Schizoaffective Disorder: The Bridge Between Schizophrenia and Bipolar

Diagnosing Schizoaffective Disorder

According to The Diagnostic and Statistical Manual of Mental Health (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), to be diagnosed with Schizophrenia, one must experience at least one symptom of these three: delusions, hallucinations or disorganized speech. They must then experience at least two of these five symptoms: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms (APA, 2013). To take this one step further, they must experience these symptoms for a minimum of six months (APA, 2013).

Schizophrenia affects only about 1% of the world’s population according to UpToDate (Fischer & Marder, 2018). This is especially hard to measure because different cultures recognize and categorize mental health disorders differently. This disorder affects men slightly more than women and the onset is typically sometime during adolescence (Fischer & Marder, 2018).

The diagnosis of bipolar I disorder requires the individual to meet certain criteria, and the following criteria are what constitutes a manic episode. According to the DSM-5, criteria A asserts that a manic episode must entail a distinguishable period of at least one week where one experiences an abnormally elevated or irritable mood (APA, 2013). This will include a jump in energy, and/or activity, and will occur almost daily (APA, 2013). Criteria B states that the shift in mood must entail three or more of the following significant behavior changes: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than is normal, flighty ideas or racing thoughts, distractibility, more attention towards goal directed activities, abnormal amount of time and thought put towards activities with potentially negative consequences such as gambling, and risky sexual encounters (APA, 2013). Criteria C includes that there are psychotic features, or a shift in mood severe enough that it impairs the individual’s ability to socially and occupationally function, or requires hospitalization so as to avoid the harming of self or others (APA, 2013). Criteria D adds that none of the previous phenomena can be caused by another condition or any substances such as drugs or treatments (APA, 2013).

According to the UpToDate article titled, “Bipolar disorder in adults: Epidemiology and pathogenesis,” bipolar disorder affects somewhere between 1% and 3% of the world’s population. This disorder affects men and women equally, and the average age of onset for bipolar I disorder is 18 years old while the average age of onset for bipolar II disorder is 20 years old (Stovall, 2018).

The schizoaffective disorder affects a mere 0.3% of the world’s population and is therefore about one third as common as schizophrenia (“National Alliance on Mental Health,” 2018). This disorder bridges the gap between schizophrenia and bipolar disorder. According to the DSM-5, one must experience at least two of the symptoms criteria of a schizophrenic and then must also have a major mood episode (mania or depression that lasts for an uninterrupted period of time), delusions or hallucinations for more than two weeks without mood symptoms, and mood symptoms that are present for the majority of the illness (that cannot be caused by substance abuse) (APA, 2013).

Schizoaffective disorder is essentially a mix of schizophrenia and bipolar, so it can be quite difficult to diagnose. Individuals might be initially diagnosed as having either one or the other initially based on their more prevalent symptoms. Due to the delusions and/or hallucinations they might be experiencing, they may come off as extremely paranoid and anxious. Peers may consider many of their thoughts, beliefs and actions to be totally out of character, and completely disorganized. They may engage in and become completely absorbed with religion. Outside of the extremes, it is common for these individuals to appear apathetic, and confused.

The bipolar characteristics of this disorder will put the person in either a manic or a depressed state. In a manic state they present as quite euphoric and may think of themselves as superior to others. They may think that they are super wealthy, high status, or extraordinarily intelligent. They may have rapid speech, racing thoughts, sleeplessness and rage. In a depressed state they may feel fatigued and sad almost constantly. They might have thoughts of suicide, difficulty concentrating, loss of appetite and desire to do complete everyday activities. Most often, a person with schizoaffective disorder will primarily present with the symptoms of psychosis before the symptoms of a mood disorder start to come around. This is different than someone with bipolar who will only present with symptoms of psychosis when experiencing a mood swing. Because most individuals will be diagnosed with either schizophrenia or bipolar disorder before being diagnosed with schizoaffective disorder, not much is know about the lifetime patterns of the illness. Looking at the onset of both schizophrenia and bipolar disorder is sometimes all that can be done because the symptoms or either one or the other will shine through initially.

Not much is actually known about the cause of schizoaffective disorder. Some studies seem to suggest that there is most likely a genetic component. The combination of a variety of genes over time might add up to a mental illness in this case. It is thought that, “these genes include some that regulate the body’s daily rhythms, such as the sleep-wake cycle; others that help control the movement of nerve cells during brain development; and still others involved in sending and receiving chemical signals in the brain (“Schizoaffective disorder - Genetics Home Reference,” 2018).” Genes that are involved in the making of GABA neurotransmitter receptors might also be associated. An individual has a higher chance of getting the disorder if a first degree relative is affected (“Schizoaffective disorder - Genetics Home Reference,” 2018).

Mental health diagnoses are different among different cultures. In the past, even the DSM has struggled with the diagnostic criteria for schizoaffective disorder. The first two versions of the DSM had schizoaffective psychosis as a subtype of schizophrenia that included both psychotic and affective characteristics (Wilson, Nian & Heckers, 2013). Because the diagnosis “schizoaffective disorder” is one that is still getting sorted out among professionals, it is more pertinent to discuss the cultural associations of schizophrenia and bipolar disorder.

According to the article titled, “Cultural Aspects of Major Mental Disorders: A Critical Review from an Indian Perspective,” schizophrenia is less prevalent in developing countries; however, this is most likely due to underreporting (Viswanath & Chaturvedi, 2012). It might not always be that certain diseases are defined differently by healthcare professionals throughout the world, but many might not be coming forward. This could be because they are not concerned, because they are worried they will be outcast, or maybe because they don’t know that anything can be done about it. Interestingly, in some religious ceremonies it is normal to hear voices that others cannot hear. This just goes to show that in some cultures it might actually be perfectly acceptable to hear voices; however, these people might not know that when these voices continue, it might actually be a sign of mental illness rather than spiritual awakening.

C.W.Z. Case Study of Schizoaffective Disorder

C.W.Z. is a 48 year old Caucasian male. In his past medical history he had been diagnosed with schizophrenia; however, after being admitted to the mental health units on short term holds at Porter hospital in May, Aurora North hospital in June and most recently at Denver Health in July, doctors have had the chance to explore his symptoms further and have since edited that diagnosis to schizoaffective disorder, bipolar type.

C.W.Z. came to Denver Health complaining of pain in his right leg and was treated for cellulitis. He then returned a day later for continued pain and after further evaluation was admitted to the mental health unit for extreme psychosis. He had not kept up with his discharge instructions from Porter hospital when admitted to Aurora North and it quickly became apparent that he had not been adhering to his newest outpatient plan either.

Not only did C.W.Z. need assistance with medication adherence, but he needed help with basic self care and safety. Along the lines of a schizophrenia diagnosis, this individuals thoughts were disorganized, he had problems with cognition, memory judgment and impulse control. He also had severe clinical manifestations such as hallucinations, delusions, mania, acute psychosis, extreme agitation, and anxiety. Among other things the presence of mania and agitation are what make his diagnosis different from schizophrenia. He clearly demonstrated racing thoughts through his racing speech, he displayed behaviors of grandiosity, slept very little, and was very easily distracted. These symptoms of schizophrenia as well as bipolar mania are what landed this patient with a diagnosis of schizoaffective disorder.

After spending approximately two hours with the patient on the mental health unit at Denver Health, some specific examples emerged that quite accurately reinforce this diagnosis. C.W.Z. was living with his mother at the time of his admission, however, in some of his stories he claimed to have been homeless in the recent past. C.M.Z. conveys that he has a degree in tech design and that whenever he tries to get a job in this field the employer gets threatened by his talent and finds a way to botch his work. He stated that if he could get any job, it would be one building lasers and robots. He would then use these lasers to make furniture just like in Ikea. It was no surprise that he had gone from job to job because he told many stories of being paranoid that his coworkers were trying to poison him. In most cases, they would poison the rim of his soda, something that he considered to be completely normal. He stated that when he gets out of Denver Health he is going to go get his laser from his friend so that he can sell it for a new car. He said that this friend used to steal his old car and put 20 miles on it every night. He also enjoyed talking about how he used to do tech design for big time rock bands. C.M.Z. would quickly jump from story to story and it was very difficult to decipher where one story ended and another one started. These are just a few examples of his delusions, disorganized and racing speech, and thoughts of grandeur.

Before arriving at Denver Health, C.M.Z. had been previously prescribed lorazepam for anxiety, zaleplon for insomnia, cariprazine for schizophrenia and bipolar mania, clonazepam for anxiety, lamotrigine for bipolar disorder, primidone for convulsions, seroquel for schizophrenia, bipolar disorder and major depressive disorder, and ambien for insomnia among other medications such as laxatives. These eight medications were being prescribed for the schizoaffective disorder. Some were for the psychosis, some were for the mania, and some were for the anxiety and insomnia. While these medications may have been effective enough to warrant a discharge order from Aurora North, C.M.Z. has been completely noncompliant in his short time out of the hospital and so the doctors at Denver Health decided to go in another direction.

All of C.M.Z’s previous medications were discontinued and he was started on atarax for a variety of things such as anxiety, insomnia and irritability, zyprexa for schizophrenia and bipolar mania, and lithium for bipolar disorder among other medications such as antibiotics. Not a single medication related to mental health was continued. This was a clean slate for both the doctors and patient. It was a significant reduction in the number of medications and while some of them are very similar, it was a bold choice to start new. Three days into being treated with this new regimen of medications C.M.Z. was starting to show signs of improvement, although, a lot more time was needed in his treatment to be able to see the full effects.

Possible Treatment Modalities

The dominant method of treating disorders such as schizoaffective disorder is with a multitude of various medications. Unfortunately, with a population of patients who are already struggling with their mental abilities, once they leave the facility it is often difficult for them to maintain such a stringent regimen. If mental health disorders could be treated with one medication rather than ten, it is much more likely that the patient would follow through with their post-discharge care.

Patients with schizoaffective disorder are commonly prescribed medications that are symptom-specific; as with C.M.Z., who was individually prescribed mood stabilizers, anxiolytics, antipsychotics, sedatives and so on. In a 2015 study published in the “Journal of Affective Disorders,” Fu, Turkoz, Bossie, Patel, and Alphs assert that, “more recently, large, well-controlled clinical trials of oral paliperidone extended-release (pali ER), administered as a monotherapy or in combination with mood stabilizers and/or antidepressants, has helped establish the drug as a safe, effective, and acute treatment of [schizoaffective disorder]” (p. 381). This study included 614 schizoaffective patients (depressive or manic) who were divided up into two groups. One group received 6 mg per day (amount could be adjusted after 3 days) of pali ER and one group received a placebo. All other medications were appropriately discontinued. Using PANSS, HAM-D-21 AND YMRS scores, the patients were analyzed after 4 days, and then after 1, 2, 3, 4, and 6 weeks. Schizoaffective disorder patients who experienced either depression or mania tended to see a significant improvement with the pali ER within the first week of treatment (Fu et al., 2015).

If patients such as C.M.Z., who struggle with noncompliance, could be treated with a single medication for schizoaffective disorder and maybe one other mood stabilizer or antidepressant, it would be extremely beneficial for maintaining a healthy, balanced lifestyle because they would be much more likely to continue on with their care. Extensive studies about the effects of paliperidone might influence health care providers to more reliably turn to simpler medication therapies for their patients. Unfortunately, while the drug therapies might be getting more and more simplified, if patients don’t have insurance, it won’t matter. Patients need to be educated about why they need to continue their medications and how they can continue to receive their medications once they are outside of treatment facilities.

Outside of a variety of different pharmacotherapy studies, there are very few studies written about alternative ways to treat schizoaffective disorder. While it is almost always necessary to treat a schizoaffective patient with medication in order for them to carry on with everyday life, psychoeducation has been found to be a complementary approach. An article written by Eduard Vieta titled, “Developing an Individualized Treatment Plan for Patients with Schizoaffective Disorder: From Pharmacotherapy to Psychoeducation,” explores an array of medications that have been studied and claimed to be beneficial for schizoaffective patients (including pali ER). The author then discusses how implementing psychotherapy alone has not been studied extensively but that “a 9-week psychoeducational program in 103 outpatients with schizophrenia and schizoaffective disorder was found to improve patients’ concept of and knowledge about their illness as well as their quality of life” (Vieta, 2010).

The article titled, “Psychoeducation and compliance in the treatment of schizophrenia: results of the Munich Psychosis Information Project Study,” included 236 schizophrenia or schizoaffective inpatients. One group attended eight psychoeducational groups for four to five months while the other had routine care. The group who attended psychoeducational groups ended up being more likely to comply with the treatment after one to two years (Pitschel-Walz et al., 2006). This study reinforces the idea that if patients are more educated about why their symptoms present the way they do, what certain signs might indicate, and why it is never a good idea to discontinue their medications, they are less likely to experience recurrences of the psychosis and mania due to noncompliance. This is relevant to C.M.Z. who had been in and out of three hospitals in three months. C.M.Z. did not seem to comprehend why it was so important to continue to take his medications once outside of the hospital. While he had been assigned to a doctor, nobody had been around to discuss his thoughts about how to keep himself out of the hospital in the future. His plan was simply to sell his laser, get a car, and find a friend to help him be less lonely.