US Pharm. 2019;44(11):10-12.

Schizoaffective disorder, a perplexing and chronic mental-health condition, is a hybrid of two mental illnesses in that it incorporates features of schizophrenia (i.e., hallucinations or delusions) and mood disorders (i.e., mania and/or depression). Symptoms may occur simultaneously or at different times. Cycles of severe symptoms are often followed by periods of improvement or high energy. This mental condition causes both a loss of contact with reality and mood problems.1 It is not known whether schizoaffective disorder is related mainly to schizophrenia or to mood disorder. Although schizoaffective disorder can be managed, it cannot be cured, and most patients will experience relapses.1

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, defines the disorder as the presence of schizophrenia symptoms concurrent with mood symptoms (depression or bipolar) that last for a considerable portion of a 1-month period.1 Schizoaffective disorder is classified into two kinds: type 1 (bipolar type), which involves some schizophrenia symptoms and episodes of mania and bipolar disorders, and type 2 (depressive type), which includes schizophrenia symptoms and major depressive episodes.1

Schizoaffective disorder usually begins in an individual’s late teens or in early adulthood, often between the ages of 16 and 30 years. It appears to occur slightly less often in men than in women, and it is rare in children.1

Symptoms

Schizoaffective symptoms, which vary from patient to patient, can range from mild to severe. Symptoms include delusions (false, irrational beliefs the patient persists in holding despite evidence to the contrary); hallucinations (sensing something that hasn’t actually happened, such as hearing voices); mania (sudden, out-of-control elevation in energy level); depression (feeling sad, empty, or worthless); failure to take care of personal hygiene or appearance; speech and communication problems, including partial or unrelated answers to questions; difficulty at school, work, or social gatherings; financial difficulties; and homelessness.2

Risk Factors

The exact cause of schizoaffective disorder has not yet been determined, but various risk factors are known1-3:

Genetics: Individuals may inherit the tendency to develop features associated with schizoaffective disorder.
Brain disorder or injury: Patients with schizophrenia and mood disorders may have problems with neuronal circuits in the brain that manage mood and thinking.
Environmental factors: Viral infections or highly stressful situations could play a role in the development of schizoaffective disorder in at-risk individuals.
Psychoactive or psychotropic drugs: Taking mind-altering drugs (i.e., those that affect emotions, thoughts, and behavior) can lead to schizoaffective disorder.

Because schizoaffective disorder reflects two mental illnesses, it is easily confused with other psychotic or mood disorders. Some psychiatrists may diagnose it simply as schizophrenia, and others may think that the patient has a mood disorder.3 It is difficult to determine exactly how many people have schizoaffective disorder, but the condition appears to be less common than either schizophrenia or mood disorder alone.3

Schizoaffective disorder may increase the risk of alcohol abuse or other substance-abuse problems, anxiety disorder, family and interpersonal conflicts, poverty and homelessness, significant health problems, social isolation, suicidal thoughts, suicide or suicide attempts, and unemployment.4

Diagnosis

The combination of symptoms associated with two other conditions makes it difficult to diagnose and treat schizoaffective patients. Diagnosis is based on the patient’s medical history and a clinical review of symptoms and answers to specific questions. There are no laboratory tests that can specifically diagnose schizoaffective disorder, but brain imaging tests (e.g., MRI and CT) and certain blood tests may be employed to ascertain that the symptoms are not attributable to another illness.3 If no physical cause is found, the patient will be referred to a mental-health professional, such as a psychiatrist or psychologist, for diagnosis by specially designed interview and assessment tools for psychotic illness.3

See TABLE 1 for a list of the diagnostic criteria for schizoaffective disorder.4


Treatment

Medication: Schizophrenia treatment centers on antipsychotics, whereas treatment for schizoaffective disorder often pairs antipsychotics with antidepressants.4 This means that the patient has symptoms of depression or bipolar disorder as well as symptoms suggestive of schizophrenia. The main medications used for psychotic symptoms such as delusions, hallucinations, and disordered thinking are antipsychotics. Although second-generation antipsychotics (e.g., aripiprazole, olanzapine) are effective for treating schizoaffective disorder, paliperidone extended-release tablets (Invega) are the only FDA-approved option for treating it.4,5

The recommended dosage of Invega for schizoaffective disorder in adults is 6 mg once daily. Initial dose titration is not required. It has not been systematically established that doses over 6 mg have additional benefit, but some patients may benefit from higher doses (up to 12 mg/day), and in some patients a lower dosage of 3 mg per day may be sufficient. Dose increases beyond 6 mg per day should be made only after clinical reassessment and generally should occur at intervals of more than 5 days. The maximum recommended dosage is 12 mg per day. Patients naïve to oral paliperidone may receive monthly IM injection of Invega Sustenna.5,6

For mood-related symptoms, an antidepressant (e.g., citalopram, escitalopram) or a mood stabilizer (e.g., topiramate, gabapentin) is prescribed.6

Psychotherapy: This type of counseling helps patients learn about their illness, set goals, and manage everyday problems related to the disorder. Family therapy can help families relate to and help a loved one who has schizoaffective disorder. Psychotherapy comprises five broad categories: psychoanalysis, behavior therapy, cognitive therapy, humanistic therapy, and integrative or holistic therapy.7

Social-Skills Training: This form of therapy generally focuses on work and social skills, grooming and self-care, and other daily activities. Social-skills training consists of learning activities involving behavioral techniques that enable persons with schizoaffective and other disabling mental-health disorders to acquire interpersonal disease-management and independent living skills for improved functioning in the community.7,8

Hospitalization: Psychotic episodes may necessitate a hospital stay, particularly if the patient is suicidal or threatens to hurt others. When psychiatric hospitalization is being considered, the psychiatrist’s decision to admit a patient depends primarily on the severity of the illness. A patient is not admitted to the hospital if he or she can be better treated in the psychiatrist’s office or another less restrictive setting.8

Electroconvulsive Therapy (ECT): This option for adults who are unresponsive to psychotherapy or medications involves sending a swift electric current through the patient’s brain under general anesthesia, eliciting a brief seizure. It is believed that ECT changes some brain chemicals and chemistry and may reverse some disease states. ECT has been highly effective for relieving major depression.1,7,8

Conclusion

Schizoaffective disorder cannot be cured. However, if a patient is diagnosed early and starts treatment immediately, frequent relapses and hospitalizations can be avoided or ameliorated, and the patient will experience fewer disruptions in their life, family relationships, and friendships.

REFERENCES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Shaker Clinic. Signs & symptoms of schizoaffective disorder. www.shakerclinic.com/disorders/schizoaffective/symptoms-effects. Accessed October 16, 2019.
3. Mayo Clinic. Schizoaffective disorder: symptoms & causes. www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/symptoms-causes/syc-20354504. Accessed October 16, 2019.
4. Mayo Clinic. Schizoaffective disorder: diagnosis & treatment. www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/diagnosis-treatment/drc-20354509. Accessed October 16, 2019.
5. Brannon GE. Schizoaffective disorder medication. https://emedicine.medscape.com/article/294763-medication. Accessed October 16, 2019.
6. National Institute of Mental Health. Mental health medications. www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml. Accessed October 16, 2019.
7. Cascade E, Kalali AH, Buckley P. Treatment of schizoaffective disorder. Psychiatry (Edgmont). 2009;6(3):15-17.
8. Dryden-Edwards R. Schizoaffective disorder. www.medicinenet.com/schizoaffective_disorder/article.htm#schizoaffective_disorder_facts. Accessed October 16, 2019.

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