Schizotypal personality disorder

Not to be confused with Schizoid personality disorder or Schizoaffective disorder.
Schizotypal personality disorder
People with schizotypal personality disorder often dress in eccentric ways.
SpecialtyPsychiatry
SymptomsStrange thinking, lack of friends, unusual appearance, suspiciousness[1]
ComplicationsSchizophrenia[1]
Usual onsetBy early adulthood[1]
Risk factorsFamily history[1]
Differential diagnosisPsychosis, autism spectrum disorder, substance misuse, other personality disorders[1]
TreatmentCounselling[2]
Frequency0.6 to 4.6%[1]
Personality disorders
Cluster A (odd)
Cluster B (dramatic)
Cluster C (anxious)
Not specified

Schizotypal personality disorder (STPD) is characterized by a long term pattern of discomfort with close relationships and eccentric behavior.[1] This may include being suspiciousness, dressing in an unusual manner, and being superstitious.[1] A small number of those effected develop schizophrenia.[1]

Risk factors include a family history of the condition.[1] Psychological stress may trigger worsening of symptoms.[1] It is a personality disorder in cluster A, a group characterized by eccentric behavior.[1] Diagnosis requires taking into account a person's culture.[1]

Treatment generally involves counselling.[2] People often request help with anxiety or depression rather than the personality disorder itself.[1] It affects about 0.6 to 4.6% of people.[1] Onset is by early adulthood.[1] Males are more commonly affected than females.[1] The term "schizotype" came into use in 1956 by Sandor Rado.[2]

Signs and symptoms

Video explanation of cluster A personality disorders
Word cloud for StPD

Comorbidity

Schizotypal personality disorder usually co-occurs with major depressive disorder, dysthymia and social phobia.[3] Furthermore, sometimes schizotypal personality disorder can co-occur with obsessive–compulsive disorder, and its presence appears to affect treatment outcome adversely.[4] The personality disorders that co-occur most often with schizotypal personality disorder are schizoid, paranoid, avoidant, and borderline.[5]

Some persons with schizotypal personality disorders go on to develop schizophrenia,[6] but most of them do not.[7] Although STPD symptomatology has been studied longitudinally in a number of community samples, the results received do not suggest any significant likelihood of the development of schizophrenia.[8] There are dozens of studies showing that individuals with schizotypal personality disorder score similar to individuals with schizophrenia on a very wide range of neuropsychological tests. Cognitive deficits in patients with schizotypal personality disorder are very similar to, but quantitatively milder than, those for patients with schizophrenia.[9] A 2004 study, however, reported neurological evidence that did "not entirely support the model that SPD is simply an attenuated form of schizophrenia".[10]

In case of methamphetamine use, people with schizotypal personality disorders are at great risk of developing permanent psychosis.[11]

Causes

Genetic

Schizotypal personality disorder is widely understood to be a "schizophrenia spectrum" disorder. Rates of schizotypal personality disorder are much higher in relatives of individuals with schizophrenia than in the relatives of people with other mental illnesses or in people without mentally ill relatives. Technically speaking, schizotypal personality disorder may also be considered an "extended phenotype" that helps geneticists track the familial or genetic transmission of the genes that are implicated in schizophrenia.[12] But there is also a genetic connection of STPD to mood disorders and depression in particular.[13]

Social and environmental

There is now evidence to suggest that parenting styles, early separation, trauma/maltreatment history (especially early childhood neglect) can lead to the development of schizotypal traits.[14][15] Neglect or abuse, trauma, or family dysfunction during childhood may increase the risk of developing schizotypal personality disorder. Over time, children learn to interpret social cues and respond appropriately but for unknown reasons this process does not work well for people with this disorder.[16]

Schizotypal personality disorders are characterized by a common attentional impairment in various degrees that could serve as a marker of biological susceptibility to STPD.[17] The reason is that an individual who has difficulties taking in information may find it difficult in complicated social situations where interpersonal cues and attentive communications are essential for quality interaction. This might eventually cause the individual to withdraw from most social interactions, thus leading to asociality.[17]

Diagnosis

DSM-5

In the American Psychiatric Association's DSM-5, schizotypal personality disorder is defined as 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."[18]

At least five of the following symptoms must be present:

  • ideas of reference
  • strange beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”, bizarre fantasies or preoccupations)
  • abnormal perceptual experiences, including bodily illusions
  • strange thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
  • suspiciousness or paranoid ideation
  • inappropriate or constricted affect
  • strange behavior or appearance
  • lack of close friends
  • excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

These symptoms must not occur only during the course of a disorder with similar symptoms (such as schizophrenia or autism spectrum disorder).[18]

ICD-10

The World Health Organization's ICD-10 uses the name schizotypal disorder (F21). It is classified as a clinical disorder associated with schizophrenia, rather than a personality disorder as in DSM-5.[19]

The ICD definition is:

A disorder characterized by eccentric behavior and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies have occurred at any stage. There is no dominant or typical disturbance, but any of the following may be present:
  • Inappropriate or constricted affect (the individual appears cold and aloof);
  • Behavior or appearance that is odd, eccentric or peculiar;
  • Poor rapport with others and a tendency to withdraw socially;
  • Odd beliefs or magical thinking, influencing behavior and inconsistent with subcultural norms;
  • Suspiciousness or paranoid ideas;
  • Obsessive ruminations without inner resistance;
  • Unusual perceptual experiences including somatosensory (bodily) or other illusions, depersonalization or derealization;
  • Vague, circumstantial, metaphorical, over-elaborate or stereotyped thinking, manifested by odd speech or in other ways, without gross incoherence;
  • Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations and delusion-like ideas, usually occurring without external provocation.
The disorder runs a chronic course with fluctuations of intensity. Occasionally it evolves into overt schizophrenia. There is no definite onset and its evolution and course are usually those of a personality disorder. It is more common in individuals related to people with schizophrenia and is believed to be part of the genetic "spectrum" of schizophrenia.

Diagnostic guidelines

This diagnostic rubric is not recommended for general use because it is not clearly demarcated either from simple schizophrenia or from schizoid or paranoid personality disorders, or possibly autism spectrum disorders as currently diagnosed. If the term is used, three or four of the typical features listed above should have been present, continuously or episodically, for at least 2 years. The individual must never have met criteria for schizophrenia itself. A history of schizophrenia in a first-degree relative gives additional weight to the diagnosis but is not a prerequisite.

Includes
  • Borderline schizophrenia
  • Latent schizophrenic reactions
  • Prepsychotic schizophrenia
  • Prodromal schizophrenia
  • Pseudoneurotic schizophrenia
  • Pseudopsychopathic schizophrenia
  • Schizotypal personality disorder
Excludes

Subtypes

Theodore Millon proposes two subtypes of schizotypal.[20][21] Any individual with schizotypal personality disorder may exhibit either one of the following somewhat different subtypes (Note that Millon believes it is rare for a personality with one pure variant, but rather a mixture of one major variant with one or more secondary variants):

Subtype Description Personality traits
Insipid schizotypal A structural exaggeration of the passive-detached pattern. It includes schizoid, depressive and dependent features. Sense of strangeness and nonbeing; overtly drab, sluggish, inexpressive; internally bland, barren, indifferent, and insensitive; obscured, vague, and tangential thoughts.
Timorous schizotypal A structural exaggeration of the active-detached pattern. It includes avoidant and negativistic features. Warily apprehensive, watchful, suspicious, guarded, shrinking, deadens excess sensitivity; alienated from self and others; intentionally blocks, reverses, or disqualifies own thoughts.

Differential diagnosis

There is a high rate of comorbidity with other personality disorders. McGlashan et al. (2000) stated that this may be due to overlapping criteria with other personality disorders, such as avoidant personality disorder, paranoid personality disorder and borderline personality disorder.[22]

There are many similarities between the schizotypal and schizoid personalities. Most notable of the similarities is the inability to initiate or maintain relationships (both friendly and romantic). The difference between the two seems to be that those labeled as schizotypal avoid social interaction because of a deep-seated fear of people. The schizoid individuals simply feel no desire to form relationships, because they see no point in sharing their time with others.

Both simple schizophrenia and STPD may share negative symptoms like avolition, impoverished thinking and flat affect. Although they can look very similar, the severity usually distinguishes them. Also, STPD is characterized by a lifelong pattern without much change whereas simple schizophrenia represents a deterioration.[23]

Treatment

Counselling

According to Theodore Millon, the schizotypal is one of the easiest personality disorders to identify but one of the most difficult to treat with psychotherapy.[20] Persons with STPD usually consider themselves to be simply eccentric, productive or nonconformist. As a rule, they underestimate maladaptiveness of their social isolation and perceptual distortions. It is not so easy to gain rapport with people who suffer from STPD due to the fact that increasing familiarity and intimacy usually increase their level of anxiety and discomfort. In most cases they do not respond to informality and humor.[24]

Group therapy is recommended for persons with STPD only if the group is well structured and supportive. Otherwise, it could lead to loose and tangential ideation.[25] Support is especially important for schizotypal patients with predominant paranoid symptoms, because they will have a lot of difficulties even in highly structured groups.[26]

Medication

STPD is rarely seen as the primary reason for treatment in a clinical setting, but it often occurs as a comorbid finding with other mental disorders. When patients with STPD are prescribed pharmaceuticals, they are most often prescribed the same drugs used to treat patients suffering from schizophrenia including traditional neuroleptics such as haloperidol and thiothixene. In order to decide which type of medication should be used, Paul Markovitz distinguishes two basic groups of schizotypal patients:[25]

  • Schizotypal patients who appear to be almost schizophrenic in their beliefs and behaviors (aberrant perceptions and cognitions) are usually treated with low doses of antipsychotic medications, e.g. thiothixene. However, it must be mentioned that long-term efficacy of neuroleptics is doubtful.
  • For schizotypal patients who are more obsessive–compulsive in their beliefs and behaviors, SSRIs like sertraline appear to be more effective.

Lamotrigine, an anti-convulsant, appears to be helpful in dealing with social isolation.[27]

Epidemiology

Reported prevalence of STPD in community studies ranges from 0.6% in a Norwegian sample, to 4.6% in an American sample.[18] A large American study found a lifetime prevalence of 3.9%, with somewhat higher rates among men (4.2%) than women (3.7%).[28] It may be uncommon in clinical populations, with reported rates of up to 1.9%.[18]

Together with other cluster A personality disorders, it is also very common among homeless people who show up at drop-in centres, according to a 2008 New York study. The study did not address homeless people who do not show up at drop-in centres.[29]

See also

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). American Psychiatric Association. 2013. pp. 655-659. doi:10.1176/appi.books.9780890425596.156852. ISBN 978-0-89042-555-8. {{cite book}}: Cite has empty unknown parameter: |1= (help)
  2. 1 2 3 Hales, Robert E. (2008). The American Psychiatric Publishing Textbook of Psychiatry. American Psychiatric Pub. p. 836. ISBN 978-1-58562-257-3. Archived from the original on 2021-08-29. Retrieved 2021-01-13.
  3. ↑ Sutker, Patricia (2002). Comprehensive handbook of psychopathology (3rd ed.). Kluwer Academic. ISBN 978-0-306-46490-4. OCLC 50322422.
  4. ↑ Murray, Robin (2008). Essential psychiatry (4th ed.). Cambridge University Press. ISBN 978-0-521-60408-6. OCLC 298067373.
  5. ↑ Tasman, Allan (2008). Psychiatry (3rd ed.). Wiley-Blackwell. ISBN 978-0-470-06571-6. OCLC 264703257.
  6. ↑ Walker, Elaine; Kestler, Lisa; Bollini, Annie; et al. (2004). "Schizophrenia: Etiology and Course". Annual Review of Psychology. Annual Reviews. 55 (1): 401–430. doi:10.1146/annurev.psych.55.090902.141950. ISSN 0066-4308. PMID 14744221.
  7. ↑ Raine, A. (2006). "Schizotypal personality: Neurodevelopmental and psychosocial trajectories". Annual Review of Psychology. 2: 291–326. doi:10.1146/annurev.clinpsy.2.022305.095318. PMID 17716072.
  8. ↑ Gooding DC; Tallent KA; Matts CW (2005). "Clinical status of at-risk individuals 5 years later: Further validation of the psychometric high-risk strategy". Journal of Abnormal Psychology. 114 (1): 170–175. doi:10.1037/0021-843x.114.1.170. PMID 15709824.
  9. ↑ Matsui, Mié; Sumiyoshi, Tomiki; Kato, Kanade; et al. (2004). "Neuropsychological Profile in Patients with Schizotypal Personality Disorder or Schizophrenia". Psychological Reports. SAGE Publications. 94 (2): 387–397. doi:10.2466/pr0.94.2.387-397. ISSN 0033-2941. PMID 15154161.
  10. ↑ Haznedar, M. M.; Buchsbaum, M. S.; Hazlett, E. A.; Shihabuddin, L.; New, A.; Siever, L. J. (2004). "Cingulate gyrus volume and metabolism in the schizophrenia spectrum". Schizophrenia Research. 71 (2–3): 249–262. doi:10.1016/j.schres.2004.02.025. PMID 15474896.
  11. ↑ Chen, C. K.; Lin, S. K.; Sham, P. C.; et al. (2005). "Morbid risk for psychiatric disorder among the relatives of methamphetamine users with and without psychosis". American Journal of Medical Genetics. 136 (1): 87–91. doi:10.1002/ajmg.b.30187. PMID 15892150.
  12. ↑ Fogelson, D.L; Nuechterlein, K.H.; Asarnow, R.A.; Payne, D.L.; Subotnik, K.L.; Jacobson, K.C.; Neale, M.C.; Kendler, K.S. (15 February 2007). "Avoidant personality disorder is a separable schizophrenia-spectrum personality disorder even when controlling for the presence of paranoid and schizotypal personality disorders". Schizophrenia Research. Elsevier BV. 91 (1–3): 192–199. doi:10.1016/j.schres.2006.12.023. ISSN 0920-9964. PMC 1904485. PMID 17306508.
  13. ↑ Comer, Ronald; Comer, Gregory. "Personality Disorders" (PDF). Worth Publishers. Princeton University. Archived (PDF) from the original on 2017-05-17. Retrieved 30 April 2017.
  14. ↑ Deidre M. Anglina, Patricia R. Cohenab, Henian Chena (2008) Duration of early maternal separation and prediction of schizotypal symptoms from early adolescence to midlife, Schizophrenia Research Volume 103, Issue 1, Pages 143–150 (August 2008)
  15. ↑ Howard Berenbaum, Ph.D., Eve M. Valera, Ph.D. and John G. Kerns, Ph.D. (2003) Psychological Trauma and Schizotypal Symptoms, Oxford Journals, Medicine, Schizophrenia Bulletin Volume 29, Number 1 Pp. 143–152
  16. ↑ Mayo Clinic Staff. "Schizotypal personality disorder". Mayo Clinic. Archived from the original on 9 March 2012. Retrieved 21 February 2012.
  17. 1 2 Roitman, SE; Cornblatt, BA; Bergman, A; Obuchowski, M; Mitropoulou, V; Keefe, RS; Silverman, JM; Siever, LJ (1997). "Attentional functioning in schizotypal personality disorder [published erratum appears in Am J Psychiatry 1997 Aug;154(8):1180]". The American Journal of Psychiatry. 154 (5): 655–660. doi:10.1176/ajp.154.5.655. ISSN 0002-953X. PMID 9137121.
  18. 1 2 3 4 Diagnostic and statistical manual of mental disorders : DSM-5. American Psychiatric Association,American Psychiatric Association. 2013. pp. 655–659. ISBN 978-0-89042-555-8. OCLC 830807378.
  19. ↑ Schizotypal Disorder Archived 2015-11-02 at the Wayback Machine in ICD-10: Clinical descriptions and guidelines. Archived 2014-03-23 at the Wayback Machine
  20. 1 2 Millon, Theodore (2004). "Chapter 12 – The Schizotypal Personality" (PDF). Personality disorders in modern life. Wiley. p. 403. ISBN 978-0-471-23734-1. OCLC 57291241. Archived from the original (PDF) on 2017-02-07.
  21. ↑ The Millon Personality Group (8 March 2017). "Eccentric/Schizotypal Personality". Millon Theory. Archived from the original on 8 March 2017. Retrieved 5 April 2019.
  22. ↑ McGlashan, Thomas H.; Grilo, Carlos M.; Skodol, Andrew E.; et al. (2000). "The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence". Acta Psychiatrica Scandinavica. 102 (4): 256–264. doi:10.1034/j.1600-0447.2000.102004256.x. ISSN 0001-690X. PMID 11089725.
  23. ↑ American Psychiatric Association, DSM-IV (1994). Appendix B: Criteria Sets and Axes Provided for Further Study. p. 713. ISBN 9780890420621.
  24. ↑ Siever, L.J. (1992). "Schizophrenia spectrum disorders". Review of Psychiatry. 11: 25–42.
  25. 1 2 Livesley, W (2001). Handbook of personality disorders : theory, research, and treatment. Guilford Press. ISBN 978-1-57230-629-5. OCLC 45750508.
  26. ↑ Oldham, John; et al. (2005). The American Psychiatric Publishing textbook of personality disorders. American Psychiatric Pub. ISBN 978-1-58562-159-0. OCLC 56733258.
  27. ↑ Grunze HC (May 2008). "The effectiveness of anticonvulsants in psychiatric disorders". 10 (1). The Journal of Clinical Endocrinology & Metabolism. PMID 18472486. Archived from the original on 29 August 2021. Retrieved 10 May 2020. {{cite journal}}: Cite journal requires |journal= (help)
  28. ↑ Pulay, AJ; Stinson, FS; Dawson, DA; Goldstein, RB; Chou, SP; et al. (2009). "Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Schizotypal Personality Disorder: Results From the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions". Primary Care Companion to the Journal of Clinical Psychiatry. 11 (2): 53–67. doi:10.4088/PCC.08m00679. PMC 2707116. PMID 19617934.
  29. ↑ Connolly, Adrian J. (2008). "Personality disorders in homeless drop-in center clients" (PDF). Journal of Personality Disorders. 22 (6): 573–588. doi:10.1521/pedi.2008.22.6.573. PMID 19072678. Archived from the original (PDF) on 2009-06-17.
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