Schizoaffective Disorder Diagnostic Criteria
A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion Al: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Specify whether:
      F25.0 Bipolar type: This subtype applies if a manic episode is part of the presentation. Major
                depressive episodes may also occur.
      F25.1 Depressive type: This subtype applies if only major depressive episodes are part of the presentation.
Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder, p 135, for definition).
Coding note: Use additional code F06.l catatonia associated with schizoaffective disorder to indicate the presence of the comorbid catatonia.
Specify if: The following course specifiers are only to be used after a I -year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.

First episode, currently in acute episode: First manifestation of the disorder meeting the
defining diagnostic symptom and time criteria. An acute episode is a time period in which the
symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period during which
an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.
Unspecified
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from O (not present) to 4 (present and severe). (See
Clinician-Rated Dimensions of Psychosis Symptom Severity in the chapter ‘􀁆ssessment
Measures.”)
Note: Diagnosis of schizoaffective disorder can be made without using this severity specifier.
Diagnostic Features
The diagnosis of schizoaffective disorder is based on the assessment of an uninterrupted period of illness during which the individual continues to display active or residual symptoms of psychotic illness. The diagnosis is usually, but not necessarily, made during the period of psychotic illness. At some time during the period, Criterion A for schizophrenia has to be met. Criteria B (social dysfunction),  C (6-month duration), and F (exclusion of autism spectrum disorder or other
communication disorder of childhood onset) for schizophrenia do not have to be met. In addition to meeting Criterion A for schizophrenia, there is a major mood episode (major depressive or manic) (Criterion A  for schizoaffective disorder). Because loss of interest or pleasure is common in schizophrenia, to meet Criterion A for schizoaffective disorder, the major depressive episode must
include pervasive depressed mood (i.e., the presence of markedly diminished interest or pleasure is
not sufficient). Episodes of depression or mania are present for the majority of the total duration of the illness (i.e., after Criterion A has been met) (Criterion C for schizoaffective disorder). To separate schizoaffective disorder from a depressive or bipolar disorder with psychotic features, delusions or hallucinations must be present for at least 2 weeks in the absence of a major mood episode (depressive or manic) at some point during the lifetime duration of the illness (Criterion B for schizoaffective disorder). The symptoms must not be attributable to the effects of a substance or
another medical condition (Criterion D for schizoaffective disorder).
Criterion C for schizoaffective disorder specifies that mood symptoms meeting criteria for a major mood episode must be present for the majority of the total duration of the active and residual portion of the illness. Criterion C requires the assessment of mood symptoms for the entire lifetime course of
a psychotic illness. If the mood symptoms are present for only a relatively brief period, the diagnosis is schizophrenia, not schizoaffective disorder. When deciding whether an individual’s presentation meets Criterion C, the clinician should review the total duration of psychotic illness (i.e., both active and residual symptoms) and determine when significant mood symptoms (untreated or in need of treatment with antidepressant and/or mood-stabilizing medication) accompanied the psychotic symptoms. This determination requires sufficient historical
information and clinical judgment. For example, an individual with a 4-year history of active and residual symptoms of schizophrenia develops depressive and manic episodes that, taken together, do not occupy more than I year during the 4-year history of psychotic illness. This presentation would not meet Criterion C.
In addition to the five symptom domain areas identified in the diagnostic criteria, the assessment
of cognition, depression, and mania symptom domains is vital for making critically important
distinctions between the various schizophrenia spectrum and other psychotic disorders.
Associated Features
Occupational and social functioning is frequently impaired, but this is not a defining criterion (in contrast to schizophrenia). Restricted social contact and difficulties with self-care are associated with schizoaffective disorder, but negative symptoms may be less severe and less persistent than those seen in schizophrenia. Anosognosia (i.e., poor insight) is also common in schizoaffective disorder, but the deficits in insight may be less severe and pervasive than those in schizophrenia. Individuals with
schizoaffective disorder may be at increased risk for later developing episodes of major depressive disorder or bipolar disorder if mood symptoms continue following the remission of symptoms meeting Criterion A for schizophrenia. There may be associated alcohol and other substance-related disorders.
There are no tests or biological measures that can provide definitive assistance in making the
diagnosis of schizoaffective disorder. Neuropsychological testing typically shows cognitive deficits in
areas such as executive function, verbal memory, and speed of processing, and these may be less pronounced than in schizophrenia. Schizoaffective disorder is often characterized by gray matter volume loss on brain imaging, in much the same way that schizophrenia is.

Prevalence
Schizoaffective disorder appears to be about one-third as common as schizophrenia. Lifetime prevalence of schizoaffective disorder was estimated to be 0.3% in a Finnish sample and is higher in women than in men when DSM-IV diagnostic criteria were used. This rate would be expected to be lower because of the more stringent requirement of DSM-5 Criterion C (i.e., mood symptoms
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR™)
meeting criteria for a major mood episode must be present for the majority of the total duration of
the active and residual portion of the illness).
Development and Course
The typical age at onset of schizoaffective disorder is early adulthood, although onset can occur
anytime from adolescence to late in life. A significant number of individuals diagnosed with another psychotic illness initially will receive the diagnosis schizoaffective disorder later when the pattern of mood episodes has become more apparent, whereas others may be diagnosed with mood disorders before independent psychotic symptoms are detected. Conversely, some individuals will have a change in diagnosis from schizoaffective disorder to a mood disorder or to schizophrenia over time. A change in diagnosis from schizoaffective disorder to schizophrenia was more common than a change to mood disorder
under DSM-IV criteria, and that difference is expected to be more  pronounced under DSM-5 as
the current Criterion C for schizoaffective disorder has become more stringent, requiring mood symptoms to be present for the majority of the illness as compared with the DSM-IV definition, which only required mood symptoms to be present for a “substantial” portion. The prognosis for schizoaffective disorder is somewhat better than the prognosis for schizophrenia but worse than the prognosis for mood disorders. Schizoaffective disorder may occur in a variety of temporal patterns. The following is a typical pattern: An individual may have pronounced auditory hallucinations and persecutory delusions for 2 months before the onset of a prominent major depressive episode. The psychotic symptoms and the full major depressive episode are then present for 4 months. Then, the individual recovers completely from the major depressive episode, but the psychotic symptoms persist for another month before they too disappear. During this period of illness, the individual’s symptoms concurrently met the criteria for a major depressive episode and Criterion A for schizophrenia, and during this same period of illness, auditory hallucinations and delusions were present both before and after the depressive phase. The
total period of illness lasted for about 7 months, with psychotic symptoms alone present during the initial 2 months, both depressive and psychotic symptoms present during the next 4 months, and psychotic symptoms alone present during the last month. In this instance, the depressive episode was present for a majority of the total duration of the psychotic disturbance, and thus the presentation qualifies for a diagnosis of schizoaffective disorder. The temporal relationship between the mood symptoms and the psychotic symptoms across the lifespan is variable. Depressive or manic symptoms can occur before the onset of psychosis, during acute psychotic episodes, during residual periods, and after cessation of psychosis. For example, an
individual might present with prominent mood symptoms during the prodromal stage of schizophrenia. This pattern is not necessarily indicative of schizoaffective disorder, since it is the cooccurrence of psychotic and mood symptoms that is diagnostic. For an individual with symptoms that clearly meet the criteria for schizoaffective disorder but who on further follow-up only presents with
residual psychotic symptoms (such as subthreshold psychosis and/or prominent negative symptoms), the diagnosis may be changed to schizophrenia, as the total proportion of psychotic illness compared with mood symptoms becomes more prominent. Schizoaffective disorder, bipolar type, may be more common in young adults, whereas schizoaffective disorder, depressive type, may be more common in
older adults. 
Risk and Prognostic Factors
Genetic and physiological. Among individuals with schizophrenia, there may be an increased risk for schizoaffective disorder in first-degree relatives. The risk for schizoaffective disorder may also be increased among individuals who have a first-degree relative with bipolar disorder or schizoaffective disorder itself. The molecular genetic composite signatures are known as polygenic risk scores for schizophrenia, bipolar disorder, and major depressive disorder may all be elevated in schizoaffective
disorder.
Culture-Related Diagnostic Issues
Cultural and socioeconomic factors must be considered, particularly when the individual and the clinician do not share the same cultural and economic background. Ideas that appear to be delusional in one cultural context (e.g., evil eye, causing illness through curses, influences of spirits) may be commonly held in others. There is also some evidence in the literature that African American and
Hispanic populations whose symptoms meet criteria for schizoaffective disorder are more likely to be diagnosed with schizophrenia. To mitigate the impact of clinician bias, care must be taken to ensure a comprehensive evaluation that includes both psychotic and mood symptoms.
Association With Suicidal Thoughts or Behavior
The lifetime risk of suicide for schizophrenia and schizoaffective disorder is 5%, and the presence of depressive symptoms is correlated with a higher risk for suicide. There is evidence that suicide rates are higher in North American populations than in European, Eastern European, South American, and Indian populations of individuals with schizophrenia or schizoaffective disorder.
Functional Consequences of Schizoaffective Disorder
Schizoaffective disorder is associated with global dysfunction, including in social and occupational domains, but dysfunction is not a diagnostic criterion (as it is for schizophrenia), and there is substantial variability between individuals diagnosed with schizoaffective disorder.
Differential Diagnosis
Other mental disorders and medical conditions. A wide variety of psychiatric and medical conditions can manifest with psychotic and mood symptoms and must be considered in the differential diagnosis of schizoaffective disorder. These include delirium; major neurocognitive disorder; substance/medication-induced psychotic disorder or neurocognitive disorder; bipolar disorders, with psychotic features; major depressive disorder, with psychotic features; depressive or bipolar disorders,
with catatonic features; schizotypal, schizoid, or paranoid personality disorder; brief psychotic disorder; schizophreniform disorder; schizophrenia; delusional disorder; and other specified and unspecified schizophrenia spectrum and other psychotic disorders.
Psychotic disorder due to another medical condition. Other medical conditions and substance use can manifest with a combination of psychotic and mood symptoms, and thus psychotic disorder due to another medical condition needs to be excluded.
Schizophrenia, bipolar, and depressive disorders. Distinguishing schizoaffective disorder from schizophrenia and from depressive and bipolar disorders with psychotic features is often difficult. Criterion C is designed to separate schizoaffective disorder from schizophrenia, and Criterion B is designed to distinguish schizoaffective disorder from a depressive or bipolar disorder with psychotic
features. More specifically, schizoaffective disorder can be distinguished from a major depressive or
bipolar disorder with psychotic features based on the presence of prominent delusions and/or
hallucinations for at least 2 weeks in the absence of a major mood episode. In contrast, in depressive or bipolar disorder with psychotic features, the psychotic features only occur during the mood episode(s). Because the relative proportion of mood to psychotic symptoms may change over time, the appropriate diagnosis may change from and to schizoaffective disorder. (For example, a diagnosis
of schizoaffective disorder for a severe and prominent major depressive episode lasting 4 months during the first 6 months of a chronic psychotic illness would be changed to schizophrenia if active psychotic or prominent residual symptoms persist over several years without a recurrence of another mood episode.) Achieving greater clarity about the relative proportion of mood to psychotic symptoms over time and about their concurrence may require collateral information from medical records and from informants.
Comorbidity
Many individuals diagnosed with schizoaffective disorder are also diagnosed with other mental disorders, especially substance use disorders and anxiety disorders. Similarly, the incidence of medical conditions, including metabolic syndrome, is increased above the base rate for the general population and leads to decreased life expectancy.