I’ve gotten a lot of hits on this blog searching for the difference between schizoaffective disorder and schizophrenia. It’s an important question for not a few reasons. It’s an even more important reason if you’re the caregiver. Grace’s exact diagnosis is schizoaffective disorder-bipolar type. When she’s stable, that means that the mood component of her diagnosis is relatively under control. She does, however, hallucinate almost daily, and we do deal with a certain level of paranoia almost every day. Grace experiences sundowning which means that as the evening comes her symptoms worsen. Last night, for example, at 6:45 PM, her speech was disorganized; she was fearful to sleep in her room. She was stumbling around the house and mumbling to herself about something I couldn’t understand. I saw her swatting at the air. For Grace, this is actually pretty decent symptom management. We wouldn’t have any sleepovers when she’s like this, but this is the reality of managing psychosis in a young person who experienced the onset of this disease at 10 years-old. Overall, I am looking for insight. Does Grace know that what she sees isn’t real? Yes. Does Grace know that her fear is a product of her brain misfiring? That’s a bit harder actually. Lately, she’s been waking up around 4 AM and lying in bed paralyzed with fear until morning. She’s too terrified to get out of bed and ask for help. There is a lack of insight into her fear. We are working on this.
What I’ve described is the “shizo-” part of schizoaffective disorder. In Grace’s case, however, she truly has almost all the symptoms of schizophrenia including the cognitive symptoms. The “-affective” part of schizoaffective disorder refers to either mania, depression or a mixed state. In Grace’s case, she has experienced all three while experiencing psychosis. I would say that it was frightening, but it was also just plain weird. She presented as an adult in her bipolar symptomatology with four weeks of severe depression, one transition week characterized by intense migraine-like headaches, and two weeks of mania. This was a predictable cycle. Attached to this was psychosis complete with positive, negative, and cognitive symptoms. During her mixed states, we battled suicidal ideation.
Some clinicians believe that schizoaffective disorder is really just a form of schizophrenia. Some don’t know what to make of it. Some clinicians believe it to be on the bipolar spectrum. Here’s what I know from the literature. If a person had psychotic symptoms prior to the emergence of affective symptoms, then you are most likely looking at a schizophreniform diagnosis. Grace has hallucinated for most of her life. The affective symptoms didn’t show up until she was ten years-old. This places her on the schizophrenia spectrum rather than the bipolar spectrum. What does it matter since she would be clinically treated the same? It matters because schizophreniform diseases tend to progress, and a child must be cared for very specifically if they fall on the schizophrenia spectrum. Bipolar disorder tends not to progress. In schizophrenia, the brain atrophies. The brain, on average, loses 5% of its mass, and there is an aggressive form of schizophrenia wherein patients can lose up to 20%. Most people will lose that 5% in the first five years after the prodromal phase of the disease. The interesting part of dealing with something like schizoaffective disorder in children is that there is no way of knowing which way a child will go until they reach about 18.
Grace is being closely watched for the development of pure schizophrenia as well as for how her current symptoms progress. There are a few things that often determine prognosis. If you have a family history of schizophrenia (Grace’s great-grandfather), maternal prenatal complications (check), and an early age of onset, then oftentimes the prognostication isn’t promising. So far, Grace is doing as well as I could ever imagine in terms of her own personal level of hope for her future, but her brain is being ravaged. She is not the same girl she was three years ago. Not by a long shot. Her biggest accomplishment this month is that she learned to unload the dishwasher. This might sound odd that a 13 year-old girl just learned to do this task, but Grace’s executive function skills are so impaired now that unloading the dishwasher was, for her, like reaching the top of Mt. Everest. She was very proud.
For one of the best discussions on the differences between schizoaffective disorder and schizophrenia, please read the following article complete with slide deck. You’ll see just how nuanced the issue really is and what a pain in the ass these nuances are for the cream of the crop in the mental health field.