02 - 7.2 Schizoaffective Disorder

7.2 Schizoaffective Disorder

7.2 Schizoaffective Disorder Schizoaffective disorder has features of both schizophrenia and mood disorders. In current diagnostic systems, patients can receive the diagnosis of schizoaffective disorder if they fit into one of the following six categories: (1) patients with schizophrenia who have mood symptoms, (2) patients with mood disorder who have symptoms of schizophrenia, (3) patients with both mood disorder and schizophrenia, (4) patients with a third psychosis unrelated to schizophrenia and mood disorder, (5) patients whose disorder is on a continuum between schizophrenia and mood disorder, and (6) patients with some combination of the above. George H. Kirby, in 1913, and August Hoch, in 1921, both described patients with mixed features of schizophrenia and affective (mood) disorders. Because their patients did not have the deteriorating course of dementia precox, Kirby and Hoch classified them in Emil Kraepelin’s manic-depressive psychosis group. In 1933, Jacob Kasanin introduced the term schizoaffective disorder to refer to a disorder with symptoms of both schizophrenia and mood disorders. In patients with the disorder, the onset of symptoms was sudden and often occurred in adolescence. Patients tended to have a good premorbid level of functioning, and often a specific stressor preceded the onset of symptoms. The family histories of the patients often included a mood disorder. Because Eugen Bleuler’s broad concept of schizophrenia had eclipsed Kraepelin’s narrow concept, Kasanin believed that the patients had a type of schizophrenia. From 1933 to about 1970, patients whose symptoms were similar to those of Kasanin’s patients were variously classified as having schizoaffective disorder, atypical schizophrenia, good-prognosis schizophrenia, remitting schizophrenia, and cycloid psychosis—terms that emphasized a relation to schizophrenia. Around 1970, two sets of data shifted the view of schizoaffective disorder from a schizophrenic illness to a mood disorder. First, lithium carbonate (Eskalith) was shown to be an effective and specific treatment for both bipolar disorders and some cases of schizoaffective disorder. Second, the United States–United Kingdom study published in 1968 by John Cooper and his colleagues showed that the variation in the number of patients classified as schizophrenic in the United States and in the United Kingdom resulted from an overemphasis in the United States on the presence of psychotic symptoms as a diagnostic criterion for schizophrenia. EPIDEMIOLOGY The lifetime prevalence of schizoaffective disorder is less than 1 percent, possibly in the range of 0.5 to 0.8 percent. These figures, however, are estimates; various studies of schizoaffective disorder have used varying diagnostic criteria. In clinical practice, a preliminary diagnosis of schizoaffective disorder is frequently used when a clinician is uncertain of the diagnosis. Gender and Age Differences Sex differences in the rates of schizoaffective disorder in clinical samples generally parallel sex differences seen in mood disorders, with approximately equal numbers of men and women who have the bipolar subtype and are more than twofold female to male predominance among individuals with the depressed subtype of schizoaffective

disorder. The depressive type of schizoaffective disorder may be more common in older persons than in younger persons, and the bipolar type may be more common in young adults than in older adults. The age of onset for women is later than that for men, as in schizophrenia. Men with schizoaffective disorder are likely to exhibit antisocial behavior and to have a markedly flat or inappropriate affect. ETIOLOGY The cause of schizoaffective disorder is unknown. The disorder may be a type of schizophrenia, a type of mood disorder, or the simultaneous expression of each. Schizoaffective disorder may also be a distinct third type of psychosis, one that is unrelated to either schizophrenia or a mood disorder. The most likely possibility is that schizoaffective disorder is a heterogeneous group of disorders encompassing all of these possibilities. Studies designed to explore the etiology have examined family histories, biological markers, short-term treatment responses, and long-term outcomes. Most studies have considered patients with schizoaffective disorder to be a homogeneous group, but recent studies have examined the bipolar and depressive types of schizoaffective disorder separately. Although much of the family and genetic research in schizoaffective disorder is based on the premise that schizophrenia and the mood disorders are completely separate entities, some data indicate that they may be genetically related. Studies of the disrupted in schizophrenia 1 (DISC1) gene, located on chromosome 1q42, suggest its possible involvement in schizoaffective disorder as well as schizophrenia and bipolar disorder. As a group, patients with schizoaffective disorder have a better prognosis than patients with schizophrenia and a worse prognosis than patients with mood disorders. Also, as a group, patients with schizoaffective disorder tend to have a nondeteriorating course and respond better to lithium than do patients with schizophrenia. Consolidation of Data A reasonable conclusion from the available data is that patients with schizoaffective disorder are a heterogeneous group: some have schizophrenia with prominent affective symptoms, others have a mood disorder with prominent schizophrenic symptoms, and still others have a distinct clinical syndrome. The hypothesis that patients with schizoaffective disorder have both schizophrenia and a mood disorder is untenable because the calculated co-occurrence of the two disorders is much lower than the incidence of schizoaffective disorder. DIAGNOSIS AND CLINICAL FEATURES The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for schizoaffective disorder are provided in Table 7.2-1. The clinician must

accurately diagnose the affective illness, making sure it meets the criteria of either a manic or a depressive episode but also determining the exact length of each episode (not always easy or even possible). Table 7.2-1 DSM-5 Diagnostic Criteria for Schizoaffective Disorder The length of each episode is critical for two reasons. First, to meet the Criterion B (psychotic symptoms in the absence of a major mood episode [depressive or manic]), it is important to know when the affective episode ends and the psychosis continues. Second, to meet Criterion C, the length of all mood episodes must be combined and compared with the total length of the illness. If the mood component is present for the majority (>50 percent) of the total illness, then that criterion is met. As with most psychiatric diagnoses, schizoaffective disorder should not be used if the symptoms are caused by substance abuse or a secondary medical condition.

Mr. C was 24 years old with no previous psychiatric history. Pregnancy, birth, early development, and adjustment through army service as a paramedic were normal. After discharge from the army, he began to study law but then quit school and traveled in Asia, where he used cannabis. Family members who saw him during this time noticed several changes: He insisted on changing his name, he began to isolate himself, and he believed that he was the heir of the Dali Lama. When he became aggressive and argumentative, he was brought home and hospitalized. On admission, he was dressed like a Tibetan monk, with his head shaved. Although oriented to time and place, he had delusions of grandeur, stating that he was the most clever man on the planet and was the ancestor of the Messiah. He was also suspicious, arrogant, and argumentative. On laboratory assessment, he was also found to have hepatitis A. He was treated with perphenazine 28 mg per day and ultimately discharged to outpatient treatment. He tried again to attend law school but could not persist for more than a year before quitting. When his psychiatrist agreed to stop his antipsychotic medications, he relapsed a month later. His second admission occurred following a manic episode during which he spent money lavishly, had angry outbursts, was excessively talkative, was hyperactive, and believed he was the Messiah. He was treated with haloperidol 5 mg per day and lithium (Eskalith) 1,200 mg. After discharge and another attempt at law school, he traveled to India. He was brought home, rehospitalized with another manic episode, and discharged on depot antipsychotic medications. After being rehospitalized because of extrapyramidal side effects, he was prescribed olanzapine 20 mg per day and valproic acid (Depakene) 1,000 mg per day. During that hospitalization, his mood seemed more depressed, but he did not meet the criteria for an episode of major depressive disorder. During the subsequent 5 years, he remained out of the hospital and had no episodes of mood disorder. He was careful to avoid using cannabis or other substances. He does not work but functions well as a husband and father. From time to time he has thoughts that he might be hurt by other people inflicting injury on his liver, but these thoughts never last more than a few days. The first aspect of establishing a differential diagnosis was determining whether the psychosis was due to a general medical condition or a substance-use disorder. These possibilities seemed unlikely because hepatitis would rarely be associated with the development of an acute manic syndrome. Although cannabis use can precipitate psychosis, the patient’s psychotic symptoms and mood disturbance also occurred in the absence of substance use. In addition, the patient’s longitudinal course was not consistent with either a substance-induced disorder or a psychosis due to a general medical condition. Mr. C’s mood episodes were distinct, but he also had clear psychotic symptoms in the absence of a mood episode, making schizoaffective disorder a more appropriate diagnosis than bipolar disorder with psychotic features. His course also showed a lack of return to his premorbid level of function despite reasonable control of his symptoms with an antipsychotic and a mood stabilizing anticonvulsant. The duration of his mood symptoms relative to the total illness

duration was significant and consistent with a diagnosis of schizoaffective disorder. Mrs. P is a 47-year-old, divorced, unemployed woman who lived alone and who experienced chronic psychotic symptoms despite treatment with olanzapine 20 mg per day and citalopram (Celexa) 20 mg per day. She believed that she was getting messages from God and the police department to go on a mission to fight against drugs. She also believed that an organized crime group was trying to stop her in this pursuit. The onset of her illness began at age 20 years when she experienced the first of several depressive episodes. She also described periods when she felt more energetic and talkative; had a decreased need for sleep; and was more active, sometimes cleaning her house throughout the night. About 4 years after the onset of her symptoms, she began to hear “voices” that became stronger when she was depressed but were still present and disturbed her even when her mood was euthymic. About 10 years after her illness began, she developed the belief that policemen were everywhere and that the neighbors were spying on her. She was hospitalized voluntarily. Two years later, she had another depressive episode, and the auditory hallucinations told her she could not live in her apartment. She was tried on lithium, antidepressants, and antipsychotic medications but continued to be chronically symptomatic with mood symptoms as well as psychosis. Mrs. P demonstrates a “classic” presentation of schizoaffective disorder in which clear depressive and hypomanic episodes are present in combination with continuous psychotic illness and first-rank symptoms. Her course is typical of many individuals with schizoaffective disorder. DIFFERENTIAL DIAGNOSIS The psychiatric differential diagnosis includes all the possibilities usually considered for mood disorders and for schizophrenia. In any differential diagnosis of psychotic disorders, a complete medical workup should be performed to rule out organic causes for the symptoms. A history of substance use (with or without positive results on a toxicology screening test) may indicate a substance-induced disorder. Preexisting medical conditions, their treatment, or both can cause psychotic and mood disorders. Any suspicion of a neurological abnormality warrants consideration of a brain scan to rule out anatomical pathology and an electroencephalogram to determine any possible seizure disorders (e.g., temporal lobe epilepsy). Psychotic disorder caused by seizure disorder is more common than that seen in the general population. It tends to be characterized by paranoia, hallucinations, and ideas of reference. Patients with epilepsy with psychosis are believed to have a better level of function than patients with schizophrenic spectrum disorders. Better control of the seizures can reduce the psychosis. COURSE AND PROGNOSIS Considering the uncertainty and evolving diagnosis of schizoaffective disorder, it is difficult to determine the long-term course and prognosis. Given the definition of the

diagnosis, patients with schizoaffective disorder might be expected to have a course similar to an episodic mood disorder, a chronic schizophrenic course, or some intermediate outcome. It has been presumed that an increasing presence of schizophrenic symptoms predicted a worse prognosis. After 1 year, patients with schizoaffective disorder had different outcomes, depending on whether their predominant symptoms were affective (better prognosis) or schizophrenic (worse prognosis). One study that followed patients diagnosed with schizoaffective disorder for 8 years found that the outcomes of these patients more closely resembled schizophrenia than a mood disorder with psychotic features. TREATMENT Mood stabilizers are a mainstay of treatment for bipolar disorders and would be expected to be important in the treatment of patients with schizoaffective disorder. One study that compared lithium with carbamazepine (Tegretol) found that carbamazepine was superior for schizoaffective disorder, depressive type, but found no difference in the two agents for the bipolar type. In practice, however, these medications are used extensively alone, in combination with each other, or with an antipsychotic agent. In manic episodes, patients who are schizoaffective should be treated aggressively with dosages of a mood stabilizer in the middle to high therapeutic blood concentration range. As the patient enters maintenance phase, the dosage can be reduced to a low to middle range to avoid adverse effects and potential effects on organ systems (e.g., thyroid and kidney) and to improve ease of use and compliance. Laboratory monitoring of plasma drug concentrations and periodic screening of thyroid, kidney, and hematological functioning should be performed. By definition, many patients who are schizoaffective have major depressive episodes. Treatment with antidepressants mirrors treatment of bipolar depression. Care should be taken not to precipitate a cycle of rapid switches from depression to mania with the antidepressant. The choice of antidepressant should take into account previous antidepressant successes or failures. Selective serotonin reuptake inhibitors (e.g., fluoxetine [Prozac] and sertraline [Zoloft]) are often used as first-line agents because they have less effect on cardiac status and have a favorable overdose profile. Agitated or insomniac patients, however, may benefit from a tricyclic drug. As in all cases of intractable mania, the use of ECT should be considered. As mentioned, antipsychotic agents are important in the treatment of the psychotic symptoms of schizoaffective disorder. Psychosocial Treatment Patients benefit from a combination of family therapy, social skills training, and cognitive rehabilitation. Because the psychiatric field has had difficulty deciding on the exact diagnosis and prognosis of schizoaffective disorder, this uncertainty must be explained to the patient. The range of symptoms can be vast because patients contend with both ongoing psychosis and varying mood states. It can be very difficult for family