Schizoaffective disorder

Schizoaffective disorder is defined by mood disorder-free psychosis in the context of a long-term psychotic and mood disorder. Delusions are false beliefs which are strongly held despite evidence to the contrary. Beliefs should not be considered delusional if they are in keeping with cultural beliefs. Delusional beliefs may or may not reflect mood symptoms (for example, someone experiencing depression may or may not experience delusions of guilt). Hallucinations are disturbances in perception involving any of the five senses, although auditory hallucinations (or "hearing voices") are the most common. Negative symptoms include alogia (lack of speech), blunted affect (reduced intensity of outward emotional expression), avolition (lack of motivation), and anhedonia (inability to experience pleasure). Negative symptoms can be more lasting and more debilitating than positive symptoms of psychosis. Mood symptoms include mania, hypomania, mixed episode, or depression, and tend to be episodic rather than continuous. A mixed episode represents a combination of symptoms of mania and depression at the same time. Symptoms of mania include elevated or irritable mood, grandiosity (inflated self-esteem), agitation, risk-taking behavior, decreased need for sleep, poor concentration, rapid speech, and racing thoughts. Symptoms of depression include low mood, apathy, changes in appetite or weight, disturbances in sleep, changes in motor activity, fatigue, guilt or feelings of worthlessness, and suicidal thinking. DSM-5 states that if a patient only experiences psychotic symptoms during a mood episode, their diagnosis is mood disorder with psychotic features and not schizophrenia or schizoaffective disorder. If the patient experiences psychotic symptoms without mood symptoms for longer than a two-week period, their diagnosis is either schizophrenia or schizoaffective disorder. If mood disorder episodes are present for the majority and residual course of the illness and up until the diagnosis, the patient can be diagnosed with schizoaffective disorder. == Causes ==

A combination of genetic and environmental factors are believed to play a role in the development of schizoaffective disorder. Viewed broadly then, biological and environmental factors interact with a person's genes in ways which may increase or decrease the risk for developing schizoaffective disorder; exactly how this happens (the biological mechanism) is not yet known. Schizophrenia spectrum disorders, of which schizoaffective disorder is a part, have been increasingly linked to advanced paternal age at the time of conception, a known cause of genetic mutations. The physiology of people diagnosed with schizoaffective disorder appears to be similar, but not identical, to that of those diagnosed with schizophrenia and bipolar disorder; however, human neurophysiological function in normal brain and mental disorder syndromes is not fully understood. While there are various medications and treatment options for those with schizoaffective disorder, this disorder can affect a person for their entire lifespan. In some cases, this disorder can affect a person's ability to have a fulfilling social life and they may also have trouble forming bonds or relationships with others. Schizoaffective disorder is also more likely to occur in women and begins at a young age. The more often cannabis is used, particularly in early adolescence, the more likely a person is to develop a psychotic illness, with frequent use being correlated with double the risk of psychosis and schizoaffective disorder. A 2009 Yale review stated that in individuals with an established psychotic disorder, cannabinoids can exacerbate symptoms, trigger relapse, and have negative consequences on the course of the illness. While cannabis use is accepted as a contributory cause of schizoaffective disorder by many, it remains controversial, since not all young people who use cannabis later develop psychosis, but those who do use cannabis have an increased odds ratio of about 3. Certain drugs can imitate symptoms of schizophrenia (which is known to have similar symptoms to schizoaffective disorder). This is important to note when including that substance-induced psychosis should be ruled out when diagnosing patients so that patients are not misdiagnosed. == Mechanisms ==

Though the pathophysiology of schizoaffective disorder remains unclear, studies suggest that dopamine, norepinephrine, and serotonin may be factors in the development of the disorder. White matter and grey matter reductions in the right lentiform nucleus, left superior temporal gyrus, and right precuneus, and other areas in the brain are also characteristic of schizoaffective disorder. Deformities in white matter have also been found to worsen with time in individuals with schizoaffective disorder. Specifically, psychotic disorders (such as schizoaffective disorder) have been associated with lower hippocampal volumes. Moreover, deformities in the medial and thalamic regions of the brain have been implicated as contributing factors to the disorder as well. == Diagnosis ==

Psychosis as a symptom of a psychiatric disorder is first and foremost a diagnosis of exclusion. ADHD stimulant medications, and sleep medications, prescribed medication-induced psychosis should be ruled out, particularly for first-episode psychosis. Illicit drugs aren't the only ones that precipitate psychosis or mania—prescribed drugs can too, and in particular, some psychiatric drugs. We investigated this and found that about 1 in 12 psychotic or manic patients in an inpatient psychiatric facility are there due to antidepressant-induced psychosis or mania. That's unfortunate for the field [of psychiatry] and disastrous for some of our patients. Substance-induced psychosis should also be ruled out. Both substance- and medication-induced psychosis can be excluded to a high level of certainty while the person is psychotic, typically in an emergency department, using both a: • Broad spectrum urine toxicology screening, and a • Full serum toxicology screening (of the blood). Some dietary supplements may also induce psychosis or mania, but cannot be ruled out with laboratory tests. So a psychotic person's family, partner, or friends should be asked whether he or she is currently taking any dietary supplements. Common mistakes made when diagnosing psychotic patients include: • Not properly excluding delirium, • Missing a toxic psychosis by not screening for substances and medications, • Not appreciating medical abnormalities (e.g., vital signs), • Not obtaining a medical history and family history, • Indiscriminate screening without an organizing framework, • Not asking family or others about dietary supplements, • Premature diagnostic closure, and • Not revisiting or questioning the initial diagnostic impression of primary psychiatric disorder. Schizoaffective disorder can only be diagnosed among those who have undergone a clinical evaluation with a psychiatrist. The criterion includes mental and physical symptoms such as hallucinations or delusions, and depressive episodes. There are also links to bad hygiene and a troubled social life for those with schizoaffective disorder. There are several theorized causations for the onset of schizoaffective disorder, including, genetics, general brain function, like chemistry, and structure, and stress. DSM-5 criteria The most widely used criteria for diagnosing schizoaffective disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-5. These two changes are intended by the DSM-5 workgroup to accomplish two goals: Comorbidities Schizoaffective disorder shares a high level of comorbidity with anxiety disorders, depression, and bipolar disorder. Individuals with schizoaffective disorder are also often diagnosed with substance abuse disorder, usually relating to tobacco, marijuana, or alcohol. Health care providers indicate the importance of assessing for co-occurring substance use disorders, as multiple diagnoses not only potentially increase negative symptomology, but may also adversely affect the treatment of schizoaffective disorder. Types One of three types of schizoaffective disorder may be noted in a diagnosis based on the mood component of the disorder: • Bipolar type, when the disturbance includes manic episodes, hypomania, or mixed episodes—major depressive episodes also typically occur; • Depressive type, when the disturbance includes major depressive episodes exclusively—that is, without manic, hypomanic, or mixed episodes. • Mixed type, when the disturbance includes both manic and depressive symptoms, but psychotic symptoms exist separately from bipolar disorder. Poorly trained clinicians used the diagnosis without making necessary exclusions of common causes of psychosis, including some prescribed psychiatric medications. Carpenter and the DSM-5 schizoaffective disorders workgroup analyzed data made available to them in 2009, and reported in May 2013 that: The Kraepelinian dichotomy was not used for DSM-I and DSM-II because both manuals were influenced by the dominant psychodynamic psychiatry of the time, but the designers of DSM-III wanted to use more scientific and biological definitions. and there is now evidence of a significant overlap in the genetics of schizophrenia and bipolar disorder. The dichotomy at the foundation of the current system forms the basis for a convoluted schizoaffective disorder definition in DSM-IV that resulted in excessive misdiagnosis. People with psychotic depression, bipolar disorder with a history of psychosis, and schizophrenia with mood symptoms also have symptoms that bridge psychosis and mood disorders. == Treatment ==

The primary treatment of schizoaffective disorder is medication, with improved outcomes using combined long-term psychological and social supports. Community support services including drop-in centers, visits by members of a community mental health team, supported employment and support groups are common. Evidence indicates that regular exercise has a positive effect on the physical and mental health of those with schizoaffective disorder. Because of the heterogeneous symptomology associated with schizoaffective disorder, it is common for patients to be misdiagnosed. Many people are either diagnosed with depression, schizophrenia, or bipolar disorder instead of schizoaffective disorder. Supportive psychotherapy and cognitive behavioral therapy are both helpful. Intensive case management (ICM) has been shown to reduce hospitalizations, improve adherence to treatment, and improve social functioning. With ICM, clients are assigned a case manager responsible for coordination of care and assisting clients to access supports to address needs in multiple areas related to well-being, including housing. Psychiatric/psychosocial rehabilitation is often a component of schizoaffective disorder treatment. This rehabilitation method focuses on solving community integration problems such as obtaining and keeping housing and increasing involvement in positive social groups. It also focuses on improving and increasing activities of daily living; increasing daily healthy habits and decreasing unhealthy behaviors, thereby significantly improving quality of life. Psychiatric rehabilitation may also focus on vocational rehabilitation. Evidence suggests that cognition-based approaches may be able to improve work and social functioning. Psychiatric rehabilitation consists of eight main areas: • Psychiatric (symptom reduction and management) • Health and Medical (maintaining consistency of care) • Housing (safe environments) • Basic living skills (hygiene, meals [including increasing healthy food intake and reducing processed food intake], safety, planning and chores) • Social (relationships, family boundaries, communication and integration of client into the community) • Education and vocation (coping skills, motivation and suitable goals chosen by client) • Finance (personal budget) • Community and legal (resources) Medication Antipsychotic medication is usually required both for acute treatment and the prevention of relapse. There is no single antipsychotic of choice in treating schizoaffective disorder, but atypical antipsychotics may be considered due to their mood-stabilizing abilities. Other antipsychotics may be prescribed to further alleviate psychotic symptoms. The management of the bipolar type of schizoaffective disorder is similar to the treatment of bipolar disorder, with the goal of preventing mood episodes and cycling. Lithium or anticonvulsant mood stabilizers such as valproic acid, carbamazepine, and lamotrigine are prescribed in combination with an antipsychotic. Though they may be useful in treating the depressive subtype of the disorder, research suggests that antidepressants are far less effective in treatment than antipsychotics and mood stabilizers. Some research has supported the efficacy of anxiolytics in treating schizoaffective disorder, though general findings on their effectiveness in treating schizoaffective disorder remain inconclusive. Due to the severe negative outcomes associated with many anti-anxiety drugs, many researchers have cautioned against their long term use in treatment. Though not approved specifically for schizoaffective disorder by the FDA, research suggests that clozapine may also be effective in treating schizoaffective disorder, particularly in those resistant to initial medication. Clozapine is an atypical antipsychotic that is recognized as being particularly effective when other antipsychotic agents have failed. Despite clozapine being highly effective at treating schizophrenia and schizoaffective disorder, clozapine treatment may be ineffective for some patients, particularly in those that are already drug-resistant. Clozapine has more side effects than other atypical antipsychotics. Serious side effects of clozapine include agranulocytosis and neutropenia. To mitigate the possibility of agranulocytosis and neutropenia, patients taking clozapine often have regular blood tests. Electroconvulsive therapy Electroconvulsive therapy (ECT) may be considered for patients with schizoaffective disorder experiencing severe depression or severe psychotic symptoms that have not responded to treatment with antipsychotics. == Epidemiology ==

Compared to depression, schizophrenia, and bipolar disorder, schizoaffective disorder is less commonly diagnosed. Schizoaffective disorder is estimated to occur in 0.3 to 0.8 percent of people at some point in their life. 30% of cases occur between the ages of 25 and 35. Children are less likely to be diagnosed with this disorder, as the onset presents itself in adolescence or young adulthood. == History ==

The term schizoaffective psychosis was introduced by the American psychiatrist Jacob Kasanin in 1933 to describe an episodic psychotic illness with predominant affective symptoms, that was thought at the time to be a good-prognosis schizophrenia. In 1959, psychiatrist Kurt Schneider (18871967) began to further refine conceptualizations of the different forms that schizoaffective disorders can take since he observed "concurrent and sequential types". (18561926). Embracing the Kraepelinian dichotomy in DSM-III in 1980, while a step forward from psychodynamic explanations of the disorder, introduced significant problems in schizoaffective disorder diagnosis, as explained recently by the DSM-5 workgroup. 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 bipolar disorder than to schizophrenia. DSM-III placed schizoaffective disorder in "Psychotic Disorders Not Otherwise Specified" before being formally recognized in DSM-III-R. The poor prognosis for DSM-IV schizoaffective disorder was not based on patient outcomes research, but was caused by poorly defined criteria interacting with clinical tradition and belief; clinician enculturation with unscientific assumptions from the diagnosis' history (discussed above), including the invalid Kraepelinian dichotomy; == Research ==

Little is known of the causes and mechanisms that lead to the development of schizoaffective disorder. == See also ==