User:Ctom1999/Schizoaffective disorder

Peer Review Response Summary.


 * Truthfully, it was a bit difficult to integrate feedback, as most of my peer reviews did not provide many areas for which I could improve the article. As such, most of my edits and revisions are based on suggestions from User: Ajr1234's peer review.
 * Mechanisms
 * One critique lauded at this section was that it was hard to understand. This was due to certain terms like 'white matter' and 'hippocampal volume' not being defined. I agreed with these sentiments, however, I felt as though defining these terms in length might jeopardize the flow of the article, so I instead opted to link to wiki articles for both white matter and the hippocampus. I also added links for other jargon, including "precuneus", "lentiform nucleus", and "superior temporal gyrus". One concession I did make in this regard was for the addition of context explaining how some of these systems actually relate to SAD. Specifically, I gave more through explanations for the hippocampus and hippocampal volume. I also changed "White matter irregularities" to "White matter reductions", as this more clearly illustrates the type of dysfunction that occurs. This also led me to adding information linking grey matter to SAD as well.
 * Neutrality
 * As suggested by User: Thatbaddie205, I edited the sentence ,"Health care providers stress the importance of assessing for co-occurring substance", removing the word stress in order to maintain neutrality.
 * Sources
 * As was suggested, I looked for additional sources to strengthen the article. This brought my source count up from the initial 8, to an amended 10. On this front, I think I can still add more sources, though I am unsure if adding a future diagnosis section as suggested would be appropriate. If anything, I feel as though this information is something I can add to the "Research" section of the article.

Lead
There are two types of schizoaffective disorder: the bipolar type, which is distinguished by symptoms of mania, hypomania, or mixed episode; and the depressive type, which is distinguished by symptoms of depression only.  There are three forms of schizoaffective disorder: bipolar (or manic) type  (marked by symptoms of schizophrenia and mania), depressive type (marked by symptoms of schizophrenia and depression), and mixed type (marked by symptoms of schizophrenia, depression, and mania). Common symptoms of the disorder include hallucinations, delusions, and disorganized speech and thinking. Auditory hallucinations, or "hearing voices", are most common. The onset of symptoms usually begins in  adolescence or  young adulthood. On a ranking scale of symptom progression of mental health issues relating to the schizophrenic spectrum,  schizoaffective disorder falls between mood disorders and schizophrenia in regards to severity  a mood disorder would be the first diagnosis; as symptoms progress it would then be diagnosed as schizoaffective disorder, and if symptoms progress even more it would then be diagnosed as schizophrenia, with other disorders included on the ranking as well depending on symptoms. A mood disorder would be the less severe diagnoses, while schizophrenia would be the more severe diagnosis with schizoaffective disorder being a bridge between the two disorders. Schizoaffective disorder and other disorders on the schizophrenic spectrum are evaluated as a psychotic disorder in the DSM-V, so the line between psychotic or not psychotic begins at a mood disorder, as being considered not psychotic, and schizoaffective disorder along with other disorders of the schizophrenia spectrum, as being considered psychotic. A mood disorder is not in the schizophrenic spectrum.

Article body

 *  Mechanisms 
 *  Though the pathophysiology of schizoaffective disorder remains unclear, studies suggest that dopamine, norepinephrine, and serotonin may be factors in the development of the disorder.   White matter and Grey Matter reductions in the right lentiform nucleus, left superior temporal gyrus, and right precuneus, and other areas in the brain are also characteristic of schizoaffective disorder.   Deformities in white matter have also been found to worsen with time in individuals with schizoaffective disorder.   Due to it's role in emotional regulation, researchers believe that the hippocampus is also involved in the progression of schizoaffective disorder.   Specifically, psychotic disorders (such as schizoaffective disorder) have been associated with lower hippocampal volumes.   Moreover, deformities in the medial and thalamic regions of the brain have been implicated as contributing factors to the disorder as well. 
 * Diagnosis
 * Types
 * One of two  three  types of schizoaffective disorder may be noted in a diagnosis based on the mood component of the disorder:
 * Depressive type, when the disturbance includes major depressive episodes exclusively—that is, without manic, hypomanic, or mixed episodes.
 * Bipolar type, when the disturbance includes manic episodes, hypomania, or mixed episodes—major depressive episodes also typically occur;
 *  Mixed type, when the disturbance includes both manic and depressive symptoms, but psychotic symptoms exist separately from bipolar disorder. 
 *  Comorbidities 
 *  Schizoaffective disorder shares a high level of comorbidity with other psychiatric disorders, specifically anxiety disorders, depression, and bipolar disorder  .    Individuals with schizoaffective disorder are also often diagnosed with substance abuse disorder, usually relating to tobacco, marijuana, or alcohol.    Health care providers indicate the importance of assessing for co-occurring substance use disorders, as multiple diagnoses not only potentially increase negative symptomology, but may also adversely affect the treatment of schizoaffective disorder. 
 * Epidemiology
 *  Compared to depression, schizophrenia, and bipolar disorder, schizoaffective disorder is less commonly diagnosed.  Schizoaffective disorder is estimated to occur in 0.3 to 0.8 percent of people at some point in their life. 30% of cases occur between the ages of 25 and 35. It is more common in women than men; however, this is because of the high concentration of women in the depressive subcategory, whereas the bipolar subtype has a roughly even gender distribution. Children are less likely to be diagnosed with this disorder, as the onset presents itself at a later age  in adolescence or young adulthood. 
 * Research
 * Evidence is lacking about schizoaffective disorder's causes, which are likely multiple, and its mechanisms (knowing them leads to specific and consistently-effective treatments) and about how exactly mood episodes and psychosis are related (knowing them may lead to a simpler, clearer, and more usable behavioral definition of the disorder and a better diagnostic system). Little is known of the causes and mechanisms that lead to the development of schizoaffective disorder. Whether schizoaffective disorder is a variant of schizophrenia (as in DSM-5 and ICD-10 classification systems), a variant of bipolar disorder, or part of a dimensional continuum between psychotic depression, bipolar disorders and schizophrenia is currently being investigated.
 * Research into the assessment and treatment of schizoaffective disorder will rely less on DSM and ICD criteria as time progresses, and more on the dimensional Research Domain Criteria currently being developed by the U.S. National Institute of Mental Health (NIMH). The Research Domain Criteria initiative, led by Bruce Cuthbert of NIMH, is the inspiration for the Roadmap for Mental Health Research in Europe (ROAMER). The purpose of the Research Domain Criteria initiative is to address the marked variability and overlap within and among the disorder categories, and to foster development of more effective assessment and treatment for each individual patient. Over the coming decades, advances resulting from the Research Domain Criteria in the U.S. and ROAMER in Europe will be incorporated into future versions of the DSM and ICD, with the hope of eventually leading to personalized mental health of greater diagnostic accuracy and with more targeted and useful treatments, including biomedical, psychosocial, and possibly preventive approaches.
 * This section seemed wholly irrelevant outside of the opening sentence. The opening claim also never cited as source, and my own research yielded nothing. As such, I deleted it and instead chose to focus on how research is assessing the validity of SZA being classified as it's own disorder.
 * More recently, some research suggests the need for a more specialized classification for schizoaffective disorder. In a 2017 examining diagnostic heterogeneity study, researchers found that when compared to a schizophrenia sample, individuals with schizoaffective disorder rate higher in suicidality and anxiety disorder comorbidity.
 * Treatment
 * The primary treatment of schizoaffective disorder is medication, with improved outcomes using combined long-term psychological and social supports. Hospitalization may occur for severe episodes either voluntarily or (if mental health legislation allows it) involuntarily. Long-term hospitalization is uncommon since deinstitutionalization started in the 1950s, although it still occurs. Community support services including drop-in centers, visits by members of a community mental health team, supported employment and support groups are common  [fixed citation formatting error] . Evidence indicates that regular exercise has a positive effect on the physical and mental health of those with schizoaffective disorder. Participating in internet forums is sometimes used by people with schizoaffective disorder in addition to outpatient medication treatment.[citation needed]
 * No articles I could find backed up this claim. There were articles detailing schizophrenia's outcomes in relation to internet forum use, but they were behind paywalls. Said article was also published in 2005. Because of the heterogeneous symptomology associated with schizoaffective disorder, it is common for patients to be misdiagnosed. Many people are either diagnosed with depression, schizophrenia, or bipolar disorder instead of schizoaffective disorder. Because of the broad range of symptoms of Schizoaffective disorder, patients are often misdiagnosed in a clinical setting. In fact, almost 39% of people are misdiagnosed  when it comes to psychiatric disorders.  [fixed citation formatting error]   While various medications and treatment options exist for those diagnosed with schizoaffective disorder, symptoms may continue to impact a person for their entire lifespan.Schizoaffective disorder can affect a person's ability to  experience  experience a fulfilling social life and they may also exhibit difficulty forming bonds or relationships with others. Schizoaffective disorder is more likely to occur in women and symptoms begin manifesting at a young age.
 * All other edits to this section were made to address formatting issues. Many of the citations in the original article were placed in the middle of phrases/sentences. Also removed italicization from the word "experience".
 * Medication
 * Antipsychotic medication is usually required both for acute treatment and the prevention of relapse. There is no single antipsychotic of choice in treating schizoaffective disorder, but atypical antipsychotics should  may  be considered because they have  due to their  mood-stabilizing  abilities .  To date,  Paliperidone  (Invega)  is  the only  an antipsychotic  medication  with FDA approval for the treatment of schizoaffective disorder.  Other antipsychotics may be prescribed to further alleviate psychotic symptoms.  Antipsychotics should be used at the minimum dose necessary to control symptoms. Potential side effects include extrapyramidal symptoms, including tremor, muscle stiffness, and restlessness or akathisia. Atypical antipsychotics carry a risk of metabolic syndrome, including weight gain, increased blood sugar, and increased blood cholesterol, so regular monitoring of weight and blood work should be carried out. Some atypical antipsychotics, such as ziprasidone and aripiprazole, are associated with less risk than others, such as olanzapine. Medication choice is based on how effectively it reduces symptoms, how few side effects it causes, and cost.
 * In people with treatment-refractory psychosis, a clozapine trial should  may  be considered.  Though not approved for treatment use by the FDA, research suggests that Clozapine may also be effective in treating schizoaffective disorder, particularly in those resistant to initial medication.  Clozapine is an atypical antipsychotic that is recognized as being particularly effective when other antipsychotic agents have failed.  When combined with cognitive therapy, Clozapine has been found to decrease positive and negative symptoms of psychosis at a higher rate in schizoaffective individuals.  Clozapine should also be considered in people with chronic and persistent suicidal thinking and behavior, as it has  is also associated with a decreased  been shown to reduce the risk of suicide in patients with schizoaffective disorder and a history of suicidality. Between 0.5 and 2% of patients taking clozapine may develop a life-threatening complication called agranulocytosis, which is a significant drop in a type of white blood cell. Because of this risk, people taking clozapine must have regular monitoring of blood cell counts.  Despite this, clozapine treatment may be ineffective for some patients, particularly in those that are already drug-resistant. 
 * For depression, if an antidepressant is prescribed, extra attentiveness must be given by the prescribing clinician due its risk for long-term mood cycle acceleration (that is, inducing more frequent episodes of depression per unit of time) and prescribed medication-induced psychosis or mania  Antidepressants have also been used to treat schizoaffective disorder .  Though they may be useful in treating the depressive subtype of the disorder, research suggests that antidepressants are far less effective in treatment than antipsychotics and mood stabilizers.  For individuals who show emerging psychosis, mania, mixed episode symptoms, or mood cycle acceleration, switching to an antipsychotic plus lithium or lamotrigine is preferable to antidepressants.
 * For the final sentence, I could not find any evidence to back up this claim, and actually found some studies that refute it. Also, of the three sources cited in the original article, only one of them makes mention of SZA. As such, I decided to delete it entirely.
 * For individuals who experience anxiety, anti-anxiety medications can be used, usually on a short-term basis. Benzodiazepines, including lorazepam, clonazepam and diazepam, are types of anti-anxiety medications. Care must be taken when prescribing benzodiazepines due to the risk of the person developing tolerance and dependence.  Some research has supported the efficacy of anxiolytics in treating schizoaffective disorder, though general findings on their effectiveness in treating schizoaffective disorder remain inconclusive.   Due to the severe negative outcomes associated with many anti-anxiety drugs, many researchers have cautioned against their long term use in treatment. 
 * Therapy
 * Skillfully delivered psychosocial treatments are perhaps the most important component of pushing for and encouraging improved overall functioning in schizoaffective disorder.  Psychosocial treatments have been found to improve outcomes related to schizoaffective disorder.  Supportive psychotherapy and cognitive behavioral therapy are both helpful. Intensive case management (ICM) has been shown to reduce hospitalizations, improve adherence to treatment, and improve social functioning. With ICM, clients are assigned a case manager responsible for coordination of care and assisting clients to access supports to address needs in multiple areas related to well-being, including housing.
 * High quality psychosocial or psychiatric rehabilitation is very important for recovery from schizoaffective disorder. Psychiatric or psychosocial rehabilitation  Psychiatric/psychosocial rehabilitation is often a component of schizoaffective disorder treatment. This rehabilitation method  focuses on solving community integration problems such as obtaining and keeping housing and increasing involvement in positive social groups. It also focuses on improving and increasing activities of daily living; increasing daily healthy habits (such as normalizing sleep-wake cycles; increasing early morning natural light exposure; increasing moderate exercise [such as 20–30 minutes of moderate to brisk early morning to pre-afternoon walking daily, in order to help normalize circadian rhythms]; helping individuals understand the specific benefits of healthy food choices; increasing stress-reduction activities such as yoga, tai chi, or meditation); and decreasing unhealthy behaviors (such as substance use and smoking); thereby significantly improving quality of life. High quality psychiatric rehabilitation may also focus on vocational rehabilitation. including preparing the client for volunteer, part-time paid work, returning to school for further education, job skills training for full-time flexible or supported employment, and other client self-improvement efforts. Core principles of effective psychiatric rehabilitation must include providing hope when the client lacks it, respect for the client wherever they are in the recovery process, empowering the client, teaching the client wellness planning, and emphasizing the importance for the client to develop social support networks. A long-term goal of psychiatric and vocational rehabilitation is that the client learn and actively engage in active stress management while in education or employment, while receiving treatment.  Evidence suggests that cognition-based approaches may be able to improve work and social functioning. 
 * Deleted segment explaining what vocational rehab is, seeing as there was already a link to another article present. Also added source to a claim.
 * History
 * Other psychiatrists, before and after Kasanin, have made scientific observations of schizoaffective disorder based on assumptions of a biological and genetic cause of the illness. In 1863, German psychiatrist Karl Kahlbaum (1828–1899) described schizoaffective disorders as a separate group in his vesania typica circularis. Kahlbaum distinguished between cross-sectional and longitudinal observations. (Cross-sectional refers to observation of a single, specific episode of the illness, for example, one episode of psychotic depression; while longitudinal refers to long-term observation of many distinct episodes [similar or different] often occurring over the span of years.) In 1920, psychiatrist Emil Kraepelin (1856–1926) , the founder of contemporary scientific psychiatry, observed a "great number" of cases that had characteristics of both groups of psychoses that he originally posited were two distinct and separate illnesses, dementia praecox (now called schizophrenia) and manic depressive insanity (now called bipolar disorders [plural since there are more than one type of bipolar disorder] and recurrent depression).
 * Added hyperlinks to other articles (cross sectional and longitudinal) explaining terms and jargon so as to increase brevity and readability. Also deleted repetitive language.