The schizoaffective disorder diagnosis: a conundrum in the clinical setting

Cytokines and Madness: A Unifying Hypothesis of Schizophrenia Involving Interleukin-22

Schizophrenia is a severe neuropsychiatric illness of uncertain etiopathogenesis in which antipsychotic drugs can attenuate the symptoms, but patients rarely return to the premorbid level of functioning. In fact, with each relapse, people living with schizophrenia progress toward disability and cognitive impairment. Moreover, our patients desire to live normal lives, to manage their daily affairs independently, date, get married, and raise and support a family. Those of us who work daily with schizophrenia patients know that these objectives are rarely met despite the novel and allegedly improved dopamine blockers. We hypothesize that poor outcomes in schizophrenia reflect the gray matter volume reduction, which continues despite antipsychotic treatment. We hypothesize further that increased gut barrier permeability, due to dysfunctional aryl hydrocarbon receptor (AhR), downregulates the gut barrier protectors, brain-derived neurotrophic factor (BDNF), and interleukin-22 (IL-22), facilitating microbial translocation into the systemic circulation, eventually reaching the brain. Recombinant human IL-22 could ameliorate the outcome of schizophrenia by limiting bacterial translocation and by initiating tissue repair. This short review examines the signal transducer and transcription-three (STAT3)/AhR axis and downregulation of IL-22 and BDNF with subsequent increase in gut barrier permeability. Based on the hypothesis presented here, we discuss alternative schizophrenia interventions, including AhR antagonists, mitochondrial transplant, membrane lipid replacement, and recombinant human IL-22.

EEG alpha reactivity on eyes opening discriminates patients with schizophrenia and schizoaffective disorder

OBJECTIVE

Alpha activity in the electroencephalogram (EEG) is typically dominant during rest with closed eyes but suppressed by visual stimulation. Previous research has shown that alpha-blockade is less pronounced in schizophrenia patients compared to healthy individuals, but no studies have examined it in schizoaffective disorder.

METHODS

A resting state EEG was used for the analysis of the alpha-reactivity between the eyes closed and the eyes opened conditions in overall (8 - 13 Hz), low (8 - 10 Hz) and high (10 - 13 Hz) alpha bands in three groups: schizophrenia patients (SC, n = 30), schizoaffective disorder (SA, n = 30), and healthy controls (HC, n = 36). All patients had their first psychotic episode and were receiving antipsychotic therapy.

RESULTS

A significant decrease in alpha power was noted across all subjects from the eyes-closed to eyes-open condition, spanning all regions. Alpha reactivity over the posterior regions was lower in SC compared to HC within overall and high alpha. SA showed a trend towards reduced alpha reactivity compared to HC, especially evident over the left posterior region within the overall alpha. Alpha reactivity was more pronounced over the middle and right posterior regions of SA as compared to SC, particularly in the high alpha. Alpha reactivity in SC and SA patients was associated with various negative symptoms.

CONCLUSIONS

Our findings imply distinct alterations in arousal mechanisms in SC and SA and their relation to negative symptomatology. Arousal is more preserved in SA.

SIGNIFICANCE

This study is the first to compare the EEG features of arousal in SC and SA.

Schizoaffective disorder in homeless patients: A systematic review

BACKGROUND

Schizoaffective psychosis is a severe and chronic psychiatric disorder defined by the presence of mood symptoms, like mania and/or depression and schizophrenia, such as hallucinations and/or delusions.

AIMS

We aim to find out whether there is a correlation between schizoaffective psychosis and being homeless.

METHOD

To do so, a literature search was carried out in the PubMed platform in April 2022, using the keywords 'schizoaffective' and 'homeless'.

RESULTS

In this review, 28 articles from this search were included. Intrinsic characteristics, rates of psychiatric readmission, prediction of homelessness, medication noncompliance, and substance use were explored, as they were the main themes of the results.

CONCLUSIONS

The homeless population suffers from great diagnostic variability and the diagnosis schizoaffective psychosis is still evolving contributing to such diagnostic and treatment difficulties. Their frequent visits to the healthcare services, especially emergency room leads to consequent interaction with multiple healthcare professionals, resulting in a myriad of diagnoses, with clinical remission and therapeutic goals not being attained. More studies are necessary for a better evaluation of this super difficult population.

Alternative Diagnostic Models of the Psychotic Disorders: Evidence-Based Choices

Standard diagnostic systems, the predominantly categorical DSM-5 and ICD-11, have limitations in validity, utility, and predictive and descriptive power. For psychotic disorders, these issues were partly addressed in current versions, but additional modifications are thought to be needed. Changes should be evidence based. We reviewed categorical, modified-categorical, and continuum-based models versus factor-based models of psychosis. Factors are clusters of symptoms or single prominent aspects of illness. Consistent evidence from studies of the genetics, pathobiology, and clinical presentation of psychotic disorders all support an underlying structure of factors, not categories, as best characterizing psychoses. Factors are not only the best fit but also comprehensive, as they can encompass any key feature of illness, including symptoms and course, as well as determinants of risk or response. Factors are inherently dimensional, even multidimensional, as are the psychoses themselves, and they provide the detail needed for either grouping or distinguishing patients for treatment decisions. The tools for making factor-based diagnoses are available, reliable, and concordant with actual practices used for clinical assessments. If needed, factors can be employed to create categories similar to those in current use. In addition, they can be used to define unique groupings of patients relevant to specific treatments or studies of the psychoses. Lastly, factor-based classifications are concordant with other comprehensive approaches to psychiatric nosology, including personalized (precision treatment) models and hierarchical models, both of which are currently being explored. Factors might be considered as the right primary structural choice for future versions of standard diagnostic systems, both DSM and ICD.

Neurocognition in Bipolar and Depressive Schizoaffective Disorder: A Comparison with Schizophrenia

INTRODUCTION

Schizoaffective disorder (SA) is classified into bipolar (bSA) and depressive (dSA) subtypes. Although clinical differences between both have been reported, there is no clear information regarding their specific cognitive profile.

OBJECTIVE

To compare neurocognition between SA subtypes and schizophrenia (SC).

METHODS

A total of 61 patients were assessed and divided into 3 groups: 35 SC, 16 bSA, and 10 dSA. All participants signed an informed consent letter. The MATRICS Consensus Cognitive Battery, Central and South American version was used to assess neurocognition. The study was performed at the Instituto Nacional de Psiquiatría "Ramón de la Fuente". Participants were identified by specialized psychiatrists. Trained neuropsychologists carried out the clinical and cognitive assessment, which lasted 2 h approximately.

RESULTS

The cognitive assessment showed a significant difference in Trail Making Test part A subtest (F[2,58] = 4.043; p = 0.023]. Post hoc analyses indicated that dSA obtained a significantly higher score than SC (MD = -11.523; p = 0.018). The f test showed a large effect size (f = 0.401). No statistical differences were observed regarding other cognitive variables.

CONCLUSIONS

The cognitive profile of SA subtypes and SC is similar since no differences were found in most subtests. However, dSA may be less impaired than SC in measures of processing speed. Further research with larger samples must be conducted.

Clozapine in patients with schizoaffective disorder: A systematic review

Schizoaffective disorder is defined by the appearance of positive psychotic symptomatology as well as affective features, even when it is considered a controversial nosologic entity, proving difficult to accord on its definition or diagnostic criteria. Due to these conceptual differences, it has been a challenge to study effective therapeutic measures and, consequently, the availability of data in the current literature, resulting in the extrapolation of clinical guidelines and recommendations initially established for patients with schizophrenia or bipolar disorder. The current study aimed to systematically search and summarize the published evidence to date about the use of clozapine in patients with schizoaffective disorder. Seven studies were identified, that are heterogeneous on their designs and methodology, including samples of patients mixed with bipolar or schizophrenic disorders. The evidence was summarized both in a table and a narrative fashion, suggesting that clozapine may be an effective treatment for both psychotic and affective symptoms, indistinctively of an acute or maintenance phase.

Paliperidone to Treat Psychotic Disorders

PURPOSE OF REVIEW

This is a comprehensive review of the literature regarding the use of paliperidone in the treatment of schizophrenia and schizoaffective disorder. It covers the background and presentation of schizophrenia and schizoaffective disorder, as well as the mechanism of action and drug information for paliperidone. It covers the existing evidence of the use of paliperidone for the treatment of schizophrenia and schizoaffective disorder.

RECENT FINDINGS

Schizophrenia and schizoaffective disorder lead to significant cognitive impairment. It is thought that dopamine dysregulation is the culprit for the positive symptoms of schizophrenia and schizoaffective disorder. Similar to other second-generation antipsychotics, paliperidone has affinity for dopamine D₂ and serotonin 5-HT_2A receptors. Paliperidone was granted approval in the United States in 2006 to be used in the treatment of schizophrenia and in 2009 for schizoaffective disorder.

SUMMARY

Schizophrenia and schizoaffective disorder have a large impact on cognitive impairment, positive symptoms and negative symptoms. Patients with either of these mental illnesses suffer from impairments in everyday life. Paliperidone has been shown to reduce symptoms of schizophrenia and schizoaffective disorder.

Schizophrenia-schizoaffective-bipolar spectra: an epistemological perspective

For decades clinicians and researchers have been thinking and writing about the spectrum of schizophrenia disorders. Indeed both Kraepelin and Bleuler believed in schizophrenia as a spectrum, both in a clinical (individual) and hereditary (family) continuum, from just some exquisite personality traits to unquestionable chronic and debilitating psychosis. Other authors would put the schizophrenia spectrum disorders on different levels of continuum: developmental, psychofunctional, existential, and genetic. Here, we would like to present an historical chronology for the schizophrenia-schizoaffective-bipolar spectra plus a tridimensional model for these spectra: the first axis for categories (affective versus nonaffective psychoses), the second axis for dimensions (personality versus full blown psychosis), and a third axis for biomarkers (remission versus relapse). We believe that without the schizophrenia-schizoaffective-bipolar spectra concept in our minds all our efforts will keep failing one the hardest quest: searching for biomarkers in schizophrenia and related disorders.

Diagnostic Stability of Primary Psychotic Disorders in a Research Sample

Psychiatric diagnosis is often treated as a stable construct both clinically and in research; however, some evidence suggests that diagnostic change may be common, which may impact research validity and clinical care. In the present study we examined diagnostic stability in individuals with psychosis over time. Participants with a diagnosis of any psychotic disorder (n = 142) were assessed at two timepoints using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. We found a 25.4% diagnostic change rate across the total sample. People with an initial diagnosis of psychosis not otherwise specified and schizophreniform disorder had the highest rates of change, followed by those with schizophrenia and schizoaffective disorder; people with bipolar disorder had the lowest change rate. Most participants with an unstable initial diagnosis of schizophrenia, schizophreniform disorder, bipolar disorder, or psychosis not otherwise specified converted to a final diagnosis of schizoaffective disorder. Participants with an unstable initial diagnosis of schizoaffective disorder most frequently converted to a diagnosis of schizophrenia. Our findings suggest that diagnostic change is relatively common, occurring in approximately a quarter of patients. People with an initial diagnosis of schizophrenia-spectrum disorder were more likely to have a diagnostic change, suggesting a natural stability of some diagnoses more so than others.

Voluntary and involuntary admissions with schizoaffective disorder: do they differ from schizophrenia?

OBJECTIVES

Schizoaffective disorder and schizophrenia are common presentations to psychiatry services. Research to date has focussed on hypothesised biological differences between these two disorders. Little is known about possible variations in admission patterns. Our study compared demographic and clinical features of patients admitted voluntarily and involuntarily with diagnoses of schizoaffective disorder or schizophrenia to three psychiatry admission units in Ireland.

METHODS

We studied all admissions to three acute psychiatry units in Ireland for periods between 1 January 2008 and 31 December 2018. We recorded demographic and clinical variables for all admissions. Voluntary and involuntary admissions of patients with schizoaffective disorder were compared to those with schizophrenia.

RESULTS

We studied 5581 admissions to the study units for varying periods between January 2008 and December 2018, covering a total of 1 976 154 person-years across the 3 catchment areas. The 3 study areas had 218.8, 145.5 and 411.2 admissions per 100 000 person-years, respectively. Of the 5581 admissions over the study periods, schizoaffective disorder accounted for 5% (n = 260) and schizophrenia for 17% (n = 949). Admissions with schizoaffective disorder were significantly more likely to be female and older, and less likely to have involuntary admission status, compared to those with schizophrenia. As first admissions were not distinguished from re-admissions in this dataset, these findings merit further study.

CONCLUSIONS

Admissions with a schizoaffective disorder differ significantly from those with schizophrenia, being, in particular, less likely to be involuntary admissions. This suggests that psychotic symptoms might be a stronger driver of involuntary psychiatry admission than affective symptoms.

Clozapine in patients with schizoaffective disorder: A systematic review

Schizoaffective disorder is defined by the appearance of positive psychotic symptomatology as well as affective features, even when it is considered a controversial nosologic entity, proving difficult to accord on its definition or diagnostic criteria. Due to these conceptual differences, it has been a challenge to study effective therapeutic measures and, consequently, the availability of data in the current literature, resulting in the extrapolation of clinical guidelines and recommendations initially established for patients with schizophrenia or bipolar disorder. The current study aimed to systematically search and summarize the published evidence to date about the use of clozapine in patients with schizoaffective disorder. Seven studies were identified, that are heterogeneous on their designs and methodology, including samples of patients mixed with bipolar or schizophrenic disorders. The evidence was summarized both in a table and a narrative fashion, suggesting that clozapine may be an effective treatment for both psychotic and affective symptoms, indistinctively of an acute or maintenance phase.

On the diagnostic and neurobiological origins of bipolar disorder

Psychiatry is constructed around a taxonomy of several hundred diagnoses differentiated by nuances in the timing, co-occurrence, and severity of symptoms. Bipolar disorder (BD) is notable among these diagnoses for manic, depressive, and psychotic symptoms all being core features. Here, we trace current understanding of the neurobiological origins of BD and related diagnoses. To provide context, we begin by exploring the historical origins of psychiatric taxonomy. We then illustrate how key discoveries in pharmacology and neuroscience gave rise to a generation of neurobiological hypotheses about the origins of these disorders that facilitated therapeutic innovation but failed to explain disease pathogenesis. Lastly, we examine the extent to which genetics has succeeded in filling this void and contributing to the construction of an objective classification of psychiatric disturbance.

Neuroimaging Studies in Patients With Mental Disorder and Co-occurring Substance Use Disorder: Summary of Findings

Introduction: More than half of psychiatric patients have comorbid substance use disorder (dual diagnosis) and this rate, confirmed by many epidemiological studies, is substantially higher compared to general population. Combined operation of self-medication mechanisms, common etiological factors, and mutually causative influences most likely accounts for comorbidity, which, despite its clinical prevalence, remains underrepresented in psychiatric research, especially in terms of neuroimaging. The current paper attempts to review and discuss all existing methodologically sustainable structural and functional neuroimaging studies in comorbid subjects published in the last 20 years. Methods: Performing a systematic PubMed/MEDLINE, Web of Science, and Cochrane databases search with predefined key-words and selection criteria, 43 structural and functional neuroimaging studies were analyzed. Results: Although markedly inconsistent and confounded by a variety of sources, available data suggest that structural brain changes are slightly more pronounced, yet not qualitatively different in comorbid patients compared to non-comorbid ones. In schizophrenia (SZ) patients, somewhat greater gray matter reduction is seen in cingulate cortex, dorsolateral prefrontal and frontotemporal cortex, limbic structures (hippocampus), and basal ganglia (striatum). The magnitude of structural changes is positively correlated to duration and severity of substance use, but it is important to note that at least in the beginning of the disease, dual diagnosis subjects tend to show less brain abnormalities and better cognitive functioning than pure SZ ones suggesting lower preexisting neuropathological burden. When analysing neuroimaging findings in SZ and bipolar disorder subjects, dorsolateral prefrontal, cingular, and insular cortex emerge as common affected areas in both groups which might indicate a shared endophenotypic (i.e., transdiagnostic) disruption of brain networks involved in executive functioning, emotional processing, and social cognition, rendering affected individuals susceptible to both mental disorder and substance misuse. In patients with anxiety disorders and substance misuse, a common neuroimaging finding is reduced volume of limbic structures (n. accumbens, hippocampus and amygdala). Whether this is a neuropathological marker of common predisposition to specific behavioral symptoms and drug addiction or a result from neuroadaptation changes secondary to substance misuse is unknown. Future neuroimaging studies with larger samples, longitudinal design, and genetic subtyping are warranted to enhance current knowledge on comorbidity.

A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy

BACKGROUND

Ritualistic behaviors are common in obsessive compulsive disorder (OCD), while catatonic stupor occasionally occurs in psychotic or mood disorders. Schizoaffective disorder is a specific mental disorder involving both psychotic and affective symptoms. The syndrome usually represents a specific diagnosis, as in the case of the 10th edition of the International Classification of Diseases (ICD-10) or the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, symptom-based diagnosis can result in misdiagnosis and hinder effective treatment. Few cases of ritualistic behaviors and catatonic stupor associated with schizoaffective disorder have been reported. Risperidone and modified electroconvulsive therapy (MECT) were effective in our case.

CASE PRESENTATION

A 35-year-old man with schizoaffective disorder-depression was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled us to make the diagnosis of OCD. Sertraline add-on treatment exacerbated the psychotic symptoms, such as pressure of thoughts and delusion of control. In the presence of obvious psychotic symptoms and depression, schizoaffective disorder-depression was diagnosed according to ICD-10. Meanwhile, the patient unfortunately developed catatonic stupor and respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone were administered. As a result, we successfully cured the patient with the abovementioned treatment strategies. Eventually, the patient was diagnosed with schizoaffective disorder-depression with ritualistic behaviors and catatonia. Risperidone and MECT therapies were dramatically effective.

CONCLUSION

Making a differential diagnosis of mental disorders is a key step in treating disease. Sertraline was not recommended for treating schizoaffective disorder-depression according to our case because it could exacerbate positive symptoms. Controversy remains about whether antipsychotics should be administered for catatonic stupor. However, more case studies will be needed. Risperidone with MECT was beneficial for the patient in our case.

Sensory prediction errors in the continuum of psychosis

Sensory prediction errors are fundamental brain responses that signal a violation of expectation in either the internal or external sensory environment, and are therefore crucial for survival and adaptive behaviour. Patients with schizophrenia show deficits in these internal and external sensory prediction errors, which can be measured using electroencephalography (EEG) components such as N1 and mismatch negativity (MMN), respectively. New evidence suggests that these deficits in sensory prediction errors are more widely distributed on a continuum of psychosis, whereas psychotic experiences exist to varying degrees throughout the general population. In this paper, we review recent findings in sensory prediction errors in the auditory domain across the continuum of psychosis, and discuss these in light of the predictive coding hypothesis.

Coping strategies in schizoaffective disorder and schizophrenia: Differences and similarities

Aims of the current study were to explore differences in coping between 58 patients with schizoaffective disorder (SAD) and 89 with schizophrenia (SZ) and to identify factors associated with coping in both disorders. The demographic and clinical characteristics of patients with SAD and with SZ were compared using ANOVA and χ(2). Pearson's correlations were calculated between coping styles and socio-demographic and clinical variables in each group. The significant ones were subsequently analyzed using multiple regressions. Patients with SAD used emotion oriented coping more frequently than patients 2016with SZ. In patients with SAD, self-esteem contributed to task-oriented; avolition-anhedonia (AA) to emotion-oriented; duration of illness and years of education to distraction; AA to social diversion. In patients with SZ, AA, the mental component summary score of the Short Form - 36 Health Survey (SF-36) and self-esteem contributed to emotion oriented coping; the mental component summary score of SF-36 to distraction; AA to social diversion. Our results suggest that patients with SAD and SZ use diverse coping strategies. A greater attention must be given to the presence of self-esteem and AA in individuals with both disorders. These factors are potentially modifiable from specific therapeutic interventions, which can produce effects on coping strategies.

Interrater reliability of schizoaffective disorder compared with schizophrenia, bipolar disorder, and unipolar depression - A systematic review and meta-analysis

Schizoaffective disorder is a common diagnosis in clinical practice but its nosological status has been subject to debate ever since it was conceptualized. Although it is key that diagnostic reliability is sufficient, schizoaffective disorder has been reported to have low interrater reliability. Evidence based on systematic review and meta-analysis methods, however, is lacking. Using a highly sensitive literature search in Medline, Embase, and PsycInfo we identified studies measuring the interrater reliability of schizoaffective disorder in comparison to schizophrenia, bipolar disorder, and unipolar disorder. Out of 4126 records screened we included 25 studies reporting on 7912 patients diagnosed by different raters. The interrater reliability of schizoaffective disorder was moderate (meta-analytic estimate of Cohen's kappa 0.57 [95% CI: 0.41-0.73]), and substantially lower than that of its main differential diagnoses (difference in kappa between 0.22 and 0.19). Although there was considerable heterogeneity, analyses revealed that the interrater reliability of schizoaffective disorder was consistently lower in the overwhelming majority of studies. The results remained robust in subgroup and sensitivity analyses (e.g., diagnostic manual used) as well as in meta-regressions (e.g., publication year) and analyses of publication bias. Clinically, the results highlight the particular importance of diagnostic re-evaluation in patients diagnosed with schizoaffective disorder. They also quantify a widely held clinical impression of lower interrater reliability and agree with earlier meta-analysis reporting low test-retest reliability.

A critical appraisal of paliperidone long-acting injection in the treatment of schizoaffective disorder

Schizoaffective disorder (SCA) is a chronic and disabling mental illness that presents with mixed symptoms of schizophrenia and affective disorders. SCA is recognized as a discrete disorder, but with greater heterogeneity and symptom overlap, leading to difficulty and delay in diagnosis. Although the overall prognosis is intermediate between schizophrenia and mood disorders, SCA is associated with higher rates of suicide and hospitalization than schizophrenia. No treatment guidelines exist for SCA, and treatment is frequently complex, involving off-label use and polypharmacy (typically combinations of antipsychotics, mood stabilizers, and antidepressants). Oral paliperidone extended-release was the first agent to be approved for the treatment of SCA. As in schizophrenia and bipolar disorder, adherence to oral medications is poor, further contributing to suboptimal outcomes. The use of an antipsychotic in a long-acting injection (LAI) addresses adherence issues, thus potentially reducing relapse. Paliperidone palmitate represents the LAI formulation of paliperidone. In a long-term, double-blind, randomized, controlled trial of adult patients (n=334; intent-to-treat [ITT]) with SCA, paliperidone long-acting injection (PLAI) significantly delayed risk of relapse compared to placebo (hazard ratio 2.49, 95% confidence interval, 1.55–3.99; P<0.001). This study demonstrated the efficacy and safety of PLAI when used as either monotherapy or adjunctive therapy for the maintenance treatment of SCA. The results are consistent with a similarly designed study conducted in patients with schizophrenia, which suggests a benefit in the long-term control of not only psychotic but also affective symptoms. No new safety signals were observed. When used in monotherapy, PLAI simplifies treatment by reducing complex pharmacotherapy and obviating the necessity for daily oral medications. PLAI is the second agent, and the first LAI, to be approved for the treatment of SCA; as an LAI formulation, there is the advantage of improved adherence and simplified treatment in the long-term management of SCA.

Emotional awareness and delusions in schizophrenia and schizoaffective disorder

BACKGROUND AND OBJECTIVES

Emotion plays a significant role in schizophrenia. Emotional awareness (i.e., attention to and clarity of emotions) is associated with a wide range of outcomes. Given that individuals with schizophrenia and schizoaffective disorder differ in the significance of their mood symptoms, the present research examined whether the association between emotional awareness and delusions differs for these two groups of patients.

METHODS

Emotional awareness (i.e., attention to and clarity of emotions) was measured with self-report in a sample of 44 individuals diagnosed with either schizophrenia or schizoaffective disorder. Clinical ratings of delusions were made using the Scale for the Assessment of Positive Symptoms.

RESULTS

For the sample as a whole, individuals with higher levels of attention to emotion tended to have more severe delusions. In addition, diagnostic group significantly moderated the relation between emotional clarity and delusions.

LIMITATIONS

Conclusions regarding causality cannot be drawn due to the cross-sectional design. Replication is particularly important given the small sample sizes.

CONCLUSIONS

The present research indicates that emotional awareness is associated with delusions. The results raise the possibility that the emotional factors that contribute to delusional beliefs among individuals with schizophrenia differ in at least some ways from the emotional factors that contribute to delusional beliefs among individuals with schizoaffective disorder.