In DSM-II, this disorder is called Schizophrenia, schizo-affective type
For more information, see Schizophrenia
This category is for patients showing a mixture of schizophrenic symptoms and pronounced elation or depression. Within this category it may be useful to distinguish excited from depressed types as follows:
- Schizophrenia, schizo-affective type, excited
- Schizophrenia, schizo-affective type, depressed
The term Schizoaffective Disorder has been used in many different ways since it was first introduced, and at the present time there is no consensus on how this category should be defined. Some of the cases that in the past were diagnosed as Schizoaffective Disorder would in this manual be diagnosed as Schizophreniform Disorder, Major Depression or Bipolar Disorder with Mood-congruent or Mood-incongruent Psychotic Features, or Schizophrenia with a superimposed Atypical Affective Disorder. Future research is needed to determine whether there is a need for this category, and if so, how it should be defined and what its relationship is to Schizophrenia and Affective Disorder.
The category is retained in this manual without diagnostic criteria for those instances in which the clinician is unable to make a differential diagnosis with any degree of certainty between Affective Disorder and either Schizophreniform Disorder or Schizophrenia. Before using the Schizoaffective Disorder category, the clinician should consider all of the diagnoses noted in the first paragraph above, particularly Major Affective Disorders with Psychotic Features.
Examples of cases that may appropriately be diagnosed as Schizoaffective Disorder include:
- An episode of affective illness in which preoccupation with a mood-incongruent delusion or hallucination dominates the clinical picture when affective symptoms are no longer present.
- An episode of illness in which currently there is a full affective syndrome with prominent mood-incongruent psychotic features but in which inadequate information about the presence of previous nonaffective psychotic features makes it difficult to differentiate between Schizophrenia or Schizophreniform Disorder (with a superimposed Atypical Affective Disorder) and Affective Disorder.
A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.
Note: The Major Depressive Episode must include Criterion A1: depressed mood.
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.
- Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes)
- Depressive Type: if the disturbance only includes Major Depressive Episodes
Two subtypes of Schizoaffective Disorder may be noted based on the mood component of the disorder:
This subtype applies is a Manic Episode or Mixed Episode is part of the presentation. Major Depressive Episodes may also occur.
This subtype applies if only Major Depressive Episodes are part of the presentation.
General medical conditions and substance use can present with a combination of psychotic and mood symptoms. Psychotic Disorder Due to a General Medical Condition, a delirium, or a dementia is diagnosed when there is evidence from the history, physical examination, or laboratory tests indicating that the symptoms are the direct physiological consequence of a specific general medical condition. Substance-Induced Psychotic Disorder and Substance-Induced Delirium are distinguished from Schizoaffective Disorder by the fact that a substance (e.g., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the symptoms.
Schizophrenia and Mood Disorder With Psychotic Features
Distinguishing Schizoaffective Disorder from Schizophrenia and from Mood Disorder With Psychotic Features is often difficult. In Schizoaffective Disorder, there must be a mood episode that is concurrent with the active-phase symptoms of Schizophrenia, mood symptoms must be present for a substantial portion of the total duration of the disturbance, and delusions or hallucinations must be present for at least 2 weeks in the absence of prominent mood symptoms. In contrast, mood symptoms in Schizophrenia either have a duration that is brief relative to the total duration of the disturbance, occur only during the prodromal or residual phases, or do not meet full criteria for a mood episode. If psychotic symptoms occur exclusively during periods of mood disturbance, the diagnosis is Mood Disorder With Psychotic Features. In Schizoaffective Disorder, symptoms should not be counted toward a mood episode if they are clearly the result of symptoms of Schizophrenia (e.g., difficulty sleeping because of disturbing auditory hallucinations, weight loss because food is considered poisoned, difficulty concentrating because of psychotic disorganization). Loss of interest or pleasure is common in nonaffective Psychotic Disorders; therefore, to meet Criterion A for Schizoaffective Disorder, the Major Depressive Episode must include pervasive depressed mood.
Because the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, the appropriate diagnosis for an individual episode of illness may change from Schizoaffective Disorder to Schizophrenia (e.g., a diagnosis of Schizoaffective Disorder for a severe and prominent Major Depressive Episode lasting 3 months during the first 6 months of a chronic psychotic illness would be changed to Schizophrenia if active psychotic or prominent residual symptoms persist over several years without a recurrence of another mood episode). The diagnosis may also change for different episodes of illness separated by a period of recovery. For example, an individual may have an episode of psychotic symptoms that meet Criterion A for Schizophrenia during a Major Depressive Episode, recover fully from this episode, and then later develop 6 weeks of delusions and hallucinations without prominent mood symptoms. The diagnosis in this instance would not be Schizoaffective Disorder because the period of delusions and hallucinations was not continuous with the initial period of disturbance. Instead, the appropriate diagnoses for the first episode would be Mood Disorder With Psychotic Features, In Full Remission, and Schizophreniform Disorder (Provisional) for the current episode.
Mood disturbance, especially depression, commonly develop during the course of Delusional Disorder. However, such presentations do not meet criteria for Schizoaffective Disorder because the psychotic symptoms in Delusional Disorder are restricted to nonbizarre delusions and therefore do not meet Criterion A for Schizoaffective Disorder.
If there is insufficient information concerning the relationship between psychotic and mood symptoms, Psychotic Disorder Not Otherwise Specified may be the most appropriate diagnosis.
A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. (Note: The major depressive episode must include Criterion A1: Depressed mood.)
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
- Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur.
- Depressive type: This subtype applies if only major depressive episodes are part of the presentation.
- With catatonia (Note: Record catatonia associated with schizoaffective disorder to indicate the presence of the comorbid catatonia.)
The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course of the criteria.
- First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.
- First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
- First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
- Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
- Multiple episodes, currently in partial remission
- Multiple episodes, currently in full remission
- Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).
Note: Diagnosis of schizoaffective disorder can be made without using this severity specifier.
A. The clinical picture is dominated by three (or more) of the following symptoms:
- Stupor (i.e., no psychomotor activity; not actively relating to environment).
- Catalepsy (i.e., passive induction of a posture held against gravity).
- Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
- Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
- Negativism (i.e., opposition or no response to instructions or external stimuli).
- Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
- Mannerism (i.e., odd, circumstantial caricature of normal actions).
- Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
- Agitation, not influenced by external stimuli.
- Echolalia (i.e., mimicking another's speech).
- Echopraxia (i.e., mimicking another's movements).
Other mental disorders and medical conditions
A wide variety of psychiatric and medical conditions can manifest with psychotic and mood symptoms that must be considered in the differential diagnosis of schizoaffective disorder. These include psychotic disorder due to another medical condition; delirium; major neurocognitive disorder; substance/medication-induced psychotic disorder or neurocognitive disorder; bipolar disorders with psychotic features; major depressive disorder with psychotic features; depressive or bipolar disorders with catatonic features; schizotypal, schizoid, or paranoid personality disorder; brief psychotic disorder; schizophreniform disorder; schizophrenia; delusional disorder; and other specified and unspecified schizophrenia spectrum and other psychotic disorders. Medical conditions and substance use can present with a combination of psychotic and mood symptoms, and thus psychotic disorder due to another medical condition needs to be excluded.
Distinguishing schizoaffective disorder from schizophrenia and from depressive and bipolar disorders with psychotic features is often difficult. Criterion C is designed to separate schizoaffective disorder from schizophrenia, and Criterion B is designed to distinguish schizoaffective disorder from a depressive or bipolar disorder with psychotic features. More specifically, schizoaffective disorder can be distinguished from a depressive or bipolar disorder with psychotic features due to the presence of prominent delusions and/or hallucinations for at least 2 weeks in the absence of a major mood episode. In contrast, in depressive or bipolar disorders with psychotic features, the psychotic features primarily occur during the mood episode(s). Because the relative proportion of mood to psychotic symptoms may change over time, the appropriate diagnosis may change from and to schizoaffective disorder (e.g., a diagnosis of schizoaffective disorder for a severe and prominent major depressive episode lasting 3 months during the first 6 months of a persistent psychotic illness would be changed to schizophrenia if active psychotic or prominent residual symptoms persist over several years without a recurrence of another mood episode).
Other medical conditions and substance use can manifest with a combination of psychotic and mood symptoms, and thus psychotic disorder due to another medical condition needs to be excluded.