Schizoaffective disorder (SD) is a mental disorder characterized by both ongoing psychosis and significant symptoms of mood disorders. The diagnosis is made when the person has symptoms of both schizophrenia (usually psychosis) and a mood disorder—either bipolar disorder or depression. The main criterion for the schizoaffective disorder diagnosis that separates it from a mood disorder diagnosis is the presence of psychotic symptoms for at least two weeks without any mood symptoms present. The “main” disorder most resembles schizophrenia, and while the mood disorder may come and go, elements of psychosis are always present. This differs from a mood disorder with psychotic features, which is predominately a mood disorder where elements of psychosis sometimes flare up, such as during a manic episode.^[1] Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be a major depressive episode or bipolar disorder with mood-congruent or mood-incongruent psychotic features.

Figure 1. Schizoaffective disorder includes typical features of schizophrenia, combined with features of major mood episodes.

Diagnosis

The specific DSM-5 criteria for schizoaffective disorder are as follows: ^[2]

A. 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 below:

• delusions
• hallucinations
• disorganized speech (e.g., frequent derailment or incoherence).
• grossly disorganized or catatonic behavior
• negative symptoms (i.e., diminished emotional expression or avolition)

B. 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.

C. 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 portions of the illness.

D. The disturbance is not the result of the effects of a substance (e.g., drug abuse or a medication) or another underlying medical condition.

The following are specifiers based on the primary mood episode as part of the presentation:

• bipolar type: includes episodes of mania and sometimes major depression
• depressive type: includes only major depressive episodes

A patient must meet the criteria for A–D above to be diagnosed with schizoaffective disorder.

Schizoaffective disorder is one of the most misdiagnosed psychiatric disorders in clinical practice. In fact, some researchers have proposed revisions to the diagnostic criteria, while others have suggested removing the diagnosis from the DSM-5. The challenges lie within the diagnostic criteria itself, since the disorder is part of a spectrum that shares criteria with many other prominent psychiatric disorders found in clinical practice.

Differential Diagnosis

Due to having criteria that encompass both psychotic and mood symptoms, schizoaffective disorder is easy to mistake for other mental disorders. Disorders that must be ruled out during the workup of schizoaffective disorder include:

• schizophrenia
• major depressive disorder (MDD) with psychotic features
• bipolar disorder with psychotic features

There has to be a definite period of at least two weeks in which there are only psychotic symptoms (delusions and hallucinations) without mood symptoms to diagnose schizoaffective disorder. However, a major mood episode (depression or mania) is present for the majority of the total duration of the illness. If the psychotic symptoms predominate the majority of the total duration of the illness, the diagnosis leans towards schizophrenia. Also, schizophrenia requires six months of prodromal or residual symptoms; schizoaffective disorder does not require this criterion.

Patients with major depression with psychotic features (MDD with PF), only experience psychotic features during their mood episodes. In contrast, schizoaffective requires at least two weeks in which there are only psychotic symptoms (delusions and hallucinations) without mood symptoms. Patients with MDD with psychotic features do not meet criterion A of schizoaffective disorder.

Similar to the contrasts with MDD with psychotic features, patients with bipolar disorder with psychotic features only experience psychotic features (delusions and hallucinations) during a manic episode. Again, schizoaffective disorder requires a period of at least two weeks in which there are only psychotic symptoms without mood symptoms. Psychotic features in bipolar disorder do not meet criterion A of schizoaffective disorder.

Etiology

The term schizoaffective disorder first appeared as a subtype of schizophrenia in the first edition of the DSM. Schizoaffective disorder eventually became its own diagnosis despite a lack of evidence for unique differences in etiology or physiological processes. Therefore, there have been no conclusive studies on the etiology of the disorder. However, investigating the potential causes of mood disorders and schizophrenia as individual disorders allows for further discussion.

Some studies show that as high as 50% of people with schizophrenia also have comorbid depression. The etiology of both mood disorders and schizophrenia is multifactorial (remember the biopsychosocial model) and covers a range of risk factors including genetics, social factors, trauma, and stress. Among people with schizophrenia, there is a possible increased risk for first-degree relatives to develop schizoaffective disorder and vice-versa; there may also be increased risk among individuals for schizoaffective disorder who have a first-degree relative with bipolar disorder, schizophrenia, or schizoaffective disorder.

Treatment/Management

The treatment of schizoaffective disorder typically involves both pharmacotherapy and psychotherapy. The mainstay of most treatment regimens should include an antipsychotic, but the choice of treatment should be tailored to the individual. A study that reported obtained data on treatment regimens for schizoaffective showed that 93% of patients received an antipsychotic. Twenty percent of patients received a mood-stabilizer in addition to an antipsychotic, while 19% received an antidepressant along with an antipsychotic. ^[3] Prior to initiating treatment, if a patient with schizoaffective disorder is a danger to themselves or others, inpatient hospitalization should be considered; this includes patients who are neglecting activities of daily living or those who are disabled well below their baseline in terms of functioning.

Pharmacotherapy

Figure 2. Antipsychotics medications can come as syrups, pills, or injections.

Antipsychotics

Antipsychotics are used to target psychosis and aggressive behavior in schizoaffective disorder. Other symptoms include delusions, hallucinations, negative symptoms, disorganized speech, and behavior. Most first- and second-generation antipsychotics block dopamine receptors while second-generation antipsychotics have further actions on serotonin receptors. Antipsychotics include, but are not limited to paliperidone (FDA approved for schizoaffective disorder), risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and haloperidol. Clozapine is a consideration for refractory cases, much like in schizophrenia.

Mood-stabilizers

Patients who have periods of distractibility, indiscretion, grandiosity, a flight of ideas, increased goal-directed activity, and decreased need for sleep, and who are hyper-verbal fall under the bipolar specifier for schizoaffective disorder. Consider the use of mood stabilizers if the patient has a history of manic or hypomanic symptoms. These include medications such as lithium, valproic acid, carbamazepine, oxcarbazepine, and lamotrigine, which target mood dysregulation.

Antidepressants

Used to target depressive symptoms in schizoaffective disorder. Selective-serotonin reuptake inhibitors (SSRIs) are preferred due to lower risk for adverse drug effects and tolerability when compared to tricyclic antidepressants and selective norepinephrine reuptake inhibitors. SSRIs include fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. It is vital to rule out bipolar disorder before starting an antidepressant due to the risk of exacerbating a manic episode.

Psychotherapy

Patients who have schizoaffective disorder can benefit from psychotherapy, as is the case with most mental disorders. Treatment plans should incorporate individual therapy, family therapy, and psychoeducational programs. The aim is to develop their social skills and improve cognitive functioning to prevent relapse and possible rehospitalization. This treatment plan includes education about the disorder, etiology, and treatment.

Individual therapy aims to normalize thought processes and better help the patient understand the disorder to reduce the burden of symptoms. Sessions focus on everyday goals, social interactions, social skills training, and vocational training.

Family involvement is crucial in the treatment of this schizoaffective disorder. Family education aids in compliance with medications and appointments, and helps provide structure throughout the patient’s life given the dynamic nature of the schizoaffective disorder. Supportive group programs can also help if the patient has been in social isolation and provides a sense of shared experiences among participants.

Electroconvulsive Therapy

Figure 3.  A modern ECT machine.

Electroconvulsive therapy (ECT) is usually a last resort treatment. ECT is typically administered by a psychiatrist, an anesthesiologist, and a nurse, as it consists of electrical stimulation to the brain while the patient is under anesthesia. However, not only has ECT been used in urgent cases and treatment resistance, but it should also merit consideration in augmentation of current pharmacotherapy. The most common indicated symptoms are catatonia and aggression. ECT is safe and effective for most chronically hospitalized patients.

Prognosis

Given that the diagnostic criteria of schizoaffective disorder change periodically, prognostic studies have been challenging to conduct. However, a study by Harrison et al., 2001 on the overall prognosis of those with psychotic illness showed that 50% of cases showed favorable outcomes.^[4] This study defined a favorable outcome as minimal or no symptoms, and/or employment. These outcomes were highly reliant on early initiation of treatment and optimized treatment regimens as described above.

Left untreated, schizoaffective disorder has many ramifications in both social functioning and activities of daily living, including unemployment, isolation, impaired ability to care for self, etc. Untreated mental disorders have more than just social and functional consequences. Some studies show that as many as 5% of people with a psychotic illness will commit suicide over their lifetime.^[5] Research has shown that among all completed suicides, 10% are attributable to those with a psychotic illness.