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Schizoaffective Disorder
Tom Joshua P. Wy; Abdolreza Saadabadi.

Author Information
Last Update: March 31, 2021.

Continuing Education Activity

Schizoaffective disorder is among the most frequently misdiagnosed psychiatric disorders in
clinical practice. Due to concerns about the reliability and utility of the diagnostic criteria for
schizoaffective disorder, some researchers have proposed revisions, while others have
suggested altogether removing the diagnosis from the Diagnostic and Statistical Manual of
Mental Disorders. This activity describes limitations and challenges related to the diagnostic
criteria and highlights the interprofessional team's role in caring for patients with psychiatric
disorders.
Objectives:

Describe the pathophysiology of schizoaffective disorder.

Outline the classic clinical presentation of a patient with schizoaffective disorder.

Summarize the treatment options for patients with schizoaffective disorder.

Describe the importance of collaboration and communication amongst the
interprofessional team to improve patient compliance with treatment and thus
improve outcomes for patients with schizoaffective disorder.

Earn continuing education credits (CME/CE) on this topic.

Introduction
Schizoaffective disorder is one of the most misdiagnosed psychiatric disorders in clinical
practice.[1] In fact, some researchers have proposed revisions to the diagnostic criteria, and
others have suggested removing the diagnosis altogether from the DSM-5.[2] There were
significant concerns regarding the

reliability and utility of the diagnosis when it was first introduced in the DSM.[2] 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.

Etiology

The term schizoaffective disorder first appeared as a subtype of schizophrenia in the first
edition of the DSM. It eventually became its own diagnosis despite a lack of evidence for
unique differences in etiology or pathophysiology. 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.

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Some studies show that as high as 50% of people with schizophrenia also have comorbid
depression. [3] The pathogenesis of both mood disorders and schizophrenia is multifactorial
and covers a range of

risk factors, including genetics, social factors, trauma, and stress.[4] Among people with
schizophrenia,

there is a possible increased risk for first-degree relatives for schizoaffective disorder and
vice-versa; there may be increased risk among individuals for schizoaffective disorder who
have a first-degree relative with bipolar disorder schizophrenia, or schizoaffective disorder.
[5]

Epidemiology
The diagnostic criteria for schizoaffective disorder have been reworded and addended since its
inclusion in the DSM, making it difficult to subsequently conduct appropriate epidemiological
studies. Thus, there have been no large-scale studies on the epidemiology, incidence, or
prevalence of schizoaffective disorder. Research shows that 30% of cases occur between the
ages of 25 and 35, and it occurs more frequently in women.[6][7] Schizoaffective disorder
occurs about one-third as frequently as

schizophrenia, and the lifetime prevalence appears to be around 0.3%.[5] Estimates are that

schizoaffective disorder comprises 10 to 30% of inpatient admissions for psychosis.[8]

Pathophysiology
The exact pathophysiology of schizoaffective disorder is currently unknown. Some studies
have shown that abnormalities in dopamine, norepinephrine, and serotonin may play a role.[9]
Also, white matter abnormalities in multiple areas of the brain, particularly the right lentiform
nucleus, left temporal gyrus, and right precuneus, are associated with schizophrenia and
schizoaffective disorder.[10] Researchers have also found reduced hippocampal volumes and
distinct deformations in the medial and lateral thalamic regions in those with schizoaffective
disorder in comparison to controls.[11][12]

History and Physical

The first step in evaluation is obtaining a complete medical history while focusing on the
diagnostic criteria for schizoaffective disorder.
The specific DSM-5 criteria for schizoaffective disorder are as follows[1]:

A. An uninterrupted duration of illness during which there is a major mood episode

(manic ordepressive) in addition to criterion A for schizophrenia; the major depressive episode
must include depressed mood.
Criterion A for schizophrenia is as follows[13]:

Two or more of the following presentations, each present for a significant amount of time
during a 1month period (or less if successfully treated). At least one of these must be from the
first three below.

1. Delusions
2. Hallucinations

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3. Disorganized speech (e.g., frequent derailment or incoherence).

4. Grossly disorganized or catatonic behavior
5. 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 (manicor depressive) during the entire lifetime duration of the illness.
C. Symptoms that meet the criteria for a major mood episode are present for most of the
total durationof both the active and residual portions of the illness.
D. The disturbance is not the result of the effects of a substance (e.g., a drug of misuse 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.

Please note the patient must meet the criteria for A-D above to be diagnosed with
schizoaffective disorder. It is not enough to symptoms of schizophrenia while meeting the
criteria for a major mood episode. Please see the differential diagnoses and pearls sections
below for more information.

The next step of evaluation is the objective and physical portion. A thorough mental status
examination (MSE), physical examination, and neurologic examination should be completed
to help rule out other differential diagnoses.
Evaluation

The following workup is optional and typically not needed to make the diagnosis. The history
and physical are the mainstays of diagnosis. However, some elect to include additional tests or
imaging to aid in the diagnosis, such as MRI (magnetic resonance imaging), EEG
(electroencephalography), or CT (computed tomography).
Laboratory studies are tailored to the patient’s history, especially for those who have an
atypical presentation.

Complete blood count (CBC)

Lipid panel
Urine drug screen
Urine pregnancy test
Urinalysis
Thyroid-stimulating hormone (TSH) level
Rapid plasma reagent

HIV test

If the patient's neurologic exam is found to be aberrant, performing a brain MRI or CT to rule
out any suspected intracranial abnormalities may be considered.

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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.[14] A study that reported
obtained data on treatment regimens for

schizoaffective showed that 93% of patients received an antipsychotic. 20% of patients

received a mood-stabilizer in addition to an antipsychotic, while 19% received an
antidepressant along with an antipsychotic.[15] 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
Antipsychotics: 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.[16][17][18][19][20] Clozapine is a consideration for refractory
cases, much like in schizophrenia.[18]
Mood-stabilizers: Patients who have periods of distractibility, indiscretion, grandiosity, a
flight of ideas, increased goal-directed activity, 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.[21][22][23][24]

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.[25] 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.[26] 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.[27] This treatment plan includes education
about the disorder, etiology, and

treatment.
Individual therapy: This type of treatment aims to normalize thought processes and better
help the patient understand the disorder and reduce symptoms. Sessions focus on everyday
goals, social interactions, and conflict; this includes social skills training and vocational
training.

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Family and/or group therapy: Family involvement is crucial in the treatment of this
schizoaffective disorder.[28] 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.
ECT (Electroconvulsive Therapy)
ECT is usually a last resort treatment. However, not only has it been used in urgent cases and
treatment resistance, but it should also merit consideration in augmentation of current
pharmacotherapy.[29] The

most common indicated symptoms are catatonia and aggression. ECT is safe and effective for
most chronically hospitalized patients.[30]

Differential Diagnosis
Because of 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 with psychotic features
Bipolar disorder

Schizophrenia and Schizoaffective Disorder: 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. Once the
psychotic symptoms predominate the majority of the total duration of the illness, the diagnosis
leans towards schizophrenia. Also, schizophrenia requires 6 months of prodromal or residual
symptoms; schizoaffective disorder does not require this criterion.
Major Depressive Disorder Psychotic Features and Schizoaffective Disorder: Patients with
major depression with psychotic features (MDD with PF) only experience psychotic features
during their mood episodes. In contrast, schizoaffective requires at least 2 weeks in which there
are only psychotic symptoms (delusions and hallucinations) without mood symptoms. Patients
with MDD with PF do not meet criterion A of schizoaffective disorder.
Bipolar Disorder and Schizoaffective Disorder: Similar to the contrasts of MDD w/ PF,
patients with bipolar disorder with psychotic features only experience psychotic features
(delusions and hallucinations) during a manic episode. Again, schizoaffective requires a period
of at least 2 weeks in which there are only psychotic symptoms without mood symptoms.
Psychotic features in bipolar disorder do not meet criterion A of schizoaffective disorder.

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.[31] The defined

favorable as minimal or no symptoms and/or employment. These outcomes were highly reliant
on the early initiation of treatment and optimized treatment regimens as outlined above.

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Complications
Left untreated, schizoaffective disorder has many ramifications in both social functioning and
activities of daily living. These include 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.[32] Research has

shown that among all completed suicides, ten percent are attributable to those with a psychotic
illness.
[33]

Deterrence and Patient Education

Patients and their families can benefit from education regarding the condition and steps to
manage it.

Encourage the patient to undergo treatment and rehabilitation

Cognitive behavior therapy
Interventions for drug and alcohol misuse
Social skills training
Provide emotional and life support
Teach them skills and measures that promote self-care and independence
Supported employment

Pearls and Other Issues

Working through the differential of schizoaffective disorder is often a daunting task, and many
clinicians continue to have trouble making the diagnosis.[2] A few considerations when
working through the

differential diagnosis include:

Observe the criteria for each diagnosis carefully.

Do not "fill in blanks" with preconceived notions about the patient's history. Take
what the patient tells you and what family/collateral information tells you when
working through a differential.

Time frames often give clues towards one specific diagnosis. Symptom course also
plays a role; did mood symptoms or psychotic symptoms come first? For how long did
the symptoms last? History-taking is an essential skill necessary for all clinicians; it is
even more imperative in psychiatry.

Criterion B of schizoaffective disorder is key for the following reasons. One must tease
out a 2 week or longer period of just psychotic symptoms in the patient's history. If one
finds that the patient has always had mood symptoms during their entire illness, the
diagnosis by definition is not a schizoaffective disorder.

Enhancing Healthcare Team Outcomes

As with most mental disorders, schizoaffective disorder is best managed by an
interprofessional team including psychiatric specialty nurses and pharmacists, and clinicians
that practice close interprofessional communication. [Level 5] Pharmacotherapy,
psychotherapy, skills training, and vocational training work in tandem to create a holistic
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treatment plan. In addition to what the information alluded to in previous sections,

psychotherapy strongly influences medication compliance.[34] An ideal treatment course to

improve outcomes around patient-centered care may include:

Early detection of mental disorder in the primary care setting
Referral to a psychiatrist for further evaluation
A psychiatrist would stabilize the patient with pharmacotherapy or defer to a clinical
psychologist for diagnosis or additional therapy

If the patient requires inpatient hospitalization, the nursing staff and case management
become crucial in providing optimal patient care

It is critical to determine if the patient is competent to make healthcare decisions

independently; otherwise, a proxy must be a consideration.

Continuing Education / Review Questions

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