What is schizoaffective disorder

Schizoaffective disorder is a chronic mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania. Schizoaffective disorder is characterized by persistent psychosis (e.g, hallucinations, delusions) and mood episodes of depressive, manic, and/or mixed types. The coupling of symptoms from these divergent conditions makes diagnosing and treating schizoaffective patients difficult. That’s why many people with schizoaffective disorder are often incorrectly diagnosed at first with bipolar disorder or schizophrenia because it shares symptoms of multiple mental health conditions.

The two types of schizoaffective disorder, both of which include some symptoms of schizophrenia — are:

1. Schizoaffective disorder Bipolar type, which includes episodes of mania and sometimes major depression
2. Schizoaffective disorder Depressive type, which includes only major depressive episodes

Schizoaffective disorder may run a unique course in each affected person, so it’s not as well-understood or well-defined as other mental health conditions.

Schizoaffective disorder appears to be about one-third as common as schizophrenia. Lifetime prevalence of schizoaffective disorder is estimated to be 0.3%. The incidence of schizoaffective disorder is higher in females than in males, mainly due to an increased incidence of the depressive type among females. Schizoaffective disorder tends to be rare in children.

The typical age at onset of schizoaffective disorder is early adulthood, although onset can occur anywhere from adolescence to late in life. A significant number of individuals diagnosed with another psychotic illness initially will receive the diagnosis schizoaffective disorder later when the pattern of mood episodes has become more apparent.

The symptoms of schizoaffective disorder can be severe and need to be monitored closely. Depending on the type of mood disorder diagnosed, depression or bipolar disorder, people will experience different symptoms:

• Hallucinations, which are seeing or hearing things that aren’t there.
• Delusions, which are false, fixed beliefs that are held regardless of contradictory evidence.
• Disorganized thinking. A person may switch very quickly from one topic to another or provide answers that are completely unrelated.
• Depressed mood. If a person has been diagnosed with schizoaffective disorder depressive type they will experience feelings of sadness, emptiness, feelings of worthlessness or other symptoms of depression.
• Manic behavior. If a person has been diagnosed with schizoaffective disorder: bipolar type they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania.

The following is a typical pattern: An individual may have pronounced auditory hallucinations and persecutory delusions for 2 months before the onset of a prominent major depressive episode. The psychotic symptoms and the full major depressive episode are then present for 3 months. Then, the individual recovers completely from the major depressive episode, but the psychotic symptoms persist for another month before they too disappear. During this period of illness, the individual’s symptoms concurrently met criteria for a major depressive episode and schizophrenia, and during this same period of illness, auditory hallucinations and delusions were present both before and after the depressive phase. The total period of illness lasted for about 6 months, with psychotic symptoms alone resent during the initial 2 months, both depressive and psychotic symptoms present during the next 3 months, and psychotic symptoms alone present during the last month. In this instance, the duration of the depressive episode was not brief relative to the total duration of the psychotic disturbance, and thus the presentation qualifies for a diagnosis of schizoaffective disorder.

The expression of psychotic symptoms across the lifespan is variable. Depressive or manic symptoms can occur before the onset of psychosis, during acute  psychotic episodes, during residual periods, and after cessation of psychosis. For example, an individual might present with prominent mood symptoms during the prodromal stage of schizophrenia. This pattern is not necessarily indicative of schizoaffective disorder, since it is the co-occurrence of psychotic and mood symptoms that is diagnostic. For an individual with symptoms that clearly meet the criteria for schizoaffective disorder but who on further follow-up only presents with residual psychotic symptoms (such as subthreshold psychosis and/or prominent negative symptoms), the diagnosis may be changed to schizophrenia, as the total proportion of psychotic illness compared with mood symptoms becomes more prominent. Schizoaffective disorder, bipolar type, may be more common in young adults, whereas schizoaffective disorder, depressive type, may be more common in older adults.

The lifetime risk of suicide for schizophrenia and schizoaffective disorder is 5%, and the presence of depressive symptoms is correlated with a higher risk for suicide. There is evidence that suicide rates are higher in North American populations than in European, Eastern European, South American, and Indian populations of individuals with schizophrenia or schizoaffective disorder.

Untreated schizoaffective disorder may lead to problems functioning at work, at school and in social situations, causing loneliness and trouble holding down a job or attending school. People with schizoaffective disorder may need assistance and support with daily functioning. Treatment can help manage symptoms and improve quality of life.

Schizoaffective disorder complications

People with schizoaffective disorder are at an increased risk of:

• Suicide, suicide attempts or suicidal thoughts
• Social isolation
• Family and interpersonal conflicts
• Unemployment
• Anxiety disorders
• Developing alcohol or other substance abuse problems
• Significant health problems
• Poverty and homelessness.

Schizoaffective disorder outlook (prognosis)

People with schizoaffective disorder have a greater chance of going back to their previous level of function than do people with most other psychotic disorders ¹. The prognosis for patients with schizoaffective disorder is thought to lie between that of patients with schizophrenia and that of patients with a mood disorder. That is, the prognosis is better than that of schizophrenia alone but worse than that of a mood disorder alone. But long-term treatment is often needed, and results vary from person to person.

Individuals with the bipolar subtype are thought to have a prognosis similar to those with bipolar type I, whereas the prognosis of people with the depressive subtype is thought to be similar to that of people with schizophrenia. Overall, determination of the prognosis is difficult ².

The overall incidence of suicide is estimated to be about 10%. The incidence of suicide attempts varies among different ethnic and social groups ³. White individuals have a higher rate of suicide than do African Americans. People who immigrated to a country have higher suicide rates than people born in that country do. Women attempt suicide more than men do, but men complete suicide more often ⁴.

A poor prognosis in patients with schizoaffective disorder is generally associated with a poor premorbid history, an insidious onset, an absence of precipitating factors, a predominant psychosis, negative symptoms, an early onset, an unremitting course, or having a family member with schizophrenia.

Schizoaffective disorder causes

The exact cause of schizoaffective disorder is unknown. Changes in genes and chemicals in the brain (neurotransmitters) may play a role.

Risk factors for developing schizoaffective disorder

Factors that increase the risk of developing schizoaffective disorder include:

• Having a close blood relative who has schizoaffective disorder, schizophrenia or bipolar disorder
• Stressful events that trigger symptoms
• Taking mind-altering (psychoactive or psychotropic) drugs

Schizoaffective disorder symptoms

Symptoms of schizoaffective disorder are different in each person. People with the condition experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder — either bipolar type (episodes of mania and sometimes depression) or depressive type (episodes of depression).

The course of schizoaffective disorder usually features cycles of severe symptoms followed by periods of improvement with less severe symptoms.

Often, people with schizoaffective disorder seek treatment for problems with mood, daily function, or abnormal thoughts.

Psychosis and mood problems may occur at the same time or by themselves. The disorder may involve cycles of severe symptoms followed by improvement.

Signs and symptoms of schizoaffective disorder depend on the type — bipolar or depressive type — and may include, among others:

• Changes in appetite and energy
• Disorganized speech that is not logical
• False beliefs (delusions), such as thinking someone is trying to harm you (paranoia) or thinking that special messages are hidden in common places (delusions of reference)
• Lack of concern with hygiene or grooming
• Mood that is either too good, or depressed or irritable
• Periods of manic mood or a sudden increase in energy with behavior that’s out of character
• Problems sleeping
• Problems with concentration
• Sadness or hopelessness
• Seeing or hearing things that are not there (hallucinations)
• Social isolation
• Speaking so quickly that others cannot interrupt you
• Symptoms of depression, such as feeling empty, sad or worthless
• Impaired communication, such as only partially answering questions or giving answers that are completely unrelated
• Impaired occupational, academic and social functioning
• Problems with managing personal care, including cleanliness and physical appearance

Talk of suicide or suicidal behavior may occur in someone with schizoaffective disorder. If you have a loved one who is in danger of attempting suicide or has made a suicide attempt, make sure someone stays with that person. Call your local emergency number immediately. Or, if you can do so safely, take the person to the nearest hospital emergency room.

Schizoaffective disorder diagnosis

There are no medical tests to diagnose schizoaffective disorder. Diagnosis of schizoaffective disorder involves ruling out other mental health disorders and concluding that symptoms are not due to substance use, medication or a medical condition. Determining a diagnosis of schizoaffective disorder may include:

• Physical exam. This may be done to help rule out other problems that could be causing symptoms and to check for any related complications.
• Tests and screenings. These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.
• Psychiatric evaluation. A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for suicide. This also includes a discussion of family and personal history.
• Diagnostic criteria for schizoaffective disorder. Your doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Schizoaffective disorder Diagnostic Criteria DSM-5 ⁵

• A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia.
  Note: The major depressive episode must include Criterion A 1 : Depressed mood.
• B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
• C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
• D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

Specify whether:

• Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur.
• Depressive type: This subtype applies if only major depressive episodes are part of the presentation.

Specify if:

• With catatonia.

Various course specifiers are used, though only if the disorder has been present for at least 1 year and if they do not contradict diagnostic course criteria. These specifiers include the following:

• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episodes, currently in acute episode
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous
• Unspecified

Finally, the current severity of the disorder is specified by evaluating the primary symptoms of psychosis and rating their severity on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

To be diagnosed with schizoaffective disorder, the person has symptoms of both psychotic and a mood disorder. In addition, the person must have psychotic symptoms during a period of normal mood for at least 2 weeks.

The combination of psychotic and mood symptoms in schizoaffective disorder can be seen in other illnesses, such as bipolar disorder. Extreme disturbance in mood is an important part of schizoaffective disorder.

Before diagnosing schizoaffective disorder, the provider will rule out medical and drug-related conditions. Other mental disorders that cause psychotic or mood symptoms must also be ruled out. For example, psychotic or mood disorder symptoms can occur in people who:

• Use cocaine, amphetamines, or phencyclidine (PCP)
• Have seizure disorders
• Take steroid medicines.

Schizoaffective disorder treatment

People with schizoaffective disorder generally respond best to a combination of medications, psychotherapy and life skills training. Treatment varies, depending on the type and severity of symptoms, and whether the disorder is the depressive or bipolar type. In some cases, hospitalization may be needed. Long-term treatment can help to manage the symptoms.

Medications

In general, doctors prescribe medications for schizoaffective disorder to relieve psychotic symptoms, stabilize mood and treat depression. These medications may include:

• Antipsychotics. The only medication approved by the Food and Drug Administration specifically for the treatment of schizoaffective disorder is the antipsychotic drug paliperidone (Invega). However, doctors may prescribe other antipsychotic drugs to help manage psychotic symptoms such as delusions and hallucinations.
• Mood-stabilizing medications. When the schizoaffective disorder is bipolar type, mood stabilizers can help level out the mania highs and depression lows.
• Antidepressants. When depression is the underlying mood disorder, antidepressants can help manage feelings of sadness, hopelessness, or difficulty with sleep and concentration.

Psychotherapy

In addition to medication, psychotherapy, also called talk therapy, may help. Psychotherapy may include:

• Individual therapy. Psychotherapy may help to normalize thought patterns and reduce symptoms. Building a trusting relationship in therapy can help people with schizoaffective disorder better understand their condition and learn to manage symptoms. Effective sessions focus on real-life plans, problems and relationships.
• Family or group therapy. Treatment can be more effective when people with schizoaffective disorder are able to discuss their real-life problems with others. Supportive group settings can also help decrease social isolation and provide a reality check during periods of psychosis.

Life skills training

Learning social and vocational skills can help reduce isolation and improve quality of life.

• Social skills training. This focuses on improving communication and social interactions and improving the ability to participate in daily activities. New skills and behaviors specific to settings such as the home or workplace can be practiced.
• Vocational rehabilitation and supported employment. This focuses on helping people with schizoaffective disorder prepare for, find and keep jobs.

Hospitalization

During crisis periods or times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition, adequate sleep, and basic personal care and cleanliness.

Electroconvulsive therapy

For adults with schizoaffective disorder who do not respond to psychotherapy or medications, electroconvulsive therapy (ECT) may be considered.

Coping and support

Schizoaffective disorder requires ongoing treatment and support. People with schizoaffective disorder can benefit from:

• Learning about the disorder. Education about schizoaffective disorder may help the person stick to the treatment plan. Education also can help friends and family understand the disorder and be more compassionate.
• Paying attention to warning signs. Identify things that may trigger symptoms or interfere with carrying out daily activities. Make a plan for what to do if symptoms return. Contact the doctor or therapist if needed to prevent the situation from worsening.
• Joining a support group. Support groups can help make connections with others facing similar challenges. Support groups may also help family and friends cope.
• Asking about social services assistance. These services may be able to help with affordable housing, transportation and daily activities.

Also, avoid drugs, tobacco and alcohol. Drugs, tobacco and alcohol can worsen schizoaffective symptoms or interfere with medications. If necessary, get appropriate treatment for a substance use problem.

1. Ten-year outcome: patients with schizoaffective disorders, schizophrenia, affective disorders and mood-incongruent psychotic symptoms. Harrow M, Grossman LS, Herbener ES, Davies EW. Br J Psychiatry. 2000 Nov; 177:421-6. https://www.ncbi.nlm.nih.gov/pubmed/11059995/[↩]
2. Baethge C. Long-term treatment of schizoaffective disorder: review and recommendations. Pharmacopsychiatry. 2003 Mar-Apr. 36(2):45-56.[↩]
3. Bhatia T, Thomas P, Semwal P, Thelma BK, Nimgaonkar VL, Deshpande SN. Differing correlates for suicide attempts among patients with schizophrenia or schizoaffective disorder in India and USA. Schizophr Res. 2006 Sep. 86(1-3):208-14.[↩]
4. Kaplan HI, Sadock BJ, eds. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. New York, NY: Lippincott Williams & Wilkins; 2003. 508-11.[↩]
5. American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5. Washington, DC: American Psychiatric Association; 2013.[↩]