Schizotypal personality disorder

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Definition

Schizotypal personality disorder is characterized by an ongoing pattern in which the affected person distances him- or herself from social and interpersonal relationships. Affected people typically have an acute discomfort when put in circumstances where they must relate to others. These individuals are also prone to cognitive and perceptual distortions and a display a variety of eccentric behaviors that others often find confusing.

Description

People with schizotypal personality disorder are more comfortable turning inward, away from others, than learning to have meaningful interpersonal relationships. This preferred isolation contributes to distorted perceptions about how interpersonal relationships are supposed to happen. These individuals remain on the periphery of life and often drift from one aimless activity to another with few, if any, meaningful relationships.

A person with schizotypal personality disorder has odd behaviors and thoughts that would typically be viewed by others as eccentric, erratic, and bizarre. They are known on occasion to have brief periods of psychotic episodes. Their speech, while coherent, is marked by a focus on trivial detail. Thought processes of schizotypals include magical thinking, suspiciousness, and illusions. These thought patterns are believed to be the schizotypal's unconscious way of coping with social anxiety. To some extent, these behaviors stem from being socially isolated and having a distorted view of appropriate interpersonal relations.

Causes and symptoms

Causes

Schizotypal personality disorder is believed to stem from the affected person's original family, or family of origin. Usually the parents of the affected person were emotionally distant, formal, and displayed confusing parental communication. This modeling of remote, unaffectionate relationships is then reenacted in the social relationships encountered in the developing years. The social development of people with schizotypal personality disorder shows that many were also regularly humiliated by their parents, siblings, and peers resulting in significant relational mistrust. Many display low self-esteem, self-criticism and self-deprecating behavior. This further contributes to a sense that they are socially incapable of having meaningful interpersonal relationships.

Symptoms

The Diagnostic and Statistical Manual of Mental Disorders , a professional manual, specifies nine diagnostic criteria for schizotypal personality disorder:

• Incorrect interpretations of events. Individuals with schizotypal personality disorder often have difficulty seeing the correct cause and effect of situations and how they affect others. For instance, the schizotypal may misread a simple non-verbal communication cue, such as a frown, as someone being displeased with them, when in reality it may have nothing to do with them. Their perceptions are often distortions of what is really happening externally, but they tend to believe their perceptions more than what others might say or do.
• Odd beliefs or magical thinking. These individuals may be superstitious or preoccupied with the paranormal. They often engage in these behaviors as a desperate means to find some emotional connection with the world they live in. This behavior is seen as a coping mechanism to add meaning in a world devoid of much meaning because of the social isolation these individuals experience.
• Unusual perceptual experiences. These might include having illusions, or attributing a particular event to some mysterious force or person who is not present. Affected people may also feel they have special powers to influence events or predict an event before it happens.
• Odd thinking and speech. People with schizotypal personality disorder may have speech patterns that appear strange in their structure and phrasing. Their ideas are often loosely associated, prone to tangents, or vague in description. Some may verbalize responses by being overly concrete or abstract and insert words that serve to confuse rather than clarify a particular situation, yet make sense to them. They are typically unable to have ongoing conversation and tend to talk only about matters that need immediate attention.
• Suspicious or paranoid thoughts. Individuals with schizotypal personality disorder are often suspicious of others and display paranoid tendencies.
• Emotionally inexpressive. Their general social demeanor is to appear aloof and isolated, behaving in a way that communicates they derive little joy from life. Most have an intense fear of being humiliated or rejected, yet repress most of these feelings for protective reasons.
• Eccentric behavior. People with schizotypal personality disorder are often viewed as odd or eccentric due to their unusual mannerisms or unconventional clothing choices. Their personal appearance may look unkempt—clothing choices that do not "fit together," clothes may be too small or large, or clothes may be noticeably unclean.
• Lack of close friends. Because they lack the skills and confidence to develop meaningful interpersonal relationships, they prefer privacy and isolation. As they withdraw from relationships, they increasingly turn inward to avoid possible social rejection or ridicule. If they do have any ongoing social contact, it is usually restricted to immediate family members.
• Socially anxious. Schizotypals are noticeably anxious in social situations, especially with those they are not familiar with. They can interact with people when necessary, but prefer to avoid as much interaction as possible because their self-perception is that they do not "fit in." Even when exposed to the same group of people over time, their social anxiety does not seem to lessen. In fact, it may progress into distorted perceptions of paranoia involving the people with whom they are in social contact.

Demographics

Schizotypal personality disorder appears to occur more frequently in individuals who have an immediate family member with schizophrenia . The prevalence of schizotypal personality disorder is approximately 3% of the general population and is believed to occur slightly more often in males.

Symptoms that characterize a typical diagnosis of schizotypal personality disorder should be evaluated in the context of the individual's cultural situation, particularly those regarding superstitious or religious beliefs and practices. (Some behaviors that Western cultures may view as psychotic are viewed within the range of normal behavior in other cultures.)

Diagnosis

The symptoms of schizotypal personality disorder may begin in childhood or adolescence showing as a tendency toward solitary pursuit of activities, poor peer relationships, pronounced social anxiety, and underachievement in school. Other symptoms that may be present during the developmental years are hypersensitivity to criticism or correction, unusual use of language, odd thoughts, or bizarre fantasies. Children with these tendencies appear socially out-of-step with peers and often become the object of malicious teasing by their peers, which increases the feelings of isolation and social ineptness they feel. For a diagnosis of schizotypal personality disorder to be accurately made, there must also be the presence of at least four of the above-mentioned symptoms.

The symptoms of schizotypal personality disorder can sometimes be confused with the symptoms seen in schizophrenia. The bizarre thinking associated with schizotypal personality disorder can be perceived as a psychotic episode and misdiagnosed. While brief psychotic episodes can occur in the patient with schizotypal personality disorder, the psychosis is not as pronounced, frequent, or as intense as in schizophrenia. For an accurate diagnosis of schizotypal personality disorder, the symptoms for schizotypal cannot occur exclusively during the course of schizophrenia or other mood disorder that has psychotic features.

Another common difficulty in diagnosing schizotypal personality disorder is distinguishing it from other the schizoid, avoidant, and paranoid personality disorders . Some researchers believe that schizotypal personality disorder is essentially the same disorder as schizoid, but many feel there are distinguishing characteristics. Schizoids are deficient in their ability to experience emotion, while schizotypals are more pronounced in their inability to understand human motivation and communication. While avoidant personality disorder has many of the same symptoms as schizotypal personality disorder, the distinguishing symptom in schizotypal is the presence of behavior that is noticeably eccentric. The schizotypal differs from the paranoid by tangential thinking and eccentric behavior.

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)

Treatments

The patient with schizotypal personality disorder finds it difficult to engage and remain in treatment. For those higher-functioning individuals who seek treatment, the goal will be to help them function more effectively in relationships rather than restructuring their personality.

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

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

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.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., M.D., and Robert Berkow, M.D., eds. The Merck Manual of Diagnosis and Therapy. 17th edition. Whitehouse Station, NJ: Merck Research Laboratories,1999.

Millon, Theodore, Ph.D., D.Sc. Disorders of Personality: DSM IV and Beyond. New York: John Wiley and Sons, Inc., 1996.

Sperry, Len, M.D., Ph.D. Handbook of Diagnosis and Treatment of DSM-IV Personality Disorders. New York: Brunner/Mazel, Inc., 1995.

PERIODICALS

International Society for the Study of Personality Disorders. Journal of Personality Disorders. Guilford Publications, 72 Spring St., New York, NY 10012. <http://www.guilford.com> . (800) 365-7006.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005. <http://www.psych.org> .

Gary Gilles, M.A.