Schizoaffective Disorder Diagnosis

Diagnosing schizoaffective disorder

A diagnosis of schizoaffective disorder is made when a person has the symptoms of both illnesses but does not strictly have the features of either schizophrenia or a mood disorder alone. For psychiatrists, the difficulty of this kind of diagnosis is clear. Determining if a patient has one of two separate illnesses (schizophrenia or bipolar disorder), or whether there are features that are common to two illnesses (schizophrenia or bipolar disorder), or whether there is a separate and distinct condition that is different to these two illnesses (schizophrenia or bipolar disorder) is not an easy task. Family history is not a guide either. It is likely at least some of the genetic causes of the schizophrenia and bipolar disorders are found in both disorders.

The distinction between schizoaffective disorder and schizophrenia or bipolar disorder is not straightforward either. Emotion and behaviour are more fluid and less easy to classify than physical symptoms. Seriously depressed people often have delusions and hallucinations. Mania can be difficult to distinguish from an acute episode of schizophrenia, and a depressive episode can either be a symptom of an acute phase of schizophrenia or a reaction to it. For this reason, over time, a diagnosis of schizophrenia or bipolar disorder can often be altered to schizoaffective disorder.

This complex situation reminds us that all mental illnesses fall across a wide and changing spectrum of definitions that can change over time depending on the outcomes of new research. Distinctions between mental illnesses can therefore appear arbitrary and uncertain as new evidence emerges.

Note that there is likely to be an amendment to the diagnosis of schizoaffective disorder in the DSM-V due to be published in 2012.

Diagnostic & Statistical Manual of Mental Disorders (DSM-IV) Criteria for Schizoaffective Disorder:

An uninterrupted period of illness during which, at some time, there is either (1) a Major Depressive Episode, (2) a Manic Episode, or (3) a Mixed Episode concurrent with symptoms that meet (4) Criterion A for Schizophrenia.

(1) Criteria for Major Depressive Episode

  • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
    1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
    2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
    3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
    4. insomnia or hypersomnia nearly every day
    5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
    6. fatigue or loss of energy nearly every day
    7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
    8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
    9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  • The symptoms do not meet criteria for a Mixed Episode
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)
  • The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

(2) Criteria for Manic Episode

  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
  • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    1. inflated self-esteem or grandiosity
    2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    3. more talkative than usual or pressure to keep talking
    4. flight of ideas or subjective experience that thoughts are racing
    5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
    6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
    7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
  • The symptoms do not meet criteria for a Mixed Episode.
  • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

(3) Criteria for Mixed Episode

  • The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
  • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

(4) Criterion A of Schizophrenia

  • Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
    • delusions
    • hallucinations
    • disorganized speech (e.g., frequent derailment or incoherence)
    • grossly disorganized or catatonic behavior
    • negative symptoms, i.e., affective flattening, alogia, or avolition
  • keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.