Schizoaffective disorder

Signs and symptoms of schizoaffective disorder vary from person to person depending on their genetic makeup, gender and history of substance abuse. Moreover, the presentation of signs and symptoms will be different depending on the state the person is in – manic, depressive or mixed. Four domains can be used to describe the symptomatology of schizoaffective disorder:

• Behavioural symptoms:
  • Disorganized speech or the absence of speech entirely
  • Disorganized behaviours
  • Catatonic behaviours
  • Impaired social functioning
  • Impaired occupational functioning
  • Alternating between slow and rapid movements
  • Social isolation
  • Self-harm
  • Attempting suicide (Read more: suicidal tendencies)
• Physical symptoms:
  • Changes in physical appearance (i.e. no longer caring how one looks)
  • Poor personal hygiene
  • Changes in sleep and/or eating patterns
  • Significant weight gain or weight loss
  • Lack of emotional expression
    
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• Cognitive symptoms:
  • Hallucinations
  • Delusions
  • Memory impairments
  • Racing thoughts
  • Difficulty paying attention
  • Difficulty planning
  • Disorganized thinking
• Psychosocial symptoms:
  • Major episodes of depression
  • Major episodes of mania
  • Extreme paranoia
  • Poor motivation
  • Anxiety
  • Grandiose self-esteem or poor self-esteem
  • Suicidal ideation

Furthermore, mood episodes may present as follows: 

Major depressive episode: Five of the following symptoms should be present for at least two weeks. One symptom must be either depressed mood or loss of interest or pleasure:

• Depressed mood
• Decreased pleasure in activities
• Weight loss or weight gain or appetite change
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue
• Feelings of guilt or worthlessness
• Decreased concentration
• Recurrent thoughts of death or suicidal notions

Manic episode: Persistently elevated or irritable mood for at least one week. Three of the following need to be present (or four if the patient has an irritable mood):

• Inflated self-esteem or grandiosity
• Reduced need for sleep
• Pressure of speech
• Flight of ideas and racing thoughts
• Easily distracted
• Increase in goal-directed activity with psychomotor agitation
• Excessive involvement in high-risk activities (example: shopping sprees)

Mixed episode: Features of both manic episode and major depressive episode are present but only for one week.

As with many other mental illnesses, many factors interplay to give rise to schizoaffective disorder. These factors can be genetic, physical, environmental and, most importantly, behavioural like substance abuse and addiction.

• Family history: the risk of developing psychotic illnesses and mood disorders is increased if a first-degree relative has a similar affliction.
• Genetic: There seems to be a suggested inheritable genetic trait that predisposes one towards mental illnesses. With the additional hit of environmental (like exposure to drugs and toxins, emotional or mental trauma and neglect) factors, already susceptible people can easily manifest mental health disorders.
• The presence of other mental health disorders: The same factors that precipitated other mental health disorders in an individual can also lead to schizoaffective disorders.
• Substance abuse: Drug and alcohol abuse often leads to mental illnesses on the psychotic spectrum.
• Having been the victim of abuse and/or neglect: Early childhood mental trauma too often predisposes certain individuals towards the development of full-blown mental disorders later on in life.
• Developmental delays: Under normal circumstances, children achieve developmental milestones (such as sitting, standing, walking, talking, waving, etc.) at specific time periods in their lives. A slight deviation from this time frame is not considered a cause for concern, however, unusual delays or lack of development of these milestones altogether hints at abnormalities in the brain. This may be a result of genetics, insult to the fetus while in the womb, improperly treated early childhood infections or even the birthing process itself. Developmental delays suggest organic anomalies which can also produce associated mental illnesses with age.
• Prenatal exposure to certain toxins or illnesses: Consumption of these harmful substances like drugs and alcohol during pregnancy exposes the baby to them by the shared bloodstream through the placenta. Teratogenic effects or deformities in the development of organs and the overall body may arise. Brain anatomy alterations can cause mental disorders.
• Anomalous brain anatomy and chemical mediators: Research has found that variations in white matter and a reduced brain volume of certain areas is linked to the development of schizoaffective disorder. Furthermore, reduced levels of chemical mediators in the brain like serotonin, dopamine and norepinephrine are also related to it.

The doctor will take a thorough history from the patient, or a reliable attendant in case the patient is not in a state to comply, following which they will conduct a physical examination and psychiatric evaluation of the patient. It is important to remember overlapping and similar mental disorders that can mimic one another and cause mislabelling of schizoaffective disorder. 

Physical examination

To ascertain whether a physical condition is producing the signs and symptoms of schizoaffective disorder, a thorough examination will be done. Special focus will be given to neurological examination, anomalies of which would necessitate further radiological imaging. Additionally, medicines being taken for certain other unrelated diseases, like corticosteroids and amphetamines (taken by those with ADHD), can produce symptoms mimicking schizoaffective disorder.

Psychiatric evaluation 

The psychiatrist will carefully interview the patient to uncover history that may be relevant to mental health, discuss current issues and gauge the patient’s overall disposition. A diagnosis will be made using the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) criteria.

DSM-5 criteria for schizoaffective disorder: 

• An uninterrupted duration of illness during which there is a major mood episode (manic or depressive) in addition to criterion A for schizophrenia; the major depressive episode must include depressed mood. Criterion A for schizophrenia is as follows: Two or more of the following presentations, each present for a significant amount of time during a one-month period (or less if successfully treated). At least one of these must be from the first three of the following: 
  • Delusions
  • Hallucinations
  • Disorganized speech (like frequent derailment or incoherence).
  • Grossly disorganized or catatonic behaviour
  • Negative symptoms (like diminished emotional expression or avolition.) 

• Hallucinations and delusions for two or more weeks in the absence of a major mood episode (manic or depressive) during the entire lifetime duration of the illness.

• Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of the active as well as residual parts of the illness.

• The disturbance is not the result of the effects of a substance (example: a drug of misuse or a medication) or another underlying medical condition.

Following the DSM-5 evaluation, a mental status examination (MSE) will be performed.

Mental status examination

Mental status examination (MSE) is a structured assessment of the patient’s behavioural and cognitive function. The following components are evaluated under the MSE:

• Appearance
• Behaviour
• Speech
• Mood
• Affect
• Thought process
• Thought content
• Cognition
• Insight/judgment

Clinical diagnosis is supported by laboratory investigations that help elucidate the cause of schizoaffective disorder.

• Blood Tests: Organ dysfunction or blood toxin related causes can precipitate psychosis and mimic symptoms of schizoaffective disorder. Furthermore, HIV-related opportunistic infections of the brain can also present similarly. Therefore, the following tests may be done. 
  • Complete blood count
  • Kidney function test
  • Liver function test
  • Lipid panel (cholesterol test)
  • Thyroid function test
  • HIV test
  • Plasma toxicology
• Urine tests: Urine tests can help rule out the action of any toxins.
  • Urine drug screen
  • Urine pregnancy test
  • Urinalysis
• Radiological imaging investigations: An abnormal neurological examination may indicate the need to evaluate possible intracranial anomalies via imaging.
  • CT scan
  • MRI

Many other underlying conditions or other mental disorders can mimic schizoaffective disorder. The prognosis changes vastly with misdiagnosis. Therefore the following differential diagnoses should be kept in mind: 

• Substance misuse (example: cannabis)
• Organic illness (example: hypothyroidism, delirium, HIV)
• Medication side-effects (example: corticosteroids, amphetamine, etc)
• Recent tragedies (bereavement or loss of employment)
• Other psychiatric illnesses (e.g. dementia, delusional disorder, psychotic depression)

Treatment of schizoaffective disorder has two aspects: psychological and medical.

Psychological treatments

Medical therapy is not enough to fully treat the patient and enable them to lead fulfilling lives. Therefore, psychological care must be extended to them with the possible modalities:

• Cognitive behavioural therapy
• Family interventions
• Counselling
• Art therapy
• Supportive psychotherapy

Medical treatments

The doctor may recommend medications for the following purposes: 

• Acute exacerbation: Antipsychotics, especially atypical antipsychotics like risperidone, olanzapine and quetiapine, are most useful in managing an acute exacerbation.
• Long-term treatment: Medical therapy with antipsychotics brings about improvement in schizoaffective disorder patients, being most effective in those with bipolar schizoaffective disorder. Clozapine is used in cases that are not responding to other drugs.
• Treatment of ongoing depressive symptoms: A trial-and-error approach is adopted to find the most suitable antidepressant to be added to the antipsychotic regimen. Sertraline or fluoxetine are often used. Occasionally, electroconvulsive therapy may be required.
• Treatment of bipolar or manic symptoms: Mood stabilisers such as lithium may be useful in the bipolar schizoaffective disorder.

The complications for people with schizoaffective disorder are similar to those for schizophrenia and major mood disorders. They may include: 

• Difficulty staying on a treatment regimen
• Learning difficulties
• Abnormal personality (example: antisocial or dependent)
• Psychosis
• Suicidal tendency
• Manic behaviours such as spending sprees and promiscuity
• Poor social integration and function
• Self-neglect
• Difficulties with relationships
• Substance misuse (example: alcohol)
• Homicidal thoughts