Table of Contents Introduction
Schizoaffective disorder is best treated with both psychotherapy and appropriate medication. This disorder largely consists of both a thought disorder and a mood disorder. This combination can make treatment especially difficult, because the individual can be very depressed and suicidal, but refuse to take medication because of an irrational fear or paranoia (a symptom of the thought disorder). Treatment of someone with this disorder is often challenging and rarely boring for the treatment team.
Because of the complications experienced in this disorder, a patient can often be homeless, near or in poverty, on welfare, unemployed, and with little to no family or general social support. This suggests that a treatment approach which is holistic and touches about the psychological, social, and biological aspect of this disorder will be most effective. Compiling an energetic treatment team of a psychologist, social worker, and psychiatrist who can work together to help the individual will likely be the most effective. Often, because of the need for stability in the patient's life, the individual will be involved in a day treatment program rather than individual psychotherapy. Recovery from this disorder is usually not the goal of treatment; rather, stable, long-term maintenance is. Medication compliance is far more likely in clients who have a good and stable social support and treatment network as opposed to those who do not.
Because who suffer from this disorder are often poor (due to chronic unemployment), they usually present for treatment at hospitals and community mental health centers. If there are no hospitals or centers willing or able to admit them, however, the client is left with only his family or few friends to use as support in his or her disorder. This can create an inordinate burden on the family and strain important relationships within the client's life. While certainly families can provide a certain level of support, they usually cannot attend to all of the daily needs of someone with this disorder.
The format of psychotherapy will usually be individual, because the individual suffering from this disorder is usually socially uncomfortable to be able to adequately tolerate group therapy. Supportive, client-centered, non-directive psychotherapy is a modality often used, because it offers the client a warm, positive, change-oriented environment in which to explore their own growth while feeling stable and secure. A problem-solving approach can also be very beneficial in helping the individual learn better problem-solving and daily coping skills. Therapy should be relatively concrete, focusing on day-to-day functioning. Relationship issues can also be raised, especially when such issues revolve around the patient's family. Certain behavioral techniques have also been found to be effective with people who have this disorder. Social skills and occupational skills training, for instance, can be very beneficial.
At some point in therapy, the family can be brought in for psychoeducational sessions and to learn how to predict when the patient is likely to deteriorate. Group therapy in inpatient settings tends to be more beneficial than in mixed outpatient groups. Group work in such a setting usually focuses on daily-living problems, general relationship issues, and other specific areas. For instance, discussion of occupational roles and future educational plans might occur.
Since the patient will often have many issues surrounding unemployment, disability, or welfare, a social worker is usually an important part of the treatment team. This professional can ensure the client doesn't fall between agency cracks and that he or she remains out of poverty.
Individuals who are suffering from an acute psychotic episode during this disorder usually require immediate hospitalization to stabilize them on an anti-psychotic medication. Sometimes such an individual presents at the emergency room in a confused or disordered state. Other times the patient may have resorted to alcohol to try and treat unwanted feelings, and show up to the E.R. disorganized and drunk. It is vitally important, therefore, for E.R. personnel to be aware of a patient's medical history in this case before treatment can be administered.
Individuals with schizoaffective disorder can easily deteriorate when social support has been removed from their lives, or they suffer any type of serious life stressor (such as an unexpected death, relationship loss, etc.). The individual can become severely depressed and decompensate rapidly. Clinicians should always be aware of this possibility and keep careful tabs on the patient if he or she has missed a regularly scheduled appointment.
Phillip W. Long, M.D. writes,
"Antipsychotic medications are the treatment of choice. Evidence to date suggests that all of the antipsychotic drugs (except clozapine) are similarly effective in treating psychoses, with the differences being in milligram potency and side effects. Clozapine (Clozaril) has been proven to be more effective than all other antipsychotic drugs, but its serious side-effects limit its use. Self-Help
Individual patients may respond to one drug better than another, and a history of a favorable response to treatment with a given drug in either the patient or a family member should lead to use of that particular drug as the drug of first choice. If the initial choice is not effective in 2-4 weeks, it is reasonable to try another antipsychotic drug with a different chemical structure.
Often an agitated, psychotic patient can be calmed in 1-2 days on antipsychotic drugs. Usually the psychosis gradually resolves only after 2-6 weeks of a high-dose antipsychotic drug regimen. A common error is to dramatically reduce antipsychotic drug dosage just as the patient improves or leaves hospital. This error almost guarantees a relapse. Major reduction in antipsychotic drug dosage should be avoided for at least 3-6 months after hospital discharge. Decreases in antipsychotic drug dosage should be done gradually. It takes at least 2 weeks for the body to reach a new equilibrium in antipsychotic drug level after a dose reduction.
Sometimes patients view the side-effects of the antipsychotic drugs as being worse than their original psychosis. Thus clinicians must be skillful in preventing these side-effects. Sometimes these side-effects can be removed by simply reducing the patient's antipsychotic drug dosage. Unfortunately, such reduction in drug dosage often causes patients to relapse back into psychosis. Therefore clinicians have no choice but to use the following treatments for these antipsychotic side-effects:
1. Acute Dystonic Reactions:
These reactions are of abrupt onset, sometimes bizarre, frightening muscular spasms mainly affecting the musculature of the head and neck. Sometimes the eyes go into spasm and roll back into the head. Such reactions usually take place within the first 24 to 48 hours after therapy has begun or, in a small number of cases, when dosage is increased. Males are more vulnerable to the reactions than females, and the young more so than the elderly. High doses are more likely to produce such effects. Although these reactions respond dramatically to the intramuscular injection of antihistamines or anti-parkinson agents, they are frightening and are best avoided by starting with lower antipsychotic drug dosages. Anti-parkinsonian drugs (e.g., benztropine, procyclidine) should be prescribed whenever antipsychotic drugs are started. Usually these anti-parkinsonian drugs can be safely stopped in 1-3 months.
Akathisia is experienced as an inability to sit or stand still, with a subjective feeling of anxiety. Beta-adrenergic antagonists (e.g., atenolol, propranolol) are the most effective treatment for akathisia. These beta-blockers usually can be safely stopped in 1-3 months. Akathisia may also respond benzodiazepines (e.g., clonazepam, lorazepam), or to anti-parkinson drugs (e.g., benztropine, procyclidine).
Akinesia, a key feature of parkinsonism, may be overlooked, but if the patient is asked to walk briskly for some 20 paces, diminution of the swing of the arms can be noted, as can loss of facial expression. These parkinsonian side-effects of antipsychotic drugs usually respond to the addition of an anti-parkinson drug (e.g., benztropine, procyclidine).
4. Tardive Dyskinesia:
Between 10 to 20 percent of patients receiving antipsychotic agents develop some degree of tardive dyskinesia. It is now known that many cases of tardive dyskinesia are reversible and that many cases do not progress. Early signs of tardive dyskinesia are mostly seen in the area of the face. Movements of the tongue inside the buccal cavity that consist of retraction of the tongue on its longitudinal axis or irregular rotation around the longitudinal axis, with frequent movements in lateral directions, are thought to be the earliest signs. Choreoathetoid movement of the fingers and toes may also be observed, as may respiratory dyskinesia associated with irregular breathing and, perhaps, grunting.
Tardive dyskinesia is thought to result from dopamine receptor supersensitivity following chronic receptor blockade by the antipsychotic agent. Anticholinergic drugs do not improve tardive dyskinesia and may make it worse. The recommended treatment of tardive dyskinesia is to lower the dosage of antipsychotic drugs and hope for gradual remission of the choreoathetoid movements. Increasing the dosage of an antipsychotic briefly masks the symptoms of tardive dyskinesia, but symptoms will reappear later as a reflection of the progression of receptor supersensitivity.
5. Neuroleptic Malignant Syndrome:
Antipsychotic agents potentiate anticholinergic drugs, and toxic psychosis may occur. This confusional state usually appears early in treatment and, more commonly, at night and in elderly patients. Withdrawal of the offending agents is the treatment of choice. Antipsychotic drugs often interfere with body temperature regulation. Therefore, in hot climates this situation may result in hyperthermia and in cold climates hypothermia.
The neuroleptic malignant syndrome is an exceedingly rare but potentially fatal condition characterized by parkinsonian-type rigidity, increased temperature, and altered consciousness. The syndrome is ill-defined and overlaps with hyperpyrexia, parkinsonism, and neuroleptic-induced catatonia. Coma may develop and result in rare terminal deaths. This syndrome is reported most often in young males, may appear suddenly, and usually lasts 5 to 10 days after cessation of neuroleptics. There is no treatment; therefore, early recognition and discontinuation of antipsychotic drugs, followed by supportive therapy, are indicated.
6. Hypersomnia And Lethargy:
Many patients on antipsychotic drugs sleep 12-14 hours per day and develop marked lethargy. Often these side-effects disappear when treated with the newer serotonergic antidepressants (e.g., fluoxetine, trazodone). These antidepressants usually are given for 6 or more months.
7. Other Side-Effects:
Depressed S-T segments, flattened T-waves, U-waves, and prolonged Q-T intervals may be caused by antipsychotic drugs. This situation is cause for concern, is more liable to occur with low potency agents, particularly thioridazine, and could increase vulnerability to arrhythmia.
It is not possible to say to what extent antipsychotic drugs are involved in sudden death. Serious reactions to antipsychotic drugs are rare. Photosensitivity reactions are most common with chlorpromazine; vulnerable patients should wear protective screens on their exposed skin.
Pigmentary retinopathy is associated with thioridazine and may impair vision if not detected. This complication occurred at dosages below the considered safe limit of 800 mg. Dosages of above 800 mg are, therefore, not recommended.
Antipsychotic agents may affect libido and may produce difficulty in achieving and maintaining erection. Inability to reach orgasm or ejaculation and retrograde ejaculation have been reported. Antipsychotics also may cause amenorrhea, lactation, hirsutism, and gynecomastia.
Weight gain may be more liable to occur with any antipsychotic drug which causes hypersomnia and lethargy. Studies suggest that many antipsychotic drugs taken during pregnancy do not result in fetal abnormalities. Because these agents reach the fetal circulation, they may affect the newborn, thus producing postnatal depression and also dystonic symptoms.
The older (tricyclic) antidepressants often worsen schizoaffective disorder. However, the newer (serotonergic) antidepressants (e.g., fluoxetine, trazodone) have dramatically benefited many apathetic or depressed schizoaffective patients.
Benzodiazepines (e.g., lorazepam, clonazepam) often can dramatically reduce the agitation and anxiety of schizoaffective patients. This is often especially true for those suffering from catatonic excitement or stupor. Clonazepam also is an effective treatment for akathisia.
Development of a Neuroleptic Malignant Syndrome is an absolute contraindiction to the use of antipsychotic drugs. Likewise, development of severe tardive dyskinesia is a contraindication to the use of all antipsychotic drugs, except clozapine (Clozaril) and reserpine.
If the patient does not respond to antipsychotic treatment alone, lithium may be added for 2 to 3 months on a trial basis. Combined lithium-antipsychotic drug therapy is helpful in a significant percentage of patients.
The addition of carbamazepine, clonazepam, or valproate to antipsychotic drug refractory schizoaffective patients has been reported to sometimes be effective. This benefit is more often seen in patients suffering from bipolar disorder. Acute psychotic agitation or catatonia often responds to clonazepam."
Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. However, support groups in which patients can participate, sometimes with family members, other times in a group with others who suffer from this same disorder, can be very helpful. Often these groups, like regular therapy groups, will focus on specific topics each week which will be of benefit to the client. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.
Patients can be encouraged to try out new coping skills and emotion regulation with people they meet within support groups. They can be an important part of expanding the individual's skill set and develop new social relationships with others.
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