Schizoaffective?

[LadyHalcyon]

I am completing my pre-doctoral internship and one of my sites is a CMHC for clients diagnosed with an SMI. What I have noticed is that approximately 80% of my patients have a diagnosis of schizoaffective (usually with the add-on "bipolar type" ). Furthermore, they are being treated with antipsychotics by the psychiatrists. After working with these patients, I am starting to question this diagnosis. At my particular site, it seems anyone who reports AVH's receives this diagnosis. From my perspective, many times these patients either have severe PTSD, borderline, bipolar, or schizophrenia. I have encountered numerous patients who experience auditory hallucinations from ptsd and/or BPD; same for clients experiencing a manic episode. I was just wondering what people thought about schizoaffective as a diagnosis? I know the DSM criteria, but from a clinical standpoint, when/if are you more prone to diagnose schizoaffective rather than the other aforementioned diagnoses? One of my clients has severe BPD and has been experiencing auditory hallucinations since childhood. She is being prescribed abilify and the psychiatrist recently added Haldol because "the voices" were still present. This client is 350lbs and I worry about metabolic syndrome and EPS. I would appreciate any thoughts on the matter.

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[DisorderedDoc417]

I am completing my pre-doctoral internship and one of my sites is a CMHC for clients diagnosed with an SMI. What I have noticed is that approximately 80% of my patients have a diagnosis of schizoaffective (usually with the add-on "bipolar type" ). Furthermore, they are being treated with antipsychotics by the psychiatrists. After working with these patients, I am starting to question this diagnosis. At my particular site, it seems anyone who reports AVH's receives this diagnosis. From my perspective, many times these patients either have severe PTSD, borderline, bipolar, or schizophrenia. I have encountered numerous patients who experience auditory hallucinations from ptsd and/or BPD; same for clients experiencing a manic episode. I was just wondering what people thought about schizoaffective as a diagnosis? I know the DSM criteria, but from a clinical standpoint, when/if are you more prone to diagnose schizoaffective rather than the other aforementioned diagnoses? One of my clients has severe BPD and has been experiencing auditory hallucinations since childhood. She is being prescribed abilify and the psychiatrist recently added Haldol because "the voices" were still present. This client is 350lbs and I worry about metabolic syndrome and EPS. I would appreciate any thoughts on the matter.

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Would be nice to have that blood test, wouldn’t it. That way when borderlines drone on about the shadow figures and the eery out of body sensation they get when their 6th abusive relationship this week goes awry... they still get DBT and not Haldol... or trileptal, or whatever other thing people enjoy putting on borderlines med lists these days. Watch out for super duper ultra rapid cycling borderpolar disorder. That one is a doozy!

 

[st2205]

People really fitting the criteria is very rare in my experience. There’s not really any shortage of people convincing themselves that someone meets criteria, though. When I see “schizoaffective disorder” my suspicion and concern for a psychotic disorder significantly drops. Typically bad axis II coupled with very poor functioning, sometimes substance abuse, and not infrequently both.

 

[LadyHalcyon]

Would be nice to have that blood test, wouldn’t it. That way when borderlines drone on about the shadow figures and the eery out of body sensation they get when their 6th abusive relationship this week goes awry... they still get DBT and not Haldol... or trileptal, or whatever other thing people enjoy putting on borderlines med lists these days. Watch out for super duper ultra rapid cycling borderpolar disorder. That one is a doozy!

My favorite are the borderline clients who have been diagnosed with bipolar because they have extreme mood shifts that occur within the span of 20minutes....

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[LadyHalcyon]

People really fitting the criteria is very rare in my experience. There’s not really any shortage of people convincing themselves that someone meets criteria, though. When I see “schizoaffective disorder” my suspicion and concern for a psychotic disorder significantly drops. Typically bad axis II coupled with very poor functioning, sometimes substance abuse, and not infrequently both.

Yes. This has been my experience, albeit limited

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[DisorderedDoc417]

My favorite are the borderline clients who have been diagnosed with bipolar because they have extreme mood shifts that occur within the span of 20minutes....

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Yeah the super duper ultra rapid cycling. Dead giveaway. Very tough to treat, but vyvanse and clonazepam are a good start.

 

[LadyHalcyon]

Yeah the super duper ultra rapid cycling. Dead giveaway. Very tough to treat, but vyvanse and clonazepam are a good start.

Obviously. Except my clients prefer Adderall and Xanax, lol

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[DisorderedDoc417]

Obviously. Except my clients prefer Adderall and Xanax, lol

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Clonazepam for the basal crazy and sliding scale prn Xanax for the peaks. It’s a lot like treating diabetes. Just convert the Xanax to basal dosing if consistently needing extra.

 

[LadyHalcyon]

Clonazepam for the basal crazy and sliding scale prn Xanax for the peaks. It’s a lot like treating diabetes. Just convert the Xanax to basal dosing if consistently needing extra.

I had a client, a convicted pedophile, tell me the other day that he hears voices but has learned how to ignore them. He says antipsychotics don't work for him BUT the 4mg of Xanax his Pcp prescribes does the trick.

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[splik]

You are spot on. most patients with a schizoaffective disorder diagnosis have borderline personality disorder, +/- substance abuse. It should actually be a rare diagnosis. According to the DSM, 1 in 500 people have schizoaffective disorder, but you wouldn't know it by the way its dropped around in patient charts. there are people who do meet criteria for this diagnosis but they are few and far between. many people with bipolar disorder who have non-affective psychotic episodes get labeled with schizoaffective d/o too, because our diagnostic nomenclature does not allow for patients to have both bipolar and schizophrenia which would otherwise be more common that we want to admit.

In general "voices" in BPD are a transitory phenomenon that occurs in the context of interpersonal abandonment and often related to that. It may be associated with paranoid ideation. This phenomenon can also occur as a result of intensive psychotherapy/psychoanalysis in these patients. Narcissistic patients can also experiences "voices" in the context of significant narcissistic injury or failure.

Patients with PTSD can experience auditory hallucinations and visual hallucinations. This is sometimes called "traumatic hallucinosis". The hallucinations differ in content in that they are trauma-related.

we should also remember voices are very common in the general population and most of these people don't seek treatment. When they do, the voices may or may not be relevant. voices in personality disorder and PTSD represent dissociative phenomena. In psychosis they do not and are qualitatively different from dissociative experiences.

 

[LadyHalcyon]

You are spot on. most patients with a schizoaffective disorder diagnosis have borderline personality disorder, +/- substance abuse. It should actually be a rare diagnosis. According to the DSM, 1 in 500 people have schizoaffective disorder, but you wouldn't know it by the way its dropped around in patient charts. there are people who do meet criteria for this diagnosis but they are few and far between. many people with bipolar disorder who have non-affective psychotic episodes get labeled with schizoaffective d/o too, because our diagnostic nomenclature does not allow for patients to have both bipolar and schizophrenia which would otherwise be more common that we want to admit.

In general "voices" in BPD are a transitory phenomenon that occurs in the context of interpersonal abandonment and often related to that. It may be associated with paranoid ideation. This phenomenon can also occur as a result of intensive psychotherapy/psychoanalysis in these patients. Narcissistic patients can also experiences "voices" in the context of significant narcissistic injury or failure.

Patients with PTSD can experience auditory hallucinations and visual hallucinations. This is sometimes called "traumatic hallucinosis". The hallucinations differ in content in that they are trauma-related.

we should also remember voices are very common in the general population and most of these people don't seek treatment. When they do, the voices may or may not be relevant. voices in personality disorder and PTSD represent dissociative phenomena. In psychosis they do not and are qualitatively different from dissociative experiences.

Thank you. This was very helpful

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[Daedra22]

many people with bipolar disorder who have non-affective psychotic episodes get labeled with schizoaffective d/o too, because our diagnostic nomenclature does not allow for patients to have both bipolar and schizophrenia which would otherwise be more common that we want to admit.

I found this thread interesting because what splik describes here (essentially bipolar + schizophrenia) is more consistent with what I see labeled as "schizoaffective" in my area. We have the occasional person where it means more BPD/complex trauma, but I'd say the vast majority of the time someone has a problem list that starts with bipolar I disorder, then schizophrenia, and then someone comes along and adds schizoaffective; all three diagnoses then hang out in the EMR until the end of time (so it seems).

I think the bottom line is that the diagnosis of "schizoaffective" is interpreted abstractly even though the criteria are quite specific - so specific, in fact, that I rarely meet patients with psychosis on inpatient units able to give enough of a detailed history to establish this diagnosis.

 

[smalltownpsych]

Both of the Psych NPs in this town diagnose patients with schizoaffective on a daily basis. Incidence rate for a clinical sample seems to be about one in five. I don’t think I have ever really met a patient with schizoaffective disorder unless I just thought of them as a run of the mill patient with schizophrenia who was depressed too or maybe I just attributed all of their manic energy to Bipolar Disorder or the manic energy associated with uncontrolled psychosis. One day I am sure I will evaluate a patient and I will say “aha! You really do meet criteria for schizoaffective.” It has happened to me before with less common disorders that are commonly overdiagnosed and I suspected might not even be valid constructs. I still question if they are useful constructs whether clinically or in research. Another question I would have is whether some of the overdiagnosing could be driven by a drug getting FDA approval for schizoaffective and thus a promotional campaign?

 

[thoffen]

There are people with real manic episodes on a baseline that is indistinguishable from schizophrenia. And of course SCAD is a convenient diagnosis for the lazy clinician. I think part of the problem is an attitude that things must be one thing or another, that we must fit all of their pathology into a DSM diagnosis and not necessarily a unifying one. As pointed out, hallucinations certainly exist within the normal spectrum, but even if symptoms are definitely pathologic, they don't have to fit the illness categories DSM provides. That's why they have "other specified" diagnoses. They are way underutilized.

 

[hamstergang]

many people with bipolar disorder who have non-affective psychotic episodes get labeled with schizoaffective d/o too, because our diagnostic nomenclature does not allow for patients to have both bipolar and schizophrenia

I thought you could have both bipolar and schizophrenia. Are they actually exclusionary criteria for the other?

 

[NickNaylor]

The other thing to consider is the role of “the system” in this phenomenon. You said that the clinical site you’re working at is for SMI patients only - I’m assuming that means MDD, bipolar disorder, schizophrenia, and schizoaffective disorder. Thus, if you do not carry one of those diagnoses, you are unable to get services there (I presume). Our local community MH system operates under identical rules; to no one’s surprise, diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder get handed out like candy when, in reality, the operating diagnoses really should be substance-related issues or axis II pathology. However, if these diagnoses are used, the patient is then disqualified from receiving services and, at least in our area, they have no other place to go. As an example, someone with debilitating anxiety with no other complaints would simply be unable to be seen in this system because the care isn’t reimbursed. Thus, they may be diagnosed with schizophrenia if they endorse occasional AH or anything resembling a potential symptom of psychosis, even though it’s abdundantly clear that they don’t have schizophrenia. This diagnosis then follows them around everywhere, and, perhaps worse, the patient is told that this is their diagnosis, thus they pass that along to all of their future providers.

You’re right to be skeptical. There are a lot of incentives to shove people into one of these diagnostic categories, even if inaccurate, and not very many incentives to diagnose them appropriately and refer them to appropriate treatment (which may or may not be available in reality).

 

[st2205]

The other thing to consider is the role of “the system” in this phenomenon. You said that the clinical site you’re working at is for SMI patients only - I’m assuming that means MDD, bipolar disorder, schizophrenia, and schizoaffective disorder. Thus, if you do not carry one of those diagnoses, you are unable to get services there (I presume). Our local community MH system operates under identical rules; to no one’s surprise, diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder get handed out like candy when, in reality, the operating diagnoses really should be substance-related issues or axis II pathology. However, if these diagnoses are used, the patient is then disqualified from receiving services and, at least in our area, they have no other place to go. As an example, someone with debilitating anxiety with no other complaints would simply be unable to be seen in this system because the care isn’t reimbursed. Thus, they may be diagnosed with schizophrenia if they endorse occasional AH or anything resembling a potential symptom of psychosis, even though it’s abdundantly clear that they don’t have schizophrenia. This diagnosis then follows them around everywhere, and, perhaps worse, the patient is told that this is their diagnosis, thus they pass that along to all of their future providers.

You’re right to be skeptical. There are a lot of incentives to shove people into one of these diagnostic categories, even if inaccurate, and not very many incentives to diagnose them appropriately and refer them to appropriate treatment (which may or may not be available in reality).

I assume you’re speaking of Texas but what I think is under utilized as criteria for care is a “GAF under 50,” which I think is a BS number anyway but much more appropriate to label someone MDD than BPD or, worse, SAD or schizophrenia.

 

[uname943]

The other thing to consider is the role of “the system” in this phenomenon. You said that the clinical site you’re working at is for SMI patients only - I’m assuming that means MDD, bipolar disorder, schizophrenia, and schizoaffective disorder. Thus, if you do not carry one of those diagnoses, you are unable to get services there (I presume). Our local community MH system operates under identical rules; to no one’s surprise, diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder get handed out like candy when, in reality, the operating diagnoses really should be substance-related issues or axis II pathology. However, if these diagnoses are used, the patient is then disqualified from receiving services and, at least in our area, they have no other place to go. As an example, someone with debilitating anxiety with no other complaints would simply be unable to be seen in this system because the care isn’t reimbursed. Thus, they may be diagnosed with schizophrenia if they endorse occasional AH or anything resembling a potential symptom of psychosis, even though it’s abdundantly clear that they don’t have schizophrenia. This diagnosis then follows them around everywhere, and, perhaps worse, the patient is told that this is their diagnosis, thus they pass that along to all of their future providers.

You’re right to be skeptical. There are a lot of incentives to shove people into one of these diagnostic categories, even if inaccurate, and not very many incentives to diagnose them appropriately and refer them to appropriate treatment (which may or may not be available in reality).

Good point. I used to work for a safety net clinic that would treat only patients with Axis I diagnoses. I felt so dirty writing down "unspecified mood disorder" for all the many patients whom I could only identify substance use or personality disorder. It made it such a toxic work environment.

 

[deleted736562]

Unfortunately for some doctors out there, schizoaffective is really schizo(and/or)affective, which kinda covers all of psychiatry. It's a dumping ground diagnosis. DSM criteria have been actually made even more stringent than before because of the poor reliability of the diagnosis. To meet criteria, more than 50% of psychotic episodes have to be accompanied by, not only "mood symptoms", but a frank manic or depressive episode, aside from the two weeks of psychosis without affective symptoms. It's hard enough to get that sort of accurate history, nevermind finding someone who actually meets these criteria.

Nonetheless, the diagnosis itself remains very questionable and has very little utility. Granted there are patients who are frankly psychotic and also have frank disruptions in mood regulation, and these tend to be very sick, old and chronically psychotic patients from my experience. Of course the point of the dx in itself is that patients tend to have better prognosis than pts with schizophrenia, but the data on that is very questionable.

 

[thoffen]

I think it's a big problem that the DSM doesn't really have a solution within the diagnostic criteria for people who present with psychotic symptoms related to a character disorder that go far beyond "transient, stress-related paranoid ideation or severe dissociative symptoms" or mood symptoms which go beyond "affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days". I suppose it would be most appropriate to dx borderline PD (and PTSD, substace abuse issues, etc.) and also "Other specified psychotic disorder" or "Other specified depressive/bipolar&related disorder" when SCZ/SCAD & BPAD/MDD are not good fits. I'm not sure very many people even think to use the "other specified" diagnoses.

 

[Liquid8]

Honestly haven’t seen many Schizoaffective patients seen since leaving the public system, and even back then most of those were chronic patients and it wasn’t always clear who made the diagnosis.

When I have seen patients with both psychotic and affective symptoms, I don't usually think about Schizoaffectiv disorder initially. Longitudinally I have found that other diagnoses are likely to better explain a patient’s presentation: usually drugs, personality, depression with secondary psychotic features, or post psychotic depression states.

I think it just comes down to sifting through the phenomenology – there are distinct differences between your Borderlines/DID type voices vs true psychosis, although this isn’t to say a BPD patients can’t sometimes present with true psychotic symptoms either. The borderlines I see now who present with pseudo-psychotic symptoms tend to be relieved to know that medications are not necessary, but I know that I’m probably dealing with the more functional or insightful ones; as opposed to the ones who will develop a sudden increases in “voices” as a means to resist discharge after a short crisis admission.

With drugs, I think it’s about asking the question. In the last few years I have only had one patient who I thought could have met Schizoaffective criteria but as time has gone by it has become apparent that he’s not particularly truthful about his recreational drug use. Now I see him with his parents, and they’ll say he’s told them he hasn’t used anything – but he’ll now admit to smoking ice or weed etc. when asked directly, and the timing fits with the relapses.

I had a client, a convicted pedophile, tell me the other day that he hears voices but has learned how to ignore them. He says antipsychotics don't work for him BUT the 4mg of Xanax his Pcp prescribes does the trick.

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Have had one of these forensic types too. Had psychotic symptoms apparently so severe that clozapine was ineffective, yet xanax worked fine. Ran a mile when I offered him ECT.