Schizoaffective disorder: A challenging diagnosis Schizoaffective disorder: AA challengingchallenging diagnosisdiagnosis Paying close attention to the temporal relationship of psychotic and mood symptoms is key Jacob N. Miller, MD, PhD r. C, age 34, presented to the emergency department with his Department of Psychiatry wife because of increasingly bizarre behavior. He reported University of Iowa Hospitals and Clinics Iowa City, Iowa Mauditory and visual hallucinations, and believed that the “mob Mhad ordered a hit” against him. He had threatened to shoot his wife and Donald W. Black, MD Department of Psychiatry children, which led to his arrest and being briefly jailed. In jail, he was agi- University of Iowa Roy J. and Lucille A. Carver tated, defecated on the floor, and disrobed. His wife reported that Mr. C College of Medicine Iowa City, Iowa had a long history of bipolar disorder and had experienced his first manic episode and hospitalization at age 17. Since then, he had been treated Disclosures Dr. Miller reports no financial relationships with any with many different antidepressants, antipsychotics, and mood stabilizers. companies whose products are mentioned in this article, Mr. C was admitted to the hospital, where he developed a catatonic or with manufacturers of competing products. Dr. Black syndrome that was treated with a course of electroconvulsive therapy. He is a consultant to Otsuka and receives royalties from American Psychiatric Publishing, Oxford University Press, was eventually stabilized with olanzapine, 20 mg by mouth nightly, with Merck, and UpToDate. moderate improvement in his symptoms, although he never fully returned doi: 10.12788/cp.0020 to baseline. Over the next 8 years, Mr. C was often noncompliant with medication and frequently was hospitalized for mania. His symptoms included poor sleep, grandiosity, pressured speech, racing and disorganized thoughts, increased risk-taking behavior (ie, driving at excessive speeds), and hyper- religiosity (ie, speaking with God). Mr. C also occasionally used metham- phetamine, cannabis, and cocaine. Although he had responded well to treatment early in the course of his illness, as he entered his late 30s, his response was less complete, and by his 40s, Mr. C was no longer able to function independently. He eventually was prescribed a long-acting inject- able antipsychotic, paliperidone palmitate, 156 mg monthly. Eventually, his family was no longer able to care for him at home, so he was admitted to a residential care facility. In this facility, based on the long-standing nature of Mr. C’s psychotic disorder and frequency with which he presented with mania, his clinicians changed his diagnosis to schizoaffective disorder, bipolar type. It had become Current Psychiatry CHARLES HARKER Vol. 19, No. 8 31 Table psychoses,” each of whom had an abrupt onset. The term was used in the first edition DSM-5 criteria for schizoaffective 3 disorder of the DSM as a subtype of schizophrenia. In DSM-I, the “schizo-affective type” was A. An uninterrupted period of illness during defined as a diagnosis for patients with a which there is a major mood episode (major depressive or manic) concurrent with “significant admixture of schizophrenic Criterion A of schizophrenia and affective reactions.”3 Diagnostic crite- Schizoaffective Note: The major depressive episode must ria for SAD were developed for DSM-III-R, disorder include Criterion A1: Depressed mood published in 1987.4 These criteria contin- B. Delusions or hallucinations for ≥2 weeks ued to evolve with subsequent editions of in the absence of a major mood episode the DSM. (depressive or manic) during the lifetime duration of the illness DSM-5 provides a clearer separation C. Symptoms that meet criteria for a major between schizophrenia with mood symp- mood episode are present for the majority of toms, bipolar disorder, and SAD (Table5). the total duration of the active and residual In addition, DSM-5 shifts away from the portions of the illness DSM-IV diagnosis of SAD as an episode, Clinical Point D. The disturbance is not attributable to the and instead focuses more on the longitu- effects of a substance (eg, a drug of abuse, SAD’s hallmark is the a medication) or another medical condition dinal course of the illness. It has been sug- Source: Reference 5 gested that this change will likely lead to presence of symptoms reduced rates of diagnosis of SAD.6 Despite of a major mood improvements in classification, the diagno- episode concurrent sis remains controversial (Box,7-11 page 33). with symptoms of clear that mood symptoms comprised >50% schizophrenia of the total duration of his illness. DSM-5 subtypes and specifiers In DSM-5, SAD has 2 subtypes5: Schizoaffective disorder (SAD) often has • Bipolar type. The bipolar type is marked been used as a diagnosis for patients who by the presence of a manic episode (major have an admixture of mood and psychotic depressive episodes may also occur) symptoms whose diagnosis is uncertain. Its • Depressive type. The depressive type hallmark is the presence of symptoms of a is marked by the presence of only major major mood episode (either a depressive or depressive episodes. manic episode) concurrent with symptoms SAD also includes several specifiers, with characteristic of schizophrenia, such as the express purpose of giving clinicians delusions, hallucinations, or disorganized greater descriptive ability. The course of speech.1 SAD can be described as either “first epi- SAD is a controversial diagnosis. There sode,” defined as the first manifestation has been inadequate research regarding the of the disorder, or as having “multiple epidemiology, course, etiologic factors, and episodes,” defined as a minimum of 2 epi- treatment of this disorder. Debate contin- sodes with 1 relapse. In addition, SAD can ues to swirl around its conceptualization; be described as an acute episode, in partial some experts view SAD as an independent remission, or in full remission. The course disorder, while others see SAD as either a can be described as “continuous” if it is form of schizophrenia or a mood disorder.1 clear that symptoms have been present for In this review, we describe the classifica- the majority of the illness with very brief Discuss this article at tion of SAD and its features, diagnosis, and subthreshold periods. The course is des- www.facebook.com/ treatment. ignated as “unspecified” when informa- MDedgePsychiatry tion is unavailable or lacking. The 5-point Clinician-Rated Dimensions of Psychosis An evolving diagnosis Symptoms was introduced to enable clini- The term schizoaffective was first used by cians to make a quantitative assessment of Jacob Kasanin, MD, in 1933.2 He described the psychotic symptoms, although its use is Current Psychiatry 32 August 2020 9 patients with “acute schizoaffective not required. Box Classification controversies with schizoaffective disorder espite improvements in classification, a field trial using DSM-5 criteria produced a MDedge.com/psychiatry Dcontroversy continues to swirl around kappa of 0.50, which is moderate,9 but earlier the question of whether schizoaffective definitions produced relatively poor results. disorder (SAD) represents an independent Wilson et al10 point out that Criterion C, disorder that stands apart from schizophrenia which concerns duration of mood symptoms, and bipolar disorder, whether it is a produces a particularly low kappa. Another form of schizophrenia, or whether it is a reason is diagnostic switching, whereby form of bipolar disorder or a depressive patients initially diagnosed with 1 disorder disorder.7,8 Other possibilities are that SAD is receive a different diagnosis at follow- heterogeneous or that it represents a middle up. Diagnostic switching is especially point on a spectrum that bridges mood and problematic for SAD. In a large meta-analysis psychotic disorders. While the merits of by Santelmann et al,11 36% of patients initially each possibility are beyond the scope of this diagnosed with SAD had their diagnosis review, it is safe to say that each possibility changed when reassessed. This diagnostic has its proponents. For these reasons, some shift tended more toward schizophrenia argue that the concept itself lacks validity than bipolar disorder. In addition, more than and shows the pitfalls of our classification one-half of all patients initially diagnosed system.7 with schizophrenia, bipolar disorder, or major Clinical Point Poor diagnostic reliability is one reason depressive disorder were re-diagnosed with for concerns about validity. Most recently, SAD when reassessed. In patients with SAD, mood-incongruent psychotic features predict a particularly Epidemiology and gender ratio Course and outcome worse outcome The epidemiology of SAD has not been The onset of SAD typically occurs in early well studied. DSM-5 estimates that SAD adulthood, but can range from childhood is approximately one-third as common as to senescence. Approximately one-third of schizophrenia, which has a lifetime preva- patients are diagnosed before age 25, one- lence of 0.5% to 0.8%.5 This is similar to an third between age 25 and 35, and one-third estimate by Perälä et al12 of a 0.32% life- after age 35.21-23 Based on a literature review, time prevalence based on a nationally rep- Cheniaux et al7 concluded that that age at resentative sample of persons in Finland onset for patients with SAD is between age ≥30. Scully et al13 calculated a preva- those with schizophrenia and those with lence estimate of 1.1% in a representative mood disorders. sample of adults in rural Ireland. Based on The course of SAD is variable but rep- pooled clinical data, Keck et al14 estimated resents a middle ground between that of the prevalence in clinical settings at 16%, schizophrenia and the mood disorders. In a similar to the figure of 19% reported by 4- to 5-year follow-up,24 patients with SAD Levinson et al15 based on data from New had a better overall course than patients York State psychiatric hospitals.