Major Depressive Order

Schizoaffective disorder is a psychosis characterized by both affective (mood disorder) and schizophrenic (thought disorder) symptoms, with substantial loss of occupational and social functioning. Since this disorder is a mixture of two disorders thought to have different biochemical origins, schizoaffective disorder is somewhat of a puzzle to many clinicians. Affective disorders cause people to be extremely elated or depressed, and schizophrenia is expressed as positive, negative, or disorganized symptoms. The fact that patients with affective disorders can experience positive and negative symptoms, plus the fact that patients with schizophrenia experience mood changes, partially explains the difficulty in diagnosis (Keltner, Schwecke and Bostrom, 2003). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV TR), the diagnostic criteria for schizoaffective disorder include an uninterrupted period of illness during which, at some time, there is either, a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.

Criteria for Manic Episode includes a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). During the period of mood disturbance, at least three of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

Ð'* Inflated self-esteem or grandiosity

Ð'* Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

Ð'* More talkative than usual or pressure to keep talking

Ð'* Insomnia or hypersomnia nearly every day

Ð'* Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

Ð'* Flight of ideas or subjective experience that thoughts are racing

Ð'* Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

Ð'* Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

Ð'* Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) (DSM IV Ð'- TR)

Patients with schizoaffective disorder will experience schizophrenic symptoms such as

delusions or hallucinations in the absence of a prominent mood disturbance, but symptoms of a mood disorder will be present for a significant period. Substance abuse or a general medical condition must be ruled out before this diagnosis can be made. Schizoaffective disorder seems to occur more often in females than it does in males and may be partially accounted for by the differences in brain lateralization between men and women (Keltner, Schwecke and Bostrom, 2003).

The cause of schizoaffective disorder is still uncertain. It is unlikely that a single factor can be implicated in the etiology. The disease could result from a combination of influences including biological, psychological, and environmental factors.

The treatment of schizoaffective disorder is a combination of drug and psychosocial therapies. Because of the social barriers, such as unemployment, poverty, and homelessness that often complicate schizoaffective disorder, drug therapy alone is usually insufficient. Behavioral therapy, group therapy, and family therapy should also be included in the treatment process. Drug therapy can often stop the patient's psychosis, but generally only social and occupational rehabilitation therapies can overcome the aforementioned social barriers. Recovering from this disorder is an extremely lonely experience. Therefore, these patients require all the support that their families, friends, and communities can provide.

Because schizoaffective disorder is a combination of thought disorder, mood disorder, and anxiety disorder, the medical management of schizoaffective disorder often requires a combination of antipsychotic, antidepressant, and anti-anxiety medications. Treatment of an acutely psychotic patient often requires psychiatric hospitalization (Townsend, 2005).

If a person is in a psychotic state, an antipsychotic drug is most often used, since antidepressants and lithium take several weeks to start working. Antipsychotic drugs may cause tardive dyskinesia, a serious and sometimes irreversible disorder of body movement, so people are asked to take them for long periods only when there is no other alternative. After the psychosis has ended, the mood symptoms may be treated with antidepressants, anticonvulsants, or electroconvulsive therapy (ECT). Sometimes a neuroleptic is combined with lithium or an antidepressant and then gradually withdrawn. The few studies on drug treatment of this disorder suggest that antipsychotic drugs are most effective. The greater effectiveness of these new drugs may be partly due to their activity at receptors for the neurotransmitter serotonin, which is not influenced as strongly by standard antipsychotic drugs (NMHA).

Identifying Data

J.T., a twenty-seven year old African American female, was admitted to Highlands Hospital on January 31, 2006. She was diagnosed with schizoaffective disorder with mania and polysubstance abuse.

J.T. is originally from Trinidad, which is the southernmost island in the Caribbean. Her grandmother, parents, two brothers, and sister all live in Trinidad. She has a nine year old son who lives in New York with his biological father, an ex-boyfriend. The client also talks about an abusive ex-husband and her ex-mother-in-law.

One thing that J.T. values is prayer. She is catholic and attends St. Pauls, A.M.E. Church in Uniontown. She believes that through prayer, her faith prevented her from becoming an alcoholic. She has even gone so far as to volunteer at the church.

J.T. is currently unemployed and does not have a valid Green Card. She realizes that this will make finding employment difficult. She attended high school in Manhattan but did not graduate, however she did obtain her General Educational Development (GED).

Chief Complaint

There are no previous records on file for J.T. at Highlands Hospital. Nonetheless, at the age of 14 or 15 she attempted suicide by drinking Clorox. The