Researchers and clinicians have made tremendous strides in diagnosing and treating mental health conditions. Yet, for all this progress, which should be a source of hope for individuals and families affected by mental illness, there is still a large gray area when it comes to diagnosing some disorders.
A case in point: schizoaffective disorder versus bipolar disorder, both of which may develop for the first time during early adulthood. In the first case, schizoaffective disorder can bear resemblances to schizophrenia; and, its features can also be easy to misdiagnose as bipolar disorder (and vice versa). In fact, it’s very easy to misdiagnose schizoaffective disorder as bipolar disorder. This reality is only further complicated by the fact that bipolar disorder is itself commonly misdiagnosed and can be classified as either Bipolar 1 or Bipolar 2.
How then do you get an accurate diagnosis when it’s not entirely clear whether schizoaffective or bipolar disorder is the issue? As a psychologist who specializes in clinical neuropsychology and regularly works with this patient population, I often help individuals who may have been misdiagnosed get a correct diagnosis. What follow are insights based on that experience, in the hope they can help you, a loved one, or a friend, get a correct diagnosis.
Shared Features and Symptoms of Schizoaffective and Bipolar Disorder
There can be a good degree of symptom overlap between these two disorders. Schizoaffective disorder is classified as two types, bipolar type (marked by episodes of mania and major depression) and depressive type (characterized by only major depressive episodes). Meanwhile, bipolar disorder 1 and 2 are described by manic and hypomanic episodes, respectively, as well as episodes of depression. While schizoaffective disorder involves psychotic symptoms, bipolar disorder can as well, rendering diagnosis a potentially delicate task.
Consider this common scenario among patients admitted to inpatient treatment: Someone might enter treatment experiencing mood problems (mania or depression) that on their own could suggest bipolar disorder. At the same time, though, the person might be hearing things or having delusional ideas (which can occur with bipolar and schizoaffective disorder also). Some examples:
- The person may be convinced that CEOs of Fortune 500 companies regularly call him or her. (We typically call this type of delusion “non-bizarre,” insofar as it’s not entirely outside the scope of what’s possible—even if it’s a delusion.)
- Or, the person may be sure he or she’s a god. For instance, in one real-life situation, a patient refused to let us take his blood because he was convinced he was Jesus Christ and doesn’t bleed. (This would be an example of a bizarre delusion.)
Key Considerations When Diagnosing Schizoaffective/Bipolar Disorder
A common profile of those who come to me for help determining whether they have schizoaffective or bipolar disorder is that of young adults who have had their very first psychotic episode. They may have been at work and not feeling great and depressed for several weeks when they started having the belief that their coworker was hacking into their computer. When they brought the matter to their supervisor, the supervisor referred them to treatment.
By the time they consult me for the first time, they may already be taking medication for the false beliefs and delusional (psychotic) thinking. At this stage, the diagnostic challenge is to discern whether the patient has a psychotic disturbance that only occurs during a mood episode or whether there are psychotic symptoms when there’s no mood issue involved.
Making this determination is critical to accurately diagnosing schizoaffective vs. bipolar disorder. Keep in mind that one of the primary criteria for a diagnosis of schizoaffective disorder is the presence of delusions or hallucinations for two weeks in the absence of a mood disorder (such as depression or mania).
Psychotic Symptoms That Can Co-Occur with Schizoaffective and Bipolar Disorder
Delusions and hallucinations are psychotic symptoms and can occur with either schizoaffective or bipolar disorder. The point with psychotic symptoms is that the person is seeing and hearing things that aren’t there or are having beliefs that are not grounded in reality.
“Delusions” are false beliefs guiding behavior and can include delusions of grandeur and paranoid delusions. “Hallucinations” are sensory perceptions and can include hearing voices, seeing shapes, colors, things, or people who aren’t there, smelling something unpleasant that is not there, having unreal, tactile sensations (like bugs crawling on you), or experiencing an unpleasant and non-existent flavor.
How to Know Whether Psychotic Symptoms Are Schizoaffective or Bipolar-Related
Because psychotic symptoms can underlie a diagnosis of either bipolar or schizoaffective disorder, it’s important to take note of when the psychotic symptoms occur, for how long they occur, and when they go away—if at all. These criteria, when considered together, probably hold the most sway in distinguishing schizoaffective from bipolar disorder.
With bipolar disorder, psychotic symptoms can manifest when you’re depressed or when you’re manic. A key difference is that these symptoms tend to occur only when a person is having that mood episode, and once that mood episode has been controlled with the help of medication, the psychotic symptoms dissipate. For example, you can be manic for seven days, during which time you can be convinced you’re a celebrity, but once you get treatment and the episode remits, those delusions of grandeur will pass.
In contrast, with schizoaffective disorder, the psychotic symptoms can occur seemingly out of the blue, are unattached to mood changes, and must occur for at least two weeks in order to be diagnosed as schizoaffective. (That said, you can also have a two-week period of schizoaffective psychosis that precedes an episode of depression.)
Another Key Difference to Look for When Noticing Symptoms
Another key difference to look for is the presence of psychotic symptoms—the reason being that many people with bipolar disorder don’t experience psychosis. It’s therefore important for individuals and families to keep a record of symptoms. If I’m able to rule out psychotic symptoms after conducting a detailed assessment of the patient, it’s more likely the case that the person has bipolar (or another) disorder, not schizoaffective disorder.
How Neuropsychological Testing May Help with Diagnosing
Thus far, there is not a definitive qEEG (quantitative electroencephalogram) finding that, by providing a picture of the brain, allows us to distinguish between schizoaffective and bipolar disorders. Typically, with both disorders, there is often visible dysregulation in the prefrontal circuitry of the brain, suggesting impairment of executive function. In other words, both schizoaffective and bipolar disorder may manifest as dysregulation on a qEEG.
In these cases, neuropsychological testing may provide additional diagnostic information by allowing me to measure a patient’s executive functions such as problem-solving, organization and planning, and visual and verbal abstract reasoning. Typically, someone with schizoaffective disorder will be more severely impaired in these areas involving executive functioning, in addition to other neurocognitive domains such as processing speed and attention and vigilance. In contrast, someone with bipolar disorder may suffer impairment in these same areas but to a lesser degree.
In general, it’s safe to say that neurocognitive impairments are not as severe with bipolar disorder as they are with schizoaffective disorder.
Schizoaffective and bipolar disorders can be serious pathologies. In the event that you or a loved one is suffering from debilitating symptoms, early intervention and diagnosis are key to a better treatment outcome. When you insist on an accurate diagnosis, you’ll be furthering your own health and improving your quality of life.
If you or someone you know experiences mental health issues, it is important to seek help from a qualified professional. Our Resource Specialist can help you find expert mental health resources to recover in your community. Contact us now for more information on this free service to our users.
Dr. Antonio Rotondo is a licensed clinical psychologist specializing in neuropsychology at FHE Health. Learn more about how FHE Health is using neurorehabilitative services to treat mental health needs in a residential setting.
Photo by Letizia Bordoni on Unsplash
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One thought on “Schizoaffective vs. Bipolar Disorder: How to Get an Accurate Diagnosis”
One of my family members showed psychotic symptoms like delusions following a few month of depression. She is 57 years old. Her depression was moderate at the beginning and she was coping with it. It started after she received a shocking news from her daughter . Anyways, her depression progressed to a major depression in few month and mixed up with severe anxiety, coinciding with Corona immersion. She refused medical treatment at first, but finally her family doctor prescribed SSRI for her. A few days after starting medications, she started having panic attacks and delusional symptoms. I am wondering how can you categorize her symptoms? She didn’t show any manic symptoms. Her older sister was affected with major depression with psychotic features and did committed suicide when she was 67 years old . I am wondering if she has Schizoaffective disorder or other diagnosis are suited to her symptoms? She is receiving antidepressants and antipsychotic medications plus psychotherapy with very slow response.