Schizoaffective Disorder – A Challenging DiagnosisAugust 2, 2019
What is “Schizoaffective Disorder”?
“Schizoaffective disorder is a mental health condition that includes features of both schizophrenia and a mood disorder such as bipolar disorder or depression. The prefix “schizo-” refers to the psychotic symptoms of schizophrenia that affect a person’s thinking, sense of self, and perceptions. The term “-affective” refers to extreme shifts in mood, energy, and behavior,” according to the National Library of Medicine.
Identification of “Schizoaffective Disorder” and How It Has Been Classified Over the Decades
The term “schizoaffective psychosis” was coined in 1933 by psychiatrist Jacob Kasanin, MD. Dr. Kasanin recognized that some of his patients were experiencing symptoms suggesting both schizophrenia and mood/affective disorders.
The first (1952) and second (1968) editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) regarded schizoaffective disorder as a subtype of schizophrenia. Historically, the diagnostic criteria for “schizoaffective disorder” has undergone numerous revisions and some variations, and remains challenging to diagnose.
Even today, there is some debate about whether schizoaffective disorder should be classified as a subtype of schizophrenia, bipolar disorder, or other mood disorder.
Diagnostic Criteria, Signs and Symptoms
The signs and symptoms of schizoaffective disorder are numerous, and include symptoms of both schizophrenia and either depression or bipolar disorder. Examples are:
- Hallucinations (visual, audio, tactile and smell)
- Delusions, or strongly held false believes such as the perception that they are being controlled by others, being plotted against, or that they are an important or historical figure
- Manic and depressive episodes
- Disordered thinking and concentration
- Inappropriate emotional responses
- Erratic speech and behavior
- Difficulty with personal hygiene and everyday tasks
- Difficulty functioning at work, in school, and in other social situations
These are the criteria upon which a diagnosis of schizoaffective disorder is made:
- A period during which there is a major mood disorder, either depression or mania, that occurs at the same time that symptoms of schizophrenia are present
- Delusions or hallucinations for two or more weeks in the absence of a major mood episode
- Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the illness
- The abuse of drugs or a medication are not responsible for the symptoms
Prevalence, General Characteristics and Facts
According to multiple sources, the lifetime prevalence of schizoaffective disorder ranges from 0.32 to 1.1 percent. The prevalence is hard to determine because many people are allegedly incorrectly diagnosed with bipolar disorder or schizophrenia when in fact they have schizoaffective disorder.
- Men and women experience schizoaffective disorder at the same rate, but men often develop the illness at an earlier age
- Patients have a better prognosis than patients with schizophrenia but a worse prognosis than patients with mood disorder
- Patients tend to have a non-deteriorating course and to have better response to mood stabilizer medications than patients with schizophrenia
- People with schizoaffective disorder have a higher risk of substance abuse problems and dying by suicide than the general population
Types of schizoaffective disorder
There are two major types of schizoaffective disorder, diagnosed based on the patient’s mood disorder:
- bipolar type
- depressive type
Patients with the bipolar type of schizoaffective disorder experience both manic and depressive episodes, having periods of “highs” and “lows.” Patients with the depressive type of schizoaffective disorder experience low energy and feelings of hopelessness and never have symptoms of mania.
The depressive type of schizoaffective disorder is more common in older patients, whereas the bipolar type is more common in younger patients.
(Ref: National Institutes of Health, National Library of Medicine, Genetics Home Reference “Schizoaffective Disorder, Resources.” Reviewed 2018. Published June 25, 2019. https://ghr.nlm.nih.gov/condition/schizoaffective-disorder#resources).
Causes of Schizoaffective Disorder
The exact cause or etiology of schizoaffective disorder is currently unknown although theories data suggest the following, occurring either alone or in combination:
- Genetics: There is a known “inheritance pattern” in schizoaffective disorder. Certain genes and genetic variations have been identified in patients with schizoaffective disorder and are being studied.
- Brain chemistry and structure: Research into brain function and structure as an etiology of schizoaffective disorder is still a “work in progress” and so remains under consideration.
- Stress: Stressful life events may trigger symptoms or the onset of schizoaffective disorder.
- Psychoactive or Psychotropic Drug Use: Use of these types of drugs may be a risk factor for developing schizoaffective disorder.
Treatment of patients with schizoaffective disorder varies and depends on the type (bipolar or depressive) and severity of their symptoms. Long term treatment is required because there is no cure for schizoaffective disorder. With proper treatment, however, people with schizoaffective disorder are able to function without symptoms if remission can be achieved, and also avoid relapses.
Most patients respond well to a combination of medication, psychotherapy, and life-skills training. Hospitalization is necessary in some cases.
Medication management: These can include antipsychotic medications (to manage symptoms like delusions and hallucinations), mood stabilizers (for bipolar type), and antidepressants (for depressive type)
Psychotherapy: This includes individual cognitive behavioral therapy, family-focused therapy and group therapy
Life skills training: This includes social skills training and vocational training
Coding Schizoaffective Disorder
There are four codes in ICD-10-CM codes in category F25 Schizoaffective disorders. Two of these codes describe the specific type of schizoaffective disorder, either bipolar or depressive. Note the inclusion terms under each of these codes.
F25.0 Schizoaffective disorder, bipolar type
Schizoaffective disorder, manic type
Schizoaffective disorder, mixed type
Schizoaffective psychosis, bipolar type
F25.1 Schizoaffective disorder, depressive type
Schizoaffective psychosis, depressive type
The next code in category F25 is
F25.8 Other schizoaffective disorders
The 2019 ICD-10-CM Official Guidelines for Coding and Reporting (“OCG”), Section I.A.9. Other and Unspecified Codes includes this coding convention:
I.A.9.a. “Other” codes. Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate “other” codes in the Tabular List. These Alphabetic Index entries represent specific disease entries for which no specific code exists so the term is included within an “other” code.”
Therefore, code F25.8 Other schizoaffective disorders is reported if a specific type of schizoaffective disorder is documented other than “bipolar type” F25.0, or “depressive type” F25.1
Inquiring coder minds are now wondering, what “other” types of schizoaffective disorders are there? To answer this question, we turned to our copy of DSM-5. Surprisingly, there are no “other” types of schizoaffective disorder specified in DSM-5. The provider is instructed to specify either “bipolar type” or “depressive type.”
Have you been reporting code F25.8 Other schizoaffective disorders? A review of the inclusion terms listed under codes F25.0 and F25.1 is recommended in case the provider has documented the diagnosis using this alternative terminology. Inclusion terms are explained in OCG Section 1.11 Inclusion terms:
I.A.11. Inclusion terms. List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
Example 1: If the provider documents “schizoaffective disorder, mixed type,” report F25.0. Do not report F25.8.
Example 2: if the provider documents “schizoaffective psychosis, depressed type,” report F25.1. Do not report F25.8.
When should code F25.8 Other schizoaffective disorder be used? We think “never,” although we recommend discussing this with your providers.
Predictably, the last code in category F25 is
F25.9 Schizoaffective disorder, unspecified
Schizoaffective psychosis, NOS
- Note: All codes in category F25 are Major Comorbidity and Complication (MCC) codes.
“Schizoaffective Disorder” in ICD-11 – A Look Ahead
Now that we understand the two types of schizoaffective disorder and their respective ICD-10-CM codes, prepare for a change when ICD-11-CM becomes effective for use.
ICD-10-CM and DSM-5 are somewhat in sync. DSM-5, as we learned, provides the diagnostic criteria for schizoaffective disorder and instructs the provider to specify type, either bipolar or depressive. The provider is further instructed to document the episode and whether the patient is symptomatic or in a phase of remission. This type of specificity is not available for capture in ICD-10-CM, but is available in ICD-11. What is missing in ICD-11, as it currently exists, are codes that specify the type of schizoaffective disorder, bipolar or depressed. That may change in ICD-11-CM.
Below are the ICD-11 codes for Schizoaffective Disorder as they appear on the ICD-11 website – six characters with a period after the fourth character. (See our blogs on ICD-11, “WHO wanted ICD-11” Parts 1 and 2 for more information about ICD-11).
Schizoaffective disorder, unspecified
Schizoaffective disorder, continuous, unspecified
Other specified schizoaffective disorder
Schizoaffective disorder, first episode, unspecified
Schizoaffective disorder, multiple episodes, unspecified
Schizoaffective disorder, continuous, currently symptomatic
Schizoaffective disorder, continuous, in partial remission
Schizoaffective disorder, continuous, in full remission
Schizoaffective disorder, first episode, currently symptomatic
Schizoaffective disorder, first episode, in partial remission
Schizoaffective disorder, first episode, in full remission
Schizoaffective disorder, multiple episodes, currently symptomatic
Schizoaffective disorder, multiple episodes, in partial remission
Schizoaffective disorder, multiple episodes, in full remission
Schizoaffective disorder is a mental health condition that includes features of both schizophrenia and a mood disorder such as bipolar disorder or depression.
Historically, the diagnostic criteria for “schizoaffective disorder” has undergone numerous revisions and some variations, and remains challenging to diagnose.
There are two types of schizoaffective disorder; bipolar and depressed. They are distinguished by and treated according to the patient’s mood disorder.
There are four codes in ICD-10-CM codes in category F25 Schizoaffective disorders. It is important to read the inclusion terms listed below codes F25.0 Schizoaffective disorder, bipolar type and F25.1 Schizoaffective disorder, depressive type, and report the appropriate code if the diagnosis documented is listed as an inclusion term under code F25.0 or F25.1.
Discuss with your providers when it might be appropriate to code and report F25.8 Other schizoaffective disorder.
All of the codes in category F25 are MCC’s.
NJPR blogs are for educational purposes and are accurate at the time of publishing. Learn more.