Schizoaffective disorder

This is a disorder of the mind that affects your thoughts and emotions, and may affect your actions.

You may experience episodes that are combinations of both 'psychotic' symptoms and 'bipolar disorder' symptoms. These symptoms are clearly present for most of the time over a period of at least two weeks.

Types of schizoaffective disorder

Schizoaffective disorder manic type

In this type, you have both the psychotic and manic symptoms, occurring within one episode.

Schizoaffective disorder depressive type

In this type, you have both the psychotic and depressive symptoms, occurring at the same time during the episode.

Schizoaffective disorder mixed type

In this type, you have psychotic symptoms with both manic and depressive symptoms. However, The psychotic symptoms are independent and not necessarily related to the bipolar disorder symptoms.

Thought disorder/muddled thinking

You find it hard to concentrate as your thoughts seem fuzzy or muddled. Your thinking feels bizarre and disconnected. You may be unable to finish a book that you have been reading or follow a TV programme.

The muddled thinking may affect your speech, so you may jump from one topic to another and after a while, you may not be able to remember what you were trying to say in the first place. This makes it difficult for people to follow your conversation.

You may believe that your thoughts are being interfered with:

• someone or something is able to insert thoughts in your mind (you may feel like a particular thought it not yours);
• someone or something is taking certain thoughts out of your mind - that your thoughts are disappearing.

Sometimes you may feel that other people can hear your thoughts or have access to them in some way.

Beliefs that you are being controlled

You may insist that outside forces like aliens, spirits, God or the devil are controlling how you feel, think and behave. You may feel like a robot whose remote control is in someone else's hand. You might be distressed if you feel that someone else is making you think certain things, or that you have no control on a particular behaviour of yours because an outside force controls it.

Hallucinations

You may hear sounds or voices, see and smell things that are not there. Sometimes you can feel that someone is touching you or hitting you, but you can't see anyone. The most common type of hallucination is hearing voices.

What is hearing voices like?

These voices sound real. Unlike thoughts which come from your own mind, these voices seem to come from outside you and noone else can hear them. There can be one voice or several different voices which may be commenting on what you are doing.

How do people react to these voices?

As these voices sound real, you may start talking back to them. You may try to do things that these voices tell you to do, or you may be able to ignore them.

Delusions

These are beliefs or ideas which you believe in 100 per cent, without a single doubt, and which nobody else seems to accept.

These beliefs or ideas cannot be explained as part of your culture, religion or background. Other people may find your ideas strange, unrealistic or even bizarre.

How do delusions start?

• They can start suddenly when an idea or belief comes to you out of the blue.
• They may form after weeks or months of feeling that something strange is happening but you can't identify what it is. This is called 'delusional mood'.
• Sometimes they help you to understand your hallucinations, for example if you hear voices talking amongst themselves about you, then your mind may explain that your neighbours are plotting against you or the spirit world has made contact with you. This is called a 'delusional idea'.

The most common type of delusion is paranoid delusion.

• These are ideas which convince you that others might harm you, are plotting against you or spying on you.
• Feeling persecuted can be very scary and upsetting for those people who you feel are against you.
• You may want to stay away from people or protect yourself from the persecutors.

• A sense of extreme physical and mental well-being, excessive energy and elation of mood which is also called feeling 'high'.
• You may not sleep much and your concentration is affected.
• You may talk very fast, often jumping from one topic to another and have very optimistic ideas which can be unrealistic or bizarre, for example you may believe that you have special abilities and powers.
• In later stages, your speech may become incomprehensible; you may become irritable and neglect your health and safety.
• This can affect your relationships and make it difficult for you to carry on working.

• You not only feel sad all the time, but you lose interest in the things that you previously liked.
• You may also lose your motivation and energy.
• Your sleep and eating patterns may be affected.
• You may not be able to concentrate on a book or TV programme and can also experience intense feelings of guilt, worthlessness and hopelessness.

Genes

Research has shown that the same genetic risk factors may be involved in whether someone develops schizoaffective disorder, schizophrenia, bipolar disorder or depression. Having a parent with a serious mental illness like schizoaffective disorder is the strongest known risk factor for developing a serious mental illness yourself. Children with a parent who has a serious mental illness have a 1 in 3 chance of developing a serious mental illness themselves.

Stress

Stress can contribute to the start of an episode of schizoaffective disorder, such as a bereavement, physical illness, car accident or family/relationship problems. In particular, traumatic experiences in childhood can increase the chances of developing this condition in the future.

More women than men are affected by schizoaffective disorder. It tends to develop at a later age in women than men and is more likely to the depressive type.

The depressive type is also more common in older people, while the bipolar type is more common in younger people. Symptoms usually begin in early adulthood.

Some people feel that schizoaffective disorder sits in the middle of a spectrum, with schizophrenia at one end and bipolar disorder at the other.

However, schizoaffective disorder is recognised as a separate condition to schizophrenia, both in clinical practice and in the research literature.

The treatment of these disorders depends on the type. Treatment includes medication which is usually started and monitored by a psychiatrist, along with talking therapies.

Medication

How can medication help?

• Taking medication regularly can help to control the most distressing symptoms of the disorder. They can help you to feel calmer by weakening the delusions, and gradually reducing the frequency and intensity of the hallucinations.
• Your thinking becomes clearer and you may feel well enough to look after yourself, your home and re-start your studies or work, and concentrate on other aspects of life which are important to you.
• If these medications are taken regularly, they can prevent you having another episode. It is important to continue to take these medications, even if you feel well.

How long will I have to take the medication?

• Usually these medications will need to be taken for the rest of your life.
• In some cases, the medication can be gradually reduced and stopped. However, this must be done under the supervision of a doctor.

What will happen if I stop the medication?

• If a person has diabetes and stops taking their medication, they may become unwell. Similarly with schizoaffective disorder, if you stop taking your medication, you too may become unwell. This may not happen immediately, but may take 3 to 6 months.

Types of medication

• An acute episode of schizoaffective disorder may benefit from antipsychotics. Atypical antipsychotics include Olanzapine, Risperidone, Quetiapine and Amisulpride.
• In the treatment of depressive symptoms, medication may include antidepressants. There are many different types of antidepressants and you may be started on one of the newer one, a SSRI (Selective Serotonin Reuptake Inhibitor), such as Sertraline or Citalopram.
• In the treatment of manic symptoms, mood stabilisers such as lithium, sodium valproate and carbamazepine may be useful.
• The long-term treatment of schizoaffective disorder involves the use of antipsychotics with psychological (talking) treatments.
• For the manic type, often a combination of a mood stabiliser and an antipsychotic are prescribed.
• For the depressive type, a mood stabiliser and an antidepressant is preferred.

The effects and side-effects of these medications should be fully explained to you and your carer(s).

Talking therapies

Cognitive Behavioural Therapy (CBT)

People are helped to monitor their thoughts, feelings and actions. The therapist will help you to find out the unhelpful thoughts and behaviours which may be contributing to your distress.

These thoughts could be linked to your delusions and your behaviours to your hallucinatory experiences.

The therapist will help you to work out helpful ways of thinking and reacting and then to put these positive thoughts and behaviours into real situation.

CBT is recommended if you are suffering from psychotic symptoms as it can help you cope with troublesome delusions and hallucinations. It equips you with various coping strategies so that you are able to solve your issues and problems.

Family meetings

This is especially helpful if you live with your family or are in close contact with them. Family therapy will help your family to understand your problems and how best to support you.

Supportive Psychotherapy and Counselling

People are able to discuss their problems and issues with a professional in detail and gain support from telling your story to someone who will listen.

Art Therapy

Some people may have difficulty talking about their emotions. Art therapy can help you to express your emotions through art.

Self-help groups

This is an opportunity to meet other people with the same illness and to discuss alternative coping strategies, recognising early signs that you may be starting to feel unwell again.

What will happen without treatment?

The symptoms may get worse and you may have more frequent and longer episodes. There is also a risk of suicide.

Community Mental Health Services

These services are important in keeping you out of hospital or in managing your gradual return back into the community after being discharged from hospital.

Specialist services may be needed including community psychiatric nursing, social services and occupational therapy as well as support in managing your domestic and financial affairs.

There are different teams that can support you in the community:

• Early Intervention Team: provides intensive support to young people who have recently been diagnosed with schizophrenia or schizoaffective disorder.
• Assertive Outreach Team: provides extensive help and support for people who have had a diagnosis of schizophrenia or schizoaffective disorder for quite some time, especially for people who find it difficult to work with other services or have not been able to take their medications regularly for various reasons.
• Crisis Resolution Home Treatment Team: can help at you at home, prevent a hospital admission and provide intensive support after a hospital admission.
• Vocational Rehabilitation: includes day centres, day hospital or community health centres. These facilities offer different creative activities such as back to work courses, education, art and cooking.

Care Programme Approach (CPA) (England and Wales only)

This is a way of making sure that you get the right care and support. You may be given a care co-ordinator who is responsible for organising different parts of your treatment.

You will have regular meetings every 6 to 9 months which can include your family or carer(s). A plan will be made about what to do in an emergency, including what has helped in the past.

Your plan will be amended at each CPA meeting to take into account what you and your family/carer(s) would like to happen.

Self-help

If you think you are becoming unwell or need help:

• Call your local mental health team/care co-ordinator.
• Call the local Crisis Team or Emergency out-of-hours phone numbers .
• Go to your local Emergency Department if the situation is such that it cannot be dealt with at home.
• Learn to recognise the early signs that you may be getting unwell, such as not being able to sleep, feeling persecuted or anxious. Some people may start hearing voices or whispers when no one is around. It is important to get help as soon as possible, for example by calling your care co-ordinator.
• Exercise regularly and eat a healthy balanced diet.
• Learn to talk to someone you trust in your family or a friend.
• Learn relaxation techniques.

Try not to:

• Use illicit drugs as they can cause another episode.
• Drink too much alcohol - remember the safe alcohol drinking limits of 21 units per week for a man and 14 units per week for a woman.
• Get stressed.
• Smoke cigarettes - 30 to 40 people out of a 100 with mental health problems smoke. They may help you to relax and focus your thoughts in the short-term but interferes with your medication and is very harmful to your body in the long-term.

Mind: provides advice and support to anyone experiencing a mental health problem and campaigns to improve services, raise awareness and promote understanding. Infoline: 0300 123 3393.

Rethink Mental Illness: National voluntary organisation that helps people with any severe mental illness, their family and carers. Helpline: 0300 5000 927.

Sane: a national mental health helplione offering emotional support and practical information for people with mental illness, families, carers and professionals. Helpline: 0845 767 8000.

References

Bebbington P et al (2004) Psychosis, victimisation and childhood disadvantage. Evidence from the second British National Survey of Psychiatric Morbidity. British Journal of Psychiatry, 185: 220-226.

Caron J et al (2005) Socio-demographic and clinical predictors of quality of life in patients with schizophrenia or schizo-affective disorder. Psychiatry Resource, 137(3): 203-13.

Lake CR et al (2007) Schizoaffective Disorder merges Schizophrenia and bipolar disorders as one disease - there is no schizoaffective disorder. Current Opinion Psychiatry, 20(4):365-79.

Laursen TM et al (2007) A comparison of selected risk factors for unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia from a Danish population-based cohort. Journal of Clinical Psychiatry, 68(11):1673-81.

Malhi GS et al (2008) Schizoaffective disorder: diagnostic issues and future recommendations. Bipolar Disorder, 10(1Pt2):215-30.

Marneros A et al (2003) Schizoaffective disorder: clinical aspects, differential diagnosis, and treatment. Current PsychiatryRep, (53): 202-5.

Reid WH et al (1998) Suicide preventon effects associated with clozapine therapy in schizophrenia disorder. Psychiatric Services, 49/8 (1029-1033), 10752730.

Schizophrenia: core intervention in the treatment and management of schizophrenia in primary and secondary care. NICE guidelines, 2009.

Schizophrenia: atypical antipsychotics: the clinical effectiveness and cost effectiveness of newer atypical antipsychotic drugs in schizophrenia. NICE guidelines, 2002.

Credits

• Series editor: Dr Philip Timms
• User and Carer input: from members of the Royal College of Psychiatrists Public Education Editorial Board.