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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:

A major depressive episode that includes depressed mood, or
  

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.
   
 Insomnia or hypersomnia nearly every day.
  
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.
  
Insomnia or hypersomnia nearly every day.
  
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 symptoms do not meet criteria for a Mixed Episode.

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.

Associated Features:

Learning Problem
Hypoactivity
Psychotic
Euphoric Mood
Depressed Mood
Somatic/Sexual Dysfunction
Hyperactivity
Guilt/Obsession
Odd/Eccentric/Suspicious Personality
Anxious/Fearful/Dependent Personality
Dramatic/Erratic/Antisocial Personality

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.

Psychotic Disorder Due to a General Medical Condition,
A Delirium, or a Dementia;
Substance-Induced Psychotic Disorder;
Substance-Induced Delirium;
Delusional Disorder;
Psychotic Disorder Not Otherwise Specified.

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.

Treatment:

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.

 


DSM Code

295.70 Szhizoaffective Disorder

F25.0 Szhizoaffective Disorder

Disorder Sheets

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