Korean J Schizophr Res Vol. 15.

1, 2012

Schizoaffective Disorder
Andreas Marneros
Department of Psychiatry, Psychotherapy and Psychosomatics, Martin Luther University, Halle-Wittenberg, Germany

Schizoaffective disorders are a controversially discussed but existing nosological category describing an episodic condition
meeting the criteria of both schizophrenia and mood disorders and lying on a continuum between these two prototypes. Both
DSM-IV and ICD-10 classify them within the group of “schizophrenia, schizotypal and delusional disorders” with ICD-10 not
requiring the absence of mood symptoms for a certain time. Cross-sectionally, schizoaffective disorder can be subdivided into
schizodepressive, schizomanic and mixed types. In a longitudinal way, unipolar and bipolar types are distinguished. The division
into schizo-dominated and mood dominated types is based on the severity and dominance of the schizophreniform symptomatol-
ogy and implies significant consequences for treatment and prognosis. In addition, concurrent types should be differentiated
from sequential types. Schizoaffective disorder is not rare; lifetime prevalence is estimated at 0.3%. About one third of all psy-
chotic patients suffer from schizoaffective disorder. About two thirds of the patients do not only have schizoaffective episodes
but also pure schizophreniform or mood episodes or episodes of acute and transient psychotic disorder. In more than 50% of the
patients, symptoms remit more or less completely. The others suffer from light, moderate or severe residual states, which might
affect their social adaptation. The suicide rate in schizoaffective disorder is about 12%. The treatment of schizoaffective disorder
primarily is a combination of antipsychotics and mood stabilizers or antidepressants. Long-term prophylactic treatment mainly
consists of antipsychotics and mood stabilizers. Differential diagnosis of schizoaffective disorder is not at all easy. It must be
distinguished from psychotic mood disorder, where the psychotic symptoms are mood-congruent. Although DSM-IV allows
even mood-incongruent psychotic symptoms in psychotic mood disorder, these cases should better be allocated to schizoaffec-
tive disorder. Schizoaffective disorder must also be distinguished from schizophrenia with mood symptoms. In the latter, the
mood symptoms are not complete and not so prominent to meet the criteria of a mood episode, or they occur after the schizo-
phreniform have remitted. Sometimes, schizoaffective disorder is mixed up with acute and transient psychotic disorder, although
these two conditions do not have very much in common. (Korean J Schizophr Res 2012;15:5-12)
Key Words : Schizoaffective disorder · Definition · Diagnosis.

What is Schizoaffective Disorder? however, do not qualify a schizophreniform episode or a

schizophrenic course as schizoaffective ; and 2) The tendency
The term schizoaffective disorder describes a symptomat- to overdiagnose schizoaffective disorder in order to avoid
ological constellation meeting the criteria of mood episodes potential stigmatization by the diagnosis of schizophrenia
(depressive, manic or mixed) as well as those of schizophreni- can be stopped. Yet, a new trend became apparent in recent
form episodes. times : overdiagnosis of psychotic mood disorder instead of
Not every depressive or maniform symptom, though, can schizoaffective disorder, which may have unforeseeable con-
turn a schizophreniform episode into a schizoaffective one. sequences.
Instead, the complete symptomatology of a depressive, man-
ic or mixed mood episode must be present. This limitation is Schizoaffective disorder in ICD-10, DSM-IV
essential for two reasons : 1) Isolated mood symptoms, espe- and DSM-5 proposal
cially depressive ones, are common in schizophrenia. They,
ICD-101) uses the following diagnostic criteria
Received: March 25, 2012 / Accepted: April 2, 2012
for schizoaffective disorder :
Address for correspondence: Andreas Marneros, Klinik und Poliklinik für
Psychiatrie, Psychotherapie und Psychosomatik Martin-Luther-Universität G1. The disorder meets the criteria of one of the affective
Halle-Wittenberg 06097 Halle Germany disorders (F30, F31, F32) of moderate or severe degree, as
Tel: 49-345-557 3651
E-mail: [email protected]
specified for each category.
G2. Symptoms from at least one of the groups listed below

Korean J Schizophr Res 2012;15:5-12 5

Schizoaffective Disorder

must be clearly present for most of the time during a period order to make diagnoses more reliable. It is, however, point-
of at least 2 weeks : ed out that for a final definition of schizoaffective disorder
1) Thought echo, thought insertion or withdrawal, thought much more data from longitudinal studies is required. The
broadcasting. proposed changes concern criteria B and C. The DSM-IV
2) Delusions of control, influence or passivity, clearly re- term “prominent mood symptoms” is vague, and therefore
ferred to body or limb movements or specific thoughts, ac- the term “symptoms meeting criteria for a major mood epi-
tions or sensations ; sode” is recommended. For criterion C, the term “a substan-
3) Hallucinatory voices giving a running commentary on tial portion” is recommended to be replaced by the term
the patient’s behaviour or discussing the patient between “over 30%” and the term “total duration” by “life time”. The
themselves, or other types of hallucinatory voices coming changes “will likely improve the reliability of diagnosis, pos-
from some part of the body ; sibly decreasing the frequency with which it will be made”.3)
4) Persistent delusions of other kinds that are culturally in-
appropriate and completely impossible, but not merely gran- What are similarities and differences in the definitions
diose or persecutory, e. g. has visited other worlds ; can con- of both classification systems?
trol the clouds by breathing in and out ; can communicate After long discussions, both systems decided to classify
with plants or animals without speaking ; schizoaffective disorder within the group of “schizophrenia,
5) Grossly irrelevant or incoherent speech, or frequent use schizotypal and delusional disorders”, which illustrates that
of neologisms ; schizophrenia and schizoaffective disorder are not identical
6) Intermittent but frequent appearance of some forms of but somehow belong together. Attempts to classify schizoaf-
catatonic behaviour, such as posturing, waxy flexibility and fective disorder as a distinct entity or to include them in the
negativism ; group of mood disorders failed due to the data available be-
G3. Criteria G1 and G2 above must be met within the ing rather unclear and inhomogeneous.
same episode of the disorder, and concurrently for at least The most prominent difference between the two systems
part of the episode. Symptoms from both G1 and G2 must be is that ICD-10 does not require the absence of mood symp-
prominent in the clinical picture. toms for a certain time, which makes diagnoses a little more
G4. Most commonly used exclusion clause. The disorder realistic than those according to DSM-IV and probably of
is not attributable to organic mental disorder or to psychoac- DSM-5.
tive substance-related intoxication, dependence or with-
drawal. What are the deficits of ICD and DSM in regard to
the definition of schizoaffective disorder?
Diagnostic criteria for schizoaffective disorder The simple fact that both systems now define and criterio-
in DSM-IV2) slightly differ from those in ICD-10, logically delineate schizoaffective disorder and determine
as shown in the following : various subtypes must be regarded as a clear progress, con-
A. An uninterrupted period of illness during which, at sidering the long controversies about its existence and charac-
some time, there is either a Major Depressive Episode, a teristics. It is rather unessential whether schizoaffective dis-
Manic Episode, or a Mixed Episode concurrent with symp- order is included in a schizophrenia category or in a mood
toms that meet Criterion A for Schizophrenia. disorder category ; there are pros and cons for both alloca-
B. During the same period of illness, there have been de- tions. Although both systems comprise a bipolar and a depres-
lusions or hallucinations for at least 2 weeks in the absence sive type, there is a substantial difference between ICD-10
of prominent mood symptoms. and DSM-IV : DSM accounts for the longitudinal course
C. Symptoms that meet criteria for a mood episode are and thus defines two subtypes : a bipolar and a depressive
present for a substantial portion of the total duration of the one similar to the differentiation of mood disorders, whereas
active and residual periods of the illness. ICD defines manic, depressive and mixed subtypes, depend-
D. The disturbance is not due to the direct physiological ing on the current episode but not on the longitudinal course,
effects of a substance (e. g. a drug of abuse, a medication) or which must be considered a deficit not only for research but
a general medical condition. also in terms of treatment strategies.
For DSM-5, only moderate changes have been proposed in Yet, the most important problem with both systems con-

6 Korean J Schizophr Res 2012;15:5-12

 Andreas Marneros

cerns the definition of schizoaffective disorder per se. While bipolar disorder on the basis of their index episode, only 8%
the main problem with ICD-10 concerns the longitudinal as- could longitudinally be allocated to schizoaffective bipolar
pect, the issue with DSM-IV is related to the cross-sectional disorder and 36% to bipolar mood disorder after a long-term
as well as to the longitudinal definition. It is the chronologi- course of 17 years, whereas the majority (56%) could not be
cal criterion B of the DSM-IV definition - the 2 weeks’ ab- allocated to one or the other category, because they also had
sence of mood symptoms - that causes problems. The inten- schizophrenic, schizoaffective and/or mood episodes during
tion of DSM-IV (and DSM-5) was a higher reliability of the course of their disorder. To solve this problem, the longi-
diagnosis as well as a differentiation between “schizoaffec- tudinal axes and the so-called sequential types should be
tive disorder”, “psychotic depression” and “psychotic mania”, considered in future. Much more intense research is, howev-
after even “schizophrenic first-rank symptoms” have been ac- er, needed to increase reliability.6,7)
cepted as symptoms of psychotic depression or mania by DSM- Hence, it can be concluded that, due to the unsystematic
IV (and presumably also by DSM-5). This chronological crite- data available, both classification systems cannot answer the
rion, however, is rather arbitrary and causes an imbalance in question of which disorder people with alternating schizo-
favour of the schizophrenic part with the corresponding prog- phreniform, mood and schizoaffective episodes suffer from.
nostic shift. There is, however, growing evidence, especially from re-
Both systems do not answer the question of what disorder search on the course of schizophrenic and mood disorders,
patients have who show alternating schizophrenic, schizoaf- that they belong to the group of schizoaffective disorder.
fective and mood episodes in the course of their disorder.
This phenomenon can be seen quite frequently during long- Subtypes of Schizoaffective Disorder
term course.4,5) Comparative studies of such sequential types
and concurrent types - those combining schizophreniform/ Depending on the mood constellation of the disorder, sev-
schizophrenic and mood symptoms in one episode - reveal eral cross-sectional and longitudinal types can be described.
many similarities at all levels and only a few differences re- Based on the cross-sectional symptomatology of the epi-
garding sociodemographic variables and course and progno- sode, schizoaffective disorders can, according to ICD-10, be
sis.6) Hence, criticism of the fact that both systems only offer subdivided into
cross-sectional diagnoses without considering the longitudi- - Schizodepressive type (or schizoaffective disorder, de-
nal aspect is justified (DSM-IV defines the longitudinal polar- pressive type)
ity of mood, but does not consider the presence of pure mood - Schizomanic type (or schizoaffective disorder, manic
or schizophrenic episodes, which becomes apparent when try- type)
ing to diagnose schizophrenic or mood disorders during course - Mixed schizoaffective type (or schizoaffective disorder,
with one of the two systems. The following example (Fig. 1) mixed type)
may illustrate this problem : Please note : episodes are always characterized by their
In a group of 277 patients which had been diagnosed with mood component.
In schizodepressive episodes, criteria of a depressive epi-
Bipolar schizoaffectivea
(n=23)
sode exist in addition to the schizophreniform symptom con-
Bipolar affective
(n=100)
stellation. Schizomanic episodes are characterized by addi-
tional manic episodes. And in a mixed schizoaffective episode,
the criteria of a mixed mood episode as described in ICD-10,
DSM-IV and probably also in DSM-5 are met in addition to
schizophreniform symptoms. The most frequent type of epi-
sodes within schizoaffective disorder is the schizodepressive
type, whereas mixed schizoaffective episodes are rather in-
frequent, even if these are mostly underdiagnosed. The most
Bipolar, cannot be classifiedb important reason for underdiagnosing schizoaffective mixed
(n=154)
episodes is the conglomeration of symptoms from different
Fig. 1. Bipolar patients (n=277) allocation according to ICD-10. a : areas (schizophreniform, manic and depressive), which can
Only schizoaffective episodes, b : Due to schizophrenic, affective
and/or schizoaffective episodes occurring at the same time. be more or less intense or marked. The most impressing ele-

Korean J Schizophr Res 2012;15:5-12 7

Schizoaffective Disorder

ment - either manic or depressive - influences the diagnosis chiatrist Kasanin who, in 1933, described nine cases that could
and the mixture of symptoms tends to remain unconsidered. neither be allocated to schizophrenia nor to mood disorder.
Systematic studies, however, have shown that the frequency From Kasanin’s concept, however, only the term “schizoaf-
of schizoaffective mixed episodes is similar to that of mixed fective” survived, as his cases can be better described as “acute
episodes in the course of pure mood disorders.8) According and transient psychotic disorder” according to modern cri-
to our own investigations, one third of patients with schizoaf- teria.5,14) What we call “schizoaffective” today, bears much
fective disorder have at least one mixed episode during the more resemblance to Kurt Schneider’s “cases in-between”.15)
course of their disorder, which seems to be more unfavour- Schneider exactly described the psychopathological picture
able than other types in terms of therapy and prognosis.9) of schizoaffective psychoses but named them “schizophrenia”,
Another way to categorize schizoaffective episodes accord- following Karl Jasper’s principle of schizophrenic symptoms
ing to their mood component - especially in a longitudinal relativizing the diagnostic valence of mood symptoms. The
way - is the distinction of bipolar and depressive (monopolar original concept of schizoaffective disorder can probably be
or unipolar) types, as has been mentioned before. The bipolar ascribed to Karl Kahlbaum.16) Emil Kraepelin also knew such
type is characterized by the presence of manic and/or mixed states. He described them as numerous and a challenge to or
symptoms in addition to the depressive symptoms, whereas even a weakness of his dichotomy concept.17) Both Eugen
the depressive type is characterized by the presence of depres- and Manfred Bleuler knew schizoaffective psychoses ; they
sive symptomatology throughout the course. named them “mixed psychoses” and allocated them to schizo-
Unipolar and bipolar schizoaffective disorders show signifi- phrenia.18,19) Jules Angst was the first to consequently examine
cant differences, similar to those between unipolar and bipolar schizoaffective psychoses. In his pioneering book of 1966,20)
mood disorders.10-12) The most important of these differences not only the bipolar disorders were re-born, but he also inves-
are : tigated schizoaffective psychoses. In contrast to his teacher
- Gender distribution (more females with unipolar types) Manfred Bleuler, he allocated them to mood disorders. After a
- Premorbid personality (sthenic self-confident personality long definitional and conceptual odyssey, schizoaffective dis-
more frequent in bipolar types) orders were introduced into the official nomenclature in
- Age at first manifestation (younger in bipolar types) DSM-I,21) whereas ICD first used the term in its 9th edition.22)
- Frequency of episodes and cycles (more in bipolar types) In the last years, there was a turn towards reason and clinical
- Cycle length (shorter in bipolar types) reality in the ongoing discussion about existence and charac-
- Interval length (shorter in bipolar types) teristics of schizoaffective disorders:23,24) the intermediate
- Prophylactic response to mood stabilizers (better in bi- position of schizoaffective disorder - between schizophrenia
polar types) and mood disorders - that has been favoured by various re-
Yet, clinic reality shows that further differentiation is need- searchers over decades - is currently being confirmed by ge-
ed. A schizo-dominated type must be distinguished from a netic research.25-27)
mood-dominated type - on the basis of the severity and domi- In summary, the current opinion is that schizoaffective disor-
nance of the particular symptom complex. This implies sig- ders form a heterogeneous group of disorders ; they cannot be
nificant consequences for therapy and prognosis. Schizo- completely allocated to schizophrenia or mood disorders but lie
dominated types resemble schizophrenia, including their on a continuum between both prototypes and are the psycho-
prognosis being less favourable than that of mood-dominated pathological expression of a probably genetically determined over-
types, which resemble mood disorders and show a similar re- lap of affective and schizophrenic spectra.28-32)
sponse to prophylactic treatment.
In addition, concurrent types should be differentiated from Epidemiology
sequential types. As mentioned above, these types do not dif-
fer significantly with regard to the premorbid and prognostic Only in the last few years, systematic epidemiological stud-
levels.13) ies were conducted on the prevalence of schizoaffective disor-
der, mostly in clinic populations. In a big national Finnish
A Short (Hi)story of a Long Controversy general population survey, Perälä et al.33) found a lifetime
prevalence for all psychotic disorders of 3.06%. Prevalence
The term “schizoaffective” goes back to the American psy- for schizoaffective disorder was estimated to be 0.32%, com-

8 Korean J Schizophr Res 2012;15:5-12

 Andreas Marneros

pared to 0.87% for schizophrenia, 0.24% for bipolar I disor- of patients have a monomorphous course (only one type of ep-
der, 0.35% for depressive disorder with psychotic symptoms isode).
and 0.18% for persistent delusional disorder. This study evi- Polymorphism and syndrome shift between schizophreni-
dences what has also been found by clinical studies, namely form, mood and schizoaffective episodes during long-term
that schizoaffective disorder is not at all rare. Twenty to thirty course of schizoaffective disorder give reason to assume a ge-
percent of all so-called endogenous psychoses (which means netically determined psychotic continuum, expressed by vari-
schizophrenia and mood disorder) are schizoaffective disor- ous manifestations that can be ascribed to the coexistence of
ders. An international study considering several countries on genetic dispositions for both prototypes (schizophrenia and
several continents found schizoaffective disorder in more than mood disorder).30)
31% of all psychotic patients.34) Long-term course : One of the best approved findings is
that residual states (or persistent alterations) occur signifi-
Course cantly less frequently in schizoaffective disorders than in
schizophrenia, but more frequently than in pure mood disor-
Prognosis : Schizoaffective disorder mostly (60%) has a ders.4,5,38-40) Although the frequency and kind of residual states
polyphasic course, which means it consists of more than three and their social consequences depend on the population in-
episodes. Oligophasic course (less than three episodes) is rare vestigated and on definitional and methodological aspects,
(20%), and monophasic course hardly ever occurs (10%)(Fig. 2).4) the following general statements can be made : In more than
The frequency of episodes depends on how successful the 50% of schizoaffective patients, symptoms remit sufficiently
prophylactic therapy is and on whether it is a bipolar or uni- even after long-term course. Only 20% of the patients expe-
polar disorder. Bipolar disorders, as mentioned above, con- rience medium or severe subjective impairment or symp-
sist of significantly more episodes and recidivate more fre- toms and another 25% suffer from light to moderate symp-
quently than unipolar disorders. Therefore, in bipolar toms (Fig. 3). Residual symptoms occur much later than in
schizoaffective disorders the number and frequency of cy- schizophrenia but earlier than in mood disorders. More than
cles (a cycle is the time period between the beginning of an half of the patients with schizoaffective disorder show good
episode and the beginning of the next episode) is higher. The social adaptation according to the WHO criteria, even if they
length of episodes depends on the therapeutic success within have been suffering from the disorder for a long time. About
an episode, on its form - whether it is currently depressive, 75% of them are still able to work (yet 15% of them with
manic, or mixed -, on whether there is a schizo-dominating some limitations). One quarter of working patients must give
symptomatology and on whether persistent alterations (re- up their job due to their disorder. A large proportion of pa-
sidual states) occur : mixed episodes, schizo-dominated tients with schizoaffective disorder (80%), however, can still
forms and the occurrence of persistent alterations seem to live on their own and can care for those depending on them,
predispose for longer episodes.4,35) even after a long-term course of their illness (compared to
In about two thirds of patients, schizoaffective disorder about 40% of patients with schizophrenia, see).4)
shows several types of episodes during course - it is polymor- Summarizing the prognosis of schizoaffective disorder it
phous.4,36,37) This means that they do not only have schizoaf- can be said that it is more favourable than that of schizophre-
fective episodes but also pure mood or schizophreniform epi- nia, but less favourable than that of mood disorder. Hence, schizoaf-
sodes or episodes of acute and transient psychosis. One third
Medium to severe symptoms or No symptoms
impairments ; 20% or impairments ; 55%
60%

20%

10%

Polyphasic Oligophasic Monophasic Light to moderate sympotoms

(3＞episodes) (2-3 episodes) (1 episod) or impairments ; 25%

Fig. 2. Course of schizoaffective disorder. Fig. 3. Outcome of schizoaffective disorder.

Korean J Schizophr Res 2012;15:5-12 9

Schizoaffective Disorder

fective disorder occupies an intermediate position between combined with mood stabilizers, whereas the unipolar type
schizophrenia and mood disorder. needs to be treated with antipsychotics and antidepressants.
Suicidality : Suicidality is one of the biggest problems in The sequential type is totally ignored in studies. Its treatment
schizoaffective disorder. When considering only schizode- focuses on the treatment of the particular episode.
pressive episodes, suicidality appears to be even higher than Clinical studies also reported a positive effect of electro-
in pure mood disorders. Taking into account the total suicid- convulsive treatment.49) Other treatments like augmentation
al symptomatology - suicidal thoughts, suicide attempts and with l-thyroxine found only small benefit.50) The role of psy-
committed suicide - it must be noted that more than two chological treatment in schizoaffective disorder has not yet
thirds of patients with schizoaffective disorder develop sui- been systematically investigated.
cidal symptoms at least once during long-term course.41-43) The longitudinal treatment of schizoaffective disorder is a
Apparently it is the combination of melancholic hopelessness prophylactic one, mainly with mood stabilizers and antipsy-
and psychotic subjection characterizing schizodepressive epi- chotics.45,47)
sodes that are an important risk factor.43) According to epide-
miological studies, about 12% of schizoaffective patients die Differential Diagnosis
by suicide - a proportion similar to that in mood disorders.
The differential diagnosis of schizoaffective disorder is
Treatment and Prophylaxis not easy as it combines symptoms of several disorders. In
psychotic depressive, manic or mixed episodes, hallucina-
Although the clinical relevance of schizoaffective disor- tions that might exist are congruent to the modified mood of
ders is meanwhile well established and beyond doubt, their the patients (synthymic). Yet, after especially DSM-IV had
treatment has received less attention in pharmacological accepted even mood-incongruent symptoms in psychotic de-
double blind studies than other psychotic or non-psychotic pression, mania or mixed states, differential diagnosis has
major mental disorders. One of the main reasons might be become even more difficult. It has to be made according to
the problem of their definition and, most important for the the criteria described at the beginning of this paper. Psy-
pharmaceutical industry, the fact that schizoaffective disor- chotic depression, mania or mixed states with mood-incon-
der usually requires a combination of antipsychotics, antide- gruent psychotic symptoms, however, should better be allo-
pressants and mood stabilizers. Pharmacological studies cated to schizoaffective disorders.51)
dealing with schizoaffective disorder mostly investigated it Depressive symptoms are not rare in schizophrenia. The
as a subgroup of schizophrenia, seldom as a subgroup of depressive symptomatology, however, does not meet the cri-
mood disorders and even more seldom as a separate entity. teria of major depression. So-called “postschizophrenic de-
Pharmacological studies only on schizoaffective disorder are pression” or “postremissive fatigue syndrome” can be dif-
rare. Nevertheless it can be said that schizoaffective disorder ferentiated f rom schizoaffective episodes by their
is the domain of antipsychotics and mood stabilizers.44-48) occurrence after the schizophrenic episodes have remitted
All antipsychotics seem to be efficient in the treatment of and by the fact that they do not meet the criteria of major de-
schizoaffective disorder, but some atypical antipsychotics pression. Maniform symptomatology in schizophrenia can be
like olanzapine, quetiapine, risperidone, or ziprasidone are characterized by hyperactivity or euphoria but does not meet
superior or have some advantages in comparison to typical the criteria of a manic episode. “Cycloid psychosis”, or “acute
ones.46,48) The heterogeneity of the studies and the investigat- and transient psychotic disorder” defined by ICD-10 in its
ed populations do not permit a science based statement on category F 23, has nothing in common with schizoaffective
the topic. The clinical effectiveness of mood stabilizers like disorder. Nevertheless, some may mix them up. This is an
lithium, carbamazepine or valproate was reported in some, acute, short-term psychosis with a favourable outcome and
however, heterogeneous studies. does not combine schizophrenic and mood episodes (for a
Pharmacotherapy varies according to the type of schizoaf- more detailed description see).5)
fective disorder. In the schizo-dominant type, the main medi-
cation must be an antipsychotic one. In the affective-dominant Conclusion
type, mood stabilizers and antidepressants or antipsychotics
are effective. The bipolar type is treated with antipsychotics Schizoaffective disorders are a nosological nuisance but a

10 Korean J Schizophr Res 2012;15:5-12

 Andreas Marneros

clinical reality. A lot of people are affected : 20 to 30% of all G. Aschaffenburg, Editor, Handbuch der Psychiatrie. Spezieller Teil
4, Deutike, Leipzig;1911.
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