Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders

Schizoaffective disorder (SA D/O), introduced in 1933 by Dr. Jacob Kasanin, represented a first, modest change in our concept about the diagnoses of psychotic patients away from the beliefs of E. Bleuler, i.e., that hallucinations and delusions define schizophrenia, and toward the recognition of a significant role for mood disorders. SA D/O established a connection between schizophrenia and mood disorders, traditionally considered mutually exclusive, a connection that has strengthened progressively toward the diagnostic unity of all three disorders. A basic tenet of medicine holds that if discrepant symptoms can be explained by one disease instead of two or more, it is likely there is only one disease. The scientific justification for SA D/O and schizophrenia as disorders distinct from a psychotic mood disorder has been questioned. The "schizo" prefix in SA D/O rests upon the presumption that the diagnostic symptoms for schizophrenia are disease specific. They are not, since patients with severe mood disorders can evince any or all of the "schizophrenic" symptoms. "Schizophrenic" symptoms mean "psychotic" and not any specific disease. These data and a very low interrater reliability for SA D/O suggest that the concepts of SA D/O and schizophrenia as valid diagnoses are flawed. Clinically SA D/O remains popular because it encompasses both schizophrenia and psychotic mood disorder when there is a diagnostic question. We present a review of the literature in table form based on an assignment of each article assigned to one of five categories that describe the possible relationships between SA D/O, schizophrenia and psychotic mood disorders. We conclude that the data overall are compatible with the hypothesis that a single disease, a mood disorder, with a broad spectrum of severity, rather than three different disorders, accounts for the functional psychoses.     

Physiology of schizophrenia, bipolar disorder, and schizoaffective disorder

OBJECTIVE: Endophenotypes have been proposed to identify the genetic and biological substrates of complex disorders. Three physiological inhibitory endophenotypes of large effect size in schizophrenia include suppression of P50 auditory evoked responses, inhibition of leading (small anticipatory) saccades during smooth pursuit eye movements, and cancellation of reflexive saccades in the antisaccade eye movement task. The aim of this study was to determine if the pattern of endophenotype abnormalities within individuals with schizophrenia differed from that within individuals with bipolar disorder. A second aim was to determine whether subjects with schizoaffective disorder, bipolar type, were neurophysiologically more similar to subjects with schizophrenia or subjects with bipolar disorder. METHOD: Endophenotypes were recorded for subjects diagnosed with schizophrenia (N=29), bipolar disorder (DSM-IV-TR) (N=40), and schizoaffective disorder, bipolar type (N=18). Data from normal comparison subjects were used to establish normal performance. RESULTS: Logistic regression determined that P50 ratio and frequency of leading saccades identified subjects with schizophrenia and bipolar disorder with a sensitivity of 95% and a specificity of 83%. The schizoaffective disorder group was split, with six subjects physiologically classified as schizophrenia-like and 12 subjects as bipolar-like. Those classified as schizophrenia-like were significantly younger at illness onset and had higher symptom ratings. CONCLUSION: A composite endophenotype of P50 ratio and frequency of leading saccades is consistent with the current clinical nosology of schizophrenia and bipolar disorder and parses patients with schizoaffective disorder, bipolar type, into two subgroups.     

Comparison of older patients with bipolar disorder and schizophrenia/schizoaffective disorder.

OBJECTIVE: The aim of this cross-sectional study was to explore differences in measures of symptoms and cognition, side effects, and functional impairment between older patients with schizophrenia and bipolar disorder. METHODS: Representative samples (N = 132) of older patients (age >54 years) with either bipolar disorder or schizophrenia and schizoaffective disorder were compared on several clinical and psychosocial variables. The measures used included the Brief Psychiatric Rating Scale, The Scale for the Assessment of Negative Symptoms, the Geriatric Depression Scale, the Abnormal Involuntary Movement Scale, the Clinical Global Impression, and the Mini-Mental Status Examination. RESULTS: Despite being similar in age (mean age: 68 years), patients with schizophrenia/schizoaffective disorder had significantly greater negative symptoms (Cohen's d = 1.2), a higher clinical global impression of impairment (Cohen's d = 1.16), were less likely to drive (Cohen's d = 0.79), were less likely to be married (Cohen's d = 0.55), and less likely to live independently (Cohen's d = 0.45). CONCLUSION: Although the absolute ratings suggested both diagnostic samples had significant disability, those with schizophrenia and schizoaffective disorder had a greater degree of impairment.     

Social competence in schizoaffective disorder, bipolar disorder, and negative and non-negative schizophrenia

Social skill and role functioning were assessed in matched groups of patients with DSM-III-R schizoaffective disorder, bipolar disorder, and schizophrenia. Schizophrenics were categorized as negative syndrome or non-negative on the basis of the SANS. The negative schizophrenics were significantly more impaired on almost every measure of social functioning. The other three groups were not consistently different from one another. The results suggest that when patients are comparable on dimensions such as duration and severity of illness, schizoaffectives do not occupy an intermediate position between schizophrenics without negative syndrome and bipolar patients. Rather, the three groups exhibit similar degrees of social disability. In contrast, negative syndrome schizophrenics were more impaired even when they were similar in chronicity and severity.     

Association study of 21 circadian genes with bipolar I disorder, schizoaffective disorder, and schizophrenia

Objective:  Published studies suggest associations between circadian gene polymorphisms and bipolar I disorder (BPI), as well as schizoaffective disorder (SZA) and schizophrenia (SZ). The results are plausible, based on prior studies of circadian abnormalities. As replications have not been attempted uniformly, we evaluated representative, common polymorphisms in all three disorders.
Methods:  We assayed 276 publicly available 'tag' single nucleotide polymorphisms (SNPs) at 21 circadian genes among 523 patients with BPI, 527 patients with SZ/SZA, and 477 screened adult controls. Detected associations were evaluated in relation to two published genome-wide association studies (GWAS).
Results:  Using gene-based tests, suggestive associations were noted between EGR3 and BPI (p = 0.017), and between NPAS2 and SZ/SZA (p = 0.034). Three SNPs were associated with both sets of disorders ( NPAS2 : rs13025524 and rs11123857; RORB: rs10491929; p < 0.05). None of the associations remained significant following corrections for multiple comparisons. Approximately 15% of the analyzed SNPs overlapped with an independent study that conducted GWAS for BPI; suggestive overlap between the GWAS analyses and ours was noted at ARNTL .
Conclusions:  Several suggestive, novel associations were detected with circadian genes and BPI and SZ/SZA, but the present analyses do not support associations with common polymorphisms that confer risk with odds ratios greater than 1.5. Additional analyses using adequately powered samples are warranted to further evaluate these results.     

Atypical antipsychotics in bipolar and schizoaffective disorders

No data are available comparing the relative efficacy of different atypical agents in patients with bipolar disorder. A chart review of bipolar and schizoaffective disorder patients who had received courses of at least two atypical agents (n = 33) in a community psychiatry system was conducted. No differences in rates of hospitalizations were found between individual atypical agents or between atypical agents as a class and conventional neuroleptics. However, a significant reduction in rates of emergency room visits was found with atypical agents compared to conventional neuroleptics, with a trend toward greater reduction with clozapine compared to other atypical antipsychotics. Larger prospective studies are needed to confirm these preliminary observations.     

Suicidal behavior in schizophrenia and schizoaffective disorder

Individuals with schizophrenia and schizoaffective disorder are at increased risk for completed suicide and suicide attempts. Suicide risk is increased throughout the life span and most suicide attempters and completers make more than one attempt. Investigations show that individuals with these psychotic disorders are typically experiencing psychotic symptoms and in psychiatric treatment at the time of their attempts although frequently under-treated with respect to medication. We review the literature with regard to demographic and clinical risk factors for suicidal behavior among individuals with schizophrenia and schizoaffective disorder. Specifically the role of clinical symptoms, premorbid and current social functioning, depression, substance misuse and abuse and biological factors are presented. Future directions for research regarding assessment and intervention are discussed.     

Treatment adherence in schizophrenia and schizoaffective disorder

Medication nonadherence is common and difficult to detect in patients with schizoaffective disorder and schizophrenia. Roughly 50% of patients take less than 70% of prescribed doses. Many factors contribute to nonadherence, including poor illness insight, a negative attitude toward medication, substance abuse, and disorganization. Interventions to improve adherence consist of advising acceptance of illness, drawing analogies with treatment for chronic medical disease, and involving the patient in decision making. Clinicians must remain nonjudgmental, encouraging patients to disclose problems with adherence and anticipating that improvement in adherence may require a prolonged effort. Selection of medication is critical to avoid side effects and to provide a sense of well-being, which can result from improvement in insomnia, anxiety, or depression. Depot antipsychotics can improve adherence and provide the clinician with reliable information about the dosage of medication received for purposes of dose adjustments or to guide response to relapse.     

Thalamic morphology in schizophrenia and schizoaffective disorder

Background

Biomarkers are needed that can distinguish between schizophrenia and schizoaffective disorder to inform the ongoing debate over the diagnostic boundary between these two disorders. Neuromorphometric abnormalities of the thalamus have been reported in individuals with schizophrenia and linked to core features of the disorder, but have not been similarly investigated in individuals with schizoaffective disorder. In this study, we examine whether individuals with schizoaffective disorder have a pattern of thalamic deformation that is similar or different to the pattern found in individuals with schizophrenia.

Method

T1-weighted magnetic resonance images were collected from individuals with schizophrenia (n = 47), individuals with schizoaffective disorder (n = 15), and controls (n = 42). Large-deformation, high-dimensional brain mapping was used to obtain three-dimensional surfaces of the thalamus. Multiple analyses of variance were used to test for group differences in volume and measures of surface shape.

Results

Individuals with schizophrenia or schizoaffective disorder have similar thalamic volumes. Thalamic surface shape deformation associated with schizophrenia suggests selective involvement of the anterior and posterior thalamus, while deformations in mediodorsal and ventrolateral regions were observed in both groups. Schizoaffective disorder had distinct deformations in medial and lateral thalamic regions.

Conclusions

Abnormalities distinct to schizoaffective disorder suggest involvement of the central and ventroposterior medial thalamus which may be involved in mood circuitry, dorsolateral nucleus which is involved in recall processing, and the lateral geniculate nucleus which is involved in visual processing.     

A family study of psychotic symptomatology in schizophrenia,schizoaffective disorder,unipolar depression,and bipolar disorder

Summary An evaluation was made of schizophrenics (140), schizoaffectives (40), unipolar depressives (59), and bipolars (30), and their relatives who had a chart diagnosis of psychosis or depressive neurosis. The purpose was to determine whether the psychosis (delusions and hallucinations) was transmitted independently of the illness itself. If this were true, there would be an excess of pairs of probands and relatives both positive for psychosis and pairs of relatives and probands both negative for psychosis when compared to relatives and probands who were not concordant for the variable. This was found to be true in schizophrenia and schizoaffective disorder and is probably the result of the simple transmission of an illness which includes the presence of psychotic symptoms in the definition. Thus, this would be a manifestation of the genetic propensity in schizophrenia. For the affective disorders there was no evidence that psychotic probands were more likely than the nonpsychotic to have psychotic relatives. So far the reason why some patients have psychosis and others not in the affective disorders remains unexplained.     

Clozapine for treatment-refractory schizophrenia, schizoaffective disorder, and psychotic bipolar disorder: a 24-month naturalistic study

BACKGROUND: The aim of this study was to evaluate the 24-month response to clozapine in patients with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder. METHOD: Ninety-one psychotic patients with a principal DSM-III-R diagnosis of schizophrenia (N = 31), schizoaffective disorder (N = 26), or bipolar disorder with psychotic features (N = 34) were treated naturalistically with clozapine at flexible dosages over a 24-month period. Improvement was assessed by the 18-item Brief Psychiatric Rating Scale and the Clinical Global Impressions-Severity of Illness scale. RESULTS: All patients showed significant improvement 24 months from intake (p < .001). Such an improvement was significantly greater among patients with schizoaffective disorder or bipolar disorder than in patients with schizophrenia (p < .05). The presence of suicidal ideation at intake predicted greater improvement at endpoint. CONCLUSION: Clozapine appears to be effective and relatively well tolerated in acute and long-term treatment of patients with psychotic bipolar disorder or schizoaffective disorder who have not responded to conventional pharmacotherapies.     

Clozapine in the treatment of psychotic mood disorders, schizoaffective disorder, and schizophrenia

BACKGROUND: Although growing research indicates that the atypical antipsychotic agent clozapine is effective in patients with schizophrenia, little is known about the efficacy of clozapine in patients with schizoaffective disorder or psychotic mood disorders. The purpose of this study was to assess whether or not clozapine is effective in some patients with schizoaffective disorder or psychotic mood disorders. METHOD: By surveying treating clinicians and chart data, we assessed treatment response in 85 consecutive patients, including 39 with schizophrenia, 25 with schizoaffective disorder, and 14 with bipolar disorder with psychotic features, who received clozapine for at least 6 weeks at our center. RESULTS: All patients were either inadequately responsive to or unable to tolerate standard somatic therapies. Compared to patients with schizophrenia, patients with schizoaffective disorder and bipolar disorder with psychotic features displayed significantly higher response rates to clozapine. CONCLUSION: Clozapine may be a useful drug in the treatment of patients with schizoaffective disorder or psychotic mood disorders who are treatment resistant or intolerant of side effects.     

Distinct facial processing in schizophrenia and schizoaffective disorders

Although schizophrenia and schizoaffective disorders have both similar and differing clinical features, it is not well understood whether similar or differing pathophysiological processes mediate patients' cognitive functions. Using psychophysical methods, this study compared the performances of schizophrenia (SZ) patients, patients with schizoaffective disorder (SA), and a healthy control group in two face-related cognitive tasks: emotion discrimination, which tested perception of facial affect, and identity discrimination, which tested perception of non-affective facial features. Compared to healthy controls, SZ patients, but not SA patients, exhibited deficient performance in both fear and happiness discrimination, as well as identity discrimination. SZ patients, but not SA patients, also showed impaired performance in a theory-of-mind task for which emotional expressions are identified based upon the eye regions of face images. This pattern of results suggests distinct processing of face information in schizophrenia and schizoaffective disorders.     

Oxcarbazepine in the treatment of bipolar and schizoaffective disorders

Oxcarbazepine is an antiepileptic drug that has been approved by the US FDA and is indicated for use as monotherapy or adjunctive therapy in the treatment of partial seizures in adults and children aged over 4 years. The aim of this report is to investigate the results of clinical trials in order to ascertain the efficacy and safety of oxcarbazepine for use in bipolar disorder and schizoaffective disorder. Oxcarbazepine is a keto-congener of carbamazepine with fewer side effects and drug interactions. Orally administrated oxcarbazepine is rapidly and completely absorbed and has a half-life of 9 h. Currently, there is a lack of controlled clinical trials studying the use of oxcarbazepine. In light of controlled and open-label prospective studies, it may be useful for manic symptoms in the treatment of bipolar and schizoaffective patients. Case reports, retrospective and prospective studies suggest that oxcarbazepine might have prophylactic efficacy and long-term benefit for these patients. In addition, owing to its lower propensity for drug interactions and side effects, it may be useful in the treatment of refractory patients with bipolar and schizoaffective disorder. However, most of the trials have relevant methodological shortcomings. The side-effect profile of oxcarbazepine is similar to carbamazepine, but the severity of these effects appears to be slightly less. The symptoms that are most frequently associated with the use of oxcarbazepine are asthenia, headache, dizziness, somnolence, nausea, diplopia and skin rash. Isolated cases of hyponatremic coma have been reported, thus electrolyte abnormalities should be closely monitored. Oxcarbazepine is now a generic drug, but the metabolite licarbazepine and other related compounds, such as eslicarbazepine, are currently being studied under controlled conditions and might become useful therapies for bipolar and schizoaffective disorder in the future.