Schizoaffective disorder is a psychiatric diagnosis that describes a mental disorder characterized by recurring episodes of elevated or depressed mood, or simultaneously elevated and depressed mood that alternate or occur together with distortions in perception. The perceptual distortion component of the disorder, called psychosis, may affect all five senses, including sight, hearing, taste, smell and touch, but most commonly manifest as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social and occupational dysfunction. The elevated, depressed or simultaneously elevated and depressed mood episode components of the disorder, called mood disorder, are broadly recognized as depressive and bipolar types of the illness; the division is based on whether the individual has ever had a manic, hypomanic or mixed episode. Onset of symptoms usually begins in early adulthood and is rarely diagnosed in childhood (prior to age 13). The lifetime prevalence of the disorder is uncertain (due to studies using varying diagnostic criteria), although it is generally agreed to be less than 1 percent, and possibly in the range of 0.5 to 0.8 percent. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizoaffective disorder currently exists. As a group, people with schizoaffective disorder have a more favorable prognosis than people with schizophrenia, but a worse prognosis than those with mood disorders.
Studies suggest that genetics, early environment, neurobiology, psychological and social processes are important contributory factors; some recreational and prescription drugs appear to cause or worsen symptoms. Current psychiatric research is focused on the role of neurobiology, but no single organic cause has been found.
The mainstay of treatment is antipsychotic medication combined with mood stabilizer medication or antidepressant medication, or both. Antipsychotic drugs primarily work by suppressing dopamine activity; while antidepressant drugs primarily work by increasing the active levels of at least one monoamine neurotransmitter. The exact mechanism of how mood stabilizers work is uncertain. Psychotherapy, and vocational and social rehabilitation (see psychiatric rehabilitation) are also important for recovery. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, although hospital stays are less frequent and for shorter periods than they were in previous times.
The disorder is thought to mainly affect cognition and emotion, but it also usually contributes to ongoing problems with behavior and motivation. People with schizoaffective disorder are likely to have additional (comorbid) conditions, including anxiety disorders and substance abuse. Social problems, such as long-term unemployment, poverty and homelessness, are common. Furthermore, the average life expectancy of people with the disorder is shorter than those without the disorder, due to increased physical health problems and a higher suicide rate.
The diagnosis was introduced in 1933 and will be removed from or amended in the next iteration of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), to be published in 2012.
Signs and symptoms
Late adolescence and early adulthood are the peak years for the onset of schizoaffective disorder, although it has been diagnosed (very rarely) in childhood. These are critical periods in a person's social and vocational development which can be severely disrupted by disease onset.
Schizoaffective disorder is a mental illness characterized by recurring episodes of mood disorder and psychosis. Psychosis is defined by paranoia, delusions and hallucinations. Mood disorders are defined by discrete periods of clinical depression, mixed episodes and manic episodes. Individuals with the disorder may experience psychotic symptoms before, during or (commonly) after their depressive, mixed or manic episodes.
The illness tends to be difficult to diagnose since the symptoms are similar to other disorders with prominent mood and psychotic symptoms like bipolar disorder with psychotic features, recurrent depression with psychotic features and schizophrenia.
There are many similarities between schizoaffective disorder, schizophrenia, bipolar disorder with psychotic features, and recurrent depression with psychotic features. The main similarity between schizoaffective disorder, bipolar disorder with psychotic features, and major depressive disorder with psychotic features, is that in all three disorders psychosis occurs during mood episodes. By contrast, in schizoaffective disorder, as it is presently defined, psychosis must also occur during periods without mood symptoms. In schizophrenia, mood episodes have been thought to be absent or less prominent than in schizoaffective disorder, although this distinction is currently under debate. Since these differences can be difficult to detect, a firm diagnosis of schizoaffective disorder may thus require an extended period of observation and treatment.
Untreated, the individual with schizoaffective disorder may experience delusions. It should be noted that delusions in schizoaffective disorder are acute manifestations of an active psychosis and are not personality traits; that is, they go away when the psychosis subsides. Manifestations of delusions include the individual being convinced that he or she is Jesus or the Antichrist, has some special purpose or destiny (such as to save the world), or is being monitored, watched or persecuted by something (commonly governmental agencies), when in reality they are not. Individuals may also feel extremely paranoid. Other delusions may include the belief that an external force is controlling the individual's thought processes. (See thought insertion.)
Hallucinations involving all five senses can also occur in untreated or undertreated schizoaffective disorder. That is, the individual may see, hear, smell, feel or taste things that aren't there. For example, the individual may see overt visual hallucinations such as monsters, the devil or more subtle ones such as shadowy apparitions. Individuals may hear voices or, in some cases, music. Things may look or sound different. Individuals may also experience strange sensations. These hallucinations may worsen when the individual is intoxicated.
The untreated individual may quickly change their mind about their romantic partner, friends or family if they hear something negative being said about them; as a result they may attack or, conversely, isolate themself from the person or group until they regain normal thoughts, which usually takes treatment and time.
Comorbid or co-occurring anxiety disorders may also play a role in the subjective experience of schizoaffective disorder and thus may shape the individual's delusional thought content. For example, the individual may feel anxious, have trouble swallowing, and then believe that outside forces are controlling their throat functions. They may also suffer from various phobias which may also manifest as delusions.
There may be a decline in work or school functioning during episodes of illness. As stated above, individuals with schizoaffective disorder may withdraw socially and become isolated.
The untreated individual may sleep too much, or (more often) be unable to sleep.
Difficulties with thinking known as "cognitive deficits" (see executive function) may also be a problem for individuals with schizoaffective disorder. This may include difficulties with concentration, attention, logical reasoning and impulse control.
Without treatment, the individual with schizoaffective disorder may further worsen in their delusional thought processes and become further alienated from people and society.
With comprehensive treatment, many individuals with schizoaffective disorder may recover much, most or even all of their functionality.
Diagnosis
Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers to a psychiatrist, psychiatric nurse, social worker or clinical psychologist in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.
As discussed above, there are several psychiatric illnesses which may present with a similar range of psychotic symptoms; these include bipolar disorder with psychotic features, major depression with psychotic features, schizophrenia, drug intoxication, brief drug-induced psychosis, and schizophreniform disorder. These disorders need to be ruled out before a firm diagnosis of schizoaffective disorder can be made.
An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm schizoaffective disorder, tests are carried out to exclude medical illnesses which rarely may be associated with psychotic symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. It is important to rule out a delirium which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness and indicates an underlying med
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