Schizoaffective Disorder

Treatment


Phillip W. Long, M.D.
1990

Contents


Medical Treatment

Basic Principles

Both drug and psychosocial therapies are necessary to successfully treat schizoaffective disorder. Because of the unemployment, poverty, and homelessness that often complicates schizoaffective disorder, drug therapy alone usually is insufficient. Drug therapy usually can stop the patient's psychosis, but often only social and occupational rehabilitation therapies can overcome the associated unemployment, poverty and homelessness. Recovering from schizoaffective disorder is an extremely lonely experience, and these patients require all the support that their families, friends, and communities can provide.

Schizoaffective disorder appears to be a combination of a thought disorder, mood disorder, and anxiety disorder. Thus the medical management of schizoaffective disorder oftens requires a combination of antipsychotic, antidepressant, and antianxiety medication. Unfortunately, after the first year of treatment, only a minority of schizoaffective outpatients remain on their oral medications. Thus long-acting, depot antipsychotic medications that last 2-4 weeks between injections (e.g., depot haloperidol, pipotiazine, or fluphenazine) usually are required to overcome this noncompliance problem.

Hospitalization

Treatment of an acutely psychotic patient often requires psychiatric hospitalization. The presence of adequate family or social supports will often shorten the length of this hospitalization, or permit the psychotic patient to be treated solely on an outpatient basis.

Antipsychotic Drugs

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.

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.

2. Akathisia:
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).

3. Parkinsonism:
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 interfer 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 Lethary:
Many patients on antipsychotic drugs sleep 12-14 hours per day and develop marked lethary. 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.

"Drug Holidays" From Antipsychotic Drugs

It was once thought that patients should take a "drug holiday" by periodically stopping their antipsychotic drugs for a few weeks every year. This practice is no longer recommended. Research has shown that these "drug holidays" increase the risk of relapse of schizoaffective disorder, as well as increase the risk of tardive dyskinesia.

Antidepressant Drugs

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.

Antianxiety Drugs

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.

When Not To Use Antipsychotic Drugs

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.

Lithium

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.

Anticonvulsants

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.

Other Drugs

The use of megavitamins and special diets have apparently little or no effect for schizoaffective patients.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) has been used effectively in small percentage of schizoaffective patients, particularly those of the catatonic subtype. Patients with an illness duration of less than 1 year are most responsive. This therapy offers little hope for lasting improvement in chronic schizoaffective patients.

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Psychosocial Treatment

Basic Principles

Untreated schizoaffective disorder will often leave a patient friendless, penniless, and homeless. Thus circumstances often force schizophenic patients to rely heavily on their family or psychiatric group homes. There is frequently an inverse relationship between the stability of their living situation and the amount of antipsychotic drugs they require.

Supportive Psychotherapy

Traditional insight-oriented psychotherapy is not recommended in treating schizoaffective patients, whose egos are too fragile. Supportive therapy, which may include advice, reassurance, education, modeling, limit setting, and reality testing, is generally the therapy of choice.

Psychotherapy can have toxic effects, especially when there is a negative transference. One of the toxic effects of psychotherapy is dependency. A pushing, intrusive approach may make withdrawn patients worse.

Group Therapy

Group therapy, combined with drugs, produces somewhat better results than drug treatment alone, particularly with schizoaffective outpatients. Positive results are more likely to be obtained when group therapy focuses on real-life plans, problems, and relationships; on social and work roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on some practical recreational or work activity. This supportive group therapy can be especially helpful in decreasing social isolation and increasing reality testing.

Family Therapy

Family therapy can significantly decrease relapse rates for the schizoaffective family member. In high-stress families, schizophenic patients given standard aftercare relapse 50-60% of the time in the first year out of hospital. Supportive family therapy can reduce this relapse rate to below 10 percent. This therapy encourages the family to convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem, to list and consider alternative solutions, and to select and implement the consensual best solution. Self-Help groups in which family members of schizoaffective patients discuss and share issues, have been particularly helpful in this regard.

Behavior Therapy

Behavior therapy in hospital often involves rewarding desired behaviors with specific privileges, such as ground privileges or weekend passes.

When the schizoaffective patient is no longer floridly psychotic or distractible, behavior therapy usually can successfully teach much needed social and occupational skills.

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Internet Mental Health (www.mentalhealth.com) copyright 1995-2011 by Phillip W. Long, M.D.