Schizoaffective disorder is a mental health condition that includes features of both schizophrenia and a mood disorder such as bipolar disorder or depression. The prefix "schizo-" refers to the psychotic symptoms of schizophrenia that affect a person's thinking, sense of self, and perceptions. The term "-affective" refers to extreme shifts in mood, energy, and behavior.

Schizoaffective disorder has a wide range of signs and symptoms that make it challenging to diagnose. Its features overlap significantly with those of schizophrenia and bipolar disorder, and there is debate about whether schizoaffective disorder should be considered a separate diagnosis or a subtype of one of these other conditions.

Signs and symptoms of psychosis in people with schizoaffective disorder include false perceptions called hallucinations, such as hearing voices no one else can hear or experiencing visions, smells, or tactile (touch) sensations. Strongly held false beliefs (delusions) are also a characteristic feature. For example, affected individuals may be certain that they are a particular historical figure or that they are being plotted against or controlled by others.

There are two major types of schizoaffective disorder, based on which mood disorder is involved: the bipolar type and the depressive type. The bipolar type includes both dramatic "highs," called manic episodes, and "lows," called depressive episodes. The depressive type includes only depressive episodes. Manic episodes are characterized by increased energy and activity, irritability, restlessness, an inability to sleep, and reckless behavior. Depressive episodes are marked by low energy and activity, a feeling of hopelessness, and an inability to perform everyday tasks.

The psychosis and mood problems associated with schizoaffective disorder usually become evident in adolescence or young adulthood. People with this condition often have difficulty functioning at school, at work, and in social settings. Disordered thinking and concentration, inappropriate emotional responses, erratic speech and behavior, and difficulty with personal hygiene and everyday tasks are also common. People with schizoaffective disorder have a higher risk of substance abuse problems and dying by suicide than the general population.

Schizoaffective disorder is a major psychiatric disorder that is quite similar to schizophrenia. The disorder can affect all aspects of daily living, including work, social relationships, and self-care skills (such as grooming and hygiene). People with schizoaffective disorder can have a wide variety of different symptoms, including having unusual perceptual experiences (hallucinations) or beliefs others do not share (delusions), mood (such as marked depression), low motivation, inability to experience pleasure, and poor attention. The serious nature of the symptoms of schizoaffective disorder sometimes requires consumers to go to the hospital to get care. The experience of schizoaffective disorder can be described as similar to "dreaming when you are wide awake"; that is, it can be hard for the person with the disorder to distinguish between reality and fantasy.

What would it be like to hear voices or see people or things that aren’t really there? How would you feel if people seemed out to harm you, and you weren’t sure who to trust? Would you recognize that something was wrong?

Unfortunately, most people with schizophrenia are unaware that their symptoms are warning signs of a mental disorder. Their lives may be unraveling, yet they may believe that their experiences are normal. Or they may feel that they’re blessed or cursed with special insights that others can’t see.

Schizophrenia is a brain disorder that affects about 1 in 100 people. It affects men and women equally in all ethnic groups. Symptoms often start between ages 16 and 30 but most often between 18 and 22. It’s unusual to develop schizophrenia after age 45.

A few decades ago, researchers thought that schizophrenia was caused by inappropriate parenting. Now scientists recognize that a combination of genes and the environment are to blame.

“We know from studies of identical twins that when one twin has schizophrenia, the other twin has a 50% chance of having the disease, indicating that genes may account for half of the mechanisms involved in schizophrenia,” says Dr. José A. Apud, clinical director of the schizophrenia research program at NIH.

But since these twins are genetically the same, other factors must also contribute to schizophrenia. Some scientists have identified environmental factors that may play a role. But researchers don’t yet fully agree on whether or how these factors trigger the disease.

Several genes have been linked to schizophrenia. But each seems to have only a small effect on the chances of getting the disorder. “If we could understand the genes and mechanisms, we might be able to develop drugs that better target the disease,” says Apud.

Although schizophrenia has no cure, 2 main types of treatment can help. “The first line of treatment is always medication, especially antipsychotics,” says Apud. “Second, we use supportive types of psychotherapy and psychosocial treatments.” These can help with everyday living skills and possibly finding an appropriate job.

Patients often try different medications to see which work best. Some types of antipsychotics can cause weight gain, which can lead to diabetes or high cholesterol. Other types can cause a disorder where a person cannot control muscle movements. Despite these drawbacks, antipsychotics greatly improve the lives of most patients.

Problems arise when patients stop taking their medications, which is common. One NIH-funded study found that most patients stop taking antipsychotics within the first 18 months of treatment. “Because of problems with judgment and insight, they may not feel that they need treatment,” Apud says. “Side effects also play a major role in patients’ poor compliance with medications.”

People with schizophrenia often must rely on family or friends to get them into treatment. Caring for and supporting a family member with schizophrenia can be challenging. It may help to find a support group. Talking to others who care for people with schizophrenia may help your whole family.

Signs of Schizophrenia

• Hallucinations (seeing, hearing or feeling things that no one else can)
• Delusions (believing things that aren’t true)
• Thinking-related problems that make it hard to have a job or take care of yourself
• Lack of facial expression
• Talking very little or in a dull voice
• Inability to follow through with planned activities
• Trouble focusing or paying attention

Very little is known for certain about the genetics of schizoaffective disorder. Studies suggest that variations in many genes, each with a small effect, combine to increase the risk of developing the condition. There may also be genetic variations with larger effects in some affected individuals or families, but these variants are rare in the general population, and it is unclear which particular genes are involved.

The genes that have been studied as possible contributors to schizoaffective disorder have diverse functions in the brain. These genes include some that regulate the body's daily (circadian) rhythms, such as the sleep-wake cycle; others that help control the movement (migration) of nerve cells during brain development; and still others involved in sending and receiving chemical signals in the brain. In particular, several genes that have been associated with the risk of schizoaffective disorder provide instructions for making parts of a receptor for gamma-amino butyric acid (GABA), a chemical called a neurotransmitter that sends signals in the brain. GABA's primary role is to prevent the brain from being overloaded with too many signals.

Many of the genetic variations associated with schizoaffective disorder appear also to be involved in schizophrenia or bipolar disorder. Other variations seem to be specific to schizoaffective disorder. However, it is challenging to study the genetics of schizoaffective disorder because the disorder has such significant overlap with these other mental health conditions. In some studies, people with schizoaffective disorder are analyzed in the same group as those with schizophrenia or bipolar disorder, so it can be difficult to determine which genetic variations influence each of these specific diagnoses.

The inheritance pattern of schizoaffective disorder is unclear. Overall, the risk of developing this condition is greater for first-degree relatives of affected individuals (such as siblings or children) as compared to the general public. Many individuals with schizoaffective disorder also have relatives with depression, bipolar disorder, schizophrenia, or other mental health conditions. These disorders may run in families in part because they share some genetic risk factors with schizoaffective disorder.

Research with twins found that when a member of an identical twin pair has schizoaffective disorder, the risk that the co-twin will also develop the condition is about 40 percent. In nonidentical (fraternal) twins, the risk is lower, around 5 percent. Because identical twins are more genetically similar than nonidentical twins, this finding suggests that genetics plays an important role in schizoaffective disorder. However, the fact that the risk is much lower than 100 percent, even in identical twins, suggests that noninherited factors are also important causes of schizoaffective disorder.

The diagnosis of schizoaffective disorder requires that the person experience some decline in social functioning for at least a six-month period, such as problems with school or work, social relationships, or self-care. In addition, some other symptoms must be commonly present. The symptoms of schizoaffective disorder can be divided into five broad classes: positive symptoms, negative symptoms, symptoms of mania, symptoms of depression, and other symptoms. A person with schizoaffective disorder will usually have some (but not all) of the symptoms described below.

Positive Symptoms

Positive symptoms refer to thoughts, perceptions, and behaviors that are ordinarily absent in persons who are not diagnosed with schizophrenia or schizoaffective disorder, but are present in persons with schizoaffective disorder. These symptoms often vary over time in their severity, and may be absent for long periods in some persons.

Hallucinations. Hallucinations are "false perceptions"; that is, hearing, seeing, feeling, or smelling things that are not actually there. The most common type of hallucinations is auditory hallucinations. Individuals sometimes report hearing voices talking to them or about them, often saying insulting things, such as calling them names. These voices are usually heard through the ears and sound like other human voices.

Delusions. Delusions are "false beliefs"; that is, a belief which the person holds, but which others do not share. Some individuals have paranoid delusions, believing that they are not safe or others want to hurt them. Delusions of reference are common, in which the individual believes that something in the environment is referring to him or her when it is not (such as the television talking to the person). Delusions of control are beliefs that others can control one's actions. Individuals may hold these beliefs strongly and cannot usually be "talked out" of them.

Thinking Disturbances. This problem is reflected in a difficulty in communication. The individual talks in a manner that is difficult to follow. For example, the individual may jump from one topic to the next, stop in the middle of the sentence, make up new words, or simply be difficult to understand.

Negative Symptoms

Negative symptoms are the opposite of positive symptoms. They are the absence of thoughts, perceptions, or behaviors that are ordinarily present in people who are not diagnosed with schizophrenia or schizoaffective disorder. These symptoms can often persist for a long period of time, though with effort on the individual’s part they can often be improved. Many professionals think these symptoms reflect a sense of hopelessness about the future.

Blunted Affect. The expressiveness of the individual's face, voice tone, and gestures is less. However, this does not mean that the person is not reacting to his or her environment or having feelings.

Apathy. The individual does not feel motivated to pursue goals and activities. The individual may feel lethargic or sleepy, and have trouble following through on even simple plans. Individuals with apathy often have little sense of purpose in their lives and have few interests.

Anhedonia. The individual experiences little or no pleasure from activities that he or she used to enjoy or that others enjoy. For example, the person may not enjoy watching a sunset, going to the movies, or a close relationship with another person.

Poverty of Speech or Content of Speech. The individual says very little, or when he or she talks, there does not seem to be much information being conveyed. Sometimes conversing with the person with schizoaffective disorder can be very difficult.

Inattention. The individual has difficulty paying attention and is easily distracted. This can interfere with activities such as work, interacting with others, and personal care skills.

Symptoms of Mania

In general, the symptoms of mania involve an excess in behavioral activity, mood states (in particular, irritability or positive feelings), and self-esteem and confidence.

Euphoric or Expansive Mood. The individual's mood is abnormally elevated, such as extremely happy or excited (euphoria). The person may tend to talk more and with greater enthusiasm or emphasis on certain topics (expansiveness).

Irritability. The individual is easily angered or persistently irritable, especially when others seem to interfere with his or her plans or goals, however unrealistic they maybe.

Inflated Self-Esteem or Grandiosity. The individual is extremely self- confident and may be unrealistic about his or her abilities (grandiosity). For example, the individual may believe he or she is a brilliant artist or inventor, a wealthy person, a shrewd businessperson, or a healer when he or she has no special competence in these areas.

Decreased Need for Sleep. Only a few hours of sleep are needed each night (such as less than four hours) for the individual to feel rested.

Talkativeness. The individual talks excessively and may be difficult to interrupt. The individual may jump quickly from one topic to another (called flight of ideas), making it hard for others to understand.

Racing Thoughts. Thoughts come so rapidly that the individual finds it hard to keep up with them or express them.

Distractibility. The individual's attention is easily drawn to irrelevant stimuli, such as the sound of a car honking outside on the street.

Increased Goal-Directed Activity. A great deal of time is spent pursuing specific goals, at work, school, or sexually. Often these behaviors put the person at risk.

Excessive Involvement in Pleasurable Activities with High Potential for Negative Consequences. Common problem areas include spending sprees, sexual indiscretions, increased substance abuse, or making foolish business investments.

Symptoms of Depression

Depressive symptoms reflect the opposite end of the continuum of mood from manic symptoms, with a low mood and behavioral inactivity as the major features.

Depressed Mood. Mood is low most of the time, according to the person or significant others.

Diminished Interest or Pleasure. The individual has few interests and gets little pleasure from anything, including activities previously found enjoyable.

Change in Appetite and/or Weight. Loss of appetite (and weight) when not dieting, or increased appetite (and weight gain) are evident.

Change in Sleep Pattern. The individual may have difficulty falling asleep, staying asleep, or wake early in the morning and not be able to get back to sleep. Alternatively, the person may sleep excessively (such as over twelve hours per night), spending much of the day in bed.

Change in Activity Level. Decreased activity level is reflected by slowness and lethargy, both in terms of the individual's behavior and thought processes. Alternatively, the individual may feel agitated, "on edge," and restless.

Fatigue or Loss of Energy. The individual experiences fatigue throughout the day or there is a chronic feeling of loss of energy.

Feelings of Worthlessness, Hopelessness, Helplessness. Individuals may feel they are worthless as people, that there is no hope for improving their lives, or that there is no point in trying to improve their unhappy situation.

Inappropriate Guilt. Feelings of guilt may be present about events that the individual did not even do, such as a catastrophe, a crime, or an illness.

Recurrent Thoughts about Death. The individual thinks about death a great deal and may contemplate (or even attempt) suicide.

Decreased Concentration or Ability to Make Decisions. Significant decreases in the ability to concentrate make it difficult for the individual to pay attention to others or complete simple tasks. The individual may be quite indecisive about even minor things.

Other Symptoms

Individuals with schizoaffective disorder are prone to alcohol or drug abuse. Some individuals may use alcohol and drugs excessively either because of their disturbing symptoms, to experience pleasure, or when socializing with others.

Schizoaffective disorder can only be diagnosed by a clinical interview. The purpose of the interview is to determine whether the person has experienced specific "symptoms" of the disorder, and whether these symptoms have been present long enough to merit the diagnosis. In addition to conducting the interview, the diagnostician must also check to make sure the person is not experiencing any physical problems that could cause symptoms similar to schizoaffective disorder, such as a brain tumor or alcohol or drug abuse.

Schizoaffective disorder cannot be diagnosed with a blood test, X-ray, CAT-scan, or any other laboratory test. An interview is necessary to establish the diagnosis.

How Is Schizoaffective Disorder Distinguished from Schizophrenia and Affective (Mood) Disorders?

Many persons with a diagnosis of schizoaffective disorder have had, at a prior time, diagnoses of schizophrenia or bipolar disorder. Frequently, this previous diagnosis is revised to schizoaffective disorder when it becomes clear, over time, that the person experiences symptoms of mania or depression much of the time, but on other occasions has experienced psychotic symptoms such as hallucinations or delusions even when his or her mood is stable.

Many of the same methods used to treat schizophrenia are also effective for schizoaffective disorder. Antipsychotic medications are an effective treatment for schizoaffective disorder for most, but not all, persons with the disorder. These drugs are not a "cure" for the disorder, but they can reduce symptoms and prevent relapses among the majority of people with the disorder. Antidepressant medications and mood stabilizing medications (such as lithium) are occasionally used to treat affective symptoms (depressive or manic symptoms) in schizoaffective disorder.

Other important treatments include social skills training, vocational rehabilitation and supported employment, peer support, and intensive case management. Family therapy helps reduce stress in the family and teaches family members how to monitor the disorder. In addition, individual supportive counseling can help the person with the disorder learn to manage the disorder more successfully and obtain emotional support in coping with the distress resulting from the disorder. Individuals with schizoaffective disorder who work actively toward mental health recovery can positively affect the course of their illness and improve the quality of their lives. Family support for the individual’s recovery efforts can lend meaningful benefits.

The disorder usually begins in late adolescence or early adulthood, often between the ages of sixteen and thirty. The severity of symptoms usually varies over time, at times requiring hospitalization for treatment. The disorder is often life-long, although the symptoms tend to improve gradually over the person's life and many individuals who were diagnosed with the disorder when they were younger appear to have few or no symptoms from middle age on. With schizoaffective disorder, as with other major psychiatric illnesses, individuals can work to achieve their goals and live very full lives.

Studies suggest that schizoaffective disorder is less common than schizophrenia, bipolar disorder, or depression alone. However, because schizoaffective disorder can be difficult to differentiate from these other conditions, its prevalence is unknown. One study from Finland estimated that schizoaffective disorder affects 3 in 1,000 people.