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?
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.
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
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.
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).
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.
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.
with your learning, and with helping your son get the best possible outcomes.
Published May, 2009