Chronic Treatment
The chronic nature of delusional disorders suggests treatment strategies should
be tailored to the individual needs of the patients and focus on maintaining social function and improving quality of life.
For most patients with delusional disorder, some form of supportive therapy is
helpful. The goals of supportive therapy include facilitating treatment adherence and providing education about the illness and its treatment.
Educational and social interventions can include social skills training (e.g., not dis-
cussing delusional beliefs in social settings) and minimizing risk factors.
Providing realistic guidance and assistance in coping with problems stemming
from the delusional system may be very helpful.
Cognitive therapeutic approaches may be useful for some patients by identifying
delusional thoughts and then replacing them with alternative, more adaptive ones.
It is important that goals be attainable, because a patient who feels pressured or
repeatedly criticized by others will probably experience stress that may lead to a worsening of symptoms.
Insight-oriented therapy is rarely indicated.
Recurrence Rate
Delusional disorder has a relatively good prognosis when adequately treated:
52.6% of the patients recover, 28.2% achieve partial recovery, and 19.2% do not improve.
Less than 25% of all cases are later diagnosed with schizophrenia.
Less than 10% develop mood disorders.
Good prognosis is predicted with high levels of occupational and social func-
tioning, female gender, onset before age 30, sudden onset, and short duration of illness.
SCHIzOAffECTIvE DISORDER 121
PATIENT EDUCATION
Educating the family about the symptoms and course of the disorder is helpful.
This is especially true as the family frequently feels the impact of the disorder the most.
In addition to being involved with seeking help, family, friends, and peer groups
can provide support and encourage the patient to regain his or her abilities.
MEDICAl/lEGAl PITfAllS
Patients with delusional disorder are more susceptible to becoming dependent on
alcohol, tobacco, and drugs.
It is not uncommon for people with delusional disorder to make repeated com-
plaints to legal authorities.
Patients with delusional disorder may encounter legal or relationship problems as a
result of acting on their delusions.
In patients with delusional disorder who may be dangerous civil commitment
focuses on preventing harm to self or others.
Schizoaffective Disorder
Definition of Disorder
A diagnosis midway between the diagnosis of schizophrenia and bipolar I disorder.
An individual has a mixture of psychotic and depressive/manic/mixed episode(s)
that fail to meet the diagnostic criteria for either schizophrenia or bipolar I disorder.
This disorder is not caused by a drug, medication, or general medical illness.
The bipolar type of schizoaffective disorder is more common in younger patients,
whereas the depressive type is more common in older patients.
Individuals with this disorder have a better prognosis than individuals with schizo-
phrenia but a worse prognosis than individuals with bipolar I disorder.
Etiology
May either be a type of schizophrenia or a mood disorder, or both occurring at the
same time, or not related to either
May encompass bipolar and depressive types and may have a genetic component
Relatives of the persons with the depressed type of schizoaffective disorder have a
higher incidence of also having schizoaffective disorder.
There is a tendency to respond to lithium and have a better course outcome.
Balance of dopamine and serotonin in the brain may contribute to development
of the disease. Other theories consider that it may be due to in utero exposure to viruses, malnutrition, or even birth complications.
Abnormalities of the neurotransmitters serotonin, norepinephrine, and/or dop-
amine could all contribute to this disorder.
Demographics
There is a lifetime prevalence rate of less than 1%.
Diagnosis may be used when the clinician is unsure of the classification of
symptoms.
The prognosis for patients with schizoaffective disorder is thought to be between
that of patients with schizophrenia and that of patients with a mood disorder, with the prognosis better for schizoaffective disorder than for schizophrenic disorder but worse than for a mood disorder alone.
The incidence of suicide is estimated to be 10%. Whites have a higher rate of suicide
than African Americans. Immigrants have higher suicide rates than natives.
As in other psychiatric disorders, women attempt suicide more than men, but men
complete suicide more often.
Schizoaffective disorder affects more women than men, with more women in the
depressive type as compared with the bipolar type.
A poor prognosis in patients with schizoaffective disorder is generally associated
with a poor premorbid history, an insidious onset, no precipitating factors, a pre- dominant psychosis, negative symptoms, an early onset, an unremitting course, or having a family member with schizophrenia.
Risk factors Age
Young people with schizoaffective disorder tend to have a diagnosis with the bipo-
lar subtype, whereas older people tend to have the depressive subtype.
Age of onset is later in women than in men.
Gender
Prevalence is lower in men, and occurs less often in married women.
Men with schizoaffective disorder may exhibit antisocial behavior and flat or inap-
propriate affect.
Family History
Patients may have a genetic predisposition
Inconsistent study results, although relatives with the depressed type may be at
higher risk of acquiring the disorder; stressful events in the lives of susceptible people may trigger the disorder.
No studies provide data on having another disorder.
Not studied
DIAGNOSIS
Differential Diagnosis Evaluate Medical Medications
All mood and schizophrenic disorders should be considered in the differential
diagnosis of schizoaffective disorder.
Testing is done for use of amphetamines, phencyclidines (PCPs), hallucinogens,
cocaine, alcohol, and steroids, as these can present with similar symptoms.
Seizure disorders of the temporal lobe can mimic schizoaffective signs, as can HIV/
autoimmune deficiency syndrome, hyperthyroidism, neurosyphilis, delirium, metabolic syndrome, or narcolepsy.
ICD-10 Codes Schizophrenia (F20.89)
Schizoeffective Disorder (F29.9)
SCHIzOAffECTIvE DISORDER 123
Diagnostic Workup
Schizoaffective disorder must meet
DSM-5 criteria for components of schizophrenia
and mood disorders (depressed) concurrently.
Delusions or hallucinations for at least 2 weeks may be seen in the absence of mood
symptoms. Major mood episode must be present for a majority of the disorder’s total duration.
Laboratory studies include sequential multiple analysis, CBC, rapid plasma
reagent, thyroid function, drug and alcohol screens, lipid panel, enzyme-linked immunosorbent assay (ELISA) test results, and the Western Blot test.
If the patient’s neurologic findings are abnormal, computed tomography or
magnetic resonance imagery may be ordered to rule out any suspected intracra- nial pathology. Findings include decreased amounts of cortical gray matter and increased fluid-filled spaces.
Initial Assessment
Medical workup, including neurological history and evaluation of laboratory data
Psychiatric assessment, including mental status examination and history.
Mental status examination may reveal appearances ranging from well groomed to
disheveled; possible psychomotor agitation or retardation; euthymic, depressed, or manic mood; eye contact ranging from appropriate to flat affect; speech that ranges from poverty to flight of ideas or pressured; suicidal or homicidal ideation may or may not be present; presence of delusions and/or hallucinations.
Psychological testing may assist with diagnosis and in rating the severity of the
disease. These scales may be useful in assessing the patient’s progress: Positive and Negative Symptoms Scale (PANSS), Hamilton Depression Scale, and Young Mania Scale. The CAGE questionnaire (cut down, annoyed, guilty, and eye opener) is helpful in determining alcohol consumption in patients with schizoaffective disorder.
Clinical Presentation: Symptoms
All the signs and symptoms of schizophrenia, manic episodes, and depressive
disorders occur.
Symptoms can appear in concert or alternating.
May be mood incongruent, which has a poor prognosis.
Suicidal ideation or attempt(s) may occur.
DSM-5 Diagnostic Guidelines
An uninterrupted period of illness occurs during which a major depressive epi-
sode, a manic episode, or a mixed episode occurs with symptoms that meet criteria for schizophrenia. The major depressive episode must include a depressed mood.
Symptoms that meet the criteria for mood episodes are present for a substantial
portion of the active and residual periods of the illness.
The disturbance is not the direct physiologic effect of a substance (e.g., illicit drugs,
medications) or a general medical condition.
The bipolar type is diagnosed if the disturbance includes a manic or a mixed epi-
sode (or a manic or mixed episode and a major depressive episode).
The depressive type is diagnosed if the disturbance includes only major depressive
episodes.
TREATMENT OvERvIEW Acute Treatment
The major treatments include inpatient psychiatric hospitalization, medication, and
psychosocial therapies. Inpatient treatment is mandatory for patients who are dan- gerous to themselves or others and for patients who cannot take care of themselves.
Activity should be restricted if patients represent a danger to themselves or to others.
Psychopharmacologic treatment involves use of antipsychotics to treat aggressive
behavior and psychosis, along with antidepressants, and/or mood stabilizers.
Agent selection depends on whether the depressive or manic subtype is present.
In the depressive subtype, combinations of antidepressants plus an antipsychotic
are used.
In refractory cases, clozapine (Clozaril, FazaClo ODT) has been used as an antip-
sychotic agent. In the manic subtype, combinations of mood stabilizers plus an antipsychotic are used.
Early treatment with medication along with good premorbid functioning often
improves outcomes.
PSYCHOPHARMACOlOGY Of SCHIzOAffECTIvE DISORDER Overview
Second-generation (atypical) antipsychotics
are the first-line treatment for schizoaffec-
tive disorder.
Consistent evidence has demonstrated that risperidone (
Risperdal), olanzapine
(Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), asenap- ine (Saphris), and paliperidone (Invega) are efficacious in the treatment of global psychopathology and the positive symptoms of the schizophrenic spectrum disor- ders, including schizoaffective disorder. Less consistent evidence has demonstrated that the negative symptoms improve as well.
Second-line treatment:
First-generation (typical or conventional) antipsychotics;
although haloperidol (Haldol) was previously regarded as a first-line treatment for patients with schizoaffective disorder, it is now regarded as a second- or third-line treatment since atypical antipsychotics generally have a more tolerable side effect profile.
In addition to an antipsychotic agent, antidepressant medications may be pre-
scribed for the depressive symptoms. Mood stabilizers may be used to treat mixed symptoms occurring in schizoaffective disorder. Any of the SSRIs may be used for the depressive symptoms, but the most evidence available is for fluoxetine (Prozac).
Lithium (
Eskalith, Lithobid, lithium carbonate) has proven helpful as an adjunct to the antipsychotic agents. It has limited effectiveness as monotherapy in treat- ing schizoaffective disorders. When combined with an antipsychotic agent, lithium augments the antipsychotic response in general, and negative symptoms specifically.
Valproate (
Depakote) studies have reported positive and negative results. Although the evidence base is limited because most studies have few patients, one study compared valproate (Depakote) with olanzapine (Zyprexa), valproate (Depakote) with risperidone (Risperdal), olanzapine (Zyprexa) with placebo, and risperidone (Risperdal) with placebo and concluded that the valproate (Depakote) groups improved significantly more rapidly over the first 2 weeks of treatment than the antipsychotic group alone.
SCHIzOAffECTIvE DISORDER 125
CBT, modified for this population, focuses on symptom management, symptom
recovery in acute psychosis, relapse prevention, and early intervention. Patients are taught coping strategies, attention switching or attention narrowing, especially useful for dealing with hallucinations, modified self-statements and internal dialog, reattribution, awareness training, de-arousing techniques, increased activity levels, social engagement and disengagement, and reality-testing techniques.
Electroconvulsive therapy (ECT) has been suggested as a treatment for resistant
schizoaffective disorders; however, the evidence has been limited to case studies and uncontrolled studies. In general, antipsychotic treatment alone has produced better outcomes than ECT.
Emphasis is being placed on early identification of any of the schizophrenic spec-
trum disorders, including schizoaffective disorders. Earlier identification allows for earlier intervention and not requiring patients and/or families to reach a high threshold of risk, disruption, or deterioration before accessing treatment. There is evidence that if symptoms are treated prior to the onset of a psychotic episode, full-blown consequences (such as schizoaffective disorder or schizophrenia) may be delayed or even prevented.