously with the mood episodes but do not meet the diagnostic requirements for schizophrenia (e.g. hallucinations without any other psychotic symptoms). It is possible for an individual to meet the diagnostic requirements for each during different periods. Boundary with acute and transient psychotic disorder In schizoaffective disorder, the psychotic symptoms persist for at least 1 month in their full, florid form. In contrast, in acute and transient psychotic disorder, the symptom requirements for schizophrenia or a depressive, manic or mixed episode are not met. Moreover, the symptoms in acute and transient psychotic disorder tend to fluctuate rapidly in intensity and type across time, such that the content and focus of delusions or hallucinations often shift, even on a daily basis. Negative symptoms may be present in schizoaffective disorder, but do not occur in acute transient psychotic disorder. The duration of acute and transient psychotic disorder does not exceed 3 months, and most often lasts from a few days to 1 month, compared to a much longer typical course for schizoaffective disorder. Schizophrenia and other primary psychotic disorders | Schizoaffective disorder