NOTE: PA certified Peer Support Specialist and CBTN host John Ward is diagnosed with “Bipolar Type 1 or Bipolar Schizoaffective Type.”

The term “Schizoaffective” has existed as a label since the 1860s. It was included in the DSM-1 and as of the most recent update the DSM-5, Schizoaffective disorder is considered a longitudinal or “life course” diagnosis.[1]


DEFINITIONS OF SCHIZOAFFETIVE DISORDER

WIKIPEDIA[2]:

Schizoaffective disorder (SZA, SZD or SAD) is a mental disorder characterized by abnormal thought processes and deregulated emotions.

NAMI (National Alliance on Mental Health)[3]:

Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression.

MAYO CLINIC[4]:

Schizoaffective disorder is a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.

MHA (Mental Health America)[5]:

Schizoaffective disorder is characterized by persistent symptoms of psychosis resembling schizophrenia with additional periodic symptoms of mood (or affective) disorders.


ISAAC NEWTON, suspected of having been either Schizophrenic or possibly Schizoaffective.
ISAAC NEWTON, suspected of having been either Schizophrenic or possibly Schizoaffective.

Schizoaffective disorder may run a unique course in each affected person, so it’s not as well-understood or well-defined as other mental health conditions.[4]

In the mid 2000s, after graduating high school and then college three and a half years later, I comfortably (at the time) slipped into the “follow the girl” cliché and moved to San Antonio, Texas, where I would live for the next five or so years.

Transporting us into the environmental condition of my headspace I then existed in, my working knowledge of mental illness was effectively zero and my perception was that things were going well. I had not to date noticed any concerning symptoms or behavior (though these clearly had happened and existed).

Skipping for now the mostly tedious details of my life and activities over that half decade or so, my first official stay in a hospital resulted in finally crossing a self-analytical/awareness threshold and checking myself in to a mental health ward at a local facility. I could no longer deny something was going on with my behavior, and I could finally acknowledge that whatever it was was happening mostly if not entirely independent of external stimuli. Those concerning thoughts and behaviors included:

  • Regularly staying up for two or three days straight
  • Eating (not eating) on a similar scale
  • An obsession with a “theory of everything”
  • Explosive anger
  • Frequent crying spells
  • Constant suicidal ideation
  • A belief I had been chosen for a special mission by God
  • Chronic substance abuse
  • Alternating between extreme and absent libido
  • Huge levels and frequency of risk taking
  • Breaking the law
  • Prolific creative output
  • Auditory and visual hallucinations
  • Racing thoughts

During my first cray-cation I was awarded an initial diagnosis of “Bipolar Type 2,” which I was hastily assured was the “less severe” form of Bipolar. I assumed the existence of a Type 1 and looked into it, and rather quickly realized no, this is probably what I have.


SYMPTOMS OF SCHIZOAFFETIVE DISORDER

schizoaffective-graphic-1

Schizoaffective Disorder is often confused with Bipolar Disorder with psychotic features. Both diagnosis include mood changes that impact life as well as symptoms of psychosis. A person diagnosed with Schizoaffective Disorder primarily experiences symptoms of psychosis even if mood problems don’t exist. However, when mood problems flare up, such as during a depressed or manic episode, the symptoms of psychosis can worsen. Someone who is diagnosed with Bipolar Disorder with psychotic features often only experiences psychosis during a mood swing.

This distinction is not always as obvious as the description suggests. Emotion and behavior are more fluid and less easy to classify than physical symptoms.[5]

HALLUCINATIONS

Seeing or hearing things that aren’t there.[3]

Hearing voices or seeing things that aren’t there.[4]

DELUSIONS

False, fixed beliefs that are held regardless of contradictory evidence.[3]

False, fixed beliefs, despite evidence to the contrary.[4]

DISORGANIZED THINKING

A person may switch very quickly from one topic to another or provide answers that are completely unrelated.[3]

Impaired occupational, academic and social functioning; Problems with managing personal care, including cleanliness and physical appearance.[4]

DEPRESSED MOOD

If a person has been diagnosed with schizoaffective disorder depressive type they will experience feelings of sadness, emptiness, feelings of worthlessness or other symptoms of depression.[3]

Feeling empty, sad or worthless.[4]

MANIC BEHAVIOR

If a person has been diagnosed with schizoaffective disorder: bipolar type they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania.[3]

Periods of manic mood or a sudden increase in energy with behavior that’s out of character

Impaired communication, such as only partially answering questions or giving answers that are completely unrelated.[4]


Schizoaffective disorder is estimated to occur in 0.5 to 0.8 percent of people at some point in their life.[7] It is more common in women than men; however, this is because of the high concentration of women in the depressive subcategory, whereas the bipolar subtype has a more or less even gender distribution.[2]

Schizoaffective disorder is seen in about 0.3% of the population. Men and women experience schizoaffective disorder at the same rate, but men often develop the illness at an earlier age.[3]

Now more commonly referred to as Schizoaffective disorder, Bipolar Type 1 encompasses both “bipolar” mood swings (manic, or elevated, and depressed, or lowered) and psychotic symptoms, namely hallucinations and delusions.

The term schizoaffective psychosis was introduced by the American psychiatrist Jacob Kasanin in 1933 to describe an episodic psychotic illness with predominant affective symptoms, that was thought at the time to be a good-prognosis schizophrenia. Kasanin’s concept of the illness was influenced by the psychoanalytic teachings of Adolf Meyer and Kasanin postulated that schizoaffective psychosis was caused by “emotional conflicts” of a “mainly sexual nature” and that psychoanalysis “would help prevent the recurrence of such attacks.” He based his description on a case study of nine individuals.[2]

Of course being a new initiate to the adventure of MH diagnosis and treatment, and as part of a comprehensive self-prescribed mental “treatment plan” in which I agreed with myself (based on recent realizations) that I would by default assume all mental incongruities were the result of my internal failings as opposed to external stimuli/causality – I trusted the diagnosis and soldiered on armed with a quiver of Seroquel.

This failed spectacularly.

I would then go on to, through myriad experiences and treatment over the ensuing few years, slowly gain a better understanding of where to start and just what in the hell was going on. I was eventually diagnosed with Bipolar Type 1 – Schizoaffective disorder.

A natural place to start is with the ostensible, informational stuff, and perhaps the most natural question that follows “what is [INSERT DIAGNOSIS] is What is the cause? (Because there MUST be one, you shout…)

This is where you’ll run into one of the most fun/frustrating tropes of the MH industry (emphasis added):

Evidence is sorely lacking about schizoaffective disorder’s (likely multiple) causes and mechanisms.[2]

The exact cause of schizoaffective disorder is unknown. A combination of causes may contribute to the development of schizoaffective disorder.[3]

The exact cause of schizoaffective disorder is not known. A combination of factors may contribute to its development, such as genetics and variations in brain chemistry and structure.[4]

…MHA didn’t even try. (Also NAMI and the Mayo Clinic may want to check into who plagiarized who here).

If you ever get an “exact cause” out of a MH professional, or conversely something other than “a combination of factors,” I’ll eat my hat. This trope is justified (usually with disdain or an air of intellectual superiority, but to be fair sometimes apologetically) by the very valid logical conclusion that – HEY! MENTAL HEALTH IS COMPLICATED!

ROBERT HOOKE of Hooke's Law (physics) fame/infamy was a contemporary of Isaac Newton and on occasion either ripped off his ideas or straight up tried to ruin his reputation. An example of bad science.
ROBERT HOOKE of Hooke’s Law (physics) fame/infamy was a contemporary of Isaac Newton and on occasion either ripped off his ideas or straight up tried to ruin his reputation. An example of bad science.

So the tendency as a patient is to submit to medical expertise and experience – and don’t get me wrong, it should be. Just because MH professionals don’t have much of an idea when it comes to some umbrella, inverse-panacea causality, it does not preclude the notion that they more than likely know a shit load more than you do, especially at the beginning. But it’s worth mentioning for any new adventurers that it’s important to maintain personal vigilance and self-reliance (and not just because you now have a mental “illness”, but also because it’s a pretty reasonable way to live your life).

When you get the “no exact cause” explanation, utilize a little inalienable agency and ask: What is the inexact cause?

To which all respectable physicians will reply “a combination of factors” including:


CAUSES OF SCHIZOAFFECTIVE DISORDER

GENETICS

Schizoaffective disorder tends to run in families. This does not mean that if a relative has an illness, you will absolutely get it. But it does mean that there is a greater chance of you developing the illness.[3]

Having a close blood relative who has schizoaffective disorder, schizophrenia or bipolar disorder.[4]

BRAIN CHEMISTRY/STRUCTURE

Brain function and structure may be different in ways that science is only beginning to understand. Brain scans are helping to advance research in this area.[3]

STRESS

Stressful events such as a death in the family, end of a marriage or loss of a job can trigger symptoms or an onset of the illness.[3]

Stressful events that trigger symptoms.[4]

DRUG USE

Psychoactive drugs such as LSD have been linked to the development of schizoaffective disorder.[3]

Taking mind-altering (psychoactive or psychotropic) drugs.[4]


If you happen to still be exercising that self-reliant agency, you’ll notice that literally all four of these factors are themselves currently understood as essential having no exact understanding, being that they’re comprised of a combination of factors.

In fact, these four “factors” might actually be the top four most poorly understand domains of human medicine if not the anthropic science in their entirety – and I’m factoring in (see what I did there?!) things like quantum chromodynamics and string theory. That’s because the pervasive curse of the soft sciences is that they (as far as we know) can’t be modeled with any kind of discreet, deterministic patterns or generators, and even probability theory doesn’t get us nearly as far with human behavior as it might with financial markets or meteorological data.

My goal here is not to knock modern medicine or MH professionals, but to remind new adventurers that, in the crudest sense, nobody really knows a whole lot about the causes of what’s happening to you – so pay attention to not just what’s going on around you, but also what’s going on inside you – who knows, you might just be the one who figures it out!

Anyway – to summarize – Schizoaffective disorder has no exact cause, but instead may be caused by a number of factors that themselves have no exact understanding and may be comprised by a number of factors.

Welcome to the world of living with a mental “illness.”

From the aforementioned digital sources we can pull a decent outline of how Schizoaffective disorder is currently treated:


TREATMENT OF SCHIZOAFFETIVE DISORDER

Medications, including mood stabilizers, antipsychotic medications and antidepressants; Psychotherapy, such as cognitive behavioral therapy or family-focused therapy; Self-management strategies and education.[3]

People with schizoaffective disorder generally respond best to a combination of medications, psychotherapy and life skills training.[4]

The primary treatment of schizoaffective disorder is medication, with improved outcomes using combined long-term psychological and social supports.[6][2]


…and the plagiarism suspicion between NAMI and the Mayo Clinic continues!

Ribbing aside, I’m thinking the former pirated from the latter based on the Mayo Clinic’s site being considerably more detailed, so let’s use their complete outline of treatment options and efficacies:

Treatment varies, depending on the type and severity of symptoms, and whether the disorder is the depressive or bipolar type. In some cases, hospitalization may be needed. Long-term treatment can help to manage the symptoms.[4]

The Mayo Clinic also has a nice “in-depth” page for Schizoaffective disorder if you want to check it out.

MEDICATIONS[4]

In general, doctors prescribe medications for schizoaffective disorder to relieve psychotic symptoms, stabilize mood and treat depression. These medications may include:

Antipsychotics. The only medication approved by the Food and Drug Administration specifically for the treatment of schizoaffective disorder is the antipsychotic drug paliperidone (Invega). However, doctors may prescribe other antipsychotic drugs to help manage psychotic symptoms such as delusions and hallucinations.

Mood-stabilizing medications. When the schizoaffective disorder is bipolar type, mood stabilizers can help level out the mania highs and depression lows.

Antidepressants. When depression is the underlying mood disorder, antidepressants can help manage feelings of sadness, hopelessness, or difficulty with sleep and concentration.

PSYCHOTHERAPY[4]

In addition to medication, psychotherapy, also called talk therapy, may help. Psychotherapy may include:

Individual therapy. Psychotherapy may help to normalize thought patterns and reduce symptoms. Building a trusting relationship in therapy can help people with schizoaffective disorder better understand their condition and learn to manage symptoms. Effective sessions focus on real-life plans, problems and relationships.

Family or group therapy. Treatment can be more effective when people with schizoaffective disorder are able to discuss their real-life problems with others. Supportive group settings can also help decrease social isolation and provide a reality check during periods of psychosis.

LIFE SKILLS TRAINING[4]

Learning social and vocational skills can help reduce isolation and improve quality of life.

Social skills training. This focuses on improving communication and social interactions and improving the ability to participate in daily activities. New skills and behaviors specific to settings such as the home or workplace can be practiced.

Vocational rehabilitation and supported employment. This focuses on helping people with schizoaffective disorder prepare for, find and keep jobs.

HOSPITALIZATION[4]

During crisis periods or times of severe symptoms, hospitalization may be necessary to ensure safety, proper nutrition, adequate sleep, and basic personal care and cleanliness.

ELECTROCONVULSIVE THERAPY[4] (ECT)

For adults with schizoaffective disorder who do not respond to psychotherapy or medications, electroconvulsive therapy (ECT) may be considered.


SELF-MANAGEMENT OF SCHIZOAFFECTIVE DISORDER

So you’ve probably noticed I am a proponent of self-management as not just an effective tool, but a downright necessary one in terms of “recovery” (and I’m putting that in quotation marks for the same reason I put “illness” in quotation marks – not because I think it’s terrible word or label, but because I think it’s not the best one. I might call “recovery” more of an “uncovery” or “discovery” as – and let me save you the suspense – you’re never going back to the person you were before your diagnosis [which is a good thing, or at the very least not at all a bad thing]).

I do not believe self-management is the only tool you need, however. I simply believe it is the only tool you always need. Again, this stems more from the idea that it’s a tool everyone always needs, including the normies – i.e. it has nothing to do with MH or mental “illness” and everything to do with living a reasonable and fulfilling life.

Below are some good suggestions for self-management from the Mayo Clinic[4]:

  • Learning about the disorder. Education about schizoaffective disorder may help the person stick to the treatment plan. Education also can help friends and family understand the disorder and be more compassionate.
  • Paying attention to warning signs. Identify things that may trigger symptoms or interfere with carrying out daily activities. Make a plan for what to do if symptoms return. Contact the doctor or therapist if needed to prevent the situation from worsening.
  • Joining a support group. Support groups can help make connections with others facing similar challenges. Support groups may also help family and friends cope.
  • Asking about social services assistance. These services may be able to help with affordable housing, transportation and daily activities.

I would personally recommend taking Learning and Paying Attention to a much more rigorous level, and add to Join a Support Group that it will work better if it’s a meaningful one with people you respect or think you can come to respect.

In terms of learning – or good strategies, methods, and techniques for going about learning and identifying trustworthy sources when it comes to MH – that’s another article entirely. For now I’ll say (hesitantly, in not knowing who might be reading this) that sticking to established resources like the ones used in this article (big, well known names) using equally established methods of digital inquiry (like Google, Bing etc.) is a perfectly safe bet. I have tried to aggregate some obvious sources and information here, but you may also want to check out the National Institute of Mental Health and other similar sources.

In terms of paying attention – you will be limited by your own understanding of what the term means. For me, at the time I was diagnosed, I was fortunate to have had a background in statistics and research methodology. I literally sat down, developed proprietary metrics, and tracked my moods and thoughts longitudinally. I also paid attention in a less rigorous, more a priori emotional way (salient thoughts, patterns, what I noticed recurred/cycled outside of my metrics). Some key variables I paid attention to were:

  • Season (weather, sunlight)
  • News, Politics (how it affected me)
  • Work schedule
  • Sleep schedule
  • Exercise
  • Mood
  • Energy
  • Psychotic thoughts
  • Suicidal thoughts
  • Medication (dosage, changes, times of day)
  • Perceptions (how I felt about certain things)
  • Creativity (energy in a more abstract sense)
  • Self-perception (self-esteem)

I also established a number of referents or references I could use as tools to judge my improvement. Psychiatrists, psychologists, therapists, and so on are all referents against which you can test how accurately you are perceiving and measuring the variables you are testing. In fact any person with whom you interact can be a referent, especially if you have a good understanding of how they think about and perceive you.

What I mean by this is, say you have a romantic partner who usually tells you they like your creative ideas, and prior to your diagnosis there was a reliable period where they never said anything like “you know, that’s creative but it’s actually starting to sound a little crazy.” You’ve now been diagnosed, and in the reflecting you’ve already done you’ve realized those times your partner was saying you weren’t yourself (sometimes known as “massive fights”) turned out to be pretty accurate statements. Congratulations – you can now use that person’s behavior as a reliable referent for your own.

In other words – and this may sound obvious, but it’s important – one of the best ways to be and stay accurate when judging your own behavior around others is to pay close attention to how others behave around you. Keep in mind it’s equally important to observe this variable while you are stable – that’s what is giving you a valuable referent, and thus metric, in the first place.

TIP: One of the best ways to be and stay accurate when judging your own behavior around others is to pay close attention to how others behave around you.

Another self-management thing not mentioned as of yet is to just take care of yourself in a general physical sense – be healthy. Have a routine, exercise, feel good about yourself – those basic “no shit” kind of health things that we all struggle with. I have found that the better I feel physically (better diet, less smoking, more exercise, well-rested, etc.) the less frequently I have mood swings. The more stable my mood, the less often I notice the creeping and insidious psychotic developments that can get going if ignored.

Part of the difficulty is figuring out what is causing what – am I not sleeping because I’m getting manic, or am I getting manic because I’m not sleeping? Again, this is causality as opposed to correlation. My sleep patterns and manic/depressive moods are definitely correlated (I sleep less when elevated, more when depressed), but it’s impossible to ascertain the precise relationship of causality. Sleep deprivation can definitely contribute to psychoses and mood swings, even in normal people. Conversely, it might be that my mood is changing because of whatever my “illness” is up to, and that’s the thing causing me not to sleep.

And, to make it extra-fun, it could be (and likely is) a combination of many factors.

So staying physically healthy is essentially controlling for your physical health as a variable – by no means feel like you need to be running marathons, but in the simplest sense with all else considered, the more healthy you are physically, the easier it will be to stay healthy mentally.

ADAGE: THE MORE HEALTHY TOU ARE PHYSICALLY, THE EASIER IT IS TO STAY HEALTHY MENTALLY.


It is important to stay physically healthy. You should look like this immediately.
It is important to stay physically healthy. You should look like this immediately.

Anyways.

I mentioned my initial diagnosis was Bipolar disorder Type 2. This raises the question – How is Schizoaffective disorder diagnosed?

Mental “illnesses” are diagnosed by professionals using the DSM, or Diagnostical Statistical Manual of Mental Disorders. This reference book is constantly being updated and is now in its latest iteration the DSM-5 (when I was in college it was the DSM-IV-TR, the TR standing for “Text Revision”).

Here’s a brief history of Schizoaffective disorder as it relates to the DSM:

Schizoaffective disorder was included as a subtype of schizophrenia in DSM-I and DSM-II, though research showed a schizophrenic cluster of symptoms in individuals with a family history of mood disorders whose illness course, other symptoms and treatment outcome were otherwise more akin to bipolar disorder than to schizophrenia. DSM-III placed schizoaffective disorder in “Psychotic Disorders Not Otherwise Specified” before being formally recognized in DSM-III-R.

DSM-III-R included its own diagnostic criteria as well as the subtypes, bipolar and depressive. In DSM-IV, published in 1994, schizoaffective disorders belonged to the category “Other Psychotic Disorders” and included almost the same criteria and the same subtypes of illness as DSM-III-R, with the addition of mixed bipolar symptomatology.

DSM-IV and DSM-IV-TR (published in 2000) criteria for schizoaffective disorder were poorly defined and poorly operationalized. These ambiguous and unreliable criteria lasted 19 years and led clinicians to significantly overuse the schizoaffective disorder diagnosis. Patients commonly diagnosed with DSM-IV schizoaffective disorder showed a clinical picture at time of diagnosis that appeared different from schizophrenia or psychotic mood disorders using DSM-IV criteria, but who as a group, were longitudinally determined to have outcomes indistinguishable from those with mood disorders with or without psychotic features. A poor prognosis was assumed to apply to these patients by most clinicians, and this poor prognosis was harmful to many patients. The poor prognosis for DSM-IV schizoaffective disorder was not based on patient outcomes research, but was caused by poorly defined criteria interacting with clinical tradition and belief; clinician enculturation with unscientific assumptions from the diagnosis’ history (discussed above), including the invalid Kraepelinian dichotomy; and by clinicians being unfamiliar with the scientific limitations of the diagnostic and classification system.

The DSM-5 schizoaffective disorder workgroup analyzed all of the available research evidence on schizoaffective disorder, and concluded that “presenting symptoms of psychosis have little validity in determining diagnosis, prognosis, or treatment response.” Given our understanding of overlapping genetics in bipolar disorders, schizoaffective disorder, and schizophrenia, as well as the overlap in treatments for these disorders; but given the lack of specificity of presenting symptoms for determining diagnosis, prognosis or treatment response in these psychotic illness syndromes, the limits of our knowledge are clearer: Presenting symptoms of psychosis describe only presenting symptoms to be treated, and not much more. Schizoaffective disorder was changed to a longitudinal or life course diagnosis in DSM-5 for this reason.[2]


DIAGNOSING SCHIZOAFFETIVE DISORDER

Schizoaffective disorder can be difficult to diagnose because it has symptoms of both schizophrenia and either depression or bipolar disorder.[3]

To be diagnosed with schizoaffective disorder a person must have the following symptoms:

A period during which there is a major mood disorder, either depression or mania, that occurs at the same time that symptoms of schizophrenia are present.

Delusions or hallucinations for two or more weeks in the absence of a major mood episode.

Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the illness.

The abuse of drugs or a medication are not responsible for the symptoms.[3]

These symptoms and the resulting diagnosis will probably be determined using the following:

Physical exam. This may be done to help rule out other problems that could be causing symptoms and to check for any related complications.

Tests and screenings. These may include tests that help rule out conditions with similar symptoms, and screening for alcohol and drugs. The doctor may also request imaging studies, such as an MRI or CT scan.

Psychiatric evaluation. A doctor or mental health professional checks mental status by observing appearance and demeanor and asking about thoughts, moods, delusions, hallucinations, substance use, and potential for suicide. This also includes a discussion of family and personal history.

Diagnostic criteria for schizoaffective disorder. Your doctor or mental health professional may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.[4]


Let’s wrap it all up.

Schizoaffective disorder is a psychotic disorder that is more or less the mutant child of Bipolar disorder and Schizophrenia. It features the manic depressive mood swings of Bipolar in combination with the psychotic hallucinations and delusions of Schizophrenia.

It’s exact cause is unknown and may be due to a combination of factors.

It is considered a longitudinal mental “illness.”

It has two subtypes – Bipolar (mania and depression) or Depressive (just depression). It is also very similar to and often confused with Bipolar Schizoaffective Type (which is identical except the psychoses only occur during mood episodes, whereas with Schizoaffective disorder the hallucinations and delusions can occur outside of mood episodes).

That’s your quick and dirty on Schizoaffective disorder.  If you’re interested in writing about a specific diagnosis or writing guest articles in general, please click here or get in touch with us via the CBTN Contact page.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s