Schizoaffective disorder

Question 1

Schizoaffective disorder - dx

Answer 1

A. Uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with criterion A of schizophrenia (note: MDE must include criterion A1 [depressed mood]) - >1mo
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness (?)
D. Not due to a substance or another medical condition

Note: if delusions occur exclusively during mood episodes, the dx is depressive or bipolar disorder with psychotic features

Question 2

Schizoaffective disorder - mx

Answer 2

1. Psychiatric hx, MSE, physical ex (with neurological focus), ix (FBE, UEC + ca, LFTs, FBG, serum lipids, TFTs, prolactin, urine toxicology, CT/MRI brain, immunological screen/EEG if indicated). Conduct blood tests before commencing antipsychotics, if possible
2. Risk assessment - to themselves, risk of violence, insight + ability to accept treatment. Assess need for hospital admission and suitability of the ward environment (clinical condition of pt + availability of both community mental health resources and family or other social supports; be aware of drug-induced/drug-withdrawal state). Regular review in first 72 hours
3. Emergency tx of behavioural disturbance (3):
   a. Oral lorazepam 1-2mg + oral antipsychotic (e.g. haloperidol 10-20mg, chlorpromazine 50-100mg)
   b. IM lorazepam + haloperidol if oral medication refused/failed
   c. If immediate tranquilisation necessary (exceptional circumstances) = IV benzodiazepines (e.g. diazepam 10mg slow IV bolus

Question 3

Schizoaffective disorder - mx (maintenance)

Answer 3

1. Psychological and psychosocial therapies for schizophrenia (5):
   a. Assertive community tx (assistance with medication concordance, social skills training, welfare support)
   b. Psychoeducation
   c. CBT (asks pt to examine evidence for psychotic belief and using problem-solving skills to challenge and decrease the salience and threat of their beliefs)
   d. Behavioural therapy (altering dysfunctional habits or behaviours by changing the consequence of those behaivours)
   e. Motivational interviewing and CBT - for substance use/dependence
2. Instigation of antipsychotic treatment (3):
3. Oral second generation antipsychotic (SGA) other than sertindole or clozapine (reserved for special cases). Start with low dose, rising to initial target dose. Increase dose if no response within next 1-2 weeks or 3-4 weeks if response inadequate
4. Long-acting BZD (e.g. diazepam) = controlling non-acute anxiety/behavioural disturbance
5. Tx extra-pyramidal side effects with procyclidine orally (or alternative)
6. Add antidepressant (when depressed), +/- lithium or sodium valproate (when manic). Drugs used for prophylaxis of bipolar disorder can also be used for prophylaxis of the mood component of schizoaffective disorder (continue pharmacological mx for at least 12mo with lithium carbonate, aripiprazole, asenapine, olanzapine or paliperidone…)