If you have schizophrenia, you may hear voices that aren't real and see things that don't exist. Schizoaffective disorder is a condition that can make you feel detached from reality and can
affect your mood. These two disorders have some things in common. But there are important differences that affect your everyday life and the treatment you get. While doctors have studied schizophrenia for years, they still don't know exactly what causes it. Problems with brain chemicals like glutamate and dopamine may
play a role. Doctors have also noticed that people with schizophrenia have physical brain differences from others. There are other things that may also raise your chances of getting schizophrenia. If you take mind-altering drugs, for example, it can bring on some symptoms. You may be more likely to get the illness if your father was older when you were born, or if your mother had contact with certain viruses while they were pregnant, such as influenza. Researchers have not studied schizoaffective disorder as long as schizophrenia, but they have some clues about what's going on. Genes that control your body's
sleep-wake rhythms may contribute to schizoaffective disorder. Things that are going on in your life may also play a role, such as stressful events. You may also have greater chances of schizoaffective disorder if you have another mental illness or if you
have had developmental delays. Your risk of both schizophrenia and schizoaffective disorder is greater if you have a close relative with it, like a mother, father, brother, or sister. If you have schizophrenia, you have symptoms that doctors call "psychotic," which means you lose touch with
reality. You will see and hear things that aren't real, called hallucinations. You may also have delusions, which means you believe things that aren't true. Schizoaffective disorder is a little different. It's almost a blend of the symptoms of
schizophrenia and another mental health condition called bipolar disorder. In bipolar disorder, you have mood swings that include
depression and mania. If you have schizoaffective disorder, you can have these bipolar symptoms. But separate from those, you
also get psychotic symptoms similar to schizophrenia for at least 2 weeks at a time. Doctors often diagnose schizophrenia and schizoaffective disorder by checking your symptoms. They may decide you have schizophrenia if you have at least two of these: Doctors sometimes find it tricky to diagnose schizoaffective disorder because it combines symptoms of other illnesses. Your doctor will likely say you have schizoaffective disorder if these things are happening to you: There are two main types of schizoaffective disorder, depressive type and
bipolar type. Your doctor may diagnose you with one of these types based on the kind of mood symptoms you have. Doctors often treat schizophrenia with antipsychotic drugs that help manage delusions and hallucinations. These may be older antipsychotics, like
chlorpromazine (Thorazine) or haloperidol
(Haldol), or newer antipsychotics, like olanzapine (Zyprexa) or
risperidone (Risperdal). Newer antipsychotics often have fewer side effects. People with schizoaffective disorder often improve on antipsychotics as well. But your doctor may also prescribe a mood stabilizer, such as
lithium (Eskalith), to manage your mood symptoms. Whether you have schizophrenia or schizoaffective disorder, you can benefit from regular talk therapy. During therapy sessions, you may learn strategies to pursue your goals or deal with unwanted thoughts and mood changes. Without treatment, both schizophrenia and schizoaffective disorder can cause you to
struggle at school, on the job, or at social events. The psychotic symptoms of both disorders, as well as the mood symptoms of schizoaffective disorder, may make you want to withdraw from daily life. But with the right medicine and talk therapy, you can learn to manage your illness. BIPOLAR UPDATE (This is the third part of the How To Diagnose Bipolar Disorder series—Ed.) Have you had difficulty with differential diagnosis when the patient has manic symptoms and psychosis? In 2013, the DSM-5 made the issue clearer with significant changes in the criteria defining the quantity and nature of mood symptoms in these diagnoses. As a result, more patients will be diagnosed with schizophrenia compared with when using DSM-IV in either the TM or later “Text Revised” TR version. I will propose some of the implications for psychopharmacology. In the schizophrenia D criteria in DSM-5, the patient should have no mood episodes (ie, meeting full criteria for mania or depression) during the active phase of the illness, or, if the patient has episodes, those episodes occur during a minority (ie, up to 50%) of the total duration of the illness (active and residual phases). In other words, a patient with schizophrenia can have a full manic syndrome present for up to 50% of the time, as long as the other schizophrenia criteria are met. Those criteria include, from the A criteria, positive symptoms during the acute phase; the B criteria of illness duration of at least 6 months of the active and residual phases; the C criteria of deterioration in functioning compared to premorbid levels; and the E criteria of no explanation of it from a substance or medical illness. In the DSM-IV D criteria for schizophrenia, the requirement was that any mood episodes had to be brief in duration compared with the duration of the illness. An example of “brief” was a 5-week period of mania or depression in a patient who was ill for 4 years, which would translate to having a mood syndrome present 2.5% of the time. So, with DSM-IV, individuals with schizophrenia could not experience much time with any mood syndrome to meet the criteria. If mood syndromes were present longer than 2.5% of the time, the diagnosis would be schizoaffective disorder or bipolar with psychosis. However, the DSM-5 criteria for schizoaffective disorder offer the mirror image of the D criteria for schizophrenia: Here, the individual must meet criteria for a mood syndrome for the majority (ie, 50% or more) of the total time that they have been ill. In DSM-IV, it had to be substantial (ie, more than brief [2.5%]). Diagnosis also requires the other schizoaffective criteria, including 2 weeks of psychosis in the absence of prominent mood symptoms. Here, the term mood symptoms is used instead of syndrome, meaning that there cannot be any prominent symptoms—much less the full syndrome—of mania or depression present for those 2 weeks. There seem to be very few patients who meet these DSM-5 criteria for schizoaffective disorder, which require that they be in a mania (or depression) for the majority of the time and also have psychosis without any significant symptoms of a mood disorder for 2 full weeks. Making it tougher to diagnose schizoaffective disorder was probably intended by the DSM-5 authors. The evidence they considered suggested that the disorder, as defined in DSM-IV, did not exist;1,2 they wanted to eliminate it. They retained it because of pushback from field trials, with practicing psychiatrists who largely wanted to keep schizoaffective disorder in the manual. Notably, study results have shown that when the DSM-IV criteria for schizoaffective disorder were in use (1994-2013), clinicians did not seem to use it for diagnoses.3 They overdiagnosed it using unspecified criteria. Also, study results found that patients diagnosed using the criteria very often evolved over time to having a schizophrenia diagnosis, whereas schizophrenia diagnoses under DSM-IV tended to be stable over time.4 Accordingly, with the new, more inclusive DSM-5 criteria for schizophrenia, the diagnosis should continue to be stable. How about the diagnosis of mania with psychosis? In psychotic mania (in DSM-IV and DSM-5), the psychosis appears only during the time the patient is meeting criteria for mania, not after it as in schizoaffective disorder. Usually, the psychosis develops during the most severe part of the mania and tends to resolve early as the episode improves, and before the rest of the manic symptoms resolve.5 Now that you have an accurate diagnosis per DSM-5, what is the psychopharmacology treatment? If the diagnosis turns out to be schizophrenia, there is no demonstrated value to adding non-antipsychotic mood stabilizers (like lithium or valproate) to the antipsychotic for the manic component, according to the evidence reviewed in the Schizophrenia Patient Outcomes Research Team (PORT) guidelines.6 These additions only potentially contribute adverse effects. The usual psychopharmacology algorithm of employing 2 adequate monotherapy trials of antipsychotics followed by consideration of clozapine probably still applies for DSM-5 schizophrenia. If the diagnosis is bipolar with psychosis, you can use those traditional mood stabilizers as well as antipsychotics. Study results show that psychotic mania responds just as well to either class of drugs.7 But what if the patient meets the DSM-5 criteria for schizoaffective disorder, bipolar type? We do not know how to treat it, just as we did not know how to treat DSM-IV schizoaffective disorder, bipolar type. There are almost no studies, no algorithms to consult, no FDA-approved options (although some paliperidone products did manage to get the only FDA approval for schizoaffective disorder). There is still serious doubt that the condition even exists as a valid entity, and it is likely that the current criteria capture only some patients who belong in either the schizophrenia spectrum or the bipolar spectrum. It is suggested that you treat with your best psychopharmacology algorithm for schizophrenia or for bipolar with psychosis, depending on which diagnostic category best represents the patient’s presentation. If the results are unsatisfactory, try switching to your algorithm for the other diagnosis. This may produce better results than improvising with pure guesswork. Dr Osser is co-director of the VA National Bipolar Disorder Telehealth Program and an associate professor of psychiatry at Harvard Medical School at the VA Boston Healthcare System. References 1. Kotov R, Leong SH, Mojtabai R, et al. Boundaries of schizoaffective disorder: revisiting Kraepelin. JAMA Psychiatry. 2013;70(12):1276-1286. 2. Cheniaux E, Landeira-Fernandez J, Lessa Telles L, et al. Does schizoaffective disorder really exist? a systematic review of the studies that compared schizoaffective disorder with schizophrenia or mood disorders. J Affect Disord. 2008;106(3):209-217. 3. Azorin J-M, Kaladjian A, Fakra E. Current issues on schizoaffective disorder. Article in French. Encephale. 2005;31(3):359-365. 4. Jäger M, Haack S, Becker T, Frasch K. Schizoaffective disorder—an ongoing challenge for psychiatric nosology. Eur Psychiatry. 2011;26(3):159-165. 5. Carlson GA, Goodwin FK. The stages of mania. a longitudinal analysis of the manic episode. Arch Gen Psychiatry. 1973;28(2):221-228. 6. Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon LB; Schizophrenia Patient Outcomes Research Team (PORT). The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010;36(1):94-103. 7. Mohammad O, Osser DN. The psychopharmacology algorithm project at the Harvard South Shore Program: an algorithm for acute mania. Harv Rev Psychiatry. 2014;22(5):274-294. ❒ What is the difference between schizoaffective disorder and bipolar with psychotic features?Bipolar disorder consists of similar symptoms, which include episodes of depression and mania. Someone with schizoaffective disorder will experience psychosis, such as delusions and hallucinations. Due to the overlap in symptoms, achieving the proper diagnosis requires a thorough examination.
Are bipolar and schizoaffective disorder the same?The key difference is that people living with schizoaffective disorder experience symptoms of psychosis independently of mood episodes. Meanwhile, if you have bipolar disorder, symptoms of psychosis may occur during episodes of mania or depression but not otherwise.
Is there a difference between having schizoaffective vs bipolar and schizophrenia?Schizoaffective disorder is a little different. It's almost a blend of the symptoms of schizophrenia and another mental health condition called bipolar disorder. In bipolar disorder, you have mood swings that include depression and mania. If you have schizoaffective disorder, you can have these bipolar symptoms.
Is schizoaffective disorder worse than bipolar?Therefore, one person with schizoaffective disorder may have a more severe mental illness than a different person with bipolar disorder. This is not a hard-and-fast rule, as bipolar disorder, especially when it includes psychotic symptoms, can be quite severe.
What does the DSM 5 say about 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 or depressive) in addition to criterion A for schizophrenia; the major depressive episode must include depressed mood.
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Schizoaffective vs bipolar with psychotic features usmle
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