Late Onset Schizoaffective Disorder
History
A 70-year-old English-speaking Albanian woman was brought to our hospital emergency room by her son for evaluation because she was hearing voices and believed people were conspiring against her. She was also having suicidal thoughts.
During the summer of 2009, her son noticed that she began to isolate herself, halting contact with everyone, including her friends and family. She was also reportedly stealing objects of small value from various people in her life and she told her son that she was in multiple intimate relationships with nonexistent men. She claimed to hear the voices of these suitors, as well as additional male voices, which made commentary statements, such as “don’t go there,” “that food is poisonous, don’t eat it,” and “don’t trust people.”
During this period of time, the patient also began experiencing feelings of grandeur, expressing to her friends and family that she was someone of importance. In addition, she was reported to have a very elated mood and her son observed that she was staying awake for days at a time, as well as eating poorly. Furthermore, she began experiencing ideas of reference that the President of the United States was speaking directly to her from the television and sending her special messages. These symptoms progressed through fall and winter 2009.
In February 2010, she was found to have locked herself into a room in her apartment, refusing to come out, and was subsequently taken to the local hospital by ambulance. She was admitted and her length of stay exceeded a month. She was treated as a case of first break psychosis.
During her hospitalization, she exhibited persecutory delusions with guarded behavior, mood lability, intermittent anxiety, grandiosity, and auditory hallucinations. She was treated with risperidone, haloperidol decanoate, citalopram, and benztropine at different time periods.
She was scheduled for follow-up outpatient psychiatric treatment; however, she failed to keep up the follow-up appointment. She was also noncompliant with all of her psychotropic medications.
During the summer of 2010, the patient experienced a hiatus from her more intense psychotic symptoms. However, she continued to exhibit mild elevation of mood with some grandiosity. As the cold weather approached, she began spending more time indoors, again isolating herself from her social network.
In November 2010, 12 days prior to her admission, police officers found her wandering around her neighborhood. She was responding to internal stimuli, admitted to auditory hallucinations, and was disoriented to place and time. She laid claim that the voices she heard were that of “God” and also her “new husband.” Note: She had been widowed in 2005 and had not remarried since.
The officers contacted her son, who decided to have her temporarily reside with him and his family. At this point, she progressively began to decompensate, experiencing increasing hallucinations, paranoia, and delusions. She expressed concerns that her son and other household members were poisoning her food and attempting to harm her. In addition, she was exhibiting bizarre behavior, such as pacing around the house with a large kitchen knife, throwing away food from the table as the family was eating meals, talking to “God” and her “new husband,” and accusing her son of being jealous of her “new husband.”
Hospital Admission
On admission, the physical and neurological examination showed no significant abnormalities. Her mental status exam noted that she was paranoid, internally preoccupied, and responding to internal stimuli. The patient’s speech was fluent, of normal rate and rhythm, mildly pressured, and accented. Her mood was euphoric with expansive, labile affect, and was appropriate to the content but not to situation. Patient’s thought process was spontaneous, logical, and goal directed at times, but tangential at other times. Her thought content revealed persecutory and grandiose delusions, with no suicidal or homicidal ideations. She experienced auditory hallucinations of 2 male voices, one “God” and the other her “new husband.” The voices were not command in nature, sometimes commentary, and often interactive.
During the interview, patient would stop to talk to the voices and was convinced that other people could hear them as well. Her judgment and insight were both very poor. The patient was alert and oriented to person, place, time, and situation. She scored 29/30 on the Mini-Mental State Exam (MMSE).
Laboratory tests. Routine laboratory tests done including complete blood count, comprehensive metabolic profile, a serological test for syphilis, urinalysis, urine toxicology, vitamin B12, and folate were all within normal limits, with the exception of the serum glucose—which was elevated. An endocrinology consult confirmed the diagnosis of mild type 2 diabetes mellitus. Thyroid studies demonstrated she was euthymic. EKG and chest x-ray showed no abnormalities. Head CT without contrast showed atrophy and small vessel change without intracranial hemorrhage. An MRI of the brain without contrast showed findings of small vessel ischemic change.
Treatment. She was started on aripriprazole 2 mg by mouth daily and valproic acid 250 mg by mouth 3 times a day, which were both titrated upwards to 5 mg by mouth daily and 500 mg by mouth twice day, respectively. Valproic acid blood levels were subsequently therapeutic at 87. During the first few days of pharmacotherapy, there was a clear improvement in the degree of her mania and psychosis.
Discussion
Manfred Bleuler, MD, first described cases of schizophrenia that affected patients aged 40 to 60.1 In 2000, the International Late-Onset Schizophrenia Group proposed creating an additional category for cases of schizophrenia in those older than 60 years.2 Since then, the incidence of late onset and very late onset schizophrenia per 100,000 population per year has been reported at 12.63 and 17-24,4 respectively.
While the DSM-IV no longer uses age of onset of symptoms in its diagnostic criteria, it has been reported that cases of patients with schizophrenia diagnosed after the age of 65 tend to be predominantly women, have better occupational and marital histories, have more paranoid delusions and hallucinations, and have less disorganization and negative symptoms.5 Moreover, studies have stated that bipolar disorder in those over the age of 50 may have organic and neurological etiologies—8% of whom were admitted for their first onset after the age of 65.5 Although there exists a relatively abundant quantity of research and case reports involving late onset schizophrenia and a moderate amount of data on late onset bipolar disorder, a review of the literature revealed a paucity of data about the late or very late onset schizoaffective disorder. A single, retrospective chart review study identified 2 patients with late onset psychotic symptoms whose etiology was attributed to schizoaffective disorder.6 However, it failed to provide details of the cases.
Our patient presented a distinct diagnostic departure from schizophrenia. The patient’s symptoms during summer 2009 indicated a period of illness that can be construed as a mixed episode with manic symptoms concurrent with criterion A for schizophrenia; this satisfies the criterion A for schizoaffective disorder (DSM-IV and DSM-57).
The pattern of symptoms in the February and November 2010 episodes, and during her past psychiatric hospitalization, appear to meet criterion B (DSM-IV and DSM-57), “with delusions and hallucinations for at least 2 weeks in the absence of prominent mood symptoms.” This distinguishes schizoaffective disorder from bipolar disorder with psychotic features.
Symptoms described during summer 2009, summer 2010, and November 2010 indicate manic/mixed episode symptoms that satisfy criterion C for DSM-IV and DSM-57 (substantial portion vs majority of total duration of illness).
This patient first experienced the onset of psychosis with delusions at the age of 67. Because of her advanced age, it was critical that dementia be carefully excluded. However, the patient showed no signs of dementia and manifested no cognitive impairments of any kind. As previously noted, her MMSE did not demonstrate impairment. She was alert and oriented to person, place, time, and situation on daily rounds during both psychiatric hospitalizations. In addition to excluding dementia as a factor in this patient’s presentation, it was imperative to rule out any organic etiology of her symptoms, especially because this was a first break psychosis.
Patient underwent a full panel of investigations to detect any medical or medication/substance-induced causes for psychosis or dementia. Her complete blood count and comprehensive metabolic panel failed to discern any hematological or metabolic disturbances. Her urinalysis and urine toxicology did not detect a urinary tract infection or any substance use. Rapid plasma reagin test ruled out syphilis, and her vitamin B12 and folate levels were within normal limits, making organic dementia an unlikely diagnosis. Her EKG did not reveal any cardiac abnormalities and her head CT and MRI of the brain showed only small vessel ischemic changes, which were not significant enough to have caused her severe psychotic and mood symptoms.
A full endocrinological evaluation showed she was euthymic and had mild type 2 diabetes mellitus, which was not relevant to her presentation.
Outcome of the Case
Due to her history of nonadherence to medications, the patient was started on oral risperidone and then given intramuscular risperdone consta 25 mg. Aripriprazole was tapered and discontinued.
The patient also received individual, group, activity, and milieu therapies. Subsequently, she was noted to have a complete resolution of her delusions, auditory hallucinations, and mood symptoms. After 3-weeks of hospitalization, the patient was discharged home with recommendations for outpatient psychiatric and medical follow-up.
References:
1.Bleuler M. Die spatschizophrenen Krankheitsbilder. Fortschritte der Neurologie und Psychiatrie. 1943;15:259-290.
2.Howard RJ, Rabins PV, Seeman MV, Jeste DV. Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. The International Late-Onset Schizophrenia Group. Am J Psychiatry. 2000;157(2):172-178.
3.Copeland JR, Dewey ME, Scott A, et al. Schizophrenia and delusional disorder in older age: community prevalence, incidence, comorbidity and outcome. Schizophr Bull. 1998;24(1):153-161.
4Holden NL. Late paraphrenia or the paraphrenias? A descriptive study with a 10-year follow-up. Br J Psychiatry. 1987;150:635-639.
5Madhusoodanan S, Brenner R, Sajatovic M, Bogunovic O. Late Life Schizophrenia: Treatment Challenges. 2000;8:149-179.
6Webster J, Grossberg GT. Late-life onset of psychotic symptoms. American Journal of Geriatric Psychiatry. 1998;6(3):196-202.
7American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA; American Psychiatric Association, 2013