Review of schizoaffective disorder

REVIEW OF SCHIZOAFFECTIVE DISORDERS

S a t y a j e e t K u m a r S i n g hM D P s y c h i a t r y , M B B SP M C H , P a t n a

C O N T E N T

1. Introduction

2. Epidemiology

3. Etiology

4. Diagnosis & Cl inical Features

5. Diff erential Diagnosis

6. Course & Prognosis

7. Treatment

8. Conclusion

I n t r o d u c t i o n

Schizoaffective disorder [Jacob Kasanin, 1933] is a serious mental illness that has features of two different conditions, schizophrenia & an affective disorder.

It is a life-long illness with an impact in almost all areas of daily living. Most people with this illness have relapses.

Untreated, people with schizoaffective disorder may lead a lonely lives & have trouble holding down a job or attending school. Or, they may rely heavily on family or live in psychiatric hospital.


Although, there is no cure for schizoaffective disorder, but proper treatment greatly improves the quality of life of these patients.

Schizoaffective disorder is not well understood or defined, as are other mental health conditions.

In clinical practice, a preliminary diagnosis of schizoaffective disorder is frequently used when a clinician is uncertain of the diagnosis.

This is largely because it is a mix of multiple mental health conditions that may run a unique course in each affected person


In current diagnostic systems, patients can receive the diagnosis of schizoaffective disorder if they fit into one of the following categories….

Schizophrenia

With associated

mood symptom

1. Patients with schizophrenia who have mood symptoms


2. Patients of mood disorder with associated schizophrenic symptoms


Mood Disorder

With symptom of schizophrenia

Schizoaffective Disorder


3. Patients with both schizophrenic & mood disorder symptoms


Schizophrenia Mood

Disorder


4. A distinct psychosis not related to both schizophrenia & mood disorder



Schizophrenia Mood

Disorder


5. It lies on a continuum between schizophrenia & mood disorder


Schizophrenia Mood Disorder





Schizophrenia

Schizophrenia

Mood Disorder

Mood Disorder

6. Patients with some combination of the above


E p i d e m i o l o g y

Because people with schizoaffective disorder have symptoms of two separate mental illnesses, it is often misdiagnosed. As a result, it is difficult to determine exactly how many people actually are affected by schizoaffective disorder.

Prevalence of schizoaffective disorder 1. Overall prevalence -- Less than 1 percent ( Range .5 to 1 % )2. Prevalence higher in women particularly married women3. Prevalence is very rare in children.

E p i d e m i o l o g y

Usual age of onset 16 to 30 years, Women have slightly late age of onset

Two subtypes of schizoaffective disorder 1. The depressive subtype - more common in older age group2. The bipolar subtype - more common in young population

Men with schizoaffective disorder are likely to exhibit antisocial behavior & to have a markedly flat or inappropriate affect.

E t i o l o g y

The exact cause of schizoaffective disorder is unknown.

Etiologically it appears to be a type of schizophrenia, a type of mood disorder, the simultaneous expression of each or may be a distinct third type of psychosis unrelated to both [ c.f. better prognosis, better response to lithium & a non-deteriorating course than schizophrenic patients].

The most likely possibility is that schizoaffective disorder is a heterogeneous group of disorders encompassing all of the above possibilities.

E t i o l o g y

Its etiology may involve genetic, biochemical & environmental factors:

1. Genetics: Higher incidence of disorders among relatives

2. Biochemical: An imbalance of serotonin & dopamine in the brain.

3. Environmental factors: Intra-natal exposure to toxins or viral infection,

birth complications, poor social interactions or highly stressful situations

Diagnos i s & C l in i ca l f ea tures

Diagnosis of schizoaffective Disorder involves mental health evaluation & is based on DSM-IV & ICD-IO Criteria. Diagnosis using DSM-IV criteria is not an always easy task because it requires

1. The stricter time frame of 1 month’s duration of schizophrenia

symptom

2. Accurate diagnosis of accompanying affective illness

3. Uninterrupted period of illness with affective symptoms must be

present concurrent with symptoms that meet Criterion A for

Schizophrenia

4. Calculation of the exact length of each affective episode (not

always easy or even possible)

5. Determination of when the affective episode ends & the psychosis

continues

6. Calculation of the relative proportions, the affective episodes occupy

of the total duration of illness (It must be more than15-20% of

total)


D S M - I V T R C r i te r i a Fo r s c h i zo a ff e c ti v e D i s o r d e r ( S i m p l i fi e d )

A. This criterion include: 1. An uninterrupted period of illness plus2. A major depressive episode, a manic episode, or a mixed episode plus3. Symptoms that meet Criterion A of schizophrenia

B. Delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.C. Mood episode for substantial portion of the total duration of the illness.D. Exclusion of mental illness due to substance abuse or medical condition.

Specify type:1. Bipolar type: If a manic or a mixed episode & major depressive episodes2. Depressive type: If only major depressive episodes


ICD-10 recognizes schizoaffective disorder as distinct entity & can be applied to patients who have co-occurring mood symptoms & schizophrenic-like mood-incongruent psychosis. Diagnosis depends upon an approximate “balance” between the number, severity & duration of the schizophrenic and affective symptoms.I C D - 1 0 D i a g n o s ti c C r i t e r i a fo r S c h i zo a ff e c ti v e D i s o r d e r s ( S i m p l i fi e d )

G1 -- Affective disorders of moderate or severe degreeG2 -- At least one symptom for at least 2 weeks

1. Thought echo, insertion, withdrawal or broadcasting 2. Delusions of control, influence, or passivity3. Hallucinatory voices 4. Persistent delusions of other kinds that are culturally inappropriate & impossible5. Grossly irrelevant or incoherent speech or frequent neologisms 6. Intermittent or frequent catatonic behavior such as posturing, waxy flexibility & negativism

I C D - 1 0 D i a g n o s ti c C r i t e r i a fo r S c h i zo a ff e c ti v e D i s o r d e r s ( S i m p l i fi e d )

G3 -- Criteria G1 & G2 must be present within the same episode & form prominent clinical picture

G4 – Exclusion of organic mental disorders or substance abuse

D i ff e r e n t i a l D i a g n o s i s

The differential diagnosis of schizoaffective disorder includes all the possibilities usually considered for mood disorders & schizophrenia. A complete medical & psychiatric evaluation should be done to exclude…

1. Other psychiatric condition (Schizophrenia, MDD & Bipolar Disorder with Prominent Psychotic features, Substance use disorders etc.)

2. General medical condition

3. Neurological abnormalities ( Brain Tumor, Temporal lobe epilepsy, Head injury etc.)

C o u r s e & P r o g n o s i s

Patients with schizoaffective disorder are expected to have a course similar to an episodic mood disorder, chronic schizophrenia or some intermediate outcome.

One study that followed patients for 8 years found that the outcomes of these patients more closely resembled schizophrenia than a mood disorder with psychotic features.

Course & prognosis of schizoaffective disorder is difficult to predict because of following reason:

1. Uncertain & evolving nature of the illness 2. Change of prognosis with evolution of symptoms during course of illness

[Emergence of schizophrenic symptoms worsen prognosis more than affective symptoms]

Tr e a t m e n t

P H A R M A C O L O G I C A L T R E A T M E N T

Antipsychotics, mood stabilizers & antidepressants are the mainstay of treatment for schizoaffective disorder. In practice, these medicines are used extensively either alone, in combination with each other, depending upon the current & prominent symptom profile of each patient.

Antipsychotics are important in the treatment of the psychotic symptoms According to report of one recent study, carbamazepine is found to be more

superior to lithium for depressive type of schizoaffective disorders & both equally effective in bipolar type. During the manic exacerbation, dose of mood stabilizer should be in middle to high therapeutic blood concentration range. Intractable mania should be managed with ECT .

Tr e a t m e n t

Treatment with antidepressants mirrors treatment of bipolar depression. Care should be taken not to precipitate switches. Previous antidepressant successes or failures should guide the selection of an agent. SSRIs are often used as first-line agents. Agitated or insomniac patients, however, may benefit from a tricyclic drug.

P S Y C H O S O C I A L T R E A T M E N T : Patients benefit greatly from a combination of

1. Family therapy2. Social skills training & 3. Cognitive rehabilitation.

C o n c l u s i o n

The older concept that patients with schizoaffective disorder have both schizophrenia & a mood disorder is untenable.

Schizoaffective disorder represents a separate & heterogeneous group, some have schizophrenia with prominent affective symptoms, others have a mood disorder with prominent schizophrenic symptoms & still others have a distinct clinical syndrome.

Still we face difficulty in deciding the exact diagnosis, course & prognosis of schizoaffective disorder.

The range of symptoms of schizoaffective disorder can be vast & variable. It can be very difficult not only to treating psychiatrist but also for family members to keep up with the changing nature & needs of these patients.

THANKS

References…..

1. Comprehensive Text book of Psychiatry, Kaplan & Sadock, 9th

Edition

2. Synopsis of Psychiatry, Kaplan & Sadock, 10th Edition

3. Mayo Clinic

4. MedicineNet.com

5. Pubmed.com

Health & Medicine

Review of schizoaffective disorder