PSYCH PEARLS 3

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=110 BGCOLOR="#666699" TEXT="#080000" bgproperties="fixed" background="04a00840erlcjm.gif"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Arial" ><B>PSYCHIATRY I</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="PSYCHIATRY I"><U><B>home</B></U></A></div> <div> <A HREF="id18.htm" TARGET="_top" TITLE="PSYCH PEARLS 1"><U>PSYCH PEARLS 1</U></A>   |   <A HREF="id19.htm" TARGET="_top" TITLE="PSYCH PEARLS 2"><U>PSYCH PEARLS 2</U></A>   |   <B>PSYCH PEARLS 3</B>   |   <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U>Contact Me</U></A></div> <div> </div> </td> </tr><tr> <td valign="top" width=190 BGCOLOR="#CCCCFF" TEXT="#080000" background="04411c00egdysm.gif"> <div> <A HREF="id18.htm" TARGET="_top" TITLE="PSYCH PEARLS 1"><U><B>PSYCH PEARLS 1</B></U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="PSYCH PEARLS 2"><U><B>PSYCH PEARLS 2</B></U></A></div> <div> <B>PSYCH PEARLS 3</B></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> <bR> <div> <B>  <a href="http://counter.mycomputer.com/"><img alt="Counter" src="http://counter.mycomputer.com/c.count?u=DHAMMOUD&c=1" border=0></a>   </B></div> <bR> <div> <B><IMG SRC="05f9e060.gif" border=0 width="158" height="262" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> PSYCH PEARLS 3</div> <div> 51-year-old woman presents with an episode of dysphoria, sleep difficulty, psychomotor agitation, and rumination about mistakes she has made in her life. She has delusions of guilt about indirectly causing the deaths of many people. She has a history of two previous episodes with similar symptoms, but no history of manic episodes. Between episodes, she is asymptomatic. Which of the following is the most likely diagnosis</div> <bR> <div> Major depressive disorder, recurrent</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The history and findings are most suggestive of major depressive disorder, recurrent, with mood-congruent psychosis</B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The individual has depressive episodes with mood-congruent psychotic features. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The absence of a history of manic episodes makes bipolar disorder  unlikely.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Dysthymic disorder  is less likely because it is usually characterized by long periods of depressed mood, but without the full features of a depressive episode or psychosis present in this case.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Schizoaffective disorder  is diagnosed only when psychosis persists <B>for at least 2 weeks in the absence of mood episodes</B>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In schizophrenia , psychotic symptoms and emotional blunting persist in the absence of mood symptoms and are usually more prominent than any associated mood pathology.</div> <bR> <bR> <div> <B> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="979" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#000033 > <tR> <tD VALIGN=TOP HEIGHT= 4466 WIDTH="967"><div> Schizoaffective disorder is one of the most confusing and controversial diagnostic categories in psychiatry.</div> <div> People suffering from schizoaffective disorder experience a chronic roller-coaster ride of symptoms and problems that may be more difficult to cope with than either of its parent diseases, schizophrenia or affective disorders (formerly known as mood disorders). </div> <bR> <div> Researchers have identified two subtypes of schizoaffective disorder: bipolar type and depressive type.</div> <bR> <div> <B> Bipolar type is associated with the presence of manic or mixed episodes</B>. </div> <div> Such episodes bring on sudden elation, euphoria, or extreme irritability to the point of serious impairment.</div> <bR> <div>  Depressive type is associated with major depressive episodes.</div> <div>  Depressive episodes are often characterized by feelings of worthlessness, hopelessness or indifference, and inability to concentrate or remember details, and thoughts of death or suicide attempts. </div> <bR> <div> <B>Like schizophrenia and affective </B><B>disorder</B><B>s, </B><B>schizoaffective</B><B> </B><B>disorder</B><B> is caused by a chemical imbalance in the brain’s neurotransmitters. </B></div> <bR> <bR> <div> Since schizoaffective disorder bears a close resemblance to both schizophrenia and affective disorders, people with the illness experience a combination of symptoms associated with both diseases. </div> <div> To be diagnosed with schizoaffective disorder a person must not meet the criteria for either schizophrenia or affective disorder. </div> <bR> <div> However, a person must have at one time experienced both a schizophrenic and a mood disturbance and, at another time, experienced psychotic symptoms without affective symptoms. </div> <bR> <bR> <bR> <div> These symptoms include… </div> <bR> <bR> <div> <B>Psychotic Symptoms</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Delusions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hallucinations </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Disorganized thinking </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Agitation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lack of drive or initiative </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Social withdrawal </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Apathy </div> <div> <B>Affective Symptoms</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Extreme mood swings from mania to depression </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hyperactivity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thoughts of death or suicide </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Decreased need for sleep </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acute psychosis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Loss of appetite </div> <bR> <div> This disorder is characterized by the presence of <B>one of the following</B>: </div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Major Depressive Episode</U> (must include depressed mood) </div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Manic Episode</U> </div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Mixed Episode</U> </div> <div> as well as the presence of <B>at least two</B> of the following symptoms, for at least one month: </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delusions</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hallucinations</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">disorganized speech (e.g., frequent derailment or incoherence) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">grossly <B>disorganized</B> or catatonic <B>behavior</B> </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000ffff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">negative symptoms</B> (e.g., affective flattening, alogia, avolition) </div> <div> (Only one symptom is required if delusions are <I>bizarre</I> <B>or</B> hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.) </div> <div> The occurrence of the delusions or hallucinations must be in the absence of any serious mood symptoms for at least 2 weeks. The mood disorder, however, must be present for a significant minority of the time. The symptoms of this disorder also can not be better explained by the use or abuse of a substance (alcohol, drugs, medications) or a general medical condition (stroke). </div> <bR> <bR> <bR> <div> Like schizophrenia, schizoaffective disorder usually begins in early adulthood. Although research on the disorder is scarce, women seem to suffer from the illness more often than men. </div> <div> Schizoaffective disorder responds to treatment with antimanics (such as lithium), antidepressants, and antipsychotics. </div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>Major Depressive Episode</B></div> <div> <B>SYMPTOMS</B></div> <div> <B>A major depressive episode is not a </B><B>disorder</B><B> in itself, but is a part of another </B><B>disorder</B><B>, most often </B><B>major depressive </B><B>disorder</B><B> or </B><B>bipolar </B><B>disorder</B><B>. </B></div> <div> <B>A person who suffers from a major depressive episode must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at </B><B>least a 2 week period</B><B>. This mood must represent a change from the person's normal mood; social, occupational, educational or other important functioning must also be negatively impaired by the change in mood. A major depressive episode is also characterized by the presence of a majority of these symptoms: </B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). (In children and adolescents, this may be characterized as an irritable mood.) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">insomnia or hypersomnia nearly every day </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">psychomotor agitation or retardation nearly every day </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fatigue or loss of energy nearly every day </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">feelings of worthlessness or excessive or inappropriate guilt nearly every day </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diminished ability to think or concentrate, or indecisiveness, nearly every day </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0ffff0000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide </B></div> <bR> <bR> <div> <B>Depression (Major Depressive Disorder)</B></div> <div> <B>SYMPTOMS</B></div> <div> <B>A person who suffers from a major depressive disorder must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2 week period. This mood must represent a change from the person's normal mood; social, occupational, educational or other important functioning must also be negatively impaired by the change in mood. A depressed mood caused by substances (such as drugs, alcohol, medications) is not considered a major depressive disorder, nor is one which is caused by a general medical condition. Major depressive disorder cannot be diagnosed if a person has a history of manic, hypomanic, or mixed episodes (e.g., a bipolar disorder) or if the depressed mood is better accounted for by schizoaffective disorder and is not superimposed on schizophrenia, a delusion or psychotic disorder. </B></div> <bR> <div> <B>  </B></div> <div> <B> </B></div> <bR> <div> <B>This disorder is characterized by the presence of the majority of these symptoms: </B></div> <bR> <div> <B>depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). (In children and adolescents, this may be characterized as an irritable mood.) </B></div> <div> <B>markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day </B></div> <div> <B>significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. </B></div> <div> <B>insomnia or hypersomnia nearly every day </B></div> <div> <B>psychomotor agitation or retardation nearly every day </B></div> <div> <B>fatigue or loss of energy nearly every day </B></div> <div> <B>feelings of worthlessness or excessive or inappropriate guilt nearly every day </B></div> <div> <B>diminished ability to think or concentrate, or indecisiveness, nearly every day </B></div> <div> <B>recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide </B></div> <div> <B>The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. </B></div> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>Manic Episode</B></div> <div> <B>SYMPTOMS</B></div> <div> <B>A manic episode is not a </B><B>disorder</B><B> in and of itself, but instead is a part of other </B><B>disorder</B><B>s, most usually </B><B>bipolar </B><B>disorder</B><B>. </B></div> <div> <B>It is characterized by a time period of an elevated, expansive or notably irritable mood, lasting for at least one week. This </B><B>disorder</B><B> must be sufficiently severe to cause difficulty or impairment in occupational, social, educational or other important functioning and can not be better explained by a </B><B>mixed episode</B><B>. Symptoms also can not be the result of substance use or abuse (alcohol, drugs, medications) or caused by a general medical condition. A majority of the following symptoms is also present: </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">inflated self-esteem or grandiosity </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">decreased need for sleep (e.g., feels rested after only 3 hours of sleep) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">more talkative than usual or pressure to keep talking </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">flight of ideas or subjective experience that thoughts are racing </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">attention is easily drawn to unimportant or irrelevant items </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f0f0fbff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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) </B></div> <bR> <bR> <div> <B>Bipolar Disorder</B></div> <div> <B>SYMPTOMS</B></div> <div> <B>Bipolar disorder is often not recognized by the patient, relatives, friends, or even physicians. An early sign of manic-depressive illness may be hypomania--a state in which the person shows a high level of energy, excessive moodiness or irritability, and impulsive or reckless behavior. </B></div> <div> <B>Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong. </B></div> <bR> <div> <B>In its early stages, bipolar disorder may masquerade as a problem other than mental illness. For example, it may first appear as alcohol or drug abuse, or poor school or work performance. </B></div> <bR> <div> <B>If left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression. </B></div> <div> <B> </B></div> <div> <B>One of the usual differential diagnoses for bipolar disorder is that the symptoms (listed below) are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. </B></div> <div> <B>And as with nearly all mental disorder diagnoses, the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. </B></div> <bR> <div> <B>Specific symptoms of various types of this disorder follow. </B></div> <bR> <div> <B>Bipolar I Disorder </B></div> <div> <B>Bipolar I Disorder actually is a number of separate diagnoses, depending upon the type of mood most recently experienced. </B></div> <bR> <div> <B>Bipolar I Disorder, Single Manic Episode</B></div> <bR> <bR> <div> <B>Presence of only one Manic Episode and no past Major Depressive Episodes. </B></div> <div> <B>Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms. </B></div> <div> <B>Bipolar I Disorder, Most Recent Episode Hypomanic</B></div> <bR> <bR> <div> <B>Currently (or most recently) in a Hypomanic Episode. </B></div> <div> <B>There has previously been at least one Manic Episode or Mixed Episode. </B></div> <div> <B>Bipolar I Disorder, Most Recent Episode Manic</B></div> <bR> <bR> <div> <B>Currently (or most recently) in a Manic Episode. </B></div> <div> <B>There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. </B></div> <div> <B>Bipolar I Disorder, Most Recent Episode Mixed</B></div> <bR> <bR> <div> <B>Currently (or most recently) in a Mixed Episode. </B></div> <div> <B>There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode. </B></div> <div> <B>Bipolar II Disorder </B></div> <bR> <bR> <div> <B>Presence (or history) of one or more Major Depressive Episodes and at least one Hypomanic Episode. Additionally, there has never been a Manic Episode or a Mixed Episode. </B></div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>Mixed Episode</B></div> <div> <B>SYMPTOMS</B></div> <div> <B>A mixed episode is not a </B><B>disorder</B><B>, but rather a part of a mental </B><B>disorder</B><B>, most commonly </B><B>bipolar </B><B>disorder</B><B>. It consists of meeting the criteria for both a </B><B>manic episode</B><B> as well as a </B><B>major depressive episode</B><B> nearly every day for at least a full week. </B></div> <div> <B>Like all mental </B><B>disorder</B><B>s, the disturbance must be severe enough to cause distress or impairment in social, occupational, education or other important functioning and is not better accounted for by the physiological effects of substance use or abuse (alcohol, drugs, medications) or a general medical condition. </B></div> <div> <B>Criteria summarized from:</B></div> <div> <B>American Psychiatric Association. (1994). </B><B>Diagnostic and statistical manual of mental </B><B>disorder</B><B>s, fourth edition</B><B>. Washington, DC: American Psychiatric Association. </B></div> <bR> <bR> <bR> <bR> <div> <B>DSM Codes for Depression</B></div> <div> <B> <A NAME="recurrent"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Major Depressive </B><B>Disorder</B><B>, Recurrent</B><B> </B></div> <div> <B>296.36 In Full Remission </B></div> <div> <B>296.35 In Partial Remission </B></div> <div> <B>296.31 Mild </B></div> <div> <B>296.32 Moderate </B></div> <div> <B>296.33 Severe Without Psychotic Features </B></div> <div> <B>296.34 Severe With Psychotic Features </B></div> <div> <B>296.30 Unspecified </B></div> <div> <B> <A NAME="episode"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B><B>Major Depressive </B><B>Disorder</B><B>, Single Episode</B><B> </B></div> <div> <B>296.26 In Full Remission </B></div> <div> <B>296.25 In Partial Remission </B></div> <div> <B>296 21 Mild </B></div> <div> <B>296.22 Moderate </B></div> <div> <B>296.23 Severe Without Psychotic Features </B></div> <div> <B>296.24 Severe With Psychotic Features </B></div> <div> <B>296.20 Unspecified </B></div> <div> <B>608.89 Male Dyspareunia Due to...[Indicate the General Medical Condition] </B></div> <div> <B>302.72 Male Erectile </B><B>Disorder</B><B> </B></div> <div> <B>607.84 Male Erectile </B><B>Disorder</B><B> Due to...[Indicate the General Medical Condition] </B></div> <div> <B>608.89 Male Hypoactive Sexual Desire </B><B>Disorder</B><B> Due to...[Indicate the General Medical Condition] </B></div> <div> <B>302.74 Male Orgasmic </B><B>Disorder</B><B> </B></div> <div> <B>V65.2 Malingering </B></div> <div> <B>315.1 Mathematics </B><B>Disorder</B><B> </B></div> <bR> <bR> <bR> </tD> </tR> </TABLE></B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 55 ><NOBR><div> <U>Schizoaffective Disorder</U></div> <div> <B>American Description</B></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="185"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="55" ALIGN="bottom" WIDTH="185" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <div> Diagnostic Criteria</div> <div> An uninterrupted period of illness during which, at some time, there is either (1) a <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Major Depressive Episode</U></FONT>, (2) a <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Manic Episode</U></FONT>, or (3) a <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Mixed Episode</U></FONT> concurrent with symptoms that meet (4) <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>Criterion A for Schizophrenia</U></FONT>. </div> <div> <B>Note:</B> The Major Depressive Episode must include depressed mood.</div> <div>  <A NAME="a1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>(1) <B>Criteria for Major Depressive Episode</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. </div> <div> <B>Note:</B> Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.</div> <div> depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). <B>Note:</B> In children and adolescents, can be irritable mood. </div> <div> markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) </div> <div> significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. <B>Note:</B> In children, consider failure to make expected weight gains. </div> <div> insomnia or hypersomnia nearly every day </div> <div> psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) </div> <div> fatigue or loss of energy nearly every day </div> <div> feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) </div> <div> diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) </div> <div> recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms do not meet criteria for a Mixed Episode </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. </div> <div>  <A NAME="a2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>(2) <B>Criteria for Manic Episode</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: </div> <div> inflated self-esteem or grandiosity </div> <div> decreased need for sleep (e.g., feels rested after only 3 hours of sleep) </div> <div> more talkative than usual or pressure to keep talking </div> <div> flight of ideas or subjective experience that thoughts are racing </div> <div> distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) </div> <div> increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation </div> <div> 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) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms do not meet criteria for a Mixed Episode </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). </div> <div>  <A NAME="a3"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>(3) <B>Criteria for Mixed Episode</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). </div> <div>  <A NAME="a4"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>(4) <B>Criterion A of Schizophrenia</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delusions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hallucinations </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">disorganized speech (e.g., frequent derailment or incoherence) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">grossly disorganized or catatonic behavior </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">negative symptoms, i.e., affective flattening, alogia, or avolition </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Only one symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other. </div> <div> During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. </div> <div> Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. </div> <div> The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </div> <div> Specify type:</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bipolar Type:</B> if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes) </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Depressive Type:</B> if the disturbance only includes Major Depressive Episodes </div> <bR> <div> Associated Features</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Learning Problem </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypoactivity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Psychotic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Euphoric Mood </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Depressed Mood </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Somatic/Sexual Dysfunction </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hyperactivity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Guilt/Obsession </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Odd/Eccentric/Suspicious Personality </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anxious/Fearful/Dependent Personality </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dramatic/Erratic/Antisocial Personality </div> <bR> <div> Differential Diagnosis</div> <div> Psychotic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT> Due to a General Medical Condition, a delirium, or a dementia; Substance-Induced Psychotic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT>; Substance-Induced Delirium; Delusional <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT>; Psychotic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT> Not Otherwise Specified. </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 55 ><NOBR><div> <U>Schizoaffective Disorder</U></div> <div> <B>European Description</B></div> </NOBR></tD> <tD VALIGN=TOP WIDTH="185"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="55" ALIGN="bottom" WIDTH="185" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <div> The ICD-10 Classification of Mental and Behavioural <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT>s</div> <div> World Health Organization, Geneva, 1992 </div> <bR> <div> F25 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT></div> <div> These are episodic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>s in which both affective and schizophrenic symptoms are prominent within the same episode of illness, preferably simultaneously, but at least within a few days of each other. Their relationship to typical mood (affective) <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>s and to schizophrenic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>s is uncertain. They are given a separate category because they are too common to be ignored. Other conditions in which affective symptoms are superimposed upon or form part of a pre-existing schizophrenic illness, or in which they coexist or alternate with other types of persistent delusional <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>s, are classified under the appropriate category. Mood-incongruent delusions or hallucinations in affective <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>s do not by themselves justify a diagnosis of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>. </div> <div> Patients who suffer from recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> episodes, particularly those whose symptoms are of the manic rather than the depressive type, usually make a full recovery and only rarely develop a defect state. </div> <bR> <bR> <bR> <div> Diagnostic Guidelines</div> <div> A diagnosis of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> should be made only when both definite schizophrenic and definite affective symptoms are prominent simultaneously, or within a few days of each other, within the same episode of illness, and when, as a consequence of this, the episode of illness does not meet criteria for either schizophrenia or a depressive or manic episode. The term should not be applied to patients who exhibit schizophrenic symptoms and affective symptoms only in different episodes of illness. It is common, for example, for a schizophrenic patient to present with depressive symptoms in the aftermath of a psychotic episode (see post-schizophrenic depression). Some patients have recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> episodes, which may be of the manic or depressive type or a mixture of the two. Others have one or two <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> episodes interspersed between typical episodes of mania or depression. In the former case, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> is the appropriate diagnosis. In the latter, the occurrence of an occasional <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> episode does not invalidate a diagnosis of bipolar affective <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> or recurrent depressive <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> if the clinical picture is typical in other respects. </div> <bR> <div> F25.0 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT>, Manic Type</div> <div> A <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> in which schizophrenic and manic symptoms are both prominent in the same episode of illness. The abnormality of mood usually takes the form of elation, accompanied by increased self-esteem and grandiose ideas, but sometimes excitement or irritability are more obvious and accompanied by aggressive behaviour and persecutory ideas. In both cases there is increased energy, overactivity, impaired concentration, and a loss of normal social inhibition. Delusions of reference, grandeur, or persecution may be present, but other more typically schizophrenic symptoms are required to establish the diagnosis. People may insist, for example, that their thoughts are being broadcast or interfered with, or that alien forces are trying to control them, or they may report hearing voices of varied kinds or express bizarre delusional ideas that are not merely grandiose or persecutory. Careful questioning is often required to establish that an individual really is experiencing these morbid phenomena, and not merely joking or talking in metaphors. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>s, manic type, are usually florid psychoses with an acute onset; although behaviour is often grossly disturbed, full recovery generally occurs within a few weeks. </div> <bR> <bR> <bR> <div> Diagnostic Guidelines</div> <div> There must be a prominent elevation of mood, or a less obvious elevation of mood combined with increased irritability or excitement. Within the same episode, at least one and preferably two typically schizophrenic symptoms (as specified for schizophrenia [F20], diagnostic guidelines (a) - (d)) should be clearly present. </div> <div> This category should be used both for a single <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> episode of the manic type and for a recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> in which the majority of episodes are <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT>, manic type. </div> <div> Includes: </div> <div> * <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> psychosis, manic type </div> <div> * schizophreniform psychosis, manic type </div> <bR> <bR> <bR> <div> F25.1 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Disorder</FONT>, Depressive Type</div> <bR> <div> A <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> in which schizophrenic and depressive symptoms are both prominent in the same episode of illness. Depression of mood is usually accompanied by several characteristic depressive symptoms or behavioural abnormalities such as retardation, insomnia, loss of energy, appetite or weight, reduction of normal interests, impairment of concentration, guilt, feelings of hopelessness, and suicidal thoughts. At the same time, or within the same episode, other more typically schizophrenic symptoms are present; patients may insist, for example, that their thoughts are being broadcast or interfered with, or that alien forces are trying to control them. They may be convinced that they are being spied upon or plotted against and this is not justified by their own behaviour. Voices may be heard that are not merely disparaging or condemnatory but that talk of killing the patient or discuss this behaviour between themselves. <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Schizoaffective</FONT> episodes of the depressive type are usually less florid and alarming than <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> episodes of the manic type, but they tend to last longer and the prognosis is less favourable. Although the majority of patients recover completely, some eventually develop a schizophrenic defect. </div> <bR> <div> Diagnostic Guidelines</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There must be prominent depression, accompanied by at least two characteristic depressive symptoms or associated behavioural abnormalities as listed for depressive episode; within the same episode, at least one and preferably two typically schizophrenic symptoms (as specified for schizophrenia), diagnostic guidelines (a)-(d) should be clearly present. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This category should be used both for a single <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> episode, depressive type, and for a recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> in which the majority of episodes are <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT>, depressive type. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Includes: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">* <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> psychosis, depressive type </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">* schizophreniform psychosis, depressive type </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 39 WIDTH="435"><div> <B>Treatment</B></div> </tD> <tD VALIGN=TOP WIDTH="185"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="39" ALIGN="bottom" WIDTH="185" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <bR> <bR> <div> Contents</div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Medical Treatment</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Basic Principles</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hospitalization</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antipsychotic Drugs</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"Drug Holidays" From Antipsychotic Drugs</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antidepressant Drugs</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antianxiety Drugs</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When Not To Use Antipsychotic Drugs</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lithium</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anticonvulsants</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Other Drugs</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Electroconvulsive Therapy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Psychosocial Treatment</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Basic Principles</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Supportive Psychotherapy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Group Therapy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Family Therapy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f0ff000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Behavior Therapy</U><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <div> <B><U> <A NAME="head_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Medical Treatment</U></B></div> <bR> <bR> <div>  <A NAME="head_1a"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Basic Principles</div> <bR> <bR> <div> Both drug and psychosocial therapies are necessary to successfully treat <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>. Because of the unemployment, poverty, and homelessness that often complicates <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>, 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 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> is an extremely lonely experience, and these patients require all the support that their families, friends, and communities can provide. </div> <bR> <bR> <div> Schizoaffective<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT>disorder<FONT SIZE="3" COLOR="#000000" FACE="Arial" > appears to be a combination of a thought </FONT>disorder<FONT SIZE="3" COLOR="#000000" FACE="Arial" >, mood </FONT>disorder<FONT SIZE="3" COLOR="#000000" FACE="Arial" >, and anxiety </FONT>disorder<FONT SIZE="3" COLOR="#000000" FACE="Arial" >. Thus the medical management of </FONT></div> <div> schizoaffective<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT>disorder<FONT SIZE="3" COLOR="#000000" FACE="Arial" > oftens requires a combination of antipsychotic, antidepressant, and antianxiety medication. Unfortunately, after the first year of treatment, only a minority of </FONT>schizoaffective<FONT SIZE="3" COLOR="#000000" FACE="Arial" > 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. </FONT></div> <bR> <bR> <div>  <A NAME="head_1b"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Hospitalization</div> <div> 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. </div> <bR> <bR> <div>  <A NAME="head_1c"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Antipsychotic Drugs</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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: </div> <bR> <bR> <bR> <div> <B>1. Acute Dystonic Reactions:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">High doses are more likely to produce such effects.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> 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.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> 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. </div> <bR> <bR> <div> <B>2. Akathisia:</B></div> <div> 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). </div> <bR> <bR> <bR> <div> <B>3. Parkinsonism:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">These parkinsonian side-effects of antipsychotic drugs usually respond to the addition of an anti-parkinson drug (e.g., benztropine, procyclidine). </div> <bR> <bR> <bR> <div> <B>4. Tardive Dyskinesia:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Early signs of tardive dyskinesia are mostly seen in the area of the face. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Choreoathetoid movement of the fingers and toes may also be observed, as may respiratory dyskinesia associated with irregular breathing and, perhaps, grunting. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tardive dyskinesia is thought to result from dopamine receptor supersensitivity following chronic receptor blockade by the antipsychotic agent. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Anticholinergic drugs do not improve tardive dyskinesia and may make it worse.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> 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. </div> <bR> <bR> <div> <B>5. Neuroleptic Malignant Syndrome:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The neuroleptic malignant syndrome is an exceedingly rare but potentially fatal condition characterized by parkinsonian-type rigidity, increased temperature, and altered consciousness.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The syndrome is ill-defined and overlaps with hyperpyrexia, parkinsonism, and neuroleptic-induced catatonia. Coma may develop and result in rare terminal deaths. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This syndrome is reported most often in young males, may appear suddenly, and usually lasts 5 to 10 days after cessation of neuroleptics. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There is no treatment; therefore, early recognition and discontinuation of antipsychotic drugs, followed by supportive therapy, are indicated. </div> <bR> <bR> <bR> <div> <B>6. Hypersomnia And Lethary:</B></div> <div> 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. </div> <bR> <bR> <div> <B>7. Other Side-Effects:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Antipsychotics also may cause amenorrhea, lactation, hirsutism, and gynecomastia. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Weight gain may be more liable to occur with any antipsychotic drug which causes hypersomnia and lethargy.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Studies suggest that many antipsychotic drugs taken during pregnancy do not result in fetal abnormalities.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Because these agents reach the fetal circulation, they may affect the newborn, thus producing postnatal depression and also dystonic symptoms. </div> <bR> <bR> <bR> <div>  <A NAME="head_1d"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>"Drug Holidays" From Antipsychotic Drugs</div> <div> 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 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>, as well as increase the risk of tardive dyskinesia. </div> <bR> <bR> <div>  <A NAME="head_1e"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Antidepressant Drugs</div> <div> The older (tricyclic) antidepressants often worsen <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>. However, the newer (serotonergic) antidepressants (e.g., fluoxetine, trazodone) have dramatically benefited many apathetic or depressed <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patients. </div> <bR> <bR> <div>  <A NAME="head_1f"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Antianxiety Drugs</div> <div> Benzodiazepines (e.g., lorazepam, clonazepam) often can dramatically reduce the agitation and anxiety of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patients. This is often especially true for those suffering from catatonic excitement or stupor. Clonazepam also is an effective treatment for akathisia. </div> <bR> <bR> <div>  <A NAME="head_1g"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>When Not To Use Antipsychotic Drugs</div> <div> 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. </div> <bR> <bR> <div>  <A NAME="head_1h"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Lithium</div> <div> 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. </div> <bR> <bR> <div>  <A NAME="head_1i"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Anticonvulsants</div> <div> The addition of carbamazepine, clonazepam, or valproate to antipsychotic drug refractory <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patients has been reported to sometimes be effective. This benefit is more often seen in patients suffering from bipolar <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>. Acute psychotic agitation or catatonia often responds to clonazepam. </div> <bR> <bR> <div>  <A NAME="head_1j"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Other Drugs</div> <div> The use of megavitamins and special diets have apparently little or no effect for <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patients. </div> <bR> <bR> <div>  <A NAME="head_1k"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Electroconvulsive Therapy</div> <div> Electroconvulsive therapy (ECT) has been used effectively in small percentage of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> 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 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patients. </div> <bR> <div> <B><U> <A NAME="head_2"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Psychosocial Treatment</U></B></div> <bR> <bR> <div>  <A NAME="head_2a"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Basic Principles</div> <div> Untreated <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> 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. </div> <bR> <bR> <div>  <A NAME="head_2b"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Supportive Psychotherapy</div> <div> Traditional insight-oriented psychotherapy is not recommended in treating <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> 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. </div> <div> 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. </div> <bR> <bR> <div>  <A NAME="head_2c"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Group Therapy</div> <div> Group therapy, combined with drugs, produces somewhat better results than drug treatment alone, particularly with <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> 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. </div> <bR> <bR> <div>  <A NAME="head_2d"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Family Therapy</div> <div> Family therapy can significantly decrease relapse rates for the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> 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 <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patients discuss and share issues, have been particularly helpful in this regard. </div> <bR> <bR> <div>  <A NAME="head_2e"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Behavior Therapy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Behavior therapy in hospital often involves rewarding desired behaviors with specific privileges, such as ground privileges or weekend passes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patient is no longer floridly psychotic or distractible, behavior therapy usually can successfully teach much needed social and occupational skills. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Patients with concurrent schizophrenic and mood symptoms are often treated with antipsychotics plus antidepressant or thymoleptic drugs. The authors review the literature on treatment of two overlapping groups of patients: those with <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> and those with schizophrenia and concurrent mood symptoms.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> METHOD: MEDLINE searches (from 1976 onward) were undertaken to identify treatment studies of both groups, and references in these reports were checked. Selection of studies for review was based on the use of specified diagnostic criteria and of parallel-group, double-blind design (or, where few such studies addressed a particular issue, large open studies). A total of 18 treatment studies of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> and 15 of schizophrenia with mood symptoms were selected for review.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> RESULTS: For acute exacerbations of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT> or of schizophrenia with mood symptoms, antipsychotics appeared to be as effective as combination treatments, and there was some evidence for superior efficacy of atypical antipsychotics. There was evidence supporting adjunctive antidepressant treatment for schizophrenic and <FONT SIZE="3" COLOR="#800000" FACE="Arial" >schizoaffective</FONT> patients who develop a major depressive syndrome after remission of acute psychosis, but there were mixed results for treatment of subsyndromal depression. There was little evidence to support adjunctive lithium for depressive symptoms and no evidence concerning its use for manic symptoms in patients with schizophrenia. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CONCLUSIONS: Empirical data suggest that both groups of patients are best treated by optimizing antipsychotic treatment and that atypical antipsychotics may prove to be most effective. Adjunctive antidepressants may be useful for patients with major depression who are not acutely ill. Careful longitudinal assessment is required to ensure identification of primary mood <FONT SIZE="3" COLOR="#800000" FACE="Arial" >disorder</FONT>s. </div> <div> <B><U>PCP</U></B></div> <div> <B><U>Lithium</U></B></div> <div> <B><U>Glutamate</U></B></div> <div> <B><U>Risperidone</U></B></div> <div> <B><U>Ziprasidone</U></B></div> <div> <B><U>Antipsychotics</U></B></div> <div> <B><U>NMDA antagonists</U></B></div> <div> <B><U>New antipsychotics</U></B></div> <div> <B><U>Atypical antipsychotics</U></B></div> <div> <B><U>Schizophenia: new drugs</U></B></div> <div> <B><U>Bipolars v schizophrenics</U></B></div> <div> <B><U>Cannabis and schizophrenia</U></B></div> <div> <B><U>Serotonin model of schizophrenia</U></B></div> <div> <B><U>Dopamine model of schizophrenia</U></B></div> <bR> <bR> </td> </tr></table></body>