202 Schizotypal Personality Disorder

DSM-IV-TR criteria

• A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. ideas of reference (excluding delusions of reference)
2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstition, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations)
3. unusual perceptual experiences, including bodily illusions
4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, over elaborate, or stereotyped)
5. suspicious or paranoid idealization
6. inappropriate or constricted affect
7. behavior or appearance that is odd, eccentric, or peculiar
8. lack of close friends or confidants other than first-degree relatives
9. excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

• Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.
• NOTE: If criteria are met prior to the onset of Schizophrenia, add “Pre-morbid,” e.g., “Schizotypal Personality Disorder (Pre-morbid).”

Associated Features

The speech of individuals with this disorder is affected in such a manner that it may be distinguished by unclear and unusual usages. Language is impaired by different contexts and syntax, or the arrangement of words and how they are used, in other words the grammer. Schizotypal behavior is often linked to individuals with Schizophrenia. They tend to appear emotionless, showing flat or constricted affect in interpersonal situations.

Schizotypal PD is difficult to accurately diagnose because it is highly co-morbid with several personality disorders, such as: Narcissistic, Borderline, Avoidant, Paranoid, and Schizoid PD. Individuals with this disorder may experience brief psychotic episodes in response to stress. They often seek treatment for anxiety, depression, or other dysphoric symptoms rather than for the actual disorder.

The schizotypal individual has unusual thought patterns that end up disrupting their ability to communicate clearly with others. In addition, his or her ties to reality are impacted but not completely severed as in Schizophrenia. Because of this, many of these individuals are not able to realize their potential and are unable to lead truly productive lives.

Symptoms pointing to Brief Psychotic Disorder, Schizophreniform Disorder, Delusional Disorder, or Schizophrenia may develop in clinical settings. Over half may have a Major Depressive Episode.

Child vs. Adult Presentation

Schizotypal Personality Disorder may be first apparent in childhood and adolescence with solitude-seeking behavior, poor peer relationships, social anxiety, underachievement in academics, hypersensitivity, odd thoughts and speech, and bizarre fantasies.

As adults, presentation is similar but probably less severe such as less solitary activities because of boredom onset, and peer relationships are essential to advance in a life, such as with careers, friends and family.

Gender and Cultural Differences in Presentation

Generally more males are affected by Schizotypal Personality Disorder than females. Presentation in different cultural aspects do favor males as more Schizotypal affected than females probably because of a tendency for females to relate or talk to others enabling them to make relationships easier.

Females are more social and emotional than males in general, and they have the tendency to communicate more information to other people and to be more open about their feelings and emotions. Males tend to be more closed off and only share private information to those they trust the most.

Some distortions must be evaluated within the individuals cultural context, as some cultural characteristics may be mistaken as schizotypal.

Epidemiology

• The prevalence of Schizotypal Personality Disorder is approximately 3% of the general population and is believed to occur slightly more often in males.
• Approximately less than 1% in an outpatient clinical sample.
• The course is rather stable, and only a small portion go on to develop Schizophrenia or another Psychotic Disorder.
• Schizotypal Personality Disorder is generally stable across an individual’s life.
• Schizotypal Personality Disorder appears to occur more frequently in individuals who have an immediate family member with schizophrenia.

Etiology

There is a chance that genetic factors contribute to the cause of Schizotypal Personality Disorder. Familial patterns are not major here but can be more likely to contract the disorder if it is prevelant in the family genetics.

Environmental factors are less likely to contribute to this disorder than interpersonal factors because of interactions with people are social activities and may involve suspicion of others, odd beliefs and weird thinking, unusual perceptions or distortions of reality.

Oddities in children with STPD are reinforced when they are shunned and rejected by others, thus increasing their social anxiety and suspicion.

An alternative pathogenic hypothesis suggests that the child was severely abused, limited in autonomy development and peer interactions while caregivers modeled illogical formulations of reality, leading the adult with STPD to claim an unusual ability of knowing or controlling events combined with paranoid withdrawal from others.

Other hypotheses suggest that the infant’s needs were met, but without sufficient emotional intimacy or warmth. Which hindered subsequent childhood development by punitive criticism, fragmented communications, and humiliation by peers.

The diagnosis of schizotypal personality disorder is based on a clinical interview to assess symptomatic behavior. Other assessment tools helpful in confirming the diagnosis of schizotypal personality disorder include:

• Minnesota Multiphasic Personality Inventory (MMPI-2)
• Millon Clinical Multiaxial Inventory (MCMI-II)
• Rorschach Psychodiagnostic Test
• Thematic Apperception Test (TAT)

Empirically Supported Treatments

Individuals with Schizotypal Personality Disorder are generally difficult to treat, as they are not comfortable with forming new relationships and interacting with others (ie. psychologists). They want to keep to themselves and not develop new close friends, or even have communication on a regular basis with family members. They would rather stay inside all day and be alone.

For individuals that have a little bit of higher functioning compared to other Schizotypal individuals, there are various treatment options. Provided these individuals see that they have a problem and seek treatment. One option is psychodynamic oriented therapies. This helps the individual build trusting relationships. Therapies include:

Psychodynamically oriented therapies

• A psychodynamic approach would typically seek to build a therapeutically trusting relationship that attempts to counter the mistrust most people with this disorder intrinsically hold. The hope is that some degree of attachment in a therapeutic relationship could be generalized to other relationships. Offering interpretations about the patient’s behavior will not typically be helpful. More highly functioning schizotypals who have some capacity for empathy and emotional warmth tend to have better outcomes in psychodynamic approaches to treatment.

Cognitive-behavioral therapy:

• Cognitive approaches will most likely focus on attempting to identify and alter the content of the schizotypal’s thoughts. Distortions that occur in both perception and thought processes would be addressed. An important foundation for this work would be the establishment of a trusting therapeutic relationship. This would relax some of the social anxiety felt in most interpersonal relationships and allow for some exploration of the thought processes. Constructive ways of accomplishing this might include communication skills training, the use of videotape feedback to help the affected person perceive his or her behavior and appearance objectively, and practical suggestions about personal hygiene, employment, among others.

Interpersonal therapy:

• Treatment using an interpersonal approach would allow the individual with schizotypal personality disorder to remain relationally distant while he or she “warms up” to the therapist. Gradually the therapist would hope to engage the patient after becoming “safe” through lack of coercion. The goal would be to develop trust in order to help the patient gain insight into the distorted and magical thinking that dominates. New self-talk can be introduced to help orient the individual to reality-based experience. The therapist can mirror this objectivity to the patient.

Group therapy:

• may provide the patient with a socializing experience that exposes them to feedback from others in a safe, controlled environment. It is typically recommended only for schizotypals who do not display severe eccentric or paranoid behavior. Most group members would be uncomfortable with these behavioral displays and it would likely prove destructive to the group dynamic.

Family and marital therapy:

• It is unlikely that a person with schizoid personality disorder will seek family or marital therapy. Many schizoid types do not marry and end up living with and being dependent upon first-degree family members. If they do marry they often have problems centered on insensitivity to their partner’s feelings or behavior. Marital therapy ( couples therapy ) may focus on helping the couple to become more involved in each other’s lives or improve communication patterns.

Medications

According to the Encyclopedia of MD, there is considerable research on the use of medications for the treatment of schizotypal personality disorder due to its close symptomatic relationship with schizophrenia. Among the most helpful medications are the antipsychotics that have been shown to control symptoms such as illusions and phobic anxiety, among others. Amoxapine (trade name Asendin), is a tricyclic antidepressant with antipsychotic properties, and has been effective in improving schizophrenic-like and depressive symptoms in schizotypal patients. Other antidepressants such as fluoxetine (Prozac) have also been used successfully to reduce symptoms of anxiety, paranoid thinking, and depression.

Prognosis

The prognosis for the individual with schizotypal personality disorder is poor due to the ingrained nature of the coping mechanisms already in place. Schizotypals who depend heavily on family members or others are likely to regress into a state of apathy and further isolation. While some measurable gains can be made with mildly affected individuals, most are not able to alter their ingrained ways of perceiving or interpreting reality. When combined with poor social support structure, most will not enter any type of treatment.

Prevention

Since schizotypal personality disorder originates in the patient’s family of origin, the only known preventative measure is a nurturing, emotionally stimulating and expressive caretaking environment.

Portrayed in Popular Culture

• Kramer from Seinfeld
  • He is characterized by odd behavior and thinking
• Luna Lovegood and Sybill Trelawny from Harry Potter
  • They are both very eccentric with odd appearances and awkward in social settings

DSM-V Changes

• Be reformulated as the Schizotypal Type
• Individuals who match this personality disorder type have social deficits, marked by discomfort with and reduced capacity for interpersonal relationships; eccentricities of appearance and behavior, and cognitive and perceptual distortions.
• They have few close friends or relationships.
• They are anxious in social situations (even when they have the time to become familiar with the situation), feel like outcasts or outsiders, find it difficult to feel connected to others, and are suspicious of others’ motivations, including their spouse, colleagues, and friends.
• Individuals with this type are eccentric, odd, or peculiar in appearance or manner (e.g., grooming, hygiene, posture, and/or eye contact are strange or unusual).
• Their speech may be vague, circumstantial, metaphorical, over-elaborate, impoverished, overly concrete, or stereotyped. Individuals with this type experience a limited or constricted range of emotions, and are inhibited in their expression of emotions.
• They may appear detached and indifferent to other’s reactions, despite internal distress at being “set apart.”
• Odd beliefs influence their behavior, such as beliefs in superstition, clairvoyance, or telepathy.
• Their perception of reality can become further impaired, often under stress, when reasoning and perceptual processes become odd and idiosyncratic (e.g., they may make seemingly arbitrary inferences, or see hidden messages or special meanings in ordinary events) or quasi-psychotic, with symptoms such as pseudo-hallucinations, sensory illusions, over-valued ideas, mild paranoid ideation, or transient psychotic episodes.
• Individuals with this personality disorder type are, however, able to “reality test” psychotic-like symptoms and can intellectually acknowledge that they are products of their own minds.

(APA, 2010)