Differences between Schizoaffective Disorder & Bipolar Disorder?
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Q:  Differences between Schizoaffective Disorder & Bipolar Disorder?

Dear Dr. Phelps,
Our 20 year old son was diagnosed with severe OCD at the age of 16. Two years later, he attempted suicide and was diagnosed as bipolar 1, mixed. After the several hospitalizations, he dropped out of a major university. We applied for and received SSDI for him. He currently takes Strattera, Lithium, Abilify, and Luvox. These meds control his symptoms, and when he is awake, he functions well socially. He does sleep much of the time. His current psychiatrist has changed his diagnosis to schizoaffective disorder. We have questioned the diagnosis, but have not received answers that make sense to us. What are the major differences between these disorders? If, as the psychiatrist says, there are few differences, why are there two diagnoses? Would you continue to question the new diagnosis, or just go with the flow?


Dear Cindy --
What are the differences between schizoaffective disorder and bipolar disorder? As you are learning, the distinction is not clear.  Most mood experts, and the consensus committee of the International Society for Bipolar Disorders in 2008, believe that a continuum of variations exists between bipolar disorder and schizophrenia.  In other words, from bipolar disorder at one end of the spectrum, to schizophrenia at the other, there are many people in between with some degree of symptoms that belong to each condition.

As you know, bipolar disorder is technically a "mood disorder" ; whereas schizophrenia is technically a "thought disorder".  Thus, people whose problems are primarily a matter of disorganized and delusional thinking, but who also have some elements of depression, could be regarded as having moved along a spectrum toward bipolar disorder from the schizophrenia and of the spectrum by virtue of those mood symptoms. Conversely, people whose problems are primarily a matter of mood, but who also have some elements of thought disorder (e.g. delusions), might be placed along the spectrum more toward schizophrenia than a purely "bipolar" condition. 

It may be not only legitimate but important to recognize a mood component in someone who looks like they otherwise have "schizophrenia": that recognition might prompt the addition of a treatment targeted at mood -- psychotherapy or medications.

The converse situation is not so straightforward: recognizing a thought disorder component in someone who otherwise is thought to have bipolar disorder may cause practitioners to think that the only way such a person can be treated is to include an "antipsychotic" medication.  This is not always the case.  Some versions of bipolar disorder clearly include psychotic symptoms such as auditory hallucinations and delusions, particularly during the manic phase.  That does not mean such a person will require an antipsychotic medication forever, although it is generally accepted that when having psychotic symptoms, antipsychotic medications are an important part of treatment (I am one of the few exceptions I think: there are a few articles in the literature which I think clearly demonstrate that when necessary, the psychotic symptoms associated with mania can be treated without an antipsychotic.  What makes this "necessary"?  When the antipsychotic side effects run the risk of making the person hate medications and want to stop them.  The alternative is to use medications with fewer disturbing side effects, such as lithium and valproate (divalproex/Depakote).

So, having completed my small soapbox statement about the risks of the "schizoaffective" diagnosis (in other words, it may make people think that an antipsychotic is necessary when that may not necessarily be a case), may I reiterate a bottom line as regards your son: going with the flow is appropriate; sometimes it takes a while to figure out where on this spectrum between thought disorder and mood disorder a given person really lives. 

A separate question for you to learn more about, if outcomes are not really good, with time, is the controversy about the role of antidepressants in the treatment of bipolar disorder.  Suppose your son really has "bipolar disorder", primarily (sometimes manic symptoms can look like "obsessive-compulsive disorder", for example).  Antidepressants can cause mixed states, in the opinion of most mood experts.  Is it possible that the antidepressants which your son might originally have been given for "obsessive-compulsive disorder" could be in part precipitating or maintaining the current symptoms which are part of a less than optimal outcome?  As you may have learned, this is an intense controversy in psychiatry -- much more intense than the nomenclature issues above, and including yet more complex treatment decisions.  In my view, anyone with bipolar disorder, or a condition which resembles that, these understand these controversies if she/he is being offered an antidepressant medication (or is on one and not doing well).  For that reason, I have summarized those issues, from my point of view, here: Antidepressant Controversies .  By sending you to this page, I do not mean to stir up trouble.  If things are going well, you might actually be best to ignore that reference.  These are general issues, not based on knowing anything particular about your son.

Good luck with your learning, and with helping your son get the best possible outcomes.

Dr. Phelps


Published May, 2009


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