History and exam
Key diagnostic factors
common
positive symptoms
Positive symptoms refer to symptoms that are in excess of what is considered to be normal functioning. Such symptoms include hallucinations, delusional ideation, thought disorder, and bizarre behavior.
negative symptoms
Negative symptoms refer to symptoms that are the result of a deficit in what is considered to be normal functioning. Examples of negative symptoms include anhedonia, amotivation, social isolation, or flat affect.
disorder of perception
Disorders of perception include illusions and hallucinations.
Perception can be abnormal in any of the sensory modalities. Auditory hallucinations are most common. They can be perceived as being inside or outside the patient's head, and are usually described as derogatory commands or conversations and running commentaries.
Visual hallucinations may be present but less often. In a much lesser proportion, olfactory and gustatory hallucinations may present (exacerbated by unpleasant taste and smell).
Tactile hallucinations (electrical pulses, crawling sensation) rarely present in schizoaffective disorder (and their presence should prompt a ruling out of drug-induced psychosis). Cenesthetic hallucinations are less frequent still. Other perceptual experiences such as derealization and déjà vu are possible but, if prominent, a magnetic resonance imaging scan should be considered to exclude structural brain lesions.
delusions
Delusions are fixed false beliefs that do not belong to the patient's cultural background. They start to develop at the beginning of the illness, possibly as an attempt to explain prodromal, experiential changes. In this process the delusions can change in focus and complexity. The delusions, or the core of them, can become crystallized (unchanged for long periods of time).
Common delusional themes in schizoaffective disorder, as in schizophrenia, are persecutory, grandiose, nihilistic (also common in depression), religious, and somatic.
Other common delusions in schizoaffective disorder are delusions of thought control and thought broadcasting. Thought control can be experienced as thought insertion (someone placing thoughts in one's mind) and thought withdrawal (someone removing thoughts from one's mind).
disturbances in emotions
Disturbances in emotions such as anxiety, depression, elation, and perplexity can also occur at any time during the course of the illness. Occurs more commonly than in schizophrenia.
incongruent affect
Incongruent affect is common and refers to noncongruence between thought and speech content. Occurs more commonly than in schizophrenia.
disorders of stream and form of thought
Inability to give a concise answer as a result of over-inclusiveness of unnecessary details is called circumstantiality.
Tangential thinking refers to the inability to stay on topic, jumping from one subject to another with minimal connection. (When extreme it leads to incoherence, as in looseness of associations.)
Verbigeration is repetition of words in the absence of a stimulus (contrasted with perseveration, which is a repetition of the same response to different stimuli).
Word salad is a form of speech in which there is no connection between the words used.
cognitive abnormalities
Most notably, there are deficits in executive function and, to a degree, working memory.
deficit symptoms
Negative symptoms can occur at any time during the course of the illness.[36] They can be worsened by acute psychosis, depression, and adverse effects of medications.
The most common negative symptoms are asociality (withdrawal from interpersonal interactions), avolition (decrease in interests and activities), affective blunting, alogia (quantitative and qualitative decrease in speech), and anhedonia (lack of enjoyment in any previously pleasurable activities).
major depressive episodes
Major mood episodes (either major depression or mania) must occur for at least half the time the patient has met criteria for schizophrenia.[1] Symptoms of major depression include depressed mood, lack of interest/pleasure, weight changes, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, decreased concentration, and suicidal ideation. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
manic episodes
Major mood episodes (either major depression or mania) must occur for at least half the time the patient has met criteria for schizophrenia.[1] Symptoms include inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distracted easily, increase in goal-directed activity or psychomotor agitation, engaging in activities that hold the potential for harmful consequences.
Other diagnostic factors
common
neurologic deficit
Neurologic exam does not usually reveal gross neurologic deficit. "Soft signs" (minor neurologic findings) are found in over half of patients with schizophrenia (and probably schizoaffective disorder) and in a considerable number of their blood relatives. Deficits may be found in motor coordination, smooth-pursuit eye movement, sensory integration, right-left orientation, and other areas.[28][29] The clinical value of these findings is very limited. However, one study suggests the presence of primary motor coordination dysfunction on initial presentation may be associated with a more severe nonremitting course and may help identify patients who would benefit from early, more assertive treatment approaches.[30]
family history
Family history of schizophrenia is commonly seen. The risk of a patient developing schizophrenia and schizoaffective disorder is directly related to the disease presence in his or her family.
functional impairment
Social and occupational functioning is commonly impaired; however, this is not a defining criterion for schizoaffective disorder. These impairments may be less severe and persistent than in schizophrenia.[31]
uncommon
disorders of behavior
Disorders of behavior include mannerisms (goal-directed behavior carried out in a stilted fashion), stereotypies (uniformly repetitive movements), parakinesis (e.g., grimacing, twitching, and jerking), echopraxia (repetition of a movement seen in others), automatic obedience (automatic execution of directions), and waxy flexibility (ability to maintain imposed positions for long periods of time).
Catatonia can be seen with psychomotor agitation or retardation. Catatonic stupor is associated with a decreased response to surroundings, immobility, and (in its most severe form) mutism. Catatonic rigidity refers to immobility and a resistance to movement. Catatonic negativism is when a patient refuses all instructions, and catatonic excitement is when a patient exhibits an overall increase in motor activity not in response to the outside environment.
Risk factors
strong
family history of schizophrenia
The likelihood of a person developing schizoaffective disorder if there is a family history of schizophrenia is correlated with the closeness of the relationship.
substance use
weak
age of the father at patient's birth
Evidence suggests that if the father is over 35 years old or under 20 years old, there is an increased incidence of schizophrenia in offspring.[15] This correlation is present only in patients without a family history of schizophrenia. This is likely to apply to schizoaffective disorder as well.
psychological stress
Evidence suggests a link between psychological stressors and the onset of schizoaffective disorder.[16]
environment
Abuse in childhood is one of the most studied factors but the outcome of these studies with regards to an association between abuse and schizoaffective disorder is inconclusive.[17]
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