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.
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