Schizoaffective Disorder

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

Coping With Schizophrenia

Schizoaffective disorder facts

  • Schizoaffective disorder is a chronic condition that is characterized by both psychotic symptoms (delusions and hallucinations) and mood problems.
  • There are two kinds of schizoaffective disorder: bipolar and depressive.
  • There is no known single specific cause for schizoaffective disorder.
  • Schizoaffective disorder symptoms and signs include those of schizophrenia in addition to a manic episode or a major depressive episode.
  • The typical treatment for schizoaffective disorder involves the individual taking an antipsychotic drug and possibly a mood stabilizer in addition to psychoeducation.
  • For people who do not respond to the typical treatments, some may respond to non-medication medical treatments like transcranial magnetic stimulation (TMS) or electroconvulsive therapy (ECT).

What is schizoaffective disorder?

Schizoaffective disorder is a mental illness that involves persistent psychotic symptoms, like hallucinations or delusions, occurring together with mood problems of depressive, manic, or mixed episodes. The term schizoaffective was first used in 1933 by Jacob Kasanin and has been included in every edition of the mental health diagnostic manual, called the Diagnostic and Statistical Manual of Mental Disorders (DSM), since 1952. Statistics on how often this condition occurs range from 0.32% in the general United States population up to as much as 9% of psychiatrically hospitalized people. Schizoaffective disorder is thought to occur at least as often as schizophrenia and less often than bipolar disorder.

Quick GuideSchizophrenia: Symptoms, Types, Causes, Treatment

Schizophrenia: Symptoms, Types, Causes, Treatment

Schizoaffective Disorder Medication Treatment

Risperidone (Risperdal)

Risperidone is an atypical antipsychotic drug that is used for treating schizophrenia, bipolar mania and autism. Other atypical antipsychotic drugs include Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Aripiprazole (Abilify) and paliperidone (Invega).

What are the different types of schizoaffective disorder?

There are two types of schizoaffective disorder: bipolar type and depressive type. The bipolar type of schizoaffective disorder is characterized by at least one manic episode. The depressive type of this illness involves having only major depressive episodes as the mood disorder part of the illness.

What are causes and risk factors for schizoaffective disorder?

As with the vast majority of mental disorders, there is not thought to be a specific cause for schizoaffective disorder. Two-thirds of people who develop the illness are women. An immediate family history of any mental illness, especially schizoaffective disorder, bipolar disorder, or schizophrenia is a risk factor for schizoaffective disorder. Children born prematurely who were also small for their stage of development (gestational age) are also at risk for developing schizoaffective disorder, depression, or bipolar disorder. Developing schizoaffective disorder or another psychotic illness is more than twice as likely in children who suffer significant adversity like bullying, abuse, neglect, or parental death, especially by suicide, during that time of their lives.

What are symptoms and signs of schizoaffective disorder?

The symptoms and signs of schizoaffective disorder include those of schizophrenia combined with major depressive disorder and/or a manic episode. Symptoms of schizophrenia may include the following:

  • Hallucinations, like hearing voices, seeing, feeling, tasting, or smelling things that are not there
  • Delusions are ways of thinking with no basis in reality. Types of delusions include paranoid/persecutory, religious, erotic, grandiose (for example, false beliefs of superiority), jealous, body (somatic), or mixed (more than one) types and often involve the sufferer believing that an ordinary event has special and personal meaning (for example, the person with this symptom may believe that people on television are specifically talking to him or her directly)
  • Disorganized speech
  • Severely disorganized or catatonic behaviors, like rigid muscles, not speaking (mutism), purposeless moving, repeating what is said by others (echolalia) or adopting unusual body postures
  • Negative symptoms, like the decrease or absence of speech (alogia), a limited range of emotional, or movement

Symptoms of a major depressive episode might include the following:

  • Depressed or irritable mood most of every day for two weeks or more in a row
  • Inability to feel pleasure
  • Appetite changes
  • Significant weight loss in the absence of healthy dieting
  • Significant weight gain
  • Sleeping too little or too much
  • Restlessness or moving less (psychomotor agitation or retardation, respectively)
  • Low energy most days
  • Feelings of worthlessness
  • Trouble concentrating
  • Social isolation
  • Hopelessness
  • Thoughts of death, thoughts, plans or attempts at self-harm or suicide

Symptoms of a manic episode may be characterized by the following:

  • Excessive self-esteem or grandiosity
  • Expansive mood/euphoria (for example, feeling excessively happy or silly)
  • Racing thoughts
  • Rapid, frenzied/pressured speaking that may be off topic (tangential)
  • Decreased need for sleep
  • Sudden increases in energy
  • Impulsivity
  • Increase in goal-oriented activities
  • Engaging in activities that may cause problems (for example, excessive spending or sexual activity)

Similar to schizophrenia, schizoaffective disorder is associated with impairments in memory, changing attention, thinking abstractly, and planning. However, people with schizoaffective disorder tend to have better cognitive functioning versus people with schizophrenia. In terms of brain structure, individuals with schizoaffective disorder tend to have smaller brain volumes compared to the general population, particularly in certain areas of the brain.

What tests do health care professionals use to diagnose schizoaffective disorder?

To diagnose schizoaffective disorder, one first has to rule out any medical condition that may be the actual cause or contributing factor for the mood and behavioral changes. Once medical causes have been looked for and not found, a mental illness such as schizoaffective disorder could be considered. The diagnosis will best be made by a licensed mental health professional, like a psychiatrist, clinical psychologist, psychiatric nurse, nurse practitioner, or physician's assistant, who can evaluate the patient and carefully sort through a variety of mental illnesses that might look similarly upon the initial examination. Such illnesses include any other thought disorder, like schizophrenia spectrum disorders, including schizophrenia, delusional disorder, and schizotypal personality disorder, as well as any disorder in which both mood symptoms and psychosis may occur or appear to occur, like borderline personality disorder, dissociative identity disorder, bipolar disorder with psychotic features, or major depression with psychotic features.

The mental health professional will examine someone in whom schizoaffective disorder is suspected either in an office or in the emergency department. The practitioner's role is to ensure that the patient doesn't have any medical problems, including active drug use or exposure to environmental toxins, since symptoms of those conditions can mimic the thought disorder and mood swings of schizoaffective disorder. The health care professional takes the patient's history and performs a physical examination. Laboratory and other tests, sometimes including a computerized tomography (CT) scan of the brain, are performed. Physical findings can relate to the symptoms associated with schizoaffective disorder or the medications the person may be taking.

Quick GuideSchizophrenia: Symptoms, Types, Causes, Treatment

Schizophrenia: Symptoms, Types, Causes, Treatment

What are criteria for diagnosis of schizoaffective disorder?

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), in order to be diagnosed with schizoaffective disorder, an individual must meet the following diagnostic criteria:

  • An uninterrupted period of illness that includes either a major depressive disorder or a manic episode along with at least two active symptoms of schizophrenia (hallucinations, delusions, disorganized speech, severely disorganized or catatonic behaviors, negative symptoms like decreased emotional expression or movement)
  • Delusions (for example, paranoia, erotomania, grandiosity, delusional jealousy, persecutory or somatic delusions) or hallucinations occur for at least two weeks without major depressive or manic symptoms at some time during the illness.
  • The symptoms of major mood disorders occur for most of the duration of the illness.
  • The illness is not the result of a medical condition or the effects of alcohol, other drugs of abuse, a medication or exposure to an environmental toxin.

What is the treatment for schizoaffective disorder? Are there home remedies for schizoaffective disorder?

Given the potentially serious impact that schizoaffective disorder has on the lives of sufferers, home remedies are not thought to be appropriate to address its symptoms. Treatment for people living with this condition tends to be symptom-based rather than distinctly different based on the illness itself. In terms of medication treatment, individuals with the bipolar type of the disorder seem to respond best to treatment with an antipsychotic drug combined with a mood-stabilizer drug or treatment with an antipsychotic drug alone. For people with the depressive type of schizoaffective disorder, combining an antipsychotic medication with an antidepressant medication tends to work best. Since consistent treatment is important for the best outcome, psychoeducation of the person with the illness and their loved ones, as well as using long-acting medications can be important aspects of their care.

For people who don't respond to multiple trials of treatment, electroconvulsive therapy (ECT) may be an option. Treatment for people who suffer from both schizoaffective disorder and a substance-abuse disorder (dual diagnosis) tends to be most effective when both conditions are specifically addressed.

Antipsychotic medications have been shown to be effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizoaffective disorder thus has two main phases: an acute phase, when higher doses of medication might be necessary in order to alleviate psychotic and severe mood disorder symptoms, followed by a maintenance phase, which could be lifelong. During the maintenance phase, the medication dosage is gradually reduced to the minimum required to prevent further episodes. If symptoms reappear on a lower dosage, a temporary increase in medication dosage may help prevent a relapse.

Even with continued treatment, some patients have relapses. By far, though, the highest relapse rates are seen when medication is discontinued. Most patients experience substantial improvement when receiving antipsychotic agents. Some patients, however, do not respond to medications, and a few may seem not to need them. Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed in a timely manner.

Medication treatment for schizoaffective disorder

Antipsychotic medications are the cornerstone in the management of schizoaffective disorder. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and allow the patient to function better, have better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a health care professional who is well trained and experienced in treating severe mental illness. The first antipsychotic was discovered by accident and then used for schizophrenia. This was chlorpromazine (Thorazine), which was soon followed by medications such as haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), loxapine (Loxitane), and thioridazine (Mellaril). These medications have become known as "neuroleptics" because, although effective in treating positive symptoms (for example, acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they can also alleviate severe anxiety that people with schizoaffective disorder may suffer. However, they cause side effects, many of which affect the neurologic (nervous) system. Since 1989, a new class of antipsychotics (atypical antipsychotics) has been introduced. At clinically effective doses, very few of these neurological side effects, which often affect the extrapyramidal nerve tracts (which control such things as muscular rigidity, painful muscle spasms, restlessness, or tremors) are observed.

The first of the new class, clozapine (Clozaril), is not associated with extrapyramidal side effects, but it can produce other side effects, including a possible decrease in the number of white blood cells to the point of being dangerous, so the blood needs to be monitored every week during the first six months of treatment and then every two weeks to detect this side effect early if it occurs. Other atypical antipsychotics include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel and Seroquel-XR), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris), iloperidone (Fanapt), paliperidone (Invega), lurasidone (Latuda), and brexpiprazole (Rexulti). The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizoaffective disorder. That some neuroleptic medications can either be injected into muscle (for example, haloperidol, fluphenazine, risperidone, and aripiprazole) or melt once placed under the tongue (for example, asenapine) can further help the schizoaffective disorder sufferer maintain critical compliance with their care.

Although more effective and better tolerated, the use of atypical antipsychotic drugs is also associated with side effects, and current medical practice is developing better ways of understanding and minimizing these effects, identifying people at risk, and monitoring for the emergence of complications.

Mood-stabilizer medications like lithium (Lithobid), valproic acid or divalproex (Stavzor or Depakote), carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol), and lamotrigine (Lamictal) can be useful in treating active (acute) symptoms of mania as well as preventing return of such symptoms in schizoaffective disorder. Some studies have also found that oxcarbazepine (Trileptal) may also be a helpful addition to other medications that treat schizoaffective disorder. These medications may take a bit longer to work compared to the neuroleptic medications, and some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels, while some can be associated with birth defects when taken by pregnant women. Since people with schizoaffective disorder often have depression as part of the illness, medications that address that symptom may be of great benefit, as well. Serotonergic medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil or Pexeva), citalopram (Celexa), escitalopram (Lexapro), vilazodone (Viibryd), and vortioxetine (Trintellix) are often prescribed because of their effectiveness and low incidence of side effects. Other often-prescribed antidepressant medications for treatment of schizoaffective disorder include venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and bupropion (Wellbutrin).

Most of these medications take several weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, or another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least six to eight weeks (or even longer with clozapine).

Non-medication psychotherapeutic treatments for schizoaffective disorder

In spite of successful antipsychotic treatment, many patients with schizoaffective disorder have difficulty with maintaining motivation, activities of daily living, relationships, and communication skills. Therefore, psychosocial treatments are also important, and many useful treatment approaches have been developed to complement the medications in assisting people suffering from this illness:

  • Individual psychotherapy: This involves regular therapy sessions between just the patient and a therapist focused on past or current problems, thoughts, feelings, or relationships. Thus, via contact with a trained professional, people with schizoaffective disorder become able to understand more about the illness, to learn about themselves, and to better handle the problems of their daily lives. The goals of therapy often include helping the person with schizoaffective disorder become better able to distinguish between what is real and, by contrast, what is not and to acquire beneficial problem-solving skills.
  • Rehabilitation: Rehabilitation may include job and vocational counseling, problem solving, social-skills training, nutrition, and education in money management. Thus, patients learn skills required to live with the illness through successful reintegration into their community following discharge from the hospital and to minimize or eliminate the need for psychiatric hospitalizations.
  • Family psychoeducation and family therapy: Research has consistently shown that people with schizoaffective disorder who have involved families with an understanding of their illness have a better prognosis than those who battle the condition alone.
  • Self-help groups: Outside support for family members of those with schizoaffective disorder often is necessary and desirable.

Non-medication medical treatments for schizoaffective disorder

As with other schizophrenia spectrum and other psychotic disorders, people with schizoaffective disorder who do not receive enough relief of psychotic symptoms (like hallucinations or delusions) from medication and psychotherapy treatments may benefit from non-medication medical interventions like transcranial magnetic stimulation (TMS) or electroconvulsive treatment (ECT). TMS is a treatment that involves applying a magnetic field through the scalp to a small area of the brain to provide repeated stimulation. The treatment course is usually completed over about six weeks, with each treatment session taking about 20 minutes. TMS tends to have few negative effects and is considered to be quite safe.

ECT involves the use of electrical current passed through the brain using electrodes on one side of the brain through the scalp for the purpose of inducing seizures. It is done while the person is sedated under generalized anesthesia. While its effectiveness in treating psychotic symptoms when used alone does not seem to be established, it is thought to be helpful when used in addition to prescribed antipsychotic medication. Due to side effects of decreased memory and risks associated with generalized anesthesia, ECT is considered to be a treatment of last resort for schizophrenia spectrum and other psychotic disorders

What are complications of schizoaffective disorder?

There are a number of potential complications of schizoaffective disorder. Obesity, diabetes, and physical inactivity are examples of medical problems that disproportionately affect people with this and other severe mental illnesses. It is estimated that between 46%-50% of people with a psychotic disorder like schizoaffective disorder have a substance-abuse disorder at some time in their life, most commonly nicotine, followed by alcohol and marijuana abuse. There is research indicating that about one-third of people who suffer from either schizoaffective disorder or schizophrenia have attempted suicide. Suicide attempts seem to occur about four years after the first-time psychosis occurs and about seven years after the onset of the first major depressive episode for those who had a history of major depression. Even in the absence of depression, people with a psychotic disorder like schizoaffective disorder or schizophrenia are at higher risk for having suicidal thoughts or attempts.

Quick GuideSchizophrenia: Symptoms, Types, Causes, Treatment

Schizophrenia: Symptoms, Types, Causes, Treatment

What is the prognosis of schizoaffective disorder?

The prognosis of schizoaffective disorder can be challenging. Some studies indicate that about 47% of people with this illness or schizophrenia can be considered to be in remission after five years, and about one-quarter of individuals have appropriate social functioning for two years or more. The prognosis for people with schizoaffective disorder tends to depend on how well the person was functioning before the illness began, the individual's compliance with prescribed medication to treat the illness, the number of illness episodes the person has, how persistent their psychotic symptoms are, as well as their level of cognitive functioning. Overall, however, individuals who suffer from schizoaffective disorder tend to have psychotic symptoms for a longer time before getting treated and to have a more difficult course compared to those with bipolar disorder. Whether an individual suffers from schizoaffective disorder or schizophrenia, they are more likely to have more frequent, troubling hallucinations and anxiety, as well as more difficulty attending work regularly over time compared to people without those illnesses.

Is it possible to prevent schizoaffective disorder?

Once schizoaffective disorder has occurred, prevention of future episodes is best achieved when the person suffering from the illness receives consistent treatment, including medication and psychosocial treatment of their symptoms.

Are there support groups for schizoaffective disorder?

National Alliance on Mental Illness

Schizoaffective.org

REFERENCES:

Abrams, D.J., D.C. Rojas, and D.B. Arciniegas. "Is schizoaffective disorder a distinct categorical diagnosis? A critical review of the literature." Neuropsychiatric Disorders Treatment 4.6 Dec. 2008: 1089-1109.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association 2013, Arlington, Virginia.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association 2000, Washington, D.C.

Baker, A.L., et al. "Treatment of cannabis use among people with psychotic or depressive disorders: a systematic review." Journal of Clinical Psychiatry 71.3 Mar. 2010: 247-254.

Daumit, G.L., R.W. Goldberg, C. Anthony, et al. "Physical activity patterns in adults with severe mental illness." Journal of Nervous and Mental Disease 193.10 Oct. 2005: 641-646.

Harkavy-Friedman, J.M., E.A. Nelson, D.F. Venarde, and J.J. Mann. "Suicidal behaviour in schizophrenia and schizoaffective disorder: examining the role of depression." Suicide Life-Threat 34 (2004): 66-76.

Heckers, S. "Is schizoaffective disorder a useful diagnosis?" Current Psychiatric Reports (2009): 332-337.

Laursen, T.M., R. Labouriau, R.W. Licht, et al. "Family history of psychiatric illness as a risk factor for schizoaffective disorder: a Danish register-based cohort study FREE." Archives of General Psychiatry 62.8 (2005): 841-848.

Laursen, T.M., et al. "A comparison of selected risk factors for unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia from a Danish population-based cohort." The Journal of Clinical Psychiatry 68.11 (2007): 1673-1681.

Lindenmayer, J.P., H. Liu-Seifert, P.M. Kulkarni, et al. "Medication nonadherence and treatment outcome in patients with schizophrenia or schizoaffective disorder with suboptimal prior response." The Journal of Clinical Psychiatry 70.7 (2009): 990-996.

Lysaker, P.H., N.L. Beattie, A.M. Strasburger, et al. "Reported history of child sexual abuse in schizophrenia: Associations with heightened symptom levels and poorer participation over four months in vocational rehabilitation." Journal of Nervous and Mental Disease 193.13 Dec. 2005: 790-795.

Mazza, M., M. Di Nicola, G. Martinotti, et al. "Oxcarbazepine in bipolar disorder: a critical review of the literature." Expert Opinion on Pharmacotherapy 8.5 (2007): 649-656.

Robinson, D.G., M.G. Woerner, M. McMeniman, et al. "Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder." The American Journal of Psychiatry 161.3 Mar. 2004: 473-479.

Schottle, D., B.G. Schimmelmann, P. Conus, et al. "Differentiating schizoaffective and bipolar I disorder in first-episode psychotic mania." Schizophrenia Research 140.1-3 Sept. 2012: 31-36.

Smeraldi, E., R. Cavallaro, V. Folnegovic-Smalc, et al. "Long-term remission in schizophrenia and schizoaffective disorder: results from the risperidone long-acting injectable versus quetiapine relapse prevention trial (ConstaTRE)." Therapeutic Advances in Psychopharmacology Mar. 2013.

Sommer, I.E.C., C.W. Slotema, Z.J. Daskalakis, et al. "The treatment of hallucinations in schizophrenia spectrum disorders." Schizophrenia Bulletin 38.4 (2012): 704-714.

Stauder, A.D. "Group motivational interviewing as a psychotherapeutic intervention for dual diagnosis patients living with a psychotic disorder: critique of the literature." Graduate Journal of Counseling Psychology 3.1 (2012).

Varese, F., F. Smeets, M. Drukker, R. Lieverse, et al. "Childhood Adversities Increase the Risk of Psychosis: A Meta-analysis of Patient-Control, Prospective and Cross-sectional Cohort Studies." Schizophrenia Bulletin 2012.

Vieta, E. "Developing an individualized treatment plan for patients with schizoaffective disorder: from pharmacotherapy to psychoeducation." Journal of Clinical Psychiatry 71.2 (2010): 14-19.

Yogeswary, K. "Schizoaffective disorder: an overview." International Journal of Clinical Psychiatry 2.1 (2014): 11-15.

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Reviewed on 3/20/2017
References
REFERENCES:

Abrams, D.J., D.C. Rojas, and D.B. Arciniegas. "Is schizoaffective disorder a distinct categorical diagnosis? A critical review of the literature." Neuropsychiatric Disorders Treatment 4.6 Dec. 2008: 1089-1109.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Association 2013, Arlington, Virginia.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association 2000, Washington, D.C.

Baker, A.L., et al. "Treatment of cannabis use among people with psychotic or depressive disorders: a systematic review." Journal of Clinical Psychiatry 71.3 Mar. 2010: 247-254.

Daumit, G.L., R.W. Goldberg, C. Anthony, et al. "Physical activity patterns in adults with severe mental illness." Journal of Nervous and Mental Disease 193.10 Oct. 2005: 641-646.

Harkavy-Friedman, J.M., E.A. Nelson, D.F. Venarde, and J.J. Mann. "Suicidal behaviour in schizophrenia and schizoaffective disorder: examining the role of depression." Suicide Life-Threat 34 (2004): 66-76.

Heckers, S. "Is schizoaffective disorder a useful diagnosis?" Current Psychiatric Reports (2009): 332-337.

Laursen, T.M., R. Labouriau, R.W. Licht, et al. "Family history of psychiatric illness as a risk factor for schizoaffective disorder: a Danish register-based cohort study FREE." Archives of General Psychiatry 62.8 (2005): 841-848.

Laursen, T.M., et al. "A comparison of selected risk factors for unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia from a Danish population-based cohort." The Journal of Clinical Psychiatry 68.11 (2007): 1673-1681.

Lindenmayer, J.P., H. Liu-Seifert, P.M. Kulkarni, et al. "Medication nonadherence and treatment outcome in patients with schizophrenia or schizoaffective disorder with suboptimal prior response." The Journal of Clinical Psychiatry 70.7 (2009): 990-996.

Lysaker, P.H., N.L. Beattie, A.M. Strasburger, et al. "Reported history of child sexual abuse in schizophrenia: Associations with heightened symptom levels and poorer participation over four months in vocational rehabilitation." Journal of Nervous and Mental Disease 193.13 Dec. 2005: 790-795.

Mazza, M., M. Di Nicola, G. Martinotti, et al. "Oxcarbazepine in bipolar disorder: a critical review of the literature." Expert Opinion on Pharmacotherapy 8.5 (2007): 649-656.

Robinson, D.G., M.G. Woerner, M. McMeniman, et al. "Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder." The American Journal of Psychiatry 161.3 Mar. 2004: 473-479.

Schottle, D., B.G. Schimmelmann, P. Conus, et al. "Differentiating schizoaffective and bipolar I disorder in first-episode psychotic mania." Schizophrenia Research 140.1-3 Sept. 2012: 31-36.

Smeraldi, E., R. Cavallaro, V. Folnegovic-Smalc, et al. "Long-term remission in schizophrenia and schizoaffective disorder: results from the risperidone long-acting injectable versus quetiapine relapse prevention trial (ConstaTRE)." Therapeutic Advances in Psychopharmacology Mar. 2013.

Sommer, I.E.C., C.W. Slotema, Z.J. Daskalakis, et al. "The treatment of hallucinations in schizophrenia spectrum disorders." Schizophrenia Bulletin 38.4 (2012): 704-714.

Stauder, A.D. "Group motivational interviewing as a psychotherapeutic intervention for dual diagnosis patients living with a psychotic disorder: critique of the literature." Graduate Journal of Counseling Psychology 3.1 (2012).

Varese, F., F. Smeets, M. Drukker, R. Lieverse, et al. "Childhood Adversities Increase the Risk of Psychosis: A Meta-analysis of Patient-Control, Prospective and Cross-sectional Cohort Studies." Schizophrenia Bulletin 2012.

Vieta, E. "Developing an individualized treatment plan for patients with schizoaffective disorder: from pharmacotherapy to psychoeducation." Journal of Clinical Psychiatry 71.2 (2010): 14-19.

Yogeswary, K. "Schizoaffective disorder: an overview." International Journal of Clinical Psychiatry 2.1 (2014): 11-15.

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