Case report session

Hari / Tanggal: Selasa, 2 Mei 2018

NASKAH PSIKIATRI
F25.0 SKIZOAFEKTIF TIPE MANIK

Nama Dokter Muda : Siti Ubaidah P.2416

Charan Kamal Kaur Toor P.2418
Nama Perseptor : dr. Taufik Ashal, Sp.KJ

BAGIAN PSIKIATRI FAKULTAS KEDOKTERAN

UNIVERSITAS ANDALAS/ SMF PSIKIATRI
RSJ HB. SAANIN PADANG
2018
 CHAPTER 1
INTRODUCTION
1.1 Background

Schizoaffective disorder is a mental disorder characterized by the presence of

symptoms between schizophrenia and the symptoms of affective disorder that occur
together. The cause of schizoaffective disorder is unknown, but four conceptual models
have been developed.2

According to general statistics, the incidence of this disorder is approximately

0.2% in the United States in the general population and up to 9% of people are
hospitalized because of the disorder. Schizoaffective disorder is thought to occur more
frequently than bipolar disorder. Prevalence in men is lower than women. The onset of
age in women is greater than that of men, in old age depressive type schizoaffective
disorder more frequent whereas for younger age more often bipolar type schizoaffective
disorder. Men with schizoaffective disorder may show antisocial behavior.2,7

In schizoaffective disorder, clinical symptoms of episodic disturbance of

symptoms of mood disorder and schizophrenic symptoms stand out in the same episode
of disease. When schizophrenic and manic symptoms are prominent in the same episode
of disease, the disorder is called a manic-type schizoaffective disorder. In the depressive
type of schizoaffective disorder, depressive symptoms are prominent. Typical symptoms
in schizophrenic patients in the form of delusions, hallucinations, changes in thinking,
changes in perception accompanied by symptoms of mood disorder feelings both manic
and depressive.1,2,3

Diagnosis of schizoaffective disorder is established when meeting diagnostic

criteria based on DSM-IV-TR or PPDGJ-III. The differential diagnosis of schizoaffective
disorder usually includes all forms of mood disorder and schizophrenia. At any
differential diagnosis of psychotic disorders, a complete medical examination should be
performed to rule out organic causes. Patients with schizoaffective disorders have a mid-
term prognosis between the prognosis of patients with schizophrenia and the prognosis of
patients with mood disorders. In this referat, it will be discussed thoroughly about the
manic type schizoaffective. 1,2,3

1.2 Scope of problem

This case report discusses definition, etiology, clinical features, diagnosis, management,
and prognosis of manic-type schizoaffective.

1.3. Writing method

The method used in the writing of this case report is a literature review which refers to
cases and various literatures.

1.4. Writing purpose

This case report aims to add to the knowledge and understanding of aetiology, clinical
features, diagnosis, and management, a manic-type schizoaffective prognosis.
 CHAPTER II

LITERATURE REVIEW

2.1 Definitions

Schizoaffective disorders have both schizophrenic symptoms and affective

disorders that are equally prominent. Schizoaffective disorders have distinct symptoms of
schizophrenia and at the same time also have symptoms of prominent affective
disorder.1,2 Schizoaffective disorder consists of three subtypes, namely manic type,
depression, and mixture. 2.3

2.2 Epidemiology
 The lifetime prevalence of schizoaffective disorder is less than 1 percent,
possibly in the range of 0.5 to 0.8 percent. However, the picture is an approximation, as
studies on schizoaffective disorders use a variety of diagnostic criteria. In clinical
practice, the diagnosis of the onset of schizoaffective disorder is often used when a
clinician is unsure of the diagnosis. 1 . The prevalence of disorders has been reported
lower in males than in females. Males with schizoaffective disorder tend to exhibit
antisocial behavior and have a tangible or inappropriate blunt effect. The age of onset is
slower in women than in men. 1.4

2.3 Etiology

The cause of schizoaffective disorder is not known for certain, but is thought to
be caused by an imbalance of brain neurotransmitters, such as serotonin, norepinephrine,
and dopamine. In addition, it is suspected that the etiology of schizoaffective disorders is
similar to the etiology of schizophrenia. Therefore, the etiological theory of
schizoaffective disorder also includes genetic and environmental factors. 1,4,5. Four
conceptual models have been proposed related to the schizoaffective etiology. The four
models are:

1. Schizoaffective disorder may be a type of schizophrenia or a type of mood disorder.

2. Schizoaffective disorder may be a joint expression of schizophrenia and mood

disorders.

3. Schizoaffective disorder may be a different type of psychosis, a type not related to

schizophrenia or a mood disorder.

4. The greatest possibility is that schizoaffective disorder is a heterogeneous disorder

group that includes all three first possibilities. Most studies have considered patients with
schizoaffective disorder as a heterogeneous group.

2.4 Clinical Manifestations

 In a schizoaffective disorder the clinical symptoms of episodic disorder symptoms
of mood disorder and schizophrenic symptoms are prominent in the same episodes of
disease, either simultaneously or alternately within a few days. When schizophrenic and
manic symptoms are prominent in the same episode of disease, the disorder is called a
manic-type schizoaffective disorder. And in the depressive-type schizoaffective disorder,
prominent depressive symptoms.1

Typical symptoms in schizophrenic patients in the form of delusions,

hallucinations, changes in thinking, changes in perception accompanied by symptoms of
mood disorder feelings both manic and depressive.1,2 .Clinical symptoms based on the
classification guidelines and diagnosis of mental disorders (PPDGJ-III): 2.3 There should
be at least one of the following symptoms that are very clear (and usually two or more
symptoms if symptoms are less sharp or less obvious):

a) "thought echo" = the content of one's own mind repeating or echoing in its head (not
hard), and the contents of the repetitive thought, although the content is the same, but the
quality is different; or "thought insertion or withdrawal" = the contents of the alien and
the outside enter into his mind (insertion) or the contents of his mind taken out by
something from outside (withdrawal); and "thought broadcasting" = content his mind
came out so that others or the public knew it;

b) "delusion of control" = the idea of being controlled by a certain force from the outside;
or "delusion of passivitiy" = the idea of being powerless and resigned to an outside force;
(about "itself" = clearly refers to the movement of body / limbs or to mind, action, or
special sensing). "Delusional perception" = an improbable sensory experience, which is
quite distinctive for itself, is usually mystical or miraculous.

c) Auditory hallucinations: Sound hallucinations that constantly comment on the patient's

behavior, or discuss the patient's case among themselves (among the various speech
voices), or other hallucinatory sounds coming from one part of the body.

d) Other sedentary ideologies which, according to local culture, are considered unnatural
and impossible, such as certain religious or political beliefs, or strengths and abilities
above ordinary people (such as being able to control the weather, or communicating with
aliens and the world other).
e) Any persistent hallucination and senses, when accompanied by both floating and semi-
shaped ideals with no obvious affective content, or accompanied by over-valued ideas, or
if it occurs on a daily basis for weeks or months continuously.

f) Break-out or interpolated currents, which result from incoherent incoherence or

conversation, or neologism.

g) Catatonic behavior, such as excitement, posturing, or cerea flexibility, negativism,

mutism, and stupor.

h) Negative symptoms, such as a very apathetic, rare speech, and emotional or collusive
emotional response, usually resulting in the withdrawal of social intercourse and the
decline in social performance; but it must be clear that all these things are not caused by
depression or medication of neuroleptics.

The presence of specific symptoms above has been taking place over a period of one
month or more (not applicable to any nonpsychotic phase (prodromal) There should be a
consistent and meaningful change in overall quality and some aspects of personal
behavior ), manifests as loss of interest, non-purposive life, non-self-absorbed attitude
and social withdrawal.2,3
The following are the clinical manifestations of schizoaffective disorder based on
subtypes.3

a. Skizoafective Type Bead Disorders

The mood of feelings should increase prominently or there is an increase in a not-so-

conspicuous feeling combined with increased irritability or anxiety. In the same episode
it should be clear there is at least one, or better yet, two distinct symptoms of
schizophrenia (as defined for schizophrenia).
Behavioral symptoms include excessive activity, acceleration and most speech, decreased
sleep needs, ideas of greatness / "grandiose ideas" and overly optimistic. 2

a. Skizoafective Type Depressive Disorder 3

There should be a prominent depression, accompanied by at least two typical depressive
symptoms or behavioral disorders as contained in the depressive episode criteria; in the
same episode, there must be at least one or more distinct symptoms of schizophrenia (as
defined for diagnostic guidelines for schizophrenia).

The main symptoms of depressive episodes are: 2

a. Affect depressive
b. Loss of interest and excitement
c. Reduced energy leading to increased fatigue (a real fatigue after a little work) and
decreased activity.

Other symptoms of depressive episodes: 2

a. Concentration and attention are reduced

b. Self-esteem and self-confidence are reduced
c. The notion of guilt and uselessness
d. The gloomy and pessimistic outlook of the future
e. An idea or act of self-harm or suicide
f. Sleep disturbed
g. Decreased appetite.

b. Skizoafective Mixed Type Disorders2,3

Interference with symptoms of schizophrenia exists jointly with the symptoms of bipolar
affective disorder of mixed type.

2.5 Diagnosis

The diagnosis of schizoaffective disorder is only made when the definitive

symptoms of schizophrenia and affective disorder are equally prominent at the same
time, or within the first few days after another, in the same episode of the disease, and as
a consequence, the episode does not meet the criteria either schizophrenia or manic or
depressive episodes. 2.3
The main diagnostic criteria for schizoaffective disorders (Table 1) are that patients
have met diagnostic criteria for severe depressive episodes or manic episodes that
together with the discovery of diagnostic criteria for the active phase of schizophrenia. In
addition, the patient should have a delusions or hallucinations for at least two weeks
without any symptoms of prominent mood disorder. Symptoms of mood disorders should
also be found for most active and residual psychotic periods. In essence, the criteria are
written to help clinicians avoid diagnosing a mood disorder with psychotic features as a
schizoaffective disorder.1

Table 1. Diagnostic Criteria for Skizoafective Disorders (DSM-IV-TR) 1

Diagnostic Criteria For Skizoafective Disorders
A. Period of unbroken disease in the form of, at a time.
There are either severe depressive episodes, manic episodes, or a mixed episode with
symptoms that meet A's criteria for schizophrenia.
Note: Severe depressive episodes should include A1 criteria: depressed mood.
B. During the same period of illness, there is wisdom or hallucination during
at least 2 weeks without any prominent mood symptoms.
C. Symptoms that meet the criteria for mood episodes are found for the most part
meaningful of the total duration of the active and residual periods of the disease.
D. Disorders are not due to the direct physiological effects of a substance (eg, drugs
abused, a medication) or a general medical condition.
Specify type:
Bipolar type: if the disorder includes manic or mixed episodes (or a manic episode
or mixture and major depressive episodes)
Depressive type: if the disorder only includes severe depressive episodes.

DSM-IV-TR also helps the clinician to determine whether the patient is suffering
from schizoaffective disorder, bipolar type, or schizoaffective disorder, depressive type.
A patient is classified as suffering from a bipolar type if the existing episode is of a manic
type or a mixed episode and a severe depressive episode. In addition, patients are
classified as depressive type.1
 In PPDGJ-III, schizoaffective disorder is given a separate category because it is
quite common so it can not be ignored. Other conditions with affective symptoms overlap
with or constitute some existing schizophrenic disease, or where the symptoms are shared
or alternately with other types of sedentary disorders, are classified in the appropriate
category in F20-F29. Understandings or hallucinations that are not in harmony with the
mood of affective disorder do not necessarily support the diagnosis of schizoaffective
disorder.3

Table 2. Diagnostic Guidelines for Skizoafective Disorders according to PPDGJ-III3

• The diagnosis of schizoaffective disorder is only made when the definitive
symptoms of schizophrenia and schizophrenia and affective disorder are simultaneously
prominent, or within the first few days after another, in the same episode of disease, and
when , as a consequence of this, disease episodes do not meet both schizophrenia and
manic or depressive episodes.
• Can not be used for patients displaying symptoms of schizophrenia and affective
disorder but in different episodes of disease.
• If a schizophrenic patient presents depressive symptoms after a psychotic episode,
the diagnosis code is F20.4 (Post-Schizophrenia Depression). Some patients may
experience recurrent schizoaffective episodes, either manic (F25.0) or depressive (F25.1)
or a mixture of both (F25.2). Other patients experienced one or two manic or depressive
episodes (F30-F33)

The following are the criteria for diagnosis of schizoaffective disorder according to
PPDGJ III based on subtype.2

1. Skizoafective Type Manic Disorder (F25.0)

Diagnostic guidelines:

- This category is used for either single-beads skizoafective episodes as well as for
recurring disorders with most of the manic-type schizoaffective episodes
 - The affects should increase prominently or there is an increase in affective not so
prominent in combination with increased irritability or anxiety.

- In the same episode it should be clear there are at least one or better yet two,
typical symptoms of schizophrenia (as defined for schizophrenia)

2. Depression-type Skizoafective Disorder (F25.1)

Diagnostic guidelines:

- This category should be used both for single depressive episodes of depressive
type, and for recurrent disorders where most episodes are dominated by depressive type
schizoaffective
- Depressive affects should be prominent, accompanied by at least two distinctive
symptoms, both depressive and related behavioral abnormalities as noted in the
description for depressive episodes (F.32)

- In the same episode, there should be at least one, and there should be two typical
symptoms of schizophrenia (as defined in the guidelines for the diagnosis of
schizophrenia (F.20).

3. Mixed type schizoaffective disorder (F25.2)

Disorders with schizophrenia symptoms are co-existing with mixed affective bipolar
symptoms (F31.6)

2.6 Differential Diagnosis

The differential diagnosis of schizoaffective disorder usually includes all forms of

mood disorder and schizophrenia. At any differential diagnosis of psychotic disorders, a
complete medical examination should be performed to rule out organic causes. A history
of drug abuse with or without a positive toxicology screening test may indicate a
substance-induced disorder. Previous medical conditions, medications, or both can cause
psychotic and mood disorders. Any suspicion of neurologic abnormalities requires
examination of brain scans to exclude anatomical abnormalities and EEGs to determine
any possible seizure disorders. 1

2.7 Management

Management is divided by phase into acute and advanced phases.3

1. Acute Phase3
a) Pharmacotherapy
Injection
a. Olanzapine, a dose of 10 mg / mL intramuscular injection, can be repeated every
2 hours, a maximum dose of 30 mg / day

b. Aripriprazole, a dose of 9.75 mg / mL intramuscular injection, can be repeated

every 2 hours, a maximum dose of 29.25 mg / day.

c. Haloperidol, a 5mg / mL dose of intramuscular injection, can be repeated every

half hour, a maximum dose of 20mg / day.

d. Diazepam 10mg / 2 mL intravenous / intramuscular injection, maximum dose of

30mg / day.

Oral

a. Olanzapine 1 x 10 - 30 mg / day or risperidone 2 x 1- 3 mg / day or quetiapine day

I (200mg), day II (400 mg), day III (600 mg) or day I (1x300 mg-XR) and so on may be
raised to 1x600 mg-XR) or aripirazole 1 x 10-30 mg / day.
 b. Lithium carbonate 2 x 400 mg, increased to a therapeutic range of 0.8-1.2 mEq /
L (usually achieved with lithium carbonate doses 1200-1800 mg / day, in normal renal
function) or divalproate at a dose of 2 x 250 mg / day (or plasma concentrations of 50-
125 μg / L) or 1-2 x500mg / day ER.

c. Lorazepam 3 x 1-2 mg / day if necessary (rowdy anxiety or insomnia).

d. Haloperidol 5-20 mg / day

- Therapy (Monotherapy)
(1) Olanzapine, Risperidon, Quetiapine, Aripiprazol
(2) Lithium, Divalproate.
- Combination Therapy
(1) Olz +; Li / Dival Olz + Lor; Olz + Li / Dival + Lor
(2) Ris + Li / Dival; Ris + Lor; Ris + Li / Dival + Lor
(3) Que + Li / Dival
(4) Aripip + Li / Dival; Aripip + Lor; Aripip + Li / Dival + Lor
The duration of drug administration for the acute phase is 2-8 weeks or until the
absolute remission is achieved YMRS ≤ 9 or MADRS ≤ 11 and PANSS-EC ≤ 3 per
PANSS-EC item.

b) Psycho-education
c) Other Therapies
- ECT (for refractory patients)

2. Advanced Phase3

a. Psychopharmaca3
Therapy (Monotherapy)
 a) Lithium carbonate 0.6-1 mEq / L is usually achieved at doses of 900-1200 mg /
day once dose of 500 mg / day
b) Olanzapine 1 x 10 mg / day
c) Quetiapine at a dose of 300 - 600 mg / day
d) Risperhidone with 1-4 mg / day
e) Aripirazole at a dose of 10-20 mg / day
Combination Therapy
Combination of the above drugs. Use of long-term antidepressants for the major
depressive episode-type schizoaffective is not recommended as it may induce the
occurrence of manic episodes.
• Klozapine doses 300-750mg / day (refractory patient) Long-term continuous drug
administration 2-6 months until recovery is achieved symptom-free for 2 months.

2. Psycho-education

2.8 Prognosis

Schizoaffective prognosis is better than schizophrenia but worse when compared

with mood disorders. The course of the disease is less likely to deteriorate and its
response to lithium is better than schizophrenia.1,3
 CHAPTER 3

CASE ILUSTRATION

I. IDENTITY

PATIENTS PERSONAL INFORMATION

Name (initial) : Mrs.YA

Sex : Female

Place & Date of Birth/ Age : Saruaso & 6th July 1977/40 Years

No Medical Record : 02.86.81

Marital Status : Married

Nationality : Indonesia

Race : Minangkabau

Origin : Padang

Religion : Islam

Education : SMU
Job : Housewife

Adress : Jalan Saruaso Timur, Saruaso, Tanjung Emas, Tanah Datar

Name, Status, Contact of Family Member : Desriyenti, Sister, 081266589920

Nearest in Padang

INFORMATION FROM ALLO/ INFORMANT

Name (initial) : Tn. J

Sex : Laki – Laki

Age : 62 tahun

Job : Petani

Education : SD

Adress : Ampalu, Sungai Sarik, pariaman

Relationship with patient : Paman

Bonding with patient : Akrab

Impression of doctor towards information given by : (Trusted/ Not to be trusted)

II. PSYCHIATRY HISTORY

Information /anamnesis below is obtained by (circling the answer down below)

1. Autoanamnesis with patient was done on 26 April 2018 at Ward of Melati, RS Jiwa
HB Saanin, Padang
2. Alloanamnesis with the sister of the patient was done on 29 April 2018 via phone.
1. Patient came to this facilty on the behalf of (circling the correct answer)
a. Byself
b. Family
c. Police

d. Judge
e. Others

2. Main Cause

Patient complained of restlessness, unstable emotion, anger without reason, before

entering the hospital.

3. Chief Complaint

Patient complained of restlessness, unstable emotion, anger without reason, excessive of

suspicion, leaving the house without any reason, speaking and laughing by herself and
not able to sleep for 4 days before entering the hospital.

4. History of Present Illness

Patient complained of restlessness, unstable emotion, anger without reason, excessive of

suspicion, leaving the house without any reason, speaking and laughing by herself and
not able to sleep for 4 days before entering the hospital. Patient complained of excessive
speaking, movement back and forth, lack of sleep and feels very important person,
history of stealing things. Regulary controlling at Puskemas and stopped for a year.

5. History of Past Illness

a. History of Psychiatry Illness
b. History of Medical Condition
c. History of Substance Use, Abused and Addictions
6. Family History
a. Identity of Parent./ Guardian

A. Identity of Parent./ Guardian

Identity Parent/ Guardian Explanation

Father Mother

Nationality Indonesia Indonesia

 Race Minangkabau Minangkabau

Religion Islam Islam

Education SD SD

Job - -

Age - -

Address - -

Relationship Akrab Akrab Biasa

patient*
Biasa Kurang

Kurang Tak peduli

Tak peduli :-

:-

Others with
a. Characteristic or Behaviour of Parent/ Guardian
Father ( Explained by patient that can be trusted /lack of trust)
Lazy ( - ), Quiet ( - ), Short Tempered ( - ), Sensitive ( - ), Reserved ( - ), Lots of Friend
(-), Heavy Smoker ( - ), Shy ( - ), Gambler ( - ), Drinker ( - ), Anxious ( - ), Depressed
( - ), Perfectionist ( - ), Dramatic ( - ),Suspicious ( - ), Jealous ( - ), Egoistic ( - ),
Coward ( - ), Irresponsible ( - ).

Mother ( Explained by patient that can be trusted /lack of trust) Lazy ( - ), Quiet ( -
), Short Tempered ( - ), Sensitive ( - ), Reserved ( - ), Lots of Friend (-), Heavy Smoker
( - ), Shy ( - ), Gambler ( - ), Drinker ( - ), Anxious ( - ), Depressed ( - ), Perfectionist
( - ), Dramatic ( - ), Suspicious ( - ), Jealous ( - ), Egoistic ( - ), Coward ( - ),
Irresponsible ( - ).

c. Sibling

d. Amount of Sibling with Age ( circling for patient itself.)

e. Personality/ Behaviour of each sibling and relationship with patient toward sibling.
f. Other people staying at the patient house with the patient, behavioural pattern and how
is the patient towards them

No Relationship with the Attitude and behavior Relationship

patient towards patient quality (close/
normal,/less
close/ less care)
1.

2.

3.

g. History of mental illness, habit and physical illness ( related to mental illness ) to the
family

Family member Mental illness Habit Physical illness

Father none none none

Mother none none none

Siblings None none none

Grandmother none none none

Grandfather none none none

Others none none none

Pedigree scheme 17
Explanation : : Male : mental illness

: Female : Passes away

a) Patients living condition:

No Place of living Home condition

Peaceful Suitable Condusive Not condusive

1. Jr Saruaso timur, tanjung emas