Schizoaffective disorder: symptoms, types and treatment

Key points

• Psychotic symptoms and the symptoms of a mood episode, mania or depression, occur in the same illness [1][7].
• Timing sets it apart from bipolar disorder or depression with psychosis: psychosis is also present when prominent mood symptoms are absent [7].
• Two types are recognised, bipolar type and depressive type [7].
• Lifetime prevalence is about 0.3 per cent internationally. No reliable UK figure is published [7].
• The diagnosis is less stable than schizophrenia or bipolar disorder and changes for a sizeable minority [8].
• NICE has no guideline for it alone, so UK care draws on CG178 and CG185 [1][2].

What schizoaffective disorder is

Schizoaffective disorder is a mental health condition in which psychotic symptoms, such as hallucinations or delusions, occur alongside the symptoms of a mood episode, either mania or depression. It sits between schizophrenia and the mood disorders, and is recognised as a diagnosis in its own right [3][4].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

The timing rule is the whole diagnosis. In bipolar disorder or severe depression, psychotic symptoms appear only while the mood episode is under way and settle when it lifts. In schizoaffective disorder there is also a period when psychosis is present and prominent mood symptoms are not [7].

The two systems apply that rule differently, which matters when reading a diagnosis. ICD-11 looks at the current episode, requiring symptoms that would meet the bar for schizophrenia at the same time as a moderate or severe depressive, manic or mixed episode, over about a month [9]. DSM-5-TR, used mainly in research, instead requires two weeks or more of psychosis without a mood episode at some point in the illness [7].

Symptoms

Symptoms fall into three groups. Which group dominates can change over time [3][4].

Psychotic symptoms: - Hallucinations, most often hearing voices others do not hear - Delusions, firmly held beliefs others do not share - Disorganised speech, meaning speech that is hard to follow - Negative symptoms: reduced speech, flattened emotion, loss of motivation and withdrawal

Manic symptoms, seen in the bipolar type: - Elevated or irritable mood - Racing thoughts and rapid speech - Needing much less sleep without feeling tired - Impulsive decisions, including spending

Depressive symptoms: - Persistent low mood and hopelessness - Loss of interest or pleasure in most things - Tiredness, slowed movement and poor concentration - Thoughts of death or of suicide

Schizoaffective disorder is one of the most frequently misdiagnosed psychiatric conditions [7]. It is most often confused with schizophrenia, and with bipolar disorder or severe depression with psychotic features [7].

Types

Two types are recognised, defined by the mood episodes a person has had [7].

• Bipolar type. At least one manic episode has occurred.
• Depressive type. Only depressive episodes occur.

This diagnosis is less reliable than most. In one research sample about 64 per cent of people given it still had it at follow-up, against about 87 per cent of those with bipolar disorder, and where it changed it became schizophrenia in three quarters of cases [8].

Clinicians disagree about the category itself, and the lifetime rule relies on what a person recalls and on a clinician reconstructing past episodes [9]. A change of diagnosis does not mean earlier care was wrong. The pattern often becomes clear only over years [8].

Causes and risk factors

There is no single cause, and no conclusive research on why schizoaffective disorder develops [6][7].

• Family history. A first-degree relative with schizophrenia, bipolar disorder or schizoaffective disorder raises risk [7].
• Genetics. No single gene has been found that explains the condition [6].
• Brain differences. Differences in dopamine, noradrenaline and serotonin activity, and in hippocampal volume, are group averages rather than findings that identify an individual [7].
• Childhood adversity, including abuse, neglect and traumatic loss [6].
• Stressful events. Bereavement, job loss, bullying and money problems can precede an episode [6].

The chemical imbalance explanation is inferred partly from the fact that some medications help, which is not the same as showing a cause [6].

How it is diagnosed

Schizoaffective disorder is diagnosed by a psychiatrist, usually in a community mental health team or an early intervention in psychosis service [1][3]. A GP does not make the diagnosis but can refer.

Assessment covers symptoms and, above all, their timeline: when psychotic symptoms started, when mood symptoms started, and whether either occurred without the other. Physical examination, blood tests and a review of alcohol, drug and medication use rule out other causes [3][7]. No test confirms the diagnosis, and several appointments across months are usual, because the timing pattern has to be observed [3][7].

For a first episode of psychosis, NHS England sets a standard that at least 60 per cent of people referred, aged 14 to 65, start a NICE-recommended treatment package within two weeks [10].

A diagnosis opens a route to particular treatments. It does not predict how a person’s life will go, and it is not fixed [8].

Treatment

NICE has published no guideline for schizoaffective disorder alone. CG178 covers it within the group of psychotic disorders, and CG185 covers the mood side [1][2].

From CG178, for the psychosis component: - Oral antipsychotic medication together with psychological intervention, not instead of it [1]. - Individual cognitive behavioural therapy for psychosis, over at least 16 planned sessions [1]. - Family intervention, at least 10 planned sessions over three months to a year [1]. - Arts therapies, particularly for negative symptoms [1]. - Where someone declines medication, CBT and family intervention are still offered, and options reviewed within a month [1]. - Clozapine where the illness has not responded adequately to adequate doses of at least two different antipsychotics [1].

From CG185, for the mood component: - For mania or hypomania, haloperidol, olanzapine, quetiapine or risperidone [2]. - For bipolar depression, a psychological intervention designed for bipolar disorder, plus fluoxetine combined with olanzapine, or quetiapine alone, with lamotrigine as an alternative [2]. - Lithium as a first-line long-term medication, alongside a structured psychological intervention to reduce relapse [2].

Mind notes that antidepressants are not usually given alone where mania has also occurred [5]. Decisions about starting or stopping medication are made with a prescriber. Evidence specific to schizoaffective disorder is thin, because trials tend to recruit people with schizophrenia or bipolar disorder instead [1][2].

Living with schizoaffective disorder

If you are under a community mental health team you should have a care plan and a named contact. Ask whether it names your early warning signs and who to call.

• Ask your GP about the annual physical health check. Antipsychotic medication raises cardiovascular and metabolic risk, and NICE expects yearly monitoring [1].
• If you want to work, ask about supported employment, which NICE recommends for people with psychosis [1].
• You do not have to tell an employer or university your diagnosis. Describing what you need, such as adjusted hours, is often enough.
• Anyone who cares for you can ask for an assessment of their own needs and a carer support programme [1].
• Rethink Mental Illness runs support groups for people with this diagnosis and their families [3].

When to speak to a professional

Book a GP appointment if:

• You have been hearing or seeing things other people do not for more than a few days.
• You hold beliefs others find strange that are causing you distress.
• Your mood has been very low or unusually high for two weeks or more, affecting work, study or relationships.
• Symptoms have returned after a period of stability.

Ask about referral to a community mental health team, or to an early intervention service for a first episode of psychosis [10].

Get help the same day if you cannot keep yourself safe or you are thinking about suicide. Call NHS 111 and choose the mental health option, or your crisis team if you have one. Call 999 if anyone is in immediate danger. Samaritans are on 116 123, free, 24 hours a day. Shout: text SHOUT to 85258.

Common questions

Is schizoaffective disorder the same as schizophrenia?

No. Both involve psychotic symptoms, but schizoaffective disorder also involves full episodes of mania or depression across much of the illness [7]. NICE groups the two together in its psychosis guideline, so care overlaps [1].

What is the difference between schizoaffective disorder and bipolar disorder?

Timing. In bipolar disorder with psychotic features, psychosis appears only during a mood episode. In schizoaffective disorder there is also a period when psychosis is present without prominent mood symptoms [7].

Can a schizoaffective disorder diagnosis change?

Yes, more often than most diagnoses. In one research sample about 64 per cent were unchanged at follow-up, against about 87 per cent of bipolar diagnoses [8].

Is schizoaffective disorder lifelong?

The course varies. Some people have symptoms only once, while others have episodes that return over many years [4]. Treatment aims to reduce how often and how severely episodes happen.

Clinical review pending

References

1. National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management (CG178). Reproduced on NCBI Bookshelf, 2014. https://www.ncbi.nlm.nih.gov/books/NBK555203/
2. National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185). NHS Right Decisions hosted copy, 2014. https://www.rightdecisions.scot.nhs.uk/m/1845/nice-guidance-bipolar-affective-disorder-assessment-and-management.pdf
3. Rethink Mental Illness. Schizoaffective Disorder Explained. https://www.rethink.org/advice-and-information/about-mental-illness/mental-health-conditions/schizoaffective-disorder/
4. Mind. About schizoaffective disorder. https://www.mind.org.uk/information-support/types-of-mental-health-problems/schizoaffective-disorder/about-schizoaffective-disorder/
5. Mind. Treatment for schizoaffective disorder. https://www.mind.org.uk/information-support/types-of-mental-health-problems/schizoaffective-disorder/treatment/
6. Mind. Causes of schizoaffective disorder. https://www.mind.org.uk/information-support/types-of-mental-health-problems/schizoaffective-disorder/causes/
7. StatPearls. Schizoaffective Disorder. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK541012/
8. Diagnostic Stability of Primary Psychotic Disorders in a Research Sample. Frontiers in Psychiatry, 2021. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.734272/full
9. Falkai P. Should schizoaffective disorder be diagnosed cross-sectionally (ICD-11) instead of longitudinally (DSM-5)? PRO. European Psychiatry, 2021. https://www.cambridge.org/core/journals/european-psychiatry/article/should-schizoaffective-disorder-be-diagnosed-crosssectionally-icd11-instead-of-longitudinally-dsm5/D199AFCF318AA0000949DB1A1345E5C0
10. NHS England. Early intervention in psychosis: access and waiting time standard. https://www.england.nhs.uk/mental-health/adults/early-intervention-in-psychosis/