View source for Schizoaffective disorder

{{short description|Mental disorder}}
{{pp|sock|small=yes}}
{{Cleanup|date=April 2025|reason=This article is mostly about ideas about treatment, and does not read like a reference.}}{{Use dmy dates|date=February 2016}}
{{Infobox medical condition (new)
| name = Schizoaffective disorder
| field = [[psychiatry]]
| symptoms = {{hlist|[[Hallucinations]]|[[delusions]]|[[thought disorder|disorganized thought and behavior]]|[[inappropriate affect]]|[[Depression (mood)|depression]]|[[mania]]|
title=Schizoaffective Disorder Overview – Symptoms|url=https://www.nami.org/Learn-More/Mental-Health-Conditions/Schizoaffective-Disorder|website=www.nami.org}}
| complications = {{hlist|lack of motivation|cognitive issues|risk of harm to self or others|anxiety disorders}}
| onset = 16–30 years of age
| duration = 
| types = {{hlist|bipolar type<ref>{{cite web|title=Schizoaffective disorder, bipolar type|url=http://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F25-/F25.0|website=www.icd10data.com}}</ref>|depressive type<ref>{{cite web|title=Schizoaffective disorder, depressive type|url=http://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F25-/F25.1|website=www.icd10data.com}}</ref>|Mixed type (Includes both depressive and bipolar symptoms)}}
| causes = Unknown<ref name=NAMI2017/>
| risks = {{hlist|Genetics|brain chemistry and structure|stress|drug use<ref name=NAMI2017>{{cite web|title=Schizoaffective Disorder Overview – Causes|url=https://www.nami.org/Learn-More/Mental-Health-Conditions/Schizoaffective-Disorder|website=www.nami.org}}</ref>}}
| diagnosis = [[Psychiatric assessment]]
| differential = {{hlist|Psychotic depression|bipolar disorder with psychotic features|schizophreniform disorder|schizophrenia}}
| prevention = 
| treatment = 
| medication = {{hlist|[[Antipsychotics]]|[[mood stabilizers]]|[[antidepressants]]}}
| prognosis = Depends on the individual, medication response, and therapeutic support available
| frequency = 0.3%
| deaths = 
}}
'''Schizoaffective disorder''' is a [[mental disorder]] characterized by symptoms of both [[schizophrenia]] ([[psychosis]]) and a [[mood disorder]], either [[bipolar disorder]] or [[Depression (mood)|depression]].<ref name="who.int">{{cite web|title=F25 Schizoaffective disorders|website=ICD-10 Version:2010|publisher=World Health Organization|url=http://apps.who.int/classifications/icd10/browse/2010/en#/F25}}</ref><ref name="Schizoaffective_in_the_DSM5">{{cite journal|vauthors=Malaspina D, Owen MJ, Heckers S, Tandon R, Trump D, Schultz S, Barch DM, Gaebel W, Gur RE, Tsuang M, Van Os J, Carpenter W|date=May 2013|title=Schizoaffective disorder in the DSM-5|journal=Schizophrenia Research|volume=150|issue=1|pages=21–5|doi=10.1016/j.schres.2013.04.026|pmid=23707642|s2cid=14770729}}</ref> The main diagnostic criterion is the presence of psychotic symptoms for at least two weeks without prominent mood symptoms.<ref name="Schizoaffective_in_the_DSM5"/> Common symptoms include [[Hallucination|hallucinations]], [[Delusion|delusions]], [[Thought disorder|disorganized speech and thinking]], as well as mood episodes.<ref>{{cite journal|last1=Brannon|first1=Guy E|last2=Bienenfeld|first2=David|last3=Talavera|first3=Francisco|title=Schizoaffective Disorder|url=http://emedicine.medscape.com/article/294763-overview|website=Medscape Drugs & Diseases|publisher=WebMD|date=9 September 2013}}</ref> Schizoaffective disorder can often be [[misdiagnosed]]<ref name="Schizoaffective_in_the_DSM5"/> when the correct diagnosis may be [[psychotic depression]], [[bipolar I disorder]], [[schizophreniform disorder]], or schizophrenia. This is a problem as treatment and [[prognosis]] differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorders including [[anxiety disorders]].<ref name="Schizoaffective_in_the_DSM5"/><ref name="Kaplan & Saddock.">{{cite book|title=Synopsis of Psychiatry|last1=Kaplan|first1=HI|last2=Saddock|first2=VA|publisher=Lippincott, Williams & Wilkins|year=2007|isbn=978-0-7817-7327-0|location=New York}}</ref>

There are three forms of schizoaffective disorder: bipolar or manic type (marked by symptoms of schizophrenia and mania), depressive type (marked by symptoms of schizophrenia and depression), and mixed type (marked by symptoms of schizophrenia, depression, and mania).<ref name="who.int"/><ref name="Schizoaffective_in_the_DSM5"/><ref name=":12">{{Cite web |title=Schizoaffective disorder |url=https://www.rcpsych.ac.uk/mental-health/problems-disorders/schizoaffective-disorder |access-date=2022-09-30 |website=Royal College of Psychiatrists |language=en}}</ref> [[Auditory hallucination]]s are most common.<ref name="pmid18056246"/><ref>{{cite journal |vauthors=Startup H, Freeman D, Garety PA |date=19 June 2006 |title=Persecutory delusions and catastrophic worry in psychosis: developing the understanding of delusion distress and persistence |journal=Behaviour Research and Therapy |volume=45 |issue=3 |pages=523–537 |doi=10.1016/j.brat.2006.04.006 |pmid=16782048}}</ref> The onset of symptoms usually begins in adolescence or young adulthood.<ref name=":22">{{Cite web |title=Schizoaffective Disorder in Children and Adolescents |url=https://www.mindyra.com/solutions/child/schizoaffective-disorder |access-date=2022-09-30 |website=www.mindyra.com |language=en-us}}</ref>

[[Genetics]] (researched in the field of [[genomics]]); problems with [[neural circuits]]; chronic early, and chronic or short-term current [[stress (biology)|environmental stress]] appear to be important causal factors.<ref>{{Cite journal |last=Kempf |first=L. |date=11 July 2009 |title=Mood disorder with psychotic features, schizoaffective disorder, and schizophrenia with mood features: Trouble at the borders |journal=International Review of Psychiatry |volume=17 |issue=1 |pages=9–19 |doi=10.1080/09540260500064959 |pmid=16194767 |s2cid=21422704 |via=Taylor & Francis}}</ref><ref>{{Cite book |last=American Psychiatric Association |title=Diagnostic and Statistical Manual of Mental Disorders |publisher=American Psychiatric Publishing |year=2013 |isbn=978-0-89042-555-8 |edition=Fifth |location=Arlington, VA |language=en}}</ref><ref>{{Cite journal |last=Munk Laursen |first=Thomas |date=16 June 2009 |title=Bipolar Disorder, Schizoaffective Disorder, and Schizophrenia Overlap: A New Comorbidity Index |url=https://www.psychiatrist.com/jcp/medical/comorbidity/bipolar-disorder-schizoaffective-disorder-schizophrenia/ |journal=The Journal of Clinical Psychiatry |volume=70 |issue=10 |via=Psychiatrist.com}}</ref> No single isolated organic cause has been found, but extensive evidence exists for abnormalities in the metabolism of [[tetrahydrobiopterin]] (BH4), [[dopamine]], and [[glutamic acid]] in people with schizophrenia, psychotic mood disorders, and schizoaffective disorder.<ref>{{Cite journal |last=Archibald |first=Luke |date=20 December 2019 |title=Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder |journal=Alcohol Research: Current Reviews |volume=40 |issue=1 |doi=10.35946/arcr.v40.1.06 |pmid=31886105 |pmc=6927747 |via=NIH}}</ref>

While a diagnosis of schizoaffective disorder is rare, 0.3% in the general population,<ref>{{Cite journal |last=Marneros |first=Andreas |date=30 June 2012 |title=Schizoaffective Disorder |url= |journal=Korean Journal of Schizophrenia Research |volume=15 |issue=1 |pages=5–12 |doi=10.16946/kjsr.2012.15.1.5 |via=KoreaMed Synapse|doi-access=free }}</ref> it is considered a common diagnosis among psychiatric disorders.<ref>{{Cite journal |last1=Joshi |first1=Kruti |last2=Lin |first2=Jay |last3=Lingohr-Smith |first3=Melissa |last4=Fu |first4=Dong-Jing |last5=Muser |first5=Erik |date=October 2016 |title=Treatment Patterns and Antipsychotic Medication Adherence Among Commercially Insured Patients With Schizoaffective Disorder in the United States |journal=Journal of Clinical Psychopharmacology |language=en-US |volume=36 |issue=5 |pages=429–435 |doi=10.1097/JCP.0000000000000549 |pmid=27525965 |pmc=5017269 |issn=0271-0749}}</ref> Diagnosis of schizoaffective disorder is based on DSM-5 criteria, which consist principally of the presence of symptoms of schizophrenia, mania, and depression, and the temporal relationships between them.

The main current treatment is [[antipsychotic]] medication combined with either [[mood stabilizer]]s or [[antidepressant]]s (or both). There is growing concern by some researchers that antidepressants may increase psychosis, mania, and long-term mood episode cycling in the disorder.{{Citation needed|date=September 2016}} When there is risk to self or others, usually early in treatment, hospitalization may be necessary.<ref name="BeckerKilian2006"/> [[Psychiatric rehabilitation]], [[psychotherapy]], and [[vocational rehabilitation]] are very important for [[recovery approach|recovery]] of higher psychosocial function{{Citation needed|date=April 2023}}. As a group, people diagnosed with schizoaffective disorder using [[DSM-IV]] and [[ICD-10]] criteria (which have since been updated{{Clarify|date=April 2023}}) have a better [[prognosis|outcome]],<ref name="who.int"/><ref name="Schizoaffective_in_the_DSM5"/> but have variable individual psychosocial functional outcomes compared to people with mood disorders, from worse to the same.<ref name="Schizoaffective_in_the_DSM5"/><ref name="Fifteen Year Schizoaffective Follow Up">{{cite journal |vauthors=Jäger M, Bottlender R, Strauss A, Möller HJ | title =Fifteen-year follow-up of ICD-10 schizoaffective disorders compared with schizophrenia and affective disorders | journal =Acta Psychiatrica Scandinavica | volume = 109 |issue=1 | year=2004 | pages=30–7 | doi= 10.1111/j.0001-690x.2004.00208.x| pmid=14674956 | s2cid =43303750 }}</ref>{{Primary source inline|date=September 2014}} Outcomes for people with [[DSM-5]] diagnosed schizoaffective disorder depend on data from [[prospective cohort studies]], which have not been completed yet.<ref name="Schizoaffective_in_the_DSM5"/> The DSM-5 diagnosis was updated because DSM-IV criteria resulted in overuse of the diagnosis;<ref name="BeckerKilian2006"/> that is, DSM-IV criteria led to many patients being misdiagnosed with the disorder. DSM-IV [[prevalence]] estimates were less than one percent of the population, in the range of 0.5–0.8 percent;<ref name="OnTrack">{{cite web|url=http://www.medscape.com/viewarticle/703312|title=APA 2009: DSM on Track for 2012, But Difficult Decisions Lie Ahead|last=Jeffrey|first=Susan|date=26 May 2009|website=Medscape Medical News|publisher=WebMD|access-date=3 August 2009}}</ref> newer DSM-5 prevalence estimates are not yet available.{{TOC limit|3}}

== Signs and symptoms ==
Schizoaffective disorder is defined by ''mood disorder-free psychosis'' in the context of a long-term psychotic and mood disorder.<ref name="Schizoaffective_in_the_DSM5"/> [[Psychosis]] must meet criterion A for [[schizophrenia]] which may include [[delusions]], [[hallucinations]], [[thought disorder|disorganized speech and behavior]] and [[Schizophrenia#Negative symptoms|negative symptoms]].<ref name="Schizoaffective_in_the_DSM5"/>  Both delusions and hallucinations are classic symptoms of psychosis.<ref name="APP textbook">{{cite book|editor-last1=Hales|editor-first1=E.|editor-last2=Yudofsky|editor-first2=J.A.|title=The American Psychiatric Press Textbook of Psychiatry|location=Washington, DC|publisher=American Psychiatric Publishing, Inc.|year=2003}}</ref> Delusions are false beliefs which are strongly held despite evidence to the contrary.<ref name="APP textbook"/>  Beliefs should not be considered delusional if they are in keeping with cultural beliefs. Delusional beliefs may or may not reflect mood symptoms (for example, someone experiencing depression may or may not experience delusions of guilt). Hallucinations are disturbances in perception involving any of the five senses, although [[auditory hallucination]]s (or "hearing voices") are the most common. Negative symptoms include [[alogia]] (lack of speech), [[blunted affect]] (reduced intensity of outward emotional expression), [[avolition]] (lack of motivation), and [[anhedonia]] (inability to experience pleasure).<ref name="APP textbook"/>  Negative symptoms can be more lasting and more debilitating than positive symptoms of psychosis.

Mood symptoms include [[mania]], [[hypomania]], [[mixed episode]], or [[major depressive episode|depression]], and tend to be episodic rather than continuous. A mixed episode represents a combination of symptoms of mania and depression at the same time. Symptoms of mania include elevated or irritable mood, grandiosity (inflated self-esteem), agitation, risk-taking behavior, decreased need for sleep, poor concentration, rapid speech, and racing thoughts.<ref name="APP textbook"/>  Symptoms of depression include low mood, apathy, changes in appetite or weight, disturbances in sleep, changes in motor activity, fatigue, guilt or feelings of worthlessness, and [[suicidal thinking]].

DSM-5 states that if a patient only experiences psychotic symptoms during a mood episode, their diagnosis is mood disorder with psychotic features and not schizophrenia or schizoaffective disorder. If the patient experiences psychotic symptoms without mood symptoms for longer than a two-week period, their diagnosis is either schizophrenia or schizoaffective disorder. If mood disorder episodes are present for the majority and residual course of the illness and up until the diagnosis, the patient can be diagnosed with schizoaffective disorder.<ref name="who.int"/>

== Causes ==
A combination of genetic and [[environmental factor]]s are believed to play a role in the development of schizoaffective disorder.<ref name=Lancet09>{{cite journal |last1=van Os|first1=J|author-link=Jim van Os|last2=Kapur|first2=S|title=Schizophrenia |journal=Lancet |volume=374 |issue=9690 |pages=635–45 |date=August 2009 |pmid=19700006 |doi=10.1016/S0140-6736(09)60995-8 |s2cid=208792724 |url=http://xa.yimg.com/kq/groups/19525360/611943554/name/Schizophrenia+-+The+Lancet.pdf |access-date=14 August 2013 |archive-date=23 June 2013 |archive-url=https://web.archive.org/web/20130623065810/http://xa.yimg.com/kq/groups/19525360/611943554/name/Schizophrenia+-+The+Lancet.pdf }}</ref><ref name=BMJ07>{{cite journal |vauthors=Picchioni MM, Murray RM |title=Schizophrenia |journal=BMJ |volume=335 |issue=7610 |pages=91–5 |date=July 2007  |pmid=17626963 |pmc=1914490 |doi=10.1136/bmj.39227.616447.BE}}</ref>

{{blockquote|Genetic studies do not support the view that schizophrenia, psychotic [[mood disorders]] and schizoaffective disorder are distinct [[etiology|etiological]] entities, but rather the evidence suggests the existence of common inherited vulnerability that increases the risks for all these syndromes. Some susceptibility pathways may be specific for schizophrenia, others for [[bipolar disorder]], and yet other mechanisms and genes may confer risk for mixed schizophrenic and affective [or mood disorder] psychoses, but there is no support from genetics for the view that these are distinct disorders with distinct etiologies and [[pathogenesis]]. Laboratory studies of putative [[endophenotype]]s, [[brain imaging]] studies, and [[post mortem]] studies shed little additional light on the validity of the schizoaffective disorder diagnosis, as most studies combine subjects with different chronic psychoses in comparison to healthy subjects.|According to [[William T. Carpenter]] the head of the [[University of Maryland, Baltimore]] School of Medicine  DSM-5 psychotic disorders workgroup, and others.<ref name="Schizoaffective_in_the_DSM5"/>}}

Viewed broadly then, biological and environmental factors interact with a person's genes in ways which may increase or decrease the risk for developing schizoaffective disorder; exactly how this happens (the biological mechanism) is not yet known. Schizophrenia spectrum disorders, of which schizoaffective disorder is a part, have been increasingly linked to advanced [[paternal age]] at the time of conception, a known cause of genetic mutations.<ref>{{cite journal |last1=Brown|first1=A.S.|last2=Schaefer|first2=C.A|last3=Wyatt|first3=R.J.|last4=Begg|first4=M.D.|author4-link=Melissa Begg|last5=Goetz|first5=R.|last6=Bresnahan|first6=M.A. |last7=Harkavy-Friedman|first7=J.|last8=Gorman|first8=J.M.|last9=Malaspina|first9=D.|last10=Susser|first10=E.S.| title = Paternal age and risk of schizophrenia in adult offspring | journal = The American Journal of Psychiatry | volume = 159 | issue = 9 | pages = 1528–33 | date = September 2002 | pmid = 12202273 | pmc = 2989614 | doi = 10.1176/appi.ajp.159.9.1528 }}</ref> The physiology of people diagnosed with schizoaffective disorder appears to be similar, but not identical, to that of those diagnosed with schizophrenia and bipolar disorder; however, human [[neurophysiology|neurophysiological]] function in normal brain and mental disorder [[syndromes]] is not fully understood.<ref name=pmid18056246>{{cite journal |vauthors=Martin LF, Hall MH, Ross RG, Zerbe G, Freedman R, Olincy A | title = Physiology of schizophrenia, bipolar disorder, and schizoaffective disorder | journal = The American Journal of Psychiatry | volume = 164 | issue = 12 | pages = 1900–6 | date = December 2007 | pmid = 18056246 | doi = 10.1176/appi.ajp.2007.06010017 }}</ref>

While there are various medications and treatment options for those with schizoaffective disorder, this disorder can affect a person for their entire lifespan.<ref name="my.clevelandclinic.org">{{Cite web |title=Schizoaffective Disorder: Schizophrenia, Mood Disorder, Treatment |url=https://my.clevelandclinic.org/health/diseases/21544-schizoaffective-disorder |access-date=2022-03-06 |website=Cleveland Clinic}}</ref> In some cases, this disorder can affect a person's ability to have a fulfilling social life and they may also have trouble forming bonds or relationships with others. Schizoaffective disorder is also more likely to occur in women and begins at a young age.<ref name="my.clevelandclinic.org"/>

=== Substance use disorder ===
A clear causal connection between substance use and psychotic spectrum disorders, including schizoaffective disorder, has been difficult to prove. In the specific case of [[Cannabis (drug)|cannabis (marijuana)]], however, evidence supports a link between earlier onset of psychotic illness and cannabis use.<ref>{{cite journal |vauthors=Large M, Sharma S, Compton MT, Slade T, Nielssen O |title=Cannabis use and earlier onset of psychosis: a systematic meta-analysis |journal=Arch. Gen. Psychiatry |volume=68 |issue=6 |pages=555–61 |date=June 2011  |pmid=21300939 |doi=10.1001/archgenpsychiatry.2011.5|s2cid=8269634 |doi-access= }}</ref> The more often cannabis is used, particularly in early adolescence, the more likely a person is to develop a psychotic illness,<ref>{{cite journal |first1=Benjamin|last1=Chadwick |first2=Michael L.|last2=Miller |first3=Yasmin L.|last3=Hurd |year=2013 |title=Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review |journal=Frontiers in Psychiatry |volume=4 |page=129 |pmc=3796318 |doi=10.3389/fpsyt.2013.00129 |pmid=24133461|doi-access=free }}</ref><ref>{{cite journal  |last1=Moore|first1=T.H.|last2=Zammit|first2=S.|last3=Lingford-Hughes|first3=Anne|author-link3=Anne Lingford-Hughes|last4=Barnes|first4=T.R.|last5=Jones|first5=P.B.|last6=Burke|first6=M.|last7=Lewis|first7=G.|year=2007 |title= Cannabis Use during Adolescent Development: Susceptibility to Psychiatric Illness |journal=Lancet |volume=370 |issue=9584 |pages=319–328 |doi=10.1016/S0140-6736(07)61162-3 |pmid=17662880|s2cid=41595474 |url=http://orca.cf.ac.uk/619/1/Appendix%201%20%28search%20strategy%29%20Cannabis%20use%20and%20risk%20of%20developing%20psychotic%20or%20affective%20mental%20health%20outcomes%20a%20systematic%20review.pdf }}</ref><ref name="Moore TH, Zammit S, [[Anne Lingford-Hughes|Lingford-Hughes A]], et al. 2005 187-94">{{cite journal |last1=Moore|first1=T.H.|last2=Zammit|first2=S.|last3=Lingford-Hughes|first3=Anne|author-link3=Anne Lingford-Hughes|last4=Barnes|first4=T.R.|last5=Jones|first5=P.B.|last6=Burke|first6=M.|last7=Lewis|first7=G.| title = Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review | journal = Lancet | volume = 370 | issue = 9584 | pages = 187–94 | date = March 2005 | pmid = 17662880 | doi = 10.1016/S0140-6736(07)61162-3 | s2cid = 41595474 | url = http://orca.cf.ac.uk/619/1/Appendix%201%20%28search%20strategy%29%20Cannabis%20use%20and%20risk%20of%20developing%20psychotic%20or%20affective%20mental%20health%20outcomes%20a%20systematic%20review.pdf }}</ref> with frequent use being correlated with double the risk of psychosis and schizoaffective disorder.<ref>{{cite journal|last1=Sewell|first1=R.A.|last2=Ranganathan|first2=M.|last3=D'Souza|first3=D.C.|title=Cannabinoids and psychosis|journal=International Review of Psychiatry|date=Apr 2009|volume=21|issue=2|pages=152–62|pmid=19367509|doi=10.1080/09540260902782802|s2cid=8221928}}</ref> A 2009 Yale review stated that in individuals with an established psychotic disorder, [[cannabinoids]] can exacerbate symptoms, trigger relapse, and have negative consequences on the course of the illness.<ref>{{cite journal |last1=D'Souza|first1=D.C.|last2=Sewell|first2=R.A.|last3=Ranganathan|first3=M.| title = Cannabis and psychosis/schizophrenia: human studies | journal = Eur Arch Psychiatry Clin Neurosci | volume = 259 | issue = 7 | pages = 413–31 | date = July 2009 | pmid = 19609589 | pmc = 2864503 | doi = 10.1007/s00406-009-0024-2 }}</ref> While cannabis use is accepted as a contributory cause of schizoaffective disorder by many,<ref name="Henquet2008">{{cite journal |last1=Henquet|first1=C.|last2=Di Forti|first2=M.|last3=Morrison|first3=P.|last4=Kuepper|first4=R.|last5=Murray|first5=R.M.|title=Gene-environment interplay between cannabis and psychosis |journal=Schizophr Bull |volume=34 |issue=6 |pages=1111–21 |date=November 2008  |pmid=18723841 |pmc=2632498 |doi=10.1093/schbul/sbn108 }}</ref> it remains controversial,<ref name=Genes10>{{cite journal |last1=McLaren|first1=J.A.|last2=Silins|first2=E.|last3=Hutchinson|first3=D.|last4=Mattick|first4=R.P.|last5=Hall|first5=W.|title=Assessing evidence for a causal link between cannabis and psychosis: a review of cohort studies |journal=Int. J. Drug Policy |volume=21 |issue=1 |pages=10–9 |date=January 2010  |pmid=19783132 |doi=10.1016/j.drugpo.2009.09.001 }}</ref><ref name="Amar2007">{{cite journal|last1=Ben Amar|first1=M.|last2=Potvin |first2=S.|title=Cannabis and psychosis: what is the link?|journal=Journal of Psychoactive Drugs|date=Jun 2007|volume=39|issue=2|pages=131–42|pmid=17703707|doi=10.1080/02791072.2007.10399871|s2cid=21243420}}</ref> since not all young people who use cannabis later develop psychosis, but those who do use cannabis have an increased [[odds ratio]] of about 3.<ref name="Cannabis&Psychosis">{{cite journal |last=Castle|first=DJ |title=Cannabis and psychosis: what causes what? |journal=F1000 Medicine Reports |volume=5 |issue=1 |page= 1 |date=January 2013 |doi=10.3410/M5-1 |pmc= 3544398 |pmid=23361396 |doi-access=free }}</ref> Certain drugs can imitate symptoms of schizophrenia (which is known to have similar symptoms to schizoaffective disorder). This is important to note when including that substance-induced psychosis should be ruled out when diagnosing patients so that patients are not misdiagnosed.<ref name="Schizoaffective_in_the_DSM5"/>

== Mechanisms ==
Though the pathophysiology of schizoaffective disorder remains unclear, studies suggest that dopamine, norepinephrine, and serotonin may be factors in the development of the disorder.<ref name=":03">{{Citation |last1=Wy |first1=Tom Joshua P. |title=Schizoaffective Disorder |date=2022 |url=https://www.ncbi.nlm.nih.gov/books/NBK541012/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=31082056 |access-date=2022-09-28 |last2=Saadabadi |first2=Abdolreza}}</ref> [[White matter]] and [[grey matter]]  reductions in the right [[lentiform nucleus]], left [[superior temporal gyrus]], and right [[precuneus]], and other areas in the brain are also characteristic of schizoaffective disorder.<ref name=":03"/><ref name=":42">{{Cite journal |last=Correll |first=Christoph U. |date=2010-12-23 |title=Understanding Schizoaffective Disorder: From Psychobiology to Psychosocial Functioning |url=https://www.psychiatrist.com/jcp/bipolar/mood-disorders/understanding-schizoaffective-disorder-psychobiology/ |journal=The Journal of Clinical Psychiatry |language=English |volume=71 |issue=suppl 2 |pages=8–13 |doi=10.4088/JCP.9096su1cc.02 |pmid=21190647 |issn=0160-6689|doi-access=free }}</ref> Deformities in white matter have also been found to worsen with time in individuals with schizoaffective disorder.<ref name=":42"/> Due to its role in emotional regulation, researchers believe that the [[hippocampus]] is also involved in the progression of schizoaffective disorder.<ref name=":52">{{Cite journal |last1=Nasa |first1=Anurag |last2=Mosley |first2=Olivia |last3=Roman |first3=Elena |last4=Kelliher |first4=Allison |last5=Gaughan |first5=Caoimhe |last6=Levins |first6=Kirk J. |last7=Coppinger |first7=David |last8=O'Hanlon |first8=Erik |last9=Cannon |first9=Mary |last10=Roddy |first10=Darren William |date=2022-03-15 |title=MRI volumetric changes in hippocampal subfields in psychosis: a protocol for a systematic review and meta-analysis |journal=Systematic Reviews |volume=11 |issue=1 |page=44 |doi=10.1186/s13643-022-01916-5 |issn=2046-4053 |pmc=8925181 |pmid=35292116 |doi-access=free }}</ref> Specifically, psychotic disorders (such as schizoaffective disorder) have been associated with lower hippocampal volumes.<ref name=":52"/> Moreover, deformities in the medial and thalamic regions of the brain have been implicated as contributing factors to the disorder as well.<ref name=":03"/>

== Diagnosis ==
Psychosis as a [[symptom]] of a psychiatric disorder is first and foremost a [[diagnosis of exclusion]].<ref name=PsychosisExclusionaryDx/> So a new-onset episode of psychosis ''cannot'' be considered to be a symptom of a psychiatric disorder until other relevant and known medical causes of psychosis are excluded, or ruled out.<ref name=PsychosisExclusionaryDx/> Many clinicians improperly perform, or entirely miss this step, introducing avoidable diagnostic error and misdiagnosis.<ref name=PsychosisExclusionaryDx/>

An initial assessment includes a comprehensive history and physical examination. Although no biological laboratory tests exist which confirm schizoaffective disorder, biological tests should be performed to [[diagnosis of exclusion|exclude]] psychosis associated with or caused by substance use, medications, toxins or poisons, surgical complications, or other medical illnesses. Since non-medical mental health practitioners are not trained to exclude medical causes of psychosis, people experiencing psychosis should be referred to an emergency department or hospital.

[[Delirium]] should be ruled out, which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness, indicating other underlying factors which includes medical illnesses.<ref name=PsychosisExclusionaryDx/> Excluding medical illnesses associated with psychosis is performed by using [[blood tests]] to measure:

* [[Thyroid-stimulating hormone]] to exclude [[hypothyroidism|hypo-]] or [[hyperthyroidism]],
* Basic electrolytes and [[serum calcium]] to rule out a metabolic disturbance,
* [[complete blood count|Full blood count]] including [[erythrocyte sedimentation rate|ESR]] to rule out a systemic infection or chronic disease, and
* [[Serology]] to exclude [[syphilis]] or [[HIV]] infection.

Other investigations which may be performed include:
* [[EEG]] to exclude [[epilepsy]], and an
* [[MRI]] or [[CT scan]] of the head to exclude brain lesions.

Blood tests are not usually repeated for relapse in people with an established diagnosis of schizoaffective disorder, unless there is a specific ''medical'' indication. These may include serum [[blood sugar|BSL]] if [[olanzapine]] has previously been prescribed, thyroid function if [[Lithium (medication)|lithium]] has previously been taken to rule out [[hypothyroidism]], liver function tests if [[chlorpromazine]] has been prescribed, [[Creatine kinase|CPK]] levels to exclude [[neuroleptic malignant syndrome]], and a [[urinalysis]] and serum toxicology screening if substance use is suspected. Assessment and treatment may be done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

Because psychosis may be precipitated or exacerbated by common classes of [[psychiatric medications]], such as [[antidepressant]]s,<ref name="Preda A, MacLean RW, Mazure CM, Bowers MB Jr 2001 30–3">{{cite journal |last1=Preda|first1=A.|last2=MacLean|first2=R.W.|last3=Mazure|first3=C.M.|last4=Bowers|first4=M.B.| title = Antidepressant-associated mania and psychosis resulting in psychiatric admissions | journal = The Journal of Clinical Psychiatry | volume = 62 | issue = 1 | pages = 30–3 | year = 2001 | pmid = 11235925 | doi = 10.4088/JCP.v62n0107 }}</ref><ref name="Fortunati F, Mazure C, Preda A, Wahl R, Bowers M Jr 2002 331–334">{{cite journal |last1=Fortunati|first1=F.|last2=Mazure|first2=C.|last3=Preda|first3=A.|last4=Wahl|first4=R.|last5=Bowers|first5=M.| title = Plasma catecholamine metabolites in antidepressant-exacerbated mania and psychosis | journal = Journal of Affective Disorders | volume = 68 | issue = 2–3 | pages = 331–334 | year = 2002 | pmid = 12063160 | doi = 10.1016/S0165-0327(00)00327-X | url = https://uci.academia.edu/AdrianPreda/Papers/264409/Plasma_Catecholamine_Metabolites_In_Antidepressant-Exacerbated_Mania_and_Psychosis }}</ref><ref name="Effexor-Psychosis">{{cite journal |first1=A. T.|last1=Safeekh |first2=Denzil|last2=Pinto |title=Venlafaxine-induced psychotic symptoms |journal=Indian Journal of Psychiatry |volume=51 |issue=4 |pages=308–09 |date=Oct–Dec 2009 |pmid= 20048460|pmc=2802382 | doi=10.4103/0019-5545.58301 |doi-access=free }}</ref><ref name="Wellbutrin-Zyban-Psychosis">{{cite journal |last1=Javelot|first1=T.|last2=Javelot|first2=H.|last3=Baratta|first3=A.|last4=Weiner|first4=L.|last5=Messaoudi|first5=M.|last6=Lemoine|first6=P. | title = Acute psychotic disorders related to bupropion: review of the literature | journal = Encephale | volume = 36 | issue = 6 | pages = 461–71 | date = Dec 2010 | pmid = 21130229 | doi = 10.1016/j.encep.2010.01.005 }}</ref><ref name="Wellbutrin-Zyban-Psychosis2">{{cite journal |last1=Kumar|first1=S.|last2=Kodela|first2=S.|last3=Detweiler|first3=J.G.|last4=Kim|first4=K.Y.|last5=Detweiler|first5=M.B.| title = Bupropion-induced psychosis: folklore or a fact? A systematic review of the literature | journal = General Hospital Psychiatry | volume = 33 | issue = 6 | pages = 612–7 | date = Nov–Dec 2011 | pmid = 21872337 | doi = 10.1016/j.genhosppsych.2011.07.001 }}</ref> [[ADHD#Medication|ADHD stimulant medications]],<ref>{{cite journal|last1=Bramness|first1=Jørgen G|last2=Gundersen|first2=Øystein Hoel|last3=Guterstam|first3=Joar|last4=Rognli|first4=Eline Borger|last5=Konstenius|first5=Maija|last6=Løberg|first6=Else-Marie|last7=Medhus|first7=Sigrid|last8=Tanum|first8=Lars|last9=Franck|first9=Johan| display-authors = 8|title=Amphetamine-induced psychosis – a separate diagnostic entity or primary psychosis triggered in the vulnerable?|journal=BMC Medicine|date=5 December 2012|volume=12|page=221|doi=10.1186/1471-244X-12-221|pmid=23216941|pmc=3554477|issue=1 |doi-access=free }}</ref><ref name="ReferenceB">{{cite journal |last1=Kraemer|first1=M.|last2=Uekermann|first2=J.|last3=Wiltfang|first3=J.|last4=Kis|first4=B | title = Methylphenidate-induced psychosis in adult attention-deficit/hyperactivity disorder: report of 3 new cases and review of the literature | journal = Clinical Neuropharmacology | volume = 33 | pages = 204–6 | year = 2010 | pmid= 20571380 | doi=10.1097/WNF.0b013e3181e29174 | issue=4| s2cid = 34956456 }}</ref><ref name="Steven M. Berman, Ronald Kuczenski, James T. McCracken, and Edythe D. London 2009 123–42">{{cite journal |last1=Berman|first1=S.M.|last2=Kuczenski|first2=R.|last3=McCracken|first3=J.T.|last4=London|first4=E.D.| title = Potential Adverse Effects of Amphetamine Treatment on Brain and Behavior: A Review | journal = Molecular Psychiatry | volume = 14 | issue = 2 | pages = 123–42 | year = 2009 | pmid = 18698321 | pmc = 2670101 | doi = 10.1038/mp.2008.90 }}</ref> and [[hypnotics|sleep medications]],<ref name="Markowitz JS, Brewerton TD. 1996 89–91">{{cite journal |last1=Markowitz|first1=J.S.|last2=Brewerton|first2=T.D. | title = Zolpidem-induced psychosis | journal = Annals of Clinical Psychiatry | volume = 8 | issue = 2 | pages = 89–91 | date = June 1996 | pmid = 8807033 | doi = 10.3109/10401239609148806 }}</ref><ref name="Chiung-Lei H, Ching-Jui C, Ching-Feng H, Hsi-Len L. 2003 683–86">{{cite journal |last1=Chiung-Lei|first1=H.|last2=Ching-Jui|first2=C.|last3=Ching-Feng|first3=H.|last4=Hsi-Len|first4=L.|title=Zolpidem-induced distortion in visual perception |journal=Annals of Pharmacotherapy |date=May 2003 |volume=37 |issue=5 |pages=683–86 |doi=10.1345/aph.1C318|pmid=12708947 |s2cid=31602934}}</ref> [[Substance-induced psychosis|prescribed medication-induced psychosis]] should be [[diagnosis of exclusion|ruled out]], particularly for first-episode psychosis.<ref name=PsychosisExclusionaryDx/> This is an essential step to reduce diagnostic error and to evaluate potential medication sources of further [[iatrogenesis|patient harm]].<ref name=PsychosisExclusionaryDx/> Regarding prescribed medication sources of patient harm, [[Yale School of Medicine]] Professor of Psychiatry Malcolm B. Bowers Jr, MD wrote:<ref name="Malcolm2004">{{cite book |last=Bowers Jr. |first=Malcolm |title=The Role of Illicit and Prescribed Drugs in Promoting Psychotic and Manic Disorders |year=2004 |publisher=[[Xlibris]] |location=Indiana |isbn=978-1-4134-2807-0}} {{Self-published source|date=September 2014}}</ref>{{Self-published inline|certain=yes|date=December 2017}}
<blockquote>Illicit drugs aren't the only ones that precipitate psychosis or mania—prescribed drugs can too, and in particular, some psychiatric drugs. We investigated this and found that about 1 in 12 psychotic or manic patients in an inpatient psychiatric facility are there due to antidepressant-induced psychosis or mania. That's unfortunate for the field [of psychiatry] and disastrous for some of our patients.
{{blockquote|quote=It is important to be understood here. I want to call attention to the fact that some persons with a family history of even the subtler forms of bipolar disorder or psychosis are more vulnerable than others to the mania- or psychosis-inducing potential of antidepressants, stimulants and sleeping medications. While I'm not making a blanket statement against these medications, ''I am urging caution in their use''. I believe [clinicians] should ask patients and their families whether there is a family history of bipolar disorder or psychosis before prescribing these medications. Most patients and their families don't know the answer when they are first asked, so time should be allowed for the patient to ask family or relatives, between the session when asked by [the clinician] and a follow-up session. This may increase the wait for a medication slightly, but because some patients are vulnerable, this is a necessary step for [the clinician] to take. ''I believe that psychiatry as a field has not emphasized this point sufficiently''. As a result, some patients have been harmed by the very treatments that were supposed to help them; or to the disgrace of psychiatry, harmed and then misdiagnosed.<ref name="Preda A, MacLean RW, Mazure CM, Bowers MB Jr 2001 30–3"/><ref name="Fortunati F, Mazure C, Preda A, Wahl R, Bowers M Jr 2002 331–334"/><ref name="Effexor-Psychosis"/><ref name="Wellbutrin-Zyban-Psychosis"/><ref name="ReferenceB"/><ref name="Steven M. Berman, Ronald Kuczenski, James T. McCracken, and Edythe D. London 2009 123–42"/><ref name="Markowitz JS, Brewerton TD. 1996 89–91"/><ref name="Chiung-Lei H, Ching-Jui C, Ching-Feng H, Hsi-Len L. 2003 683–86"/>}}</blockquote>

Substance-induced psychosis should also be ruled out. Both substance- and medication-induced psychosis can be [[diagnosis of exclusion|excluded]] to a high level of certainty while the person is psychotic, typically in an emergency department, using both a:
* Broad spectrum urine toxicology screening, and a
* Full serum toxicology screening (of the blood).

Some [[dietary supplements]] may also induce psychosis or mania, but cannot be ruled out with laboratory tests. So a psychotic person's family, partner, or friends should be asked whether he or she is currently taking any dietary supplements.<ref>{{cite journal|title=Final rule declaring dietary supplements containing ephedrine alkaloids adulterated because they present an unreasonable risk|journal=Federal Register|date=11 February 2004|volume=69|issue=28|pages=6787–854|pmid=14968803|url=http://www.federalregister.gov/a/04-2912/p-276|publisher=HHS Food And Drug Administration |last1=Food And Drug Administration |first1=HHS }} ({{Federal Register|69|6814}} and {{Federal Register|69|6818}})</ref>

Common mistakes made when diagnosing psychotic patients include:<ref name=PsychosisExclusionaryDx>{{cite web|last1=Freudenreich|first1=Oliver|title=Differential Diagnosis of Psychotic Symptoms: Medical "Mimics"|url=http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%E2%80%9Cmimics%E2%80%9D|website=Psychiatric Times|publisher=UBM Medica|date=3 December 2012|access-date=19 October 2013|archive-date=4 June 2013|archive-url=https://web.archive.org/web/20130604094749/http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%E2%80%9Cmimics%E2%80%9D}}</ref>
* Not properly excluding delirium,
* Missing a [[Substance-induced psychosis|toxic psychosis]] by not screening for substances ''and'' medications,
* Not appreciating medical abnormalities (e.g., [[vital signs]]),
* Not obtaining a medical history and family history,
* Indiscriminate screening without an organizing framework,
* Not asking family or others about dietary supplements,
* Premature diagnostic closure, and
* Not revisiting or questioning the initial diagnostic impression of primary psychiatric disorder.
Schizoaffective disorder can only be diagnosed among those who have undergone a clinical evaluation with a psychiatrist. The criterion includes mental and physical symptoms<ref name=":02">{{Cite journal |last1=Paul |first1=Tanya |last2=Javed |first2=Sana |last3=Karam |first3=Alvina |last4=Loh |first4=Hanyou |last5=Ferrer |first5=Gerardo F |title=A Misdiagnosed Case of Schizoaffective Disorder With Bipolar Manifestations |journal=Cureus |year=2021 |volume=13 |issue=7 |article-number=e16686 |doi=10.7759/cureus.16686 |doi-access=free |issn=2168-8184 |pmc=8394638 |pmid=34466319}}</ref> such as [[hallucination]]s or [[delusion]]s, and [[Major depressive episode|depressive episodes]]. There are also links to bad hygiene and a troubled social life for those with schizoaffective disorder.<ref name=":02"/> Research has failed to conclusively demonstrate a positive relationship between schizoaffective disorder and substance abuse.<ref>{{Cite web |last=McQueen |first=Janie |title=Schizophrenia and Substance Use Disorder: What to Know |url=https://www.webmd.com/schizophrenia/schizophrenia-substance-use-disorder |access-date=2023-11-10 |website=WebMD |language=en}}</ref> There are several theorized causations for the onset of Schizoaffective disorder, including, genetics, general brain function, like chemistry, and structure, and stress.<ref name="my.clevelandclinic.org"/>

Only after these relevant and known causes of psychosis have been ruled out can a psychiatric [[differential diagnosis]] be made. A mental health clinician will incorporate family history, observation of a psychotic person's behavior while the person is experiencing active symptoms, to begin a psychiatric differential diagnosis. Diagnosis also includes self-reported experiences, as well as behavioral abnormalities reported by family members, friends, or significant others. Mistakes in this stage include:
* Not screening for [[dissociative disorders]]. [[Dissociative identity disorder]] and psychotic symptoms in schizoaffective disorder have considerable overlap, yet a different overall treatment approach.<ref>{{cite journal | last=Shibayama|first=M.| year = 2011 | title = Differential diagnosis between dissociative disorders and schizophrenia | journal = Seishin Shinkeigaku Zasshi = Psychiatria et Neurologia Japonica | volume = 113 | issue = 9| pages = 906–911 | pmid = 22117396 }}</ref>

=== DSM-5 criteria ===
The most widely used criteria for diagnosing schizoaffective disorder are from the [[American Psychiatric Association]]'s ''[[DSM-5|Diagnostic and Statistical Manual of Mental Disorders-5]]''.<ref name="Schizoaffective_in_the_DSM5"/>

The DSM-IV schizoaffective disorder definition was plagued by problems of being inconsistently (or [[reliability (statistics)|unreliably]]) used on patients;<ref name="Schizoaffective_in_the_DSM5"/> when the diagnosis is made, it does not stay with most patients over time,<ref name="Schizoaffective_in_the_DSM5"/> and it has questionable [[validity (statistics)|diagnostic validity]] (that is, it does not describe a distinct disorder, nor predict any particular outcome).<ref name="Schizoaffective_in_the_DSM5"/> These problems have been slightly reduced (or "modestly improved") in the [[DSM-5]] according to Carpenter.<ref name="Schizoaffective_in_the_DSM5"/>

When [[psychosis|psychotic]] symptoms are confined to an episode of [[mania]] or [[depression (mood)|depression]] (with or without [[mixed affective state|mixed features]]), the diagnosis is that of a "psychotic" [[mood disorder]], namely either psychotic [[bipolar disorder]] or [[psychotic depression|psychotic major depression]]. Only when psychotic states persist in a sustained fashion for two weeks or longer without concurrent affective symptoms is the diagnosis schizoaffective disorder, [[schizophreniform disorder]] or [[schizophrenia]].<ref name="Schizoaffective_in_the_DSM5"/>

The second cardinal guideline in the DSM-5 diagnosis of schizoaffective disorder is one of timeframe.
::DSM-5 requires two episodes of psychosis (whereas DSM-IV needed only one) to qualify for the schizoaffective disorder diagnosis.<ref name="Schizoaffective_in_the_DSM5"/> As such, it is no longer an "episode diagnosis."<ref name="Schizoaffective_in_the_DSM5"/> The new schizoaffective framework looks at the time from "the [first episode of] psychosis up to the current episode [of psychosis], rather than only defining a single episode with [co-occurring] psychotic and mood [[syndrome]]s."<ref name="Schizoaffective_in_the_DSM5"/> Specifically, one of the episodes of psychosis must last a minimum of two weeks without mood disorder symptoms, but the person may be mildly to moderately depressed while psychotic.<ref name="Schizoaffective_in_the_DSM5"/> The other period of psychosis "requires the overlap of mood [disorder] symptoms with psychotic symptoms to be conspicuous" and last for a greater portion of the disorder.<ref name="SadCreation">{{cite journal | last1=Malhi|first1=G.S. | title = Making up schizoaffective disorder: Cosmetic changes to a sad creation? | journal = Australian and New Zealand Journal of Psychiatry | volume = 47 | issue = 10 | pages = 891–4 | date = Oct 2013 | pmid = 24072567 | doi = 10.1177/0004867413505522 | s2cid = 206399250 }}</ref>

These two changes are intended by the DSM-5 workgroup to accomplish two goals:<ref name="Schizoaffective_in_the_DSM5"/>

* Increase the diagnosis' consistency (or reliability) when it is used;
* Significantly decrease the overall use of the schizoaffective disorder diagnosis.

If the schizoaffective diagnosis is used less often, other diagnoses (like psychotic mood disorders and schizophrenia) are likely to be used more often; but this is hypothetical until real-world data arrive. Validity problems with the diagnosis remain and await further work in the fields of [[psychiatric genetics]], [[neuroimaging]], and [[cognitive science]] that includes the overlapping fields of [[cognitive neuroscience|cognitive]], [[affective neuroscience|affective]], and [[social neuroscience]], which may change the way schizoaffective disorder is [[construct (philosophy of science)|conceptualized]] and defined in future versions of the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]] and [[ICD]].<ref name="Schizoaffective_in_the_DSM5"/><ref name=TransformingDiagnosis>{{cite news|title=NIMH Director's Blog: Transforming Diagnosis|url=http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml|access-date=20 October 2013|newspaper=NIMH Director's Blog|archive-date=29 May 2013|archive-url=https://web.archive.org/web/20130529152509/http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml}}</ref>

==== Comorbidities ====
Schizoaffective disorder shares a high level of [[comorbidity]] with anxiety disorders, depression, and bipolar disorder.<ref>{{Cite journal |last1=Laursen |first1=Thomas Munk |last2=Agerbo |first2=Esben |last3=Pedersen |first3=Carsten Bøcker |date=October 2009 |title=Bipolar disorder, schizoaffective disorder, and schizophrenia overlap: a new comorbidity index |journal=The Journal of Clinical Psychiatry |volume=70 |issue=10 |pages=1432–1438 |doi=10.4088/JCP.08m04807 |issn=1555-2101 |pmid=19538905|s2cid=34270304 }}</ref><ref>{{Cite journal |last1=Young |first1=Sarah |last2=Pfaff |first2=Danielle |last3=Lewandowski |first3=Kathryn Eve |last4=Ravichandran |first4=Caitlin |last5=Cohen |first5=Bruce M. |last6=Öngür |first6=Dost |date=2013 |title=Anxiety disorder comorbidity in bipolar disorder, schizophrenia and schizoaffective disorder |journal=Psychopathology |volume=46 |issue=3 |pages=176–185 |doi=10.1159/000339556 |issn=1423-033X |pmid=22906962|s2cid=20297075 }}</ref> Individuals with schizoaffective disorder are also often diagnosed with substance abuse disorder, usually relating to [[tobacco]], [[cannabis (drug)|marijuana]], or [[alcohol (drug)|alcohol]].<ref>{{Cite journal |last1=Archibald |first1=Luke |last2=Brunette |first2=Mary F. |last3=Wallin |first3=Diana J. |last4=Green |first4=Alan I. |date=2019-12-20 |title=Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder |journal=Alcohol Research: Current Reviews |volume=40 |issue=1 |article-number=arcr.v40.1.06 |doi=10.35946/arcr.v40.1.06 |issn=2168-3492 |pmc=6927747 |pmid=31886105}}</ref> Health care providers indicate the importance of assessing for co-occurring substance use disorders, as multiple diagnoses not only potentially increase negative symptomology, but may also adversely affect the treatment of schizoaffective disorder.

==== Types ====
One of three types of schizoaffective disorder may be noted in a diagnosis based on the mood component of the disorder:<ref name="who.int"/><ref name="Schizoaffective_in_the_DSM5"/><ref name=":12">{{Cite web |title=Schizoaffective disorder |url=https://www.rcpsych.ac.uk/mental-health/problems-disorders/schizoaffective-disorder |access-date=2022-09-30 |website=Royal College of Psychiatrists |language=en}}</ref>

* Bipolar type, when the disturbance includes [[manic episodes]], [[hypomania]], or [[mixed episodes]]—major depressive episodes also typically occur;
* Depressive type, when the disturbance includes major depressive episodes exclusively—that is, without manic, hypomanic, or mixed episodes.
* Mixed type, when the disturbance includes both manic and depressive symptoms, but psychotic symptoms exist separately from bipolar disorder.<ref name=":12"/>

==== Problems with DSM-IV schizoaffective disorder ====
The [[American Psychiatric Association|American Psychiatric Association's]] DSM-IV criteria for schizoaffective disorder persisted for 19 years (1994–2013). Clinicians adequately trained in diagnosis used the schizoaffective diagnosis too often,<ref name="Schizoaffective_in_the_DSM5"/> largely because the criteria were poorly defined, [[ambiguity|ambiguous]], and hard to use (or poorly [[operationalization|operationalized]]).<ref name="Schizoaffective_in_the_DSM5"/><ref name=pmid18199238>{{cite journal |last1=Malhi|first1=G.S.|last2=Green|first2=M.|last3=Fagiolini|first3=A.|last4=Peselow|first4=E.D.|last5=Kumari|first5=V.| title = Schizoaffective disorder: diagnostic issues and future recommendations | journal = Bipolar Disorders | volume = 10 | issue = 1 Pt 2 | pages = 215–30 | date = February 2008 | pmid = 18199238 | doi = 10.1111/j.1399-5618.2007.00564.x }}</ref> Poorly trained clinicians used the diagnosis without making necessary [[diagnosis of exclusion|exclusions]] of common causes of psychosis, including some prescribed psychiatric medications.<ref name="Schizoaffective_in_the_DSM5"/> Specialty books written by experts on schizoaffective disorder have existed for over eight years before DSM-5 describing the overuse of the diagnosis.<ref name="The Overlap of Schizophrenic and Affective Spectra">{{cite book |last1=Marneros|first1=A|last2=Akiskal|first2=HS |title=The Overlap of Schizophrenic and Affective Spectra |year=2007 |publisher=Cambridge University Press |location=New York |isbn= 978-0-521-85858-8 }}</ref><ref name="Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition">{{cite book |last1=Goodwin|first1=FK |last2=Jamison|first2=KR |title=Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition |year=2007 |publisher=Oxford University Press |location=New York |isbn=978-0-19-513579-4}}</ref><ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms">{{cite book |last1=Goodwin|first1=FK|last2=Marneros|first2=A |title=Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms |year=2005 |publisher=Cambridge University Press |location=New York |isbn=978-0-521-83517-6 }}</ref><ref name="Schizoaffective Disorders: New Research">{{cite book |author=Murray WH |title=Schizoaffective Disorders: New Research |year=2006 |publisher=[[Nova Science Publishers, Inc.]] |location=New York |isbn=978-1-60021-030-3}}</ref>

Carpenter and the DSM-5 schizoaffective disorders workgroup analyzed data made available to them in 2009, and reported in May 2013 that:<ref name="Schizoaffective_in_the_DSM5"/>
<blockquote>a recent review of psychotic disorders from large private insurance and Medicare databases in the U.S. found that the diagnosis of DSM-IV schizoaffective disorder was used for about a third of cases with non-affective psychotic disorders. Hence, this unreliable and poorly defined diagnosis is clearly overused.</blockquote>

As stated above, the DSM-IV schizoaffective disorder diagnosis is very inconsistently used or unreliable.<ref name="Schizoaffective_in_the_DSM5"/> A diagnosis is unreliable when several different mental health professionals observing the same individual make different diagnoses excessively.<ref name="Schizoaffective_in_the_DSM5"/> Even when a structured DSM-IV diagnostic interview and best estimate procedures were made by experts in the field that included information from family informants and prior clinical records, [[interrater reliability|reliability]] was still poor for the DSM-IV schizoaffective diagnosis.<ref name="Schizoaffective_in_the_DSM5"/>

The DSM-IV schizoaffective diagnosis is not stable over time either.<ref name="Schizoaffective_in_the_DSM5"/> An initial diagnosis of schizoaffective disorder during time spent at a psychiatric inpatient facility was stable at 6-month and 24-month follow ups for only 36% of patients.<ref name="Schizoaffective_in_the_DSM5"/> By comparison, diagnostic stability was 92% for schizophrenia, 83% for bipolar disorder and 74% for major depression.<ref name="Schizoaffective_in_the_DSM5"/> Most patients diagnosed with DSM-IV schizoaffective disorder are later diagnosed with a different disorder, and that disorder is more stable over time than the DSM-IV schizoaffective disorder diagnosis.<ref name="Schizoaffective_in_the_DSM5"/>

In April 2009, Carpenter and the DSM-5 schizoaffective disorder workgroup reported that they were "developing new criteria for schizoaffective disorder to improve reliability and [[face validity]]," and were "determining whether the dimensional assessment of mood [would] justify a recommendation to drop schizoaffective disorder as a diagnostic category."<ref name="OnTrack"/> Speaking to an audience at the May 2009 annual conference of the [[American Psychiatric Association]], Carpenter said:<ref name="OnTrack"/>
<blockquote>We had hoped to get rid of schizoaffective [disorder] as a diagnostic category [in the DSM-5] because we don't think it's [a] valid [scientific entity] and we don't think it's reliable. On the other hand, we think it's absolutely indispensable to clinical practice.</blockquote>

A major reason why DSM-IV schizoaffective disorder was indispensable to clinical practice is because it offered clinicians a diagnosis for patients with psychosis in the context of mood disorder whose clinical picture, at the time diagnosed, appeared different from DSM-IV "schizophrenia" or "mood disorder with psychotic features".

But DSM-IV schizoaffective disorder carries an unnecessarily worse prognosis than a "mood disorder with psychotic features" diagnosis,<ref name="Schizoaffective_in_the_DSM5"/> because [[longitudinal data|long-term data]] revealed that a significant proportion of DSM-IV schizoaffective disorder patients had 15-year outcomes indistinguishable from patients with mood disorders with or without psychotic features,<ref name="Schizoaffective_in_the_DSM5"/><ref name="Fifteen Year Schizoaffective Follow Up"/> even though the clinical picture at the time of first diagnosis looked different from both schizophrenia and mood disorders.<ref name="Schizoaffective_in_the_DSM5"/><ref name="Fifteen Year Schizoaffective Follow Up"/>

These problems with the DSM-IV schizoaffective disorder definition result in most people the diagnosis is used on being misdiagnosed;<ref name="Schizoaffective_in_the_DSM5"/> furthermore, [[cohort study|outcome studies]] done 10 years after the diagnosis was released showed that the group of patients defined by the DSM-IV and ICD-10 schizoaffective diagnosis had significantly better outcomes than predicted, so the diagnosis carries a misleading and unnecessarily poor [[prognosis]].<ref name="Schizoaffective_in_the_DSM5"/> The DSM-IV criteria for schizoaffective disorder will continue to be used on U.S. board examinations in psychiatry through the end of 2014; established practitioners may continue to use the problematic DSM-IV definition much further into the future also.

==== DSM-5 research directions ====
The new schizoaffective disorder criteria continue to have questionable diagnostic validity.<ref name="Schizoaffective_in_the_DSM5"/> Questionable diagnostic validity does not doubt that people with symptoms of psychosis and mood disorder need treatment—psychosis and mood disorder must be treated. Instead, questionable diagnostic validity means there are unresolved problems with the way the DSM-5 [[categorization|categorizes]] and defines schizoaffective disorder.

[[File:Emil Kraepelin2.gif|thumb|upright|[[Emil Kraepelin|Emil Kraepelin's]] [[Kraepelinian dichotomy|dichotomy]] ({{circa|1898}}) continues to influence [[nosology|classification and diagnosis]] in psychiatry.]]

A core concept in modern psychiatry since [[DSM III#DSM-III (1980)|DSM-III]] was released in 1980, is the categorical separation of mood disorders from schizophrenia, known as the [[Kraepelinian dichotomy]]. [[Emil Kraepelin]] introduced the idea that schizophrenia was separate from mood disorders after observing patients with symptoms of psychosis and mood disorder, over a century ago, in 1898. This was a time before [[genetics]] were known and before any treatments existed for [[mental illness]].<ref name="Craddock N p.109">{{cite journal |last1=Craddock|first1=N.|last2=Owen|first2=M.J. | title = The Kraepelinian dichotomy&nbsp;– going, going... But still not gone | journal = The British Journal of Psychiatry | volume = 196 | pages = 92–95| year = 2010 | doi = 10.1192/bjp.bp.109.073429 | pmid=20118450 | pmc=2815936 | issue=2}}</ref> The Kraepelinian dichotomy was not used for [[DSM-I]] and [[DSM-II]] because both manuals were influenced by the dominant [[psychodynamic]] psychiatry of the time,<ref name="Revolution">{{cite journal |last1=Mayes|first1=R.|last2=Horwitz|first2=A.V. | title = DSM-III and the revolution in the classification of mental illness | journal = J Hist Behav Sci | volume = 41 | issue = 3 | pages = 249–67 | year = 2005 | pmid = 15981242 | doi = 10.1002/jhbs.20103 }}</ref> but the designers of DSM-III wanted to use more scientific and biological definitions.<ref name="Revolution" /> Consequently, they looked to psychiatry's history and decided to use the Kraepelinian dichotomy as a foundation for the classification system.

The Kraepelinian dichotomy continues to be used in DSM-5 despite having been challenged by [[empirical data|data]] from modern psychiatric genetics for over eight years,<ref name="EndofKraepelinianDichotomy">{{cite journal |last1=Craddock|first1=N.|last2=Owen|first2=M.J. | title = The beginning of the end for the Kraepelinian dichotomy | journal = Br J Psychiatry | volume = 186 | issue = 5 | pages = 364–6 | date = May 2005 | pmid = 15863738 | doi = 10.1192/bjp.186.5.364 | doi-access = free }}</ref> and there is now [[empirical evidence|evidence]] of a significant overlap in the genetics of schizophrenia and bipolar disorder.<ref name="Craddock N p.109"/> According to this genetic evidence, the Kraepelinian categorical separation of mood disorders from schizophrenia at the foundation of the current classification and diagnostic system is a mistaken [[false dichotomy]].<ref name="Craddock N p.109"/><ref name=Mental_Health_on_the_Spectrum>{{cite news|title=Mental Health on the Spectrum|url=http://www.nature.com/news/mental-health-on-the-spectrum-1.12842|access-date=17 September 2013|newspaper=Nature}}</ref>

The dichotomy at the foundation of the current system forms the basis for a convoluted schizoaffective disorder definition in DSM-IV that resulted in excessive misdiagnosis.<ref name="Schizoaffective_in_the_DSM5"/> Real life schizoaffective disorder patients have significant and enduring symptoms that bridge what are incorrectly assumed to be categorically separate disorders, schizophrenia and bipolar disorder.<ref name="Structure_of_Psychotic_Disorders_in_DSM_5">{{cite journal|last1=Heckers|first1=S|last2=Barch|first2=D.M.|last3=Bustillo|first3=J|last4=Gaebel|first4=W.|last5=Gur|first5=R.|last6=Malaspina|first6=D. |last7=Owen|first7=M.J.|last8=Schultz|first8=S.|last9=Tandon|first9=R.|last10=Tsuang|first10=M.|last11=Van Os|first11=J.|last12=Carpeter|first12=W.|author-link12=William T. Carpenter|year=2013|title=Structure of the psychotic disorders classification in DSM-5|journal=Schizophrenia Research|volume=150|issue=1|pages=11–4|doi=10.1016/j.schres.2013.04.039|pmid=23707641|s2cid=14580469}}</ref> People with [[psychotic depression]], bipolar disorder with a history of psychosis, and schizophrenia with mood symptoms also have symptoms that bridge psychosis and mood disorders.<ref name="Craddock N p.109"/><ref name="Mental_Health_on_the_Spectrum"/> The categorical diagnostic manuals do not reflect reality in their separation of psychosis (via the schizophrenia diagnosis) from mood disorder, nor do they currently emphasize the actual overlap found in real-life patients.<ref name="Craddock N p.109"/><ref name="Mental_Health_on_the_Spectrum"/> Thus, they are likely to continue to introduce [[false dichotomy|either-or]] [[conceptualization|conceptual]] and diagnostic error, by way of [[confirmation bias]] into clinicians' [[mindset]]s, hindering accurate assessment and treatment.<ref name="Craddock N p.109"/><ref name="Mental_Health_on_the_Spectrum"/>

The new definition continues the lack of [[Occam's razor|parsimony]] of the old definition.<ref name="Schizoaffective_in_the_DSM5"/><ref name="Structure_of_Psychotic_Disorders_in_DSM_5"/> Simpler, clearer, and more usable definitions of the diagnosis were supported by certain members of the DSM-5 workgroup; these were debated but deemed premature, because more "research [is] needed to establish a new [[nosology|classification system]] of equal or greater validity"<ref name="Structure_of_Psychotic_Disorders_in_DSM_5"/> to the existing system.<ref name="Schizoaffective_in_the_DSM5"/><ref name="Structure_of_Psychotic_Disorders_in_DSM_5"/> Because of DSM-5's continuing problematic categorical foundation, schizoaffective disorder's conceptual and diagnostic validity remains doubtful.<ref name="Craddock N p.109"/><ref name="Mental_Health_on_the_Spectrum"/> After enough research is completed and data exists, future diagnostic advances will need to either eliminate and replace, or soften and bridge, the hard categorical separation of mood disorders from schizophrenia; most likely using a [[spectrum approach|spectrum or dimensional approach]] to diagnosis.<ref name="Schizoaffective_in_the_DSM5"/><ref name="Mental_Health_on_the_Spectrum"/>

More [[Occam's razor|parsimonious]] definitions than the current one were considered by Carpenter and the DSM-5 workgroup:<ref name="Schizoaffective_in_the_DSM5"/>
<blockquote>One option for the DSM-5 would have been to remove the schizoaffective disorder category and to add affective [or mood] symptoms [that is, [[mania]], [[hypomania]], [[mixed state (psychiatry)|mixed episode]], or [[major depressive episode|depression]]] as a dimension to [[schizophrenia]] and [[schizophreniform disorder]] ''or'' to define a single category for the co-occurrence of psychosis and mood symptoms. This option was extensively debated but ultimately deemed to be premature in the absence of sufficient clinical and theoretical validating data justifying such a … reconceptualization. Additionally, there appeared to be no practical way to introduce affect [or mood] dimensions covering the entire course of illness, that would capture the current [[conceptualization|concept]] of periods of psychosis related and unrelated to mood episodes.</blockquote>

{{blockquote|quote=[N]o valid biomarkers or laboratory measures have emerged to distinguish between affective psychosis [or psychotic [[mood disorders]]] and schizophrenia. To the contrary, ''the idea of a dichotomy between these types of conditions has proven naïve''. [T]he admixture of "schizophrenic" and affective [or mood] symptoms is a feature of many, or even most, cases with severe mental illness. Most ''presenting symptoms of psychosis have little validity in determining diagnosis, prognosis, or treatment response'' in psychosis. [U]ltimately a more ... [[spectrum approach|dimensional approach]] [to assessment and treatment] will be required.}}

The field of [[psychiatry]] has begun to question its assumptions and analyze its data in order to merge closer with [[evidence-based medicine]].<ref name="Mental_Health_on_the_Spectrum"/> The removal of the "episode diagnosis", and the addition of two episodes of psychosis, as qualifications for the DSM-5 schizoaffective diagnosis, may improve the diagnosis' consistency over DSM-IV for research purposes, where diagnostic criteria are by necessity followed ''exactingly''.<ref name="SadCreation"/> But the new definition remains long, unwieldy, and perhaps still not very useful for community clinicians—with two psychoses, one for two weeks minimum and without mood disorder (but the person can be mildly or moderately depressed) and the other with significant mood disorder and psychosis lasting for most of the time, and with lasting mood symptoms for most of the residual portion of the illness.<ref name="Schizoaffective_in_the_DSM5"/><ref name="SadCreation"/> Community clinicians used the previous definition "for about a third of cases with non-affective psychotic disorders."<ref name="Schizoaffective_in_the_DSM5"/> Non-affective psychotic disorders are, by definition, not schizoaffective disorder. For clinicians to make such sizeable errors of misdiagnosis may imply systemic problems with the schizoaffective disorder diagnosis itself. Already, at least one expert believes the new schizoaffective definition has not gone far enough to solve the previous definition's problems.<ref name="SadCreation"/>

From a scientific standpoint, modern clinical psychiatry is still a very young, underdeveloped medical specialty because its target organ, the human brain, is not yet well understood. The human brain's [[neural circuit]]s, for example, are just beginning to be mapped by modern neuroscience in the [[Human Connectome Project]] and [[CLARITY]]. Clinical psychiatry, furthermore, has begun to understand and acknowledge its current limitations—but further steps by the field are required to significantly reduce misdiagnosis and [[iatrogenesis|patient harm]]; this is crucial both for responsible patient care and to retain public trust. Looking forward, a [[paradigm shift]] is needed in psychiatric research to address unanswered questions about schizoaffective disorder. The [[spectrum approach|dimensional]] Research Domain Criteria project currently being developed by the [[National Institute of Mental Health|U.S. National Institute of Mental Health]], may be the specific problem solving framework psychiatry needs to develop a more scientifically mature understanding of schizoaffective disorder as well as all other mental disorders.<ref name="RDoC">{{cite web | url=https://www.nimh.nih.gov/news/science-updates/2013/introduction-to-rdoc | title=Introduction to RDoC | publisher=[[National Institute of Mental Health|NIMH]] | access-date=February 25, 2016 | archive-date=22 April 2018 | archive-url=https://web.archive.org/web/20180422235118/https://www.nimh.nih.gov/news/science-news/2013/introduction-to-rdoc.shtml | url-status=live }}</ref>

== Treatment ==
The primary treatment of schizoaffective disorder is medication, with improved outcomes using combined long-term psychological and social supports.<ref name=Lancet09/> Hospitalization may occur for severe episodes either voluntarily or (if mental health legislation allows it) [[involuntary commitment|involuntarily]]. Long-term hospitalization is uncommon since [[deinstitutionalization]] started in the 1950s, although it still occurs.<ref name="BeckerKilian2006">{{cite journal |last1=Becker|first1=T.|last2=Kilian|first2=R.|year=2006 |title=Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? |journal=[[Acta Psychiatrica Scandinavica. Supplementum]] |volume=113 |pages=9–16 |pmid=16445476 |doi=10.1111/j.1600-0447.2005.00711.x |issue=429|s2cid=34615961 }}</ref> Community support services including drop-in centers, visits by members of a [[Community mental health service|community mental health team]], supported employment and support groups are common.<ref>{{cite journal |last1=McGurk|first1=S.R.|last2=Mueser|first2=K.T.|last3=Feldman|first3=K.|last4=Wolfe|first4=R.|last5=Pascaris |first5=A.|date=Mar 2007 |title=Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. |journal=American Journal of Psychiatry |volume=164 |issue=3 |pages=437–41 |doi=10.1176/appi.ajp.164.3.437 |pmid=17329468}}</ref> Evidence indicates that regular exercise has a positive effect on the physical and mental health of those with schizoaffective disorder.<ref>{{cite journal |last1=Gorczynski|first1=P.|last2=Faulkner|first2=G.|title=Exercise therapy for schizophrenia |journal=Cochrane Database Syst Rev |issue=5 |article-number=CD004412 |year=2010 |pmid=20464730 |doi=10.1002/14651858.CD004412.pub2 |pmc=4164954}}</ref>

Because of the heterogeneous symptomology associated with schizoaffective disorder, it is common for patients to be [[Medical error|misdiagnosed]]. Many people are either diagnosed with [[Depression (mood)|depression]], schizophrenia, or [[bipolar disorder]] instead of schizoaffective disorder.<ref name=":02"/> Because of the broad range of symptoms of Schizoaffective disorder, patients are often misdiagnosed in a clinical setting. In fact, almost 39% of people are misdiagnosed when it comes to psychiatric disorders.<ref name=":02"/>

While various medications and treatment options ''exist'' for those diagnosed with schizoaffective disorder, symptoms may continue to impact a person for their entire lifespan.<ref name="my.clevelandclinic.org"/>''Schizoaffective'' disorder can affect a person's ability to experience a fulfilling social life and they may also exhibit difficulty forming bonds or relationships with others. Schizoaffective disorder is more likely to occur in women and symptoms begin manifesting at a young age.<ref name="my.clevelandclinic.org"/>

=== Therapy ===
Psychosocial treatments have been found to improve outcomes related to schizoaffective disorder.<ref name="BMJ best practice">{{cite web|publisher=BMJ Group|url=http://bestpractice.bmj.com/best-practice/monograph/1199/treatment/step-by-step.html|title=Schizoaffective disorders: Treatment|year=2012}}</ref> Supportive [[psychotherapy]] and [[cognitive behavioral therapy]] are both helpful.<ref>{{Cite web |title=Schizoaffective Disorder|publisher=NAMI: National Alliance on Mental Illness |url=https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-Disorder/Treatment |access-date=2022-11-20 |website=www.nami.org}}</ref> Intensive case management (ICM) has been shown to reduce hospitalizations, improve adherence to treatment, and improve social functioning.<ref>{{cite journal  |last1=Dieterich|first1=M.|last2=Irving|first2=C.B.|last3=Park|first3=B.| title=Intensive Case Management for Severe Mental Illness | journal=Cochrane Database of Systematic Reviews | volume= 1| issue=CD007906 | article-number=CD007906 | date=January 6, 2017 | doi=10.1002/14651858.CD007906.pub3 | editor1-last=Dieterich | editor1-first=Marina | pmid=28067944 | pmc=6472672 }}</ref> With ICM, clients are assigned a case manager responsible for coordination of care and assisting clients to access supports to address needs in multiple areas related to well-being, including housing.

Psychiatric/psychosocial rehabilitation is often a component of schizoaffective disorder treatment. This rehabilitation method focuses on solving community integration problems such as obtaining and keeping housing and increasing involvement in positive social groups. It also focuses on improving and increasing [[activities of daily living]]; increasing daily healthy habits and decreasing unhealthy behaviors, thereby significantly improving quality of life. Psychiatric rehabilitation may also focus on [[vocational rehabilitation]].<ref>{{cite web|publisher=PSR/RPS Canada|url=http://www.psrrpscanada.ca/index.php?src=gendocs&link=About|title=PSR/RPS Canada Core Principles and Values|archive-url=https://web.archive.org/web/20100324203048/http://www.psrrpscanada.ca/index.php?src=gendocs&link=About|archive-date=24 March 2010|url-status=live}}</ref> Evidence suggests that cognition-based approaches may be able to improve work and social functioning.<ref>{{Cite journal |last1=Kern |first1=Robert S. |last2=Glynn |first2=Shirley M. |last3=Horan |first3=William P. |last4=Marder |first4=Stephen R. |date=January 27, 2009 |title=Psychosocial Treatments to Promote Functional Recovery in Schizophrenia |url=https://academic.oup.com/schizophreniabulletin/article/35/2/347/1909008 |access-date=November 20, 2022 |journal=Schizophrenia Bulletin|volume=35 |issue=2 |pages=347–361 |doi=10.1093/schbul/sbn177 |pmid=19176470 |pmc=2659313 }}</ref>

Psychiatric rehabilitation consists of eight main areas:

* Psychiatric (symptom reduction and management)
* Health and Medical (maintaining consistency of care)
* Housing (safe environments)
* Basic living skills ([[hygiene]], meals [including increasing healthy food intake and reducing processed food intake], safety, planning and chores)
* Social ([[Intimate relationship|relationships]], family boundaries, communication and integration of client into the community)
* Education and vocation (coping skills, [[motivation]] and suitable goals chosen by client)
* Finance ([[personal budget]])
* Community and legal (resources)

=== Medication ===
[[Antipsychotic]] medication is usually required both for acute treatment and the prevention of relapse.<ref name="APP textbook"/><ref name="APA guideline">{{cite book|publisher=American Psychiatric Association|url=http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1665359|title=Practice Guideline for the Treatment of Patients with Schizophrenia|edition=Second|year=2004|archive-url=https://archive.today/20140306093804/http://psychiatryonline.org/content.aspx?bookID=28&sectionID=1665359%2346267 |archive-date=6 March 2014}}</ref> There is no single antipsychotic of choice in treating schizoaffective disorder, but [[atypical antipsychotic]]s may be considered due to their mood-stabilizing abilities.<ref name="APP textbook"/><ref name="BMJ best practice"/> To date, [[paliperidone]] (Invega) is the only antipsychotic with FDA approval for the treatment of schizoaffective disorder.<ref name="Manufacturer's Official webpage">{{cite web|publisher=Paliperidone|url=http://www.invega.com/schizoaffective-disorder-treatment/|title=Schizoaffective disorders: Treatment|year=2013|access-date=30 March 2014|archive-date=18 November 2018|archive-url=https://web.archive.org/web/20181118142027/http://www.invega.com/schizoaffective-disorder-treatment}}</ref> Other antipsychotics may be prescribed to further alleviate psychotic symptoms.<ref>{{Cite web |title=Schizoaffective disorder – Diagnosis and treatment|publisher=Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/diagnosis-treatment/drc-20354509#:~:text=The%20only%20medication%20approved%20by,such%20as%20delusions%20and%20hallucinations. |access-date=2022-11-19 |website=www.mayoclinic.org |language=en}}</ref>

Though not approved for treatment use by the FDA, research suggests that Clozapine may also be effective in treating schizoaffective disorder, particularly in those resistant to initial medication.<ref name="Rey Souto 148–156">{{Cite journal |last1=Rey Souto |first1=Diana |last2=Pinzón Espinosa |first2=Justo |last3=Vieta |first3=Eduard |last4=Benabarre Hernández |first4=Antoni |date=2021-07-01 |title=Clozapine in patients with schizoaffective disorder: A systematic review |url=https://www.elsevier.es/en-revista-revista-psiquiatria-salud-mental-486-articulo-clozapine-in-patients-with-schizoaffective-S2173505021000376 |journal=Revista de Psiquiatría y Salud Mental (English Edition) |language=en |volume=14 |issue=3 |pages=148–156 |doi=10.1016/j.rpsmen.2021.07.001 |pmid=34400122 |s2cid=237149738 |issn=2173-5050|url-access=subscription }}</ref> Clozapine is an [[atypical antipsychotic]] that is recognized as being particularly effective when other antipsychotic agents have failed.<ref name="Stahl">{{cite book|last=Stahl|first=S.M.|title=Stahl's Essential Psychopharmacology: Neuroscientific basis and practical applications|location=New York|publisher=Cambridge University Press|year=2008}}</ref> When combined with cognitive therapy, Clozapine has been found to decrease positive and negative symptoms of psychosis at a higher rate in schizoaffective individuals.<ref name="Rey Souto 148–156"/> Clozapine has also been associated with a decreased risk of suicide in patients with schizoaffective disorder and a history of suicidality.<ref name="APA guideline"/> Despite this, clozapine treatment may be ineffective for some patients, particularly in those that are already drug-resistant.<ref>{{Cite web |title=New Center Aims to Bolster Treatment of Schizoaffective Disorders |url=https://www.hopkinsmedicine.org/news/articles/new-center-aims-to-bolster-treatment-of-schizoaffective-disorders |access-date=2022-11-19 |website=www.hopkinsmedicine.org |language=en}}</ref>

The management of the bipolar type of schizoaffective disorder is similar to the [[treatment of bipolar disorder]], with the goal of preventing mood episodes and cycling.<ref name="Stahl"/> [[Lithium (medication)|Lithium]] or anticonvulsant mood stabilizers such as [[valproic acid]], [[carbamazepine]], and [[lamotrigine]] are prescribed in combination with an antipsychotic.<ref name="BMJ best practice"/>

Antidepressants have also been used to treat schizoaffective disorder.<ref>{{Cite journal |last1=Cascade |first1=Elisa |last2=Kalali |first2=Amir H. |last3=Buckley |first3=Peter |date=March 2009 |title=Treatment of Schizoaffective Disorder |journal=Psychiatry (Edgmont) |volume=6 |issue=3 |pages=15–17 |issn=1550-5952 |pmc=2719459 |pmid=19724749}}</ref> Though they may be useful in treating the depressive subtype of the disorder, research suggests that antidepressants are far less effective in treatment than antipsychotics and mood stabilizers.<ref>{{Cite journal |first=Brian |last=Miller |date=2021-05-25 |title=Which Pharmacotherapies Are Most Effective for Schizoaffective Disorder? |url=https://www.psychiatrictimes.com/view/which-pharmacotherapies-most-effective-schizoaffective-disorder |journal=Psychiatric Times |series=Vol 38, Issue 5 |language=en |volume=05}}</ref>

Some research has supported the efficacy of [[anxiolytic]]s in treating schizoaffective disorder, though general findings on their effectiveness in treating schizoaffective disorder remain inconclusive.<ref name=":0">{{Cite journal |last1=Dold |first1=Markus |last2=Li |first2=Chunbo |last3=Tardy |first3=Magdolna |last4=Khorsand |first4=Vesal |last5=Gillies |first5=Donna |last6=Leucht |first6=Stefan |date=2012-11-14 |title=Benzodiazepines for schizophrenia |journal=The Cochrane Database of Systematic Reviews |volume=2012 |issue=11 |article-number=CD006391 |doi=10.1002/14651858.CD006391.pub2 |issn=1469-493X |pmc=7052813 |pmid=23152236}}</ref> Due to the severe negative outcomes associated with many anti-anxiety drugs, many researchers have cautioned against their long term use in treatment.<ref name=":0"/>

=== Electroconvulsive therapy ===
[[Electroconvulsive therapy]] (ECT) may be considered for patients with schizoaffective disorder experiencing severe depression or severe psychotic symptoms that have not responded to treatment with antipsychotics.<ref name="APA guideline"/>

== Epidemiology ==
Compared to depression, schizophrenia, and bipolar disorder, schizoaffective disorder is less commonly diagnosed.<ref name=":3">{{Cite web |title=Schizoaffective disorder: MedlinePlus Genetics |url=https://medlineplus.gov/genetics/condition/schizoaffective-disorder/ |access-date=2022-09-30 |website=medlineplus.gov |language=en}}</ref> Schizoaffective disorder is estimated to occur in 0.3 to 0.8 percent of people at some point in their life.<ref name="Kaplan & Saddock. p.501-502">{{cite book|title=Synopsis of Psychiatry|last1=Kaplan|first1=HI|last2=Saddock|first2=VA|publisher=Lippincott, Williams & Wilkins|year=2007|isbn=978-0-7817-7327-0|location=New York|pages=501–502}}</ref> 30% of cases occur between the ages of 25 and 35.<ref>{{Cite journal|last1=Wy|first1=T. J. P.|last2=Saadabadi|first2=A.|date=2019|title=Schizoaffective Disorder|url=https://www.ncbi.nlm.nih.gov/books/NBK541012/|journal=StatPearls [Internet] Treasure Island (FL)|pmid=31082056|via=NCBI}}</ref> 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 roughly even gender distribution.<ref>{{Cite journal |last1=Sommer |first1=Iris E. |last2=Tiihonen |first2=Jari |last3=van Mourik |first3=Anouk |last4=Tanskanen |first4=Antti |last5=Taipale |first5=Heidi |date=2020-05-01 |title=The clinical course of schizophrenia in women and men-a nation-wide cohort study |journal=npj Schizophrenia |volume=6 |issue=1 |page=12 |doi=10.1038/s41537-020-0102-z |issn=2334-265X |pmc=7195359 |pmid=32358572}}</ref> Children are less likely to be diagnosed with this disorder, as the onset presents itself in adolescence or young adulthood.<ref name=":22"/><ref name="PsychosisExclusionaryDx2">{{cite web |last1=Freudenreich |first1=Oliver |date=3 December 2012 |title=Differential Diagnosis of Psychotic Symptoms: Medical "Mimics" |url=http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%E2%80%9Cmimics%E2%80%9D |access-date=19 October 2013 |website=Psychiatric Times |publisher=UBM Medica |archive-date=4 June 2013 |archive-url=https://web.archive.org/web/20130604094749/http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%E2%80%9Cmimics%E2%80%9D }}</ref>

== History ==
The term ''schizoaffective psychosis'' was introduced by the American psychiatrist [[Jacob S. Kasanin|Jacob Kasanin]] in 1933<ref name=pmid16857267>{{cite journal |last1=Lake|first1=C.R.|last2=Hurwitz|first2=N.| title = Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders | journal = Psychiatry Research | volume = 143 | issue = 2–3 | pages = 255–87 | date = August 2006 | pmid = 16857267 | doi = 10.1016/j.psychres.2005.08.012 | s2cid = 35916818 }}</ref> to describe an episodic psychotic illness with predominant affective symptoms, that was thought at the time to be a good-prognosis schizophrenia.<ref name="Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition"/><!--page 102--> Kasanin's concept of the illness was influenced by the [[Psychoanalysis|psychoanalytic]] teachings of [[Adolf Meyer (psychiatrist)|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."<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 190--> He based his description on a case study of nine individuals.<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 190-->

[[File:Karl Ludwig Kahlbaum.JPG|thumb|right|upright|[[Karl Kahlbaum]] (1828{{ndash}}1899)]]

Other psychiatrists, before and after Kasanin, have made scientific observations of schizoaffective disorder based on assumptions of a biological and genetic cause of the illness. In 1863, German psychiatrist [[Karl Kahlbaum]] (1828{{ndash}}1899) described schizoaffective disorders as a separate group in his ''vesania typica circularis''.<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 189--> Kahlbaum distinguished between [[Cross-sectional study|cross-sectional]] and [[Longitudinal study|longitudinal]] observations. In 1920, psychiatrist [[Emil Kraepelin]] (1856{{ndash}}1926) observed a "great number" of cases that had characteristics of both groups of psychoses that he originally posited were two distinct and separate illnesses, ''dementia praecox'' (now called schizophrenia) and ''manic depressive insanity'' (now called bipolar disorders and recurrent depression).<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 190-->

Kraepelin acknowledged that "there are many overlaps in this area," that is, the area between schizophrenia and mood disorders.<ref>{{harvnb|Marneros|Akiskal|2007|pages=3–4}}.</ref> In 1959, psychiatrist [[Kurt Schneider]] (1887{{ndash}}1967) began to further refine conceptualizations of the different forms that schizoaffective disorders can take since he observed "concurrent and sequential types".<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 190--> (The ''concurrent type'' of illness he referred to is a longitudinal course of illness with episodes of mood disorder and psychosis occurring predominantly at the same time [now called psychotic mood disorders or affective psychosis]; while his ''sequential type'' refers to a longitudinal course predominantly marked by alternating mood and psychotic episodes.)<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 189--> Schneider described schizoaffective disorders as "cases in-between" the traditional Kraepelinian dichotomy of schizophrenia and mood disorders.<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 189-->

The historical clinical observation that schizoaffective disorder is an overlap of schizophrenia and mood disorders is explained by genes for both illnesses being present in individuals with schizoaffective disorder; specifically, recent research shows that schizophrenia and mood disorders share common genes ''and'' polygenic variations.<ref>{{cite journal |last1=Van Snellenberg|first1=J.X.|last2=de Candia|first2=T. | title = Meta-analytic evidence for familial coaggregation of schizophrenia and bipolar disorder | journal = Arch. Gen. Psychiatry | volume = 66 | issue = 7 | pages = 748–55 | date = July 2009 | pmid = 19581566 | doi = 10.1001/archgenpsychiatry.2009.64 |s2cid=20216200 | doi-access =  }}</ref><ref>{{cite journal | title = Schizophrenia and bipolar disorder may share genetic origins | journal = Harv Ment Health Lett | volume = 25 | issue = 12 | page = 7 | date = June 2009 | pmid = 19582944 }}</ref><ref>{{cite journal |last1=Purcell|first1=S.M.|last2=Wray|first2=N.R.|last3=Stone|first3=J.L.|last4=Visscher|first4=P.M.|last5=O'Donovan|first5=M.C.|last6=Sullivan |first6=P.F.|last7=Sklar|first7=P.| title = Common polygenic variation contributes to risk of schizophrenia and bipolar disorder | journal = Nature | volume = 460 | issue = 7256 | pages = 748–52 | date = July 2009 | pmid = 19571811 | doi = 10.1038/nature08185 | pmc = 3912837 | bibcode = 2009Natur.460..748P }}</ref><ref>{{cite journal |last1=Potash|first1=J.B.|last2=Bienvenu|first2=OJ | title = Neuropsychiatric disorders: Shared genetics of bipolar disorder and schizophrenia | journal = Nature Reviews Neurology | volume = 5 | issue = 6 | pages = 299–300 | date = June 2009 | pmid = 19498428 | doi = 10.1038/nrneurol.2009.71 | s2cid = 21986987 }}</ref>

[[File:Emil Kraepelin 1926.jpg|thumb|right|upright|[[Emil Kraepelin]] (1856{{ndash}}1926). Embracing the [[Kraepelinian dichotomy]] in [[DSM-III]] in 1980, while a step forward from [[psychodynamic]] explanations of the disorder, introduced significant problems in schizoaffective disorder diagnosis, as explained recently by the [[DSM-5]] workgroup.]]
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.<ref name="Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition"/><!--page=96--> DSM-III-R included its own diagnostic criteria as well as the subtypes, bipolar and depressive.<ref name="Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition"/><!--page=96--> 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.<ref name="Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms"/><!--page 192-->

DSM-IV and DSM-IV-TR (published in 2000) criteria for schizoaffective disorder were poorly defined and poorly [[operationalization|operationalized]].<ref name="Schizoaffective_in_the_DSM5"/> These [[ambiguous]] and unreliable criteria lasted 19 years and led clinicians to significantly overuse the schizoaffective disorder diagnosis.<ref name="Schizoaffective_in_the_DSM5"/> 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 [[longitudinal study|longitudinally determined]] to have outcomes indistinguishable from those with mood disorders with or without psychotic features.<ref name="Schizoaffective_in_the_DSM5"/> A poor prognosis was assumed to apply to these patients by most clinicians, and this poor prognosis was [[iatrogenic|harmful]] to many patients.<ref name="Schizoaffective_in_the_DSM5" /><ref name="Schizoaffective Disorder Diagnosis & Substandard Treatment">{{cite journal |last1=Lake|first1=C.R.|last2=Hurwitz|first2=N. | title = Schizoaffective disorder merges schizophrenia and bipolar disorders as one disease | journal = Current Opinion in Psychiatry | volume = 20 | pages = 365–79| year = 2007 | pmid=17551352 | doi=10.1097/YCO.0b013e3281a305ab | issue=4| s2cid = 37664803 }}</ref> The poor prognosis for DSM-IV schizoaffective disorder was not based on [[cohort study|patient outcomes]] [[empirical research|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;<ref name="Craddock N p.109"/><ref name="Mental_Health_on_the_Spectrum"/> and by clinicians being unfamiliar with the [[empirical science|scientific]] limitations of the diagnostic and classification system.<ref name="Schizoaffective_in_the_DSM5"/>

The DSM-5 schizoaffective disorder workgroup analyzed all of the available research [[Empirical science#Philosophy of science|evidence]] on schizoaffective disorder, and concluded that "presenting symptoms of psychosis have little validity in determining diagnosis, prognosis, or treatment response."<ref name="Schizoaffective_in_the_DSM5"/> 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 [[syndrome]]s, the limits of our knowledge are clearer: ''Presenting symptoms of psychosis describe only presenting symptoms to be treated, and not much more''.<ref name="Schizoaffective_in_the_DSM5"/> Schizoaffective disorder was changed to a longitudinal or life course diagnosis in DSM-5 for this reason.<ref name="Schizoaffective_in_the_DSM5"/>

Stigma of schizoaffective disorder include moralist arguments, religious causes, and others during history.<ref>{{Cite book |last1=Assis |first1=Jorge Cândido de |url=https://link.springer.com/10.1007/978-3-031-24556-5 |title=Between Reason and Illusion: Demystifying Schizophrenia |last2=Villares |first2=Cecília Cruz |last3=Bressan |first3=Rodrigo Affonseca |date=2023 |publisher=Springer Nature Switzerland |isbn=978-3-031-24555-8 |series=Copernicus Books |location=Cham |language=en |doi=10.1007/978-3-031-24556-5}}</ref><ref>{{Cite book |last=Farrell |first=Michael |title=Controversies in schizophrenia: issues, causes, and treatment |date=2024 |publisher=Routledge, Taylor & Francis Group |isbn=978-1-003-41355-4 |location=New York, NY}}</ref>

== Research ==
Little is known of the causes and mechanisms that lead to the development of schizoaffective disorder.<ref name="SadCreation"/><ref name="Mental_Health_on_the_Spectrum"/> Whether schizoaffective disorder is a variant of schizophrenia (as in DSM-5 and ICD-10 classification systems), a variant of bipolar disorder, or part of a dimensional continuum between [[psychotic depression]], bipolar disorders and schizophrenia is currently being investigated.<ref name="Mental_Health_on_the_Spectrum" />

More recently, some research suggests the need for a more specialized classification for schizoaffective disorder. In a 2017 examining diagnostic heterogeneity study, researchers found that when compared to a schizophrenia sample, individuals with schizoaffective disorder rate higher in suicidality and anxiety disorder comorbidity.<ref>{{Cite journal |last1=Seldin |first1=Katherine |last2=Armstrong |first2=Kristan |last3=Schiff |first3=Max L. |last4=Heckers |first4=Stephan |date=2017 |title=Reducing the Diagnostic Heterogeneity of Schizoaffective Disorder |journal=Frontiers in Psychiatry |volume=8 |page=18 |doi=10.3389/fpsyt.2017.00018 |pmid=28239362 |pmc=5300988 |issn=1664-0640|doi-access=free }}</ref>
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== References ==
{{Reflist|30em}}

== Further reading ==
{{refbegin}}
* {{cite book |last1=Moore|first1=D.P.|last2=Jefferson|first2=J.W. |title=Handbook of medical psychiatry|date=2004|publisher=Elsevier/Mosby|location=Philadelphia |isbn=978-0-323-02911-7|edition=2nd | pages = 126–127 }}
* {{cite book| last1=Goetzt|first1=C.G. |title=Textbook of clinical neurology|date=2003|publisher=W.B. Saunders|location=Philadelphia|isbn=978-0-7216-3800-3|edition=2nd|page=48}}
{{refend}}

== External links ==
{{Medical resources
| ICD11           = {{ICD11|6A21}}
| ICD10           = {{ICD10|F|25 || f|20}}
| ICD9            = {{ICD9|295.70}}
| DiseasesDB      = 33444
| MedlinePlus     = 000930
| OMIM            = 181500
| eMedicineSubj   = article
| eMedicineTopic  = 294763
| MeshID          = D011618
| SNOMED CT       = 68890003
}}

{{Portal bar|Medicine}}
{{Mental and behavioral disorders|selected = schizophrenia}}
{{Bipolar disorder}}
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[[Category:Bipolar spectrum]]
[[Category:Mood disorders]]
[[Category:Schizophrenia]]
[[Category:Schizophrenia or other primary psychotic disorders]]