Schizoaffective Illness

WHAT IS IT?

Schizoaffective Disorder is diagnostically heterogeneous. In the past, it was considered a subtype of schizophrenia. Today, it is classified separately, with recognition that making the diagnostic determination can be difficult and may require longitudinal observation and multiple sources of information. Schizoaffective Disorder is further broken down into two subtypes based on the mood component. If only Major Depressive episodes are present, this is considered the Depressive Subtype. If Manic episodes or Mixed episodes occur with or without Major Depressive episodes, this is considered the Bipolar Subtype. As mental health professionals are learning to understand the complexities of making this diagnosis, there has been an increase in the frequency of the diagnosis. Some estimate that as many as 20% of the seriously mentally ill population may be suffering from Schizoaffective Disorder.

WHAT ARE THE SYMPTOMS?

The symptoms of Schizoaffective Disorder are a combination of significant mood symptoms, either manic or depressive in nature, and of the psychotic symptoms characteristic of schizophrenia. Specifically, Schizoaffective Disorder should be considered when there has been a period of illness of at least one month duration where delusions or hallucinations were present and prominent mood symptoms were not present for at least two weeks, and there were either two weeks of symptoms of Major Depression, or one week of symptoms of Manic or Mixed Episode. In the Bipolar Subtype, the mood symptoms are manic or mixed in nature for at least one week or longer, and for the Depressed Subtype, symptoms of depression are prominent for two weeks or longer.

Individuals with Schizoaffective Disorders may be at increase risk for later developing episodes of pure Mood Disorder or of Schizophrenia. Many people have shifts in their symptoms over time, showing more or less of the mood or psychotic symptoms at various points. This can cause diagnostic confusion, and raises the question of re-diagnosis to schizophrenia or to bipolar disorder. The diagnosis may also change for different episodes of illness separated by a period of recovery.

In addition to the mood and psychotic symptoms, persons with this disorder may have considerable ongoing problems in social and occupational functioning, difficulties with self-care, and an increased risk of suicide. These functional problems are often secondary to chronic problems with mood, such as a persistent moderate to low-grade depression, or mood instability and impulsivity. There may be associated Alcohol and other Substance-Related Disorders. Some people can have problems similar to those of a person with schizophrenia, such as stress intolerance or poor concentration. A major difference is that persons with Schizoaffective Disorder more often have a past history of successful vocational and social functioning and with appropriate vocational and social skills training, many are able to work and socialize effectively after the onset of the illness.

WHAT CAUSES IT?

Little is known about the etiology of this disorder, particularly since it is so polymorphous. There is substantial evidence that there is an increased risk for Schizophrenia and for Mood Disorders in first-degree biological relatives. Curiously, there appears to be no greater rate of Schizoaffective Disorder itself in family members.

Schizoaffective Disorder has a lower incidence than schizophrenia and bipolar disorder and more often affects women. Its age of onset is later than that of schizophrenia, with a mean age somewhere in the late 20s. Schizoaffective Disorder, Bipolar Type, may be more common in young adults, whereas Schizoaffective Disorder, Depressed Type, may be more common in older adults.

WHAT IS THE EXPECTED OUTCOME?

Its course and outcome is intermediate between that of mood disorders and schizophrenia, better than for Schizophrenia, and worse than for a Mood Disorder. More often patients have some areas of adequate functioning and are more likely to improve to pre-illness levels between episodes. We have no good information on its course over a lifetime.

ARE THERE ANY UNIQUE PROBLEMS?

Because persons with this disorder have obtained some normal social and work skills previous to illness and more often have fewer residual symptoms and more positive functioning after the illness is established, they have unique problems in adapting to their illness. Their families also have higher expectations of them because they have seen the

person do better in the past. They are also more likely to have married and have children and, therefore, are sometimes in more complex, and more stressful, social circumstances and responsibilities.

In some ways, they have a harder time coping with their disabilities than persons with schizophrenia because they have "tasted" greater possibilities. This can have demoralizing effects and, along with their already greater susceptibility to depression, create a greater risk of suicide. In fact, studies show that persons with Schizoaffective Disorder have the greatest risk of suicide of all the major psychiatric disorders, with a rate of 20 to 25% of those patients who have been hospitalized.

WHAT DO PATIENTS NEED?

Long-term supportive, biological and rehabilitative treatment, similar to that recommended for persons with schizophrenia. Community support programs have proven effective for many. Persons with Schizoaffective Disorder can benefit enormously from a consistent one-to-one ongoing supportive psychotherapy with a therapist to whom they are attached, and where the therapy stresses the monitoring of demoralization and depressed mood. Because of the variability of the illness, these persons may need more short-term hospitalizations for protection and treatment/management of symptom exacerbations than do people with schizophrenia.

WHAT ABOUT MEDICATION?

The pharmacologic treatment usually involves multiple major medications for treatment of both the psychotic and affective symptoms. In the Bipolar Type, lithium or other mood regulators in combination with antipsychotic medications are used whereas in the Depressed Type antidepressant and antipsychotic medications are used. This panoply of medications raises the potential for a wider range and increased level of side effects and their consequent distress. This can create problems with medication compliance and, obviously, makes life more complicated for the individual patient.

ANY WORDS OF ADVICE?

Because of the prior history of better functioning, and because most of these patients regain most of their social competence, it is easy for others to become frustrated or angry because of the patient’s lack of vocational and social functioning. Family members and those involved in the vocational rehabilitation must be patient and not allow social competence and past vocational capacity make them expect quick vocational achievement. Becoming angry and frustrated is counter-productive and shows a lack of knowledge and a lack of understanding of this illness.

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Research in Schizoaffective Disorders

by James A. Weber, AMI-GC Member

According to Dr. Joseph Fanelli of Rush-Presbyterian-St. Luke’s Medical Center, research is getting “hot” in the area of Schizoaffective Disorders. Speaking at the AMI-GC meeting in October of 1997, Dr. Fanelli provided an update on new atypical, anti-psychotic medications that affect both serotonin and dopamine receptors in the brain.

Risperdal, he said, is equal in efficacy to typical, older, anti-psychotic medications such as Haldol in its effect on positive symptoms and possibly superior in affecting negative symptoms. The medication is also more potent than Clozaril in relation to serotonin and dopamine. Dosages range from ½ to 254 mg. With 3 to 6 mg representing the middle of the road.

Dr. Fanelli stated that Zyprexa is equal in efficacy to typical medication in its effect on positive symptoms and superior in terms of negative symptoms. The “miracle”effect, i.e., the way in which persons taking Clozaril sometimes show instant improvement is not usually seen with Zyprexa. Significant improvement may take months to manifest itself. Initial doses of Zyprexa are from 2.5 to 20 mg/day. And dosages can go to 30, 40 or 50 mg/day. Measuring 14 on the anti-histamine scale, Zyprexa causes increase appetite and weight gain in comparison to Risperdal whose anti-histamine rating is only 1.7.

Just introduced, Seroquel provides efficacy for positive symptoms equal to typical medications. Dosages range from 250 to 750 mg/day.

According to Dr. Fanelli, research is showing that Schizoaffective Disorders are more treatable using combinations of anti-psychotic medications. He recommended that various anti-psychotics should be tried until one, or a combination, is found that works. These anti-psychotics can be combined if necessary with medications for treating other conditions such as depression or sleep disorders.

Overall, Dr. Fanelli said that Schizophrenia is now being studied as a chronic, negative symptom illness with peaks and valleys in positive symptoms. He presented a PANSS Rating Scale consisting of 7 positive symptoms, 7 negative symptoms, and 16 general psychopathology symptoms, each of which is rated in terms of 7 levels ranging from “absent” of “definition does not apply” to “extreme.”

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