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SCHIZOTYPAL PERSONALITY DISORDER
 


Prediction: Lifelong Duration

      Occupational-Economic:
  • Works poorly with others (works best when alone)
      Wisdom vs Irrationality:
  • Eccentricity, odd beliefs, perceptual distortions
      Courage vs Negative Emotion: N/A
      Community vs Detachment:
  • Suspiciousness, social withdrawal, intimacy avoidance, inability to feel pleasure, restricted emotional expression
      Moderation vs Disinhibition: N/A
      Justice vs Antagonism: N/A
      Medical: N/A

SYNOPSIS

Schizotypal Disorder F21 - ICD10 Description, World Health Organization

Schizotypal disorder is characterized by eccentric behaviour and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies occur at any stage. The symptoms may include a cold or inappropriate affect; anhedonia; odd or eccentric behaviour; a tendency to social withdrawal; paranoid or bizarre ideas not amounting to true delusions; obsessive ruminations; thought disorder and perceptual disturbances; occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation. There is no definite onset. The evolution and course are usually those of a personality disorder.
Schizotypal Personality Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with schizotypal personality disorder needs to show at least 5 of the following criteria:

  • Ideas of reference (excluding delusions of reference).

  • Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations).

  • Unusual perceptual experiences, including bodily illusions.

  • Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).

  • Suspiciousness or paranoid ideation.

  • Inappropriate or constricted affect.

  • Behavior or appearance that is odd, eccentric, or peculiar.

  • Lack of close friends or confidants other than first-degree relatives.

  • Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
Like personality disorders, schizotypal disorder is a deeply ingrained and enduring behaviour pattern, manifesting as an inflexible response to a broad range of personal and social situations. This behavior represents an extreme or significant deviation from the way in which the average individual in a given culture relates to others. This behaviour pattern tends to be stable. It causes subjective distress and problems in social performance.

    NOTE: The World Health Organization's ICD-10 does not classify schizotypal disorder as a personality disorder, but it admits that "the evolution and course are usually those of a personality disorder". The ICD-10 treats schizotypal disorder as a mild, arrested or premorbid form of schizophrenia. In contrast, the American Psychiatric Association's DSM-5 classifies this disorder both as a personality disorder, and as part of the schizophrenia spectrum of disorders.

Core Features:

Individuals with schizotypal personality disorder grow up being socially and emotionally withdrawn and odd or eccentric. The core features of this disorder are: (1) detachment (suspiciousness, social withdrawal, intimacy avoidance, inability to feel pleasure, restricted emotional expression), and (2) irrationality (eccentricity, odd beliefs, perceptual distortions). This disorder is only diagnosed if: (1) it begins no later than early adulthood, (2) these behaviors occur at home, work, and in the community, and (3) these behaviors lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning. This disorder should not be diagnosed if its symptoms occur exclusively during the course of a psychotic disorder or autism spectrum disorder.

Lack Of Social Skills And Personality Disorders

There are certain social skills that are essential for healthy social functioning. Individuals with schizoid personality disorder lack the essential social skills of: normal behavior, normal beliefs, and normal perception. They also lack intimacy, sociabililty, and emotional expressiveness (that are also lacking in individuals with schizoid personality disorder); and lack trust (that is also lacking in individuals with paranoid personality disorder).

    Social Skills That Are Lacking In Schizotypal Personality Disorder

    SOCIAL SKILL LOW LEVEL HIGH LEVEL
    Normal Behavior Eccentricity (odd, unusual or bizarre behavior) Normal behavior and appearance
    Normal Beliefs Odd beliefs (paranoid or bizarre ideas not amounting to true delusions) Normal beliefs and experiences
    Normal Perception Perceptual distortions (depersonal- ization, derealization, dissociative, or thought-control experiences) Normal perception
    Intimacy Intimacy avoidance Wanting close friendships or intimate romantic relationships
    Sociability Social withdrawal Friendly; interested in social contacts and activities
    Emotional Expressiveness Lack of emotional expression Open expression of emotions; full range of emotions
    Trust Suspiciousness Trusting the loyalty and good intentions of significant others (e.g., family, friends)

Paranoid, schizoid, and schizotypal personality disorder are so closely related that they are referred to as the "detached" cluster of personality disorders.

    Social Skills That Are Lacking In The "Detached" Cluster Of Personality Disorders

    PERSONALITY DISORDER LACKING LACKING LACKING
    Paranoid Personality Trust (instead has suspiciousness) Forgiveness (instead has bearing grudges) Gratitude (instead has feeling victimized)
    Schizoid Personality Intimacy (instead has intimacy avoidance) Sociability (instead has social withdrawal) Emotional expressiveness (instead has lack of emotional expression)
    Schizotypal Personality Normal Behavior (instead has eccentricity) Normal Beliefs (instead has odd beliefs) Normal Perception (instead has perceptual distortions)

Social Functioning:

Individuals with schizotypal personality disorder have acute discomfort with close relationships. Thus these individuals have few close friends and little desire for sexual intimacy.

Detachment

Individuals with schizotypal personality disorder have little reaction to emotionally arousing situations, and restricted emotional expression. Thus they may appear indifferent or cold. They may have social withdrawal with avoidance of social contacts and activity. Individuals with this disorder may have undue suspiciousness and feelings of persecution. They may have excessive social anxiety with these paranoid fears.

Irrationality

Individuals with schizotypal personality disorder do not have psychotic symptoms (i.e., delusions, hallucinations, disorganized speech, or grossly disorganized/catatonic behavior). However, they may have ideas of reference and odd beliefs that are almost delusions. Likewise, they may have unusual perceptual experiences, including bodily illusions, that are almost hallucinations. They may have odd speech (e.g., vague, circumstantial, overelaborate, or stereotyped) that is almost grossly disorganized.

Effective Therapies

There has been only one randomized, placebo-controlled clinical trail for the effectiveness of therapy for the core symptoms of schizotypal personality disorder. This was a 9-week randomized, double-blind, placebo-controlled study of low-dose risperidone (starting dose of 0.25 mg/day, titrated upward to 2 mg/day). Patients receiving active medication had significantly (p <.05) lower scores on the PANSS negative and general symptom scales by week 3 and on the PANSS positive symptom scale by week 7 compared with patients receiving placebo. Side effects were generally well tolerated, and there was no group difference in dropout rate for side effects. Thus low-dose risperidone appears to be effective in reducing symptom severity in schizotypal personality disorder and is generally well tolerated. In another two-year follow-up study that was not placebo-controlled; 25.0% of patients with schizotypal personality disorder that were randomized to receive "integrated treatment" developed psychosis compared to 48.3% for patients randomized to "standard treatment". Note: The fact that schizotypal personality disorder frequently converts into a psychotic disorder, and dramatically responds to antipsychotic medication; all supports the conclusion that this disorder isn't a "personality disorder", but instead is simply an early stage in the development of schizophrenia. Individuals with this disorder seldom voluntarily present for treatment; yet low-dose antipsychotic medication can be very beneficial. Thus a trusting relationship with primary care physician who prescribes this antipsychotic medication is probably the best therapy.

Ineffective Therapies

Six months of cognitive behavioral therapy was shown, on 3-year followup, to not affect transition to psychosis.

Which Behavioral Dimensions Are Involved?

The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, community, moderation, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")

    Schizotypal Personality Disorder: Irrationality And Detachment
            Wisdom vs Irrationality:
      • Eccentricity, odd beliefs, perceptual distortions
            Courage vs Negative Emotion: N/A
            Community vs Detachment:
      • Suspiciousness, social withdrawal, intimacy avoidance, inability to feel pleasure, restricted emotional expression
            Moderation vs Disinhibition: N/A
            Justice vs Antagonism: N/A

Prevalence

Schizotypal personality disorder occurs in 0.6%-4.6% of the general population. This disorder occurs slightly more commonly in males.

Course

Schizotypal personality disorder may first appear in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language, and bizarre fantasies. These children may appear odd or eccentric and attract teasing. With some adolescents, these schizotypal features may be caused by transient emotional turmoil, and these features disappear when the turmoil resolves. For other adolescents, these schizotypal features persist into adulthood, and they become chronic and stable. Only a small proportion of individuals with this disorder go on to develop schizophrenia or another psychotic disorder.

Familial Pattern

Schizotypal personality disorder is more common among first-degree biological relatives of those with schizophrenia, and visa versa.

Complications

In response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). If the psychotic episode lasts longer, this disorder may actually develop into brief psychotic disorder, schizophreniform disorder, delusional disorder or schizophrenia.

Comorbidity

Personality disorders are an overlooked and underappreciated source of psychiatric morbidity. Comorbid personality disorders may, in fact, account for much of the morbidity attributed to axis I disorders in research and clinical practice. "High percentages of patients with schizotypal (98.8%), borderline (98.3%), avoidant (96.2%), and obsessive-compulsive (87.6%) personality disorder and major depressive disorder (92.8%) exhibited moderate (or worse) impairment or poor (or worse) functioning in at least one area."
Some other disorders frequently occur with this disorder:

    Non-Personality Disorders:

            Schizophrenia Spectrum and Other Psychotic Disorders:
      • This disorder may be a premorbid antecendent of a psychotic disorder. In response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). If the psychotic episode lasts longer, this disorder may actually develop into delusional disorder or schizophrenia.
            Depressive Disorders:
      • Half have a history of major depressive disorder.

    Personality Disorders:

            Negative Emotion Cluster:
      • Avoidant personality disorder.
            Detached Cluster:
      • Paranoid, schizoid personality disorders.
        Note: Paranoid, schizoid, and schizotypal personality disorders are all closely related since they all share the same core feature of detachment. If an individual has one of these detached personality disorders, they are very likely to have another.
            Antagonistic Cluster:
      • Borderline personality disorder.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.

Primate Evolution:

There appears to be three different ways in which primates have evolved socially:
  • The chimpanzees have evolved to be socially antagonistic, competitive, callous, and manipulative. Thus chimpanzee social behavior most closely mirrors the antagonistic behavior of the antisocial-narcissistic-borderline-histrionic cluster of personality disorders.

  • In contrast, the bonobos have evolved to be socially anxious, peaceful, cooperative, and loving. Thus bonobo social behavior most closely mirrors the negative emotion (anxious) behavior of the avoidant-dependent cluster of personality disorders.

  • Another separate evolutionary path was followed by the orangutans. They evolved to become solitary hermits. Thus orangutan social behavior most closely mirrors the detached behavior of the paranoid-schizoid-schizotypal cluster of personality disorders.


Core Behaviors Of The Detached Cluster Of Personality Disorders

Religious Hermit

History is filled with thousands of stories of religious hermits who withdrew to a solitary place for a life of religious seclusion.

The core feature of the paranoid-schizoid-schizotypal cluster of personality disorders is detachment. Individuals with these disorders are socially and emotionally withdrawn; thus prefer a solitary life.

    Detachment: The Core Feature of the Detached Cluster of Personality Disorders

    • suspiciousness:
      In the past week, did you suspect that people were exploiting, harming, or deceiving you?
    • social withdrawal:
      In the past week, did you mostly prefer to be alone?
    • intimacy avoidance:
      In the past week, did you avoid close friendships (outside of your family) or romantic relationships?
    • inability to feel pleasure:
      In the past week, did few things in life give you pleasure?
    • restricted emotional expression:
      In the past week, did you seldom smile or show much emotion?

Parental Behaviors Which Increase The Risk Of Developing A Personality Disorder

Research has shown that genetic, environmental, and prenatal factors all play important roles in the development of personality disorder. Recent research has also shown that low parental affection and harsh parenting increase the risk of a child later developing a personality disorder.

"Low affection" was defined as: low parental affection, low parental time spent with the child, poor parental communication with the child, poor home maintenance, low educational aspirations for the child, poor parental supervision, low paternal assistance to the child's mother, and poor paternal role fulfillment. "Harsh parenting" was defined as: harsh punishment, inconsistent maternal enforcement of rules, frequent loud arguments between the parents, difficulty controlling anger toward the child, possessiveness, use of guilt to control the child, and verbal abuse.

Setting Goals In Therapy

    Questions To Ask When Setting Goals

    In The Past Week:
    • WHO: was your problem?
    • EVENT: what did he/she do?
    • RESPONSE: how did you respond to that event?
    • OUTCOME: did your response help?
    • TRIGGER: what did you do that could have triggered this problem?
    • GOAL: what life skill(s) do you have to work on? (from checklist)

    Example Of Setting Goals In Interviewing A Person With Schizotypal Personality Disorder

    In The Past Week:
    • WHO: was your problem?
      "The people in my apartment."

    • EVENT: what did he/she do?
      "Whenever I meet them, it's as if their force field is sucking mine dry. Being with them exhausts me spiritually."

    • RESPONSE: how did you respond to that event?
      "I try to avoid these neighbors by staying at home as much as I can."

    • OUTCOME: did your response help?
      "No, if anything, this is getting worse."

    • TRIGGER: what did you do that could have triggered this problem?
      "It's as if I am in spiritual warfare with my neighbors; that's why I avoid them."

    • GOAL: what life skill(s) do you have to work on? (from checklist)
      "I want to work on: (1) Trust ("trusting the loyalty and good intentions of significant others"), and (2) Sociability ("being friendly; interested in social contacts and activities")."

Description

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Free Diagnosis Of This Disorder

Rating Scales



Treatment

Research

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Internet Mental Health 1995-2011 Phillip W. Long, M.D.