Occasionally,
clinicians are confronted with a client whose disorder of mood is equal
of anything seen in the major or
bipolar disorders but whose mental
and cognitive processes are so deranged as to suggest the presence of
Schizophrenia. The often severe
disturbances of psychological functioning seen in these conditions,
such as mood-incongruent delusions and hallucinations are indeed reminiscent
of a schizophrenic episode. Unlike schizophrenia, the schizoaffective
pattern tends to be episodic, with a good prognosis for individual attacks,
with lucid periods between episodes.
During a continuous
period of illness, for a material part of at least one month (or less,
if effectively treated) the patient has had 2 or more of the following
symptoms:
Delusions (only one symptom is required if a delusion is bizarre,
such as being abducted in a space
ship from the sun).
Hallucinations
(only one symptom is required if hallucinations include at least two
voices are talking to one another or of a voice that keeps up a running
commentary on the patient's thoughts or actions).
Speech that shows incoherence, derailment or other disorganization.
Severely
disorganized or catatonic behavior.
Any negative symptom such as flat affect, muteness, lack of volition.
During this same
continuous period of illness the patient has either:
For at least 2
weeks of this period there have been delusions or hallucinations and
no prominent mood symptoms.
The mood episode symptoms have been present during a substantial part
of the active and residual portions of the illness. This disorder is
not caused directly by a general medical condition or the use of substances,
including prescription medications.
Criteria for
Major Depressive Episode
Five (or more)
of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least
one of the symptoms is either (1) depressed mood or (2) loss of interest
or pleasure.
Depressed
mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad or empty) or observation made by others
(e.g., appears tearful). Note: In children and adolescents, can
be irritable mood.
Markedly
diminished interest or pleasure in all, or almost all, activities most
of the day, nearly every day (as indicated by either subjective account
or observation made by others).
Significant
weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), or decrease or increase in
appetite nearly every day. Note: In children, consider failure
to make expected weight gains.
Psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being
slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day (not merely self-reproach or
guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific
plan for committing suicide.
The symptoms do not meet criteria for a Mixed
Episode The symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning. The
symptoms are not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition
(e.g., hypothyroidism). The symptoms are not better accounted for by
Bereavement, i.e., after the
loss of a loved one, the symptoms persist for longer than 2 months or
are characterized by marked functional impairment, morbid preoccupation
with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor
retardation.
Criteria for
Manic Episode
A distinct period
of abnormally and persistently elevated, expansive, or irritable mood,
lasting at least 1 week (or any duration if hospitalization is necessary).
During
the period of mood disturbance, three (or more) of the following symptoms
have persisted (four if the mood is only irritable) and have been present
to a significant degree:
Inflated
self-esteem or grandiosity.
Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
More talkative than usual or pressure to keep talking.
Psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed
down).
Flight of ideas or subjective experience that thoughts are racing.
Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli).
Increase in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation.
Excessive involvement in pleasurable activities that have a high potential
for painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
The mood disturbance
is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others,
or to necessitate hospitalization to prevent harm to self or others,
or there are psychotic features.
The symptoms are
not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication, or other treatment) or a general medical
condition (e.g., hyperthyroidism).
Criteria for
Mixed Episode
The criteria are
met both for a Manic
Episode and for a Major Depressive
Episode (except for duration) nearly every day during at least
a 1-week period.
The mood disturbance
is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others,
or to necessitate hospitalization to prevent harm to self or others,
or there are psychotic features.
The symptoms are
not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication, or other treatment) or a general medical
condition (e.g., hyperthyroidism).
Criterion A for Schizophrenia
Two (or more)
of the following, each present for a significant portion of time during
a 1-month period (or less if successfully treated):
Delusions.
Hallucinations.
Disorganized
speech (e.g., frequent derailment or incoherence).
Grossly
disorganized or catatonic behavior.
Negative
symptoms, i.e., affective flattening, alogia, or avolition.
Only one symptom
is required if delusions are bizarre or hallucinations consist of
a voice keeping up a running commentary on the person's behavior or
thoughts, or two or more voices conversing with each other.
During the same
period of illness, there have been delusions or hallucinations for
at least 2 weeks in the absence of prominent mood symptoms.
Symptoms that
meet criteria for a mood episode are present for a substantial portion
of the total duration of the active and residual periods of the illness.
The disturbance
is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition.
Differential
Diagnosis:
Some disorders
display similar or sometimes even the same symptom. The clinician,
therefore, in his/her diagnostic attempt has to differentiate against
the following disorders which he/she needs to rule out to establish
a precise diagnosis.
Cause:
The exact cause
of the disorder is usually not determined, but factors that affect
the development of both schizophrenia
and affective disorders may
play a role in the development of schizoaffective disorders. These
would include genetic, biochemical, and psychosocial factors. Risk
factors include a family history of schizophrenia or affective disorder.
The incidence and prevalence of this disorder are unknown, but it
is thought to be less common than schizophrenia or affective disorders.
Women may be affected more often than men. While affective disorders
can be common in children, schizophrenia is not; therefore schizoaffective
disorder tends to be rare in children.
With
a schizoaffective disorder, a person will have features of 2 different
diagnoses: schizophrenia and affective disorders (also known as mood
disorders). Often this diagnosis is used on a provisional basis when
there is uncertainty about the diagnosis or about which symptoms represent
the primary underlying disorder. At some time during the illness, a
major depressive episode or manic episode is usually present.
The treatment
of people with schizoaffective disorder depends upon the mood disorder
associated with the illness. Medication is the most common form of
treatment for this disorder. Neuroleptic medications are the major
groups of medications used to treat psychotic symptoms. The medication
may take up to 3 weeks to relieve symptoms.
With a manic mood disturbance, lithium may be used with or without
neuroleptic medication. With a depressed mood disturbance, treatment
with antidepressants alone is usually not effective. Neuroleptic medications
may be used in combination with antidepressants in some people.
Self-help methods
for the treatment of this disorder are often overlooked by the medical
profession because very few professionals are involved in them. However,
support groups in which patients can participate, sometimes with family
members, other times in a group with others who suffer from this same
disorder, can be very helpful.
Counseling
and Psychotherapy [
See Therapy Section ]:
The format of
psychotherapy will usually be individual, because the individual suffering
from this disorder is usually socially uncomfortable to be able to
adequately tolerate group therapy. Supportive, client-centered, non-directive
psychotherapy is a modality often used, because it offers the client
a warm, positive, change-oriented environment in which to explore
their own growth while feeling stable and secure. A problem-solving
approach can also be very beneficial in helping the individual learn
better problem-solving and daily coping skills. Therapy should be
relatively concrete, focusing on day-to-day functioning. Relationship
issues can also be raised, especially when such issues revolve around
the patient's family. Certain behavioral techniques have also been
found to be effective with people who have this disorder. Social skills
and occupational skills training, for instance, can be very beneficial.
Pharmacotherapy
[ See Psychopharmacology
Section ] :
Antipsychotic
medications are the treatment of choice. Evidence to date suggests
that all of the antipsychotic drugs (except clozapine) are similarly
effective in treating psychoses, with the differences being in milligram
potency and side effects. Clozapine (Clozaril) has been proven to
be more effective than all other antipsychotic drugs, but its serious
side-effects limit its use. (Phillip W. Long, M.D)
Special Antipsychotic
Adverse Reactions
Neuroleptic Malignant
Syndrome. May occur at any point during the course of treatment. Includes
symptoms of autonomic instability, altered mental status, which may
progress to hyperthermia, stupor, and muscle hypertonicity. Death
may occur. Cause: Neuroleptics (phenothiazines, etc.) Characteristics.
Same symptoms as malignant hyperthermia (see below) but generally
develops over days instead of minutes. Treatment: As per malignant
hyperthermia.
Malignant Hyperthermia.
Cause. 1:20,000 in response to a muscle-relaxing agent (such as succinylcholine)
or an inhaled anesthetic (such as halothane). Is hereditary. May also
be secondary to physical or emotional stress. Characteristics. Hyperthermia,
muscle rigidity, tachycardia, acidosis, shock, coma, rhabdomyolysis.
Treatment includes IV dantrolene 1 to 10 mg/kg IV titrated to effect,
management of acidosis and shock, peripheral cooling (see management
of heat stroke below).
Tardive
Dyskinesia. Involuntary movements of the tongue, face, mouth, or jaw
associated with long-term administration of antipsychotics. Elderly
females at highest risk. May be irreversible.
|
|
