Schizoaffective Disorder and Bipolar Disorder

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Schizoaffective Disorder and Bipolar Disorder

By Leigh Ann Hartless
Dr. Qualls
Internship
Spring 2016

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Schizoaffective Disorder and Bipolar Disorder

This spring I interned at the Southwest Virginia Mental Health Institute in Marion
Virginia. I started at the end of January 2016 and stayed there until April 2016. Throughout my
time there, I saw many different things including how each ward worked and within the wards,
how each team (treatment team) worked with each other. The hospital has many different wards
for different things there are two or three with acute care- meaning they should not be there long
or they will be there a long time and other wards such as: geriatrics and medical. The wards also
have a mixed variety of non-forensic patients and forensic patients (or criminally committed or
not). Before someone is committed to the hospital, they must go through court. There, the judge
decides if they need to be committed or not and if it is based on a voluntary or involuntary
means. When someone is committed on a voluntary order, they have a tad more freedom of when
they can leave; whereas the treatment teams have more control over that for involuntary.
Each treatment team has a Doctor, Psychologist, a nurse, and several social workers who
all work together to work with the patient and their families and insurance. Each team, however,
is very different. When my advisor, David Mask, told me they would be different, I was not
expecting complete opposites of each other. In one team, the Doctor is more of the leader
where everyone has to report to and not really challenge him a lot. On other teams, while it may
be similar, there is more room to talk and discuss patients. My favorite teams were the ones
where I could not tell who the Doctor was. These teams seemed to work well together and unite
more than the others.
The hospital also has a Physical Therapist. When I was first introduced to this idea of
mental health patients needing Physical Therapy, I was confused and wondered how that would

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help their mental condition. After shadowing with the PT for a couple of days, I realized that the
patients are learning other ways to cope with certain things, whether it is mania or others,
through physical activities. For example: one patient suffers from mania and when she is manic
the PT will ask her to concentrate on one task such as moving her legs in a certain way, this in
turn calms her down a little. The PT also mentioned that sometimes the patients will open up to
her more because they see her as an escape from the ward and more freedom.
The experience I had with the PT, mixed with the experience of watching how the teams
treat the patients for their condition, makes me think about more effective ways of treatment in
correlation with the medications. Thinking about this through the brain of the future counselor, I
feel like the Hospital could use more one on one therapy. While they do group therapy, I think
there is high quality in helping someone through just talking to them. Once again, I mean this in
correlation with medication because some disorders such as Schizoaffective Disorder and
Bipolar Disorder are more chemical.

What is Schizoaffective Disorder?

Within my time at the Southwestern Virginia Mental Health Institute, I experienced a lot
of people with Schizoaffective Disorder. Schizoaffective Disorder is when symptoms such as:
hallucinations or delusions lasting up to or more than 2 weeks and an uninterrupted period of
time where a major mood episode is seen. (www.janssencns.com). Schizoaffective Disorder is
different from Schizophrenia because there are more, and more sever, symptoms for
Schizophrenia. Schizoaffective disorder is also more common than Schizophrenia. During my
time at the Southwest Virginia Mental Health Institute, I only saw one patient with Schizophrenia
yet many with Schizoaffective Disorder.

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Schizoaffective Disorder is caused by many different things but it comes down to a

chemical imbalance in the brain. Recent studies such as the one done by Thomas E. Smith, Hull,
J. W., Israel, L. M., & Wilson, D. R. in 2000, focus on the aspect of insight in regards to
Schizophrenia and Schizoaffective disorder. It has been proposed that poor insight in
schizophrenia [Schizoaffective Disorder] is (1) a direct manifestation of positive, negative, or
disorganized symptoms; (2) a separate, independent symptom domain; (3) a defensive coping
strategy; or (4) a function of impaired neurocognition, similar to the syndrome of anosognosia
described in some neurological conditions. (Smith, Hull, Israel, & Wilson, 2000, pg. 193). The
researchers used 46...outpatient individuals and had them complete assessments of symptoms
neurocognition, and insight (Smith, et. al., 2000, page 193), from there the researchers used
different scales and used a regression equation to review the results. The results of this study
showed high levels of awareness of having a mental disorder but much more variability in
ratings of symptom unawareness and misattribution (Smith, et. al., 2000, page 197).
Other studies focus on recovery and predictors of recovery at the first episodes of
Schizoaffective Disorder. At the beginning of one study conducted by Delbert G. Robinson,
Woerner, M. G., McMeniman, M., Mendelowitz, A., Bilder, R.M, they assessed patients at
baseline (or without medication) and then were treated with different medications (Delbert G.
Robinson, Woerner, M. G., McMeniman, M., Mendelowitz, A., Bilder, R.M, 2004, pg. 474). The
results of this study showed that patients with first-episode schizophrenia or schizoaffective
disorder can recover. However, [there is a] low rate of recovery during the early years of the
illness (Delbert, et. al., 2004, pg. 478). In an earlier and similar study, Delbert G. Robinson,
Woerner, M.G., Alvir, J. M.J., Geisler, S., Koreen, A., Sheitman, B., Chakos, M., Mayerhoff, D.,
Bilder, R., Goldman, R., & Lieberman, J. A. sought to examined the same thing as above:

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predictors of treatment response from first episodes (Delbert G. Robinson, Woerner, M.G.,
Alvir, J. M.J., Geisler, S., Koreen, A., Sheitman, B., Chakos, M., Mayerhoff, D., Bilder, R.,
Goldman, R., & Lieberman, J. A, 1999, pg. 544). Their method was to put them on a series of
medications progressing from one phase of the algorithm to the next until they responded
(Delbert, et. al. 1999, pg. 545) and later performed a multivariate analysis. This study found that
Although attention may not change with conventional antipsychotic treatment, [the] data
suggest that baseline attention (assessed in a different manner) predicts positive symptom
improvement in first-episode patients (Delbert, et. al. 1999, pg. 548).
Lastly, studies are being done to see what a better medication is for Schizoaffective
Disorder. In a study conducted by PV Tran, GD Tollefson, TM Sanger, Y Lu, PH Berg and CM
Beasley, Jr, two new medications were put against each other: olanzapine and haloperidol. The
study consisted of about 300 patients who met the DSM-III criteria (PV Tran, GD Tollefson,
TM Sanger, Y Lu, PH Berg and CM Beasley, Jr, 1999, pg. 15). The study was a double blind
study and each patient began with 5 mg/day; after a seven day period, the dose could be
increased or decreased by 5 mg (PV Tran, et. al., 1999, pg. 15). The researchers found that, after
many statistical tests, olanzapine outperformed haloperidol and that ...olanzapine represents an
important alternative treatment option in schizoaffective disorder (PV Tran, et. al., 1999, pg.
21).

What is Bipolar Disorder?

Schizoaffective Disorder was not the only very common thing I noticed. I also saw many
people with Bipolar Disorder, typically when they also have Schizoaffective Disorder. Bipolar
Disorder is defined by the DSM by having the following episodes: Major Depressive Episode,

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Manic Episode, Mixed Episode and Hypomanic Episode. These episodes must not derive from
some other circumstance or illness that would logically, or better, account for its expression.
(www.jbrf.org). Within Bipolar Disorder there are two different sub groups, Bipolar 1 and
Bipolar 2. The differences in these are between full mania (7 days) and hypomania (4 days)
(www.jbrf.org).
Bipolar Disorder is also caused by chemical imbalances in the brain and has a high
genetic determination (Robert L. Leahy, 2007, pg. 419). It is commonly paired with another
disorder in the patient and many bipolar patients not only lack insight into their mania but often
have poor recollections of their manic episodes (Robert L. Leahy, 2007, pg. 419). The
researcher states that while the clinician should be treating the specific episode [they should
also be]... laying the groundwork for maintenance treatment over the long term (Robert L.
Leahy, 2007, pg. 420).
Another article goes into the treatment of Bipolar Disorder. The article, written by John R
Geddes and Miklowitz, D.J. in 2013, states several medications such as: lithium and olanzapine
are the best medications to use. They go further to state that emphasis has been put on
conducting pharmacotherapy with targeted psychotherapy...Psychological approaches build on
evidence that psychosocial stressors, including excessive family discord or distress, negative life
events, or events that disrupt sleep and wake rhythms or accelerate goal attainment are associated
with relapses and worsening symptomatic states (John R Geddes and Miklowitz, D.J., 2013).
They also go on to mention other types of therapy, such as: Group psychoeducation,
Interpersonal and social rhythm therapy, Cognitive-behavioral therapy, Family focused therapy,
and more.

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How do they correlate?

Schizoaffective Disorder and Bipolar disorder are not only sometimes found in the same
patient, however studies have shown they may share common genetic determinants (Paul
Lichtenstein, PhD , Yip B. H. , MSc, Bjrk, C. , MSc, Pawitan Y., PhD, Cannon T.D, PhD,
Sullivan P. F, MD, Hultman C.M, PhD.). In this study, conducted in 2009, researchers look at
nuclear families in Sweden. They acquired and linked the multi-generation register and the
hospital discharge register (Paul Lichtenstein, PhD, et. al., 2009) and assessed about two
million nuclear families for genetic and environmental contributions to liability for
schizophrenia and bipolar disorder (Paul Lichtenstein, et. al., PhD, 2009). They found that
the comorbidity between disorders was mainly (63%) due to additive genetic effects common to
both disorders (Paul Lichtenstein, PhD, et. al., 2009).
Lastly, a study was conducted to try and pinpoint the exact location these two mental
disorders occur in the brain. The researchers, NL Johnston-Wilson, Sims, C.D., Hofmann, J-P.,
Anderson, L., Shore, A.D., Torrey, E.F., Yolken, R.H., took post mortem brains and looked at
them through two-dimensional electrophoresis, multivariate analysis and protein sequencing
(NL Johnston-Wilson, Sims, C.D., Hofmann, J-P., Anderson, L., Shore, A.D., Torrey, E.F.,
Yolken, R.H., & the Stanley Neuropathology Consortium, 2000, pg.148). The results of this
study showed identification of five proteins which are differentially expressed in the frontal
cortex regions of the brains of individuals with psychiatric diseases (NL Johnston-Wilson, et.
al., 2000, pg. 148).
These findings well represent my experience at the Southwest Virginia Mental Health
Institute. They show that while each mental disorder is very different, they show a lot of
commonalities and can co-exists with each other in the same patient very well. I enjoyed my

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experience at the hospital because it helped me learn the differences between certain disorders
from seeing them and it helped me learn to recognize one and that many are very similar.

References

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Delbert G. Robinson, Woerner, M.G., Alvir, J. M.J., Geisler, S., Koreen, A., Sheitman, B.,
Chakos, M., Mayerhoff, D., Bilder, R., Goldman, R., & Lieberman, J. A. (1999). Predictors of
Treatment Response From a First Episode of Schizophrenia or Schizoaffective Disorder. Am J
Psychiatry, 156 (4), 544-549. Retrieved from
http://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.4.544
Delbert G. Robinson, Woerner, M. G., McMeniman, M., Mendelowitz, A., Bilder, R. M. ( 2004).
Symptomatic and Functional Recovery From a First Episode of Schizophrenia or Schizoaffective
Disorder. Am J Psychiatry, 161, 473479 Retreived from
http://ils.unc.edu/bmh/neoref/nrschizophrenia/jsp/review/tmp/393.pdf
Diagnosis by the DSM. http://www.jbrf.org/diagnosis-by-the-dsm/

John R Geddes and Miklowitz, D.J. (2013).Treatment of bipolar disorder. US National Library
of Medicine National Institutes of Health. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876031/
NL Johnston-Wilson, Sims, C.D., Hofmann, J-P., Anderson, L., Shore, A.D., Torrey, E.F.,
Yolken, R.H., & the Stanley Neuropathology Consortium. (2000). Disease-specific
alterations in frontal cortex brain proteins in schizophrenia, bipolar disorder, and major
depressive disorder. Molecular Psychiatry, 5, 142149. Retrieved from
http://www.plasmaproteome.org/Bios_and_bibliographies/PDF's/Disease-specific
%20alterations%20in%20frontal%20cortex%20brain%20proteins%20in
%20schizophrenia%20bipolar-Johnston-Wilson-2000-Mol%20Psychiatry.pdf
Paul Lichtenstein, PhD , Yip B. H. , MSc, Bjrk, C. , MSc, Pawitan Y., PhD, Cannon T.D, PhD,
Sullivan P. F, MD, Hultman C.M, PhD. (2009). Common genetic determinants of
schizophrenia and bipolar disorder in Swedish families: a population-based study. The
Lancet, 373 (9659: 17-23): 234239. Retrieved from
http://www.sciencedirect.com/science/article/pii/S0140673609600726
PV Tran, Tollefson, G.D., Sanger, T.M., Lu,Y., Berg, P.H., & Beasley, Jr. C.M. (1999).
Olanzapine versus haloperidol in the treatment of schizoaffective disorder. Acute and
long-term therapy.The British Journal of Psychiatry, 174, 15-22. Retrieved from
https://www.researchgate.net/profile/Todd_Sanger/publication/13087485_Olanzapine_ve
rsus_haloperidol_in_the_treatment_of_schizoaffective_disorder._Acute_and_longterm_therapy/links/0fcfd511079cd312b1000000.pdf
Robert L. Leahy. (2007) Bipolar Disorder: Causes, Contexts, and Treatments. Journal of Clinical
Psychology, 63 (5), 417424. Retrieved from
https://www.researchgate.net/profile/Robert_Leahy/publication/6404413_Bipolar_disord
er_Causes_contexts_and_treatments/links/54cf9baa0cf29ca810ff4366.pdf

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Thomas E. Smith, Hull, J. W., Israel, L. M., & Willson, D. R. (2000). Insight, Symptoms, and
Neurocognition in Schizophrenia and Schizoaffective Disorder. Schizophrenia Bulletin,
26 (1), 193-200. Retrieved from
http://schizophreniabulletin.oxfordjournals.org/content/26/1/193.full.pdf
What is Schizoaffective Disorder? http://www.janssencns.com/invega/schizoaffectivedisorder/about/about-schizoaffective-disorder/definition