Which of the following best describes a person with a diagnosis of schizotypal personality disorder?

Schizotypal Personality Disorder

The essential features of theschizotypal personality disorder are cognitive, perceptual, and behavioral eccentricities, and a pervasive discomfort with close relationships. Patients with this personality disorder frequently embrace unusual beliefs (such as telepathy, clairvoyance, and magical thinking) to a degree that exceeds cultural and subcultural norms. Socially, they are inept and uncomfortable. The style of their clothing may be inappropriate and strange, further reflecting their eccentric nature. Their speech is often vague, digressive, or inappropriately abstract, and they may talk to themselves in public. The content of that speech may also reflect ideas of reference, bodily illusions, and paranoia, but there is usually an absence of formal thought disorders, and their reality testing is intact. Under periods of stress, however, these patients may decompensate into brief psychotic states.

The differential diagnosis for schizotypal personality disorder includes schizophrenia and several personality disorders. Paranoid and schizoid personality disorders share many of the core features of schizotypal personality disorder, but differ by degree or absence of eccentricity. Borderline personality disorder shares some of the unusual speech and perceptual style, but it demonstrates stronger affect and connection to others. Patients with avoidant personality disorder, while uncomfortable and inept in social settings, are not eccentric and crave contact with others. Schizophrenia differs from schizotypal personality disorder in that the schizotype possesses good reality testing and lacks psychosis.

Schizotypal personality disorder affects about 3% of the population. There is no known sex ratio. While there is no known genetic etiology, there appears to be a higher occurrence of this disorder in the biological relatives of schizophrenic patients, and the disorder is frequently diagnosed in women with fragile X syndrome.

Differential Diagnosis and Comorbidity

STPD is the prototypic schizophrenia-spectrum disorder, which shares with schizophrenia common phenomenological features emerging from common spectrum-related risk factors. It has been speculated that STPD subjects have more developed compensatory mechanisms such as preservation of frontal integrity and function, as well as the capacity to recruit other related brain regions to compensate for dysfunctional areas during cognitive demands. Therefore, STPD individuals are more protected from the severe cognitive deterioration and social deficits of schizophrenia. Moreover, STPD lacks the severity of psychosis seen in patients with schizophrenia, and they are thus spared from multiple hospitalizations and long-term exposure to psychotropic medication. The differentiation between STPD, schizoid, and paranoid personality disorders is complicated by their shared phenomenological features. For example, both schizoid and STPD are characterized by a lack of close friendships. However, in SZPD this results from diminished pleasure or absence of pleasure from casual or intimate relationships. In contrast, the asociality observed in STPD individuals is secondary to suspiciousness, odd, bizarre behavior, and excessive social anxiety.

Observational studies

Olanzapine, mean dose 5.4 mg/day, has been given to 21 patients with apathy in the absence of depression after long-term treatment with selective serotonin reuptake inhibitors for non-psychotic depression in an open, flexible-dose study [16]. The more frequent adverse effects were sedation (n = 12), increased appetite (n = 8), stiffness (n = 7), edema (n = 6), and dry mouth (n = 5).

The efficacy and safety of switching 108 Asian patients from their regimen of neuroleptic medications to olanzapine (initial dose 10 mg/day) for 6 weeks has been studied in an open, multicenter, randomized study [17]. They were randomly assigned to one of two groups: the direct switch group (n = 54) received only olanzapine, while the start-taper switch group (n = 54) received olanzapine and their usual neuroleptic drug in decreasing doses for the first 2 weeks. There were statistically significant improvements from baseline to end-point in both switch groups in the Clinical Global Impressions—Severity of Illness Scale score and the Positive and Negative Syndrome Scale total score. Nevertheless, there were no significant differences between the switch groups in any measure of efficacy. Weight gain occurred in both switch groups and both showed statistically significant improvement from baseline to end-point on the Simpson–Angus Scale and Barnes Akathisia Scale.

In 19 patients previously treated with clozapine, olanzapine was used instead [9]. Eight were considered to be responders and the rest decompensated, seven of them enough to require hospitalization. Overall Brief Psychiatric Rating Scale (BPRS) scores increased significantly from baseline to final assessment.

In an open study of the efficacy of olanzapine in the treatment of bipolar mixed state (n = 9), the results showed improvement in acute symptoms [18].

In a study supported by Eli Lilly and Company it was concluded that olanzapine may be effective in a significant number of neuroleptic drug-resistant schizophrenic patients [19]. However, of 25 patients who entered an open trial for 6 months, 14 discontinued olanzapine, one because of an adverse reaction (depression), two because of lack of compliance, and 11 because of lack of efficacy.

Of 14 consecutive patients with bipolar I disorder, who were inadequately responsive to standard psychotropic agents and who were given olanzapine, 8 improved [20]. The most common adverse effects were sedation, tremor, dry mouth, and increased appetite with weight gain.

The response to olanzapine in 150 consecutive patients has been assessed by reviewing their records [21]. Patients with a moderate-to-marked response to olanzapine were more likely to be younger, to be female, and to have a diagnosis of bipolar disorder. No information on adverse reactions was provided.

Schizotypal Personality Disorder

Schizotypal personality disorder (STPD) was a new addition to DSM-III (APA, 1980). It was developed originally through interviews of biological relatives of persons diagnosed with schizophrenia. STPD is a pervasive pattern of interpersonal deficits, cognitive–perceptual aberrations, and eccentricities of behavior (APA, 2013). The interpersonal deficits are characterized in large part by an acute discomfort with and reduced capacity for close relationships. The diagnosis criteria involve odd beliefs or magical thinking (e.g., superstitiousness or clairvoyance) that is not delusional; unusual perceptual experiences that do not meet the threshold for a hallucination; peculiar thinking or speech; suspiciousness; inappropriate or constricted affect; odd, eccentric, or peculiar appearance or behavior; social withdrawal; and excessive social anxiety (APA, 2013).

STPD occurs somewhat more often in males (Parnas et al., 2005). There is insufficient research to describe the childhood precursors of STPD. Persons with STPD would be expected to appear peculiar and odd to their peers during adolescence, and may have been teased or ostracized. As adults, they may drift toward esoteric, fringe groups that support their magical thinking and aberrant beliefs. The symptomatology of STPD does not appear to remit with age (Raine, 2006). The course appears to be relatively stable, with some proportion of schizotypal persons remaining marginally employed, withdrawn, and transient throughout their lives.

An initial concern of many clinicians when confronted with a person with STPD is whether the more appropriate diagnosis is schizophrenia. Persons with STPD can resemble closely persons within the prodromal phase (i.e., the initial phase, before symptomatology is fully developed) of schizophrenia. This differentiation is determined largely by the absence of a recent deterioration in functioning that is seen in persons who are in the prodromal phase. Studies examining cortical abnormalities in individuals with STPD suggest abnormalities in the superior temporal gyrus, parahippocampus, temporal horn of the lateral ventricles, thalamus, septum pellucidum, and cerebrospinal fluid which are similar to abnormalities found in individuals with schizophrenia (New et al., 2008). Correlates of central nervous system dysfunction seen in persons with schizophrenia have also been observed in laboratory tests of persons with STPD, including performance on tests of visual and auditory attention (Parnas et al., 2005). The World Health Organization (1992) in fact considers STPD to be a form of schizophrenia rather than a PD. There is compelling empirical support for a genetic association of STPD with schizophrenia (Kwapil and Barrantes-Vidal, 2012; South et al., 2012). However, schizotypal symptomatology is evident within the general population in persons with no apparent genetic relationship to schizophrenia, and persons with STPD very rarely develop schizophrenia (Raine, 2006).

A predominant model for the psychopathology of STPD is deficits in the attention and selection processes that organize a person’s cognitive–perceptual evaluation of and relatedness to his or her environment (Raine, 2006). These deficits may lead to discomfort within social situations, misperceptions, and suspicions, and to a coping strategy of social isolation. Persons with STPD may seek treatment for their feelings of anxiousness and perceptual disturbances. Treatment of persons with STPD should be cognitive, behavioral, supportive, and/or pharmacologic, as they will often find the intimacy and emotionality of reflective, exploratory psychotherapy to be too stressful (Kwapil and Barrantes-Vidal, 2012). Practical advice and social skills training are usually helpful and often necessary, as their social decision-making may itself be problematic. Low doses of neuroleptic medications (e.g., thiothixene) have shown some effectiveness in the treatment of schizotypal symptoms, particularly the perceptual aberrations and social anxiousness (Silk and Feurino, 2012).

Schizotypal Personality Disorder

Like the person with a borderline personality, the individual with a schizotypal personality seems to lack a core. This person also is stalked by a rather unsettling sensation that he or she is somehow empty. This blandness becomes an invitation to an in-pouring of vivid fantasy and psychotic-like process. The world becomes peopled with clairvoyant messages, ghost-like presences, magical hunches, and secretive glances. Like a child withdrawn into a world peopled with pretend playmates, the person with a schizotypal personality silently retreats from life. Unlike a person with a schizoid personality described earlier, a person struggling with a schizotypal personality disorder is frequently sensitive to rejection. This person wants contact but does not know how to make it. There is a desperate quality here, in which the eccentric professor finds more solace in his books than with others of his species. They may find that the only safe place to fulfill their needs for intimacy lies in the addictive world of massively multiplayer online gaming (MMO). Here in the world of MMOs they find it easier to befriend an avatar than the human who created it. One of my adolescent patients would spend endless days running with stray dogs in the woods near his house. Apparently, they were kinder companions than the children at his school. Moreover, he was “the king” of his dogs, whereas he was merely “the dog boy” at his school. Thus these fantasy wanderings may provide a firmer sense of self-esteem to these patients.

Because of the withdrawal into their private worlds, these patients may develop idiosyncratic ways of thinking and using words, tending to become metaphoric and vague. There may have been a tiny bit of schizotypal flair to the oddness of Emily Dickinson. Unfortunately, these traits may result in further problems with socialization, as reflected by Ms. Dickinson suggesting to her guest that he choose between a glass of wine or a rose from the garden. With the right guest, this eccentric gesture is endearing; with the wrong guest, it is puzzling if not downright bizarre. When stressed, the person with a schizotypal personality may decompensate into micropsychotic episodes including delusions and hallucinations. And as part of the schizophrenia spectrum, people with this personality disorder can be more likely to develop schizophrenia itself, or they may have relatives afflicted by it. In a sense, this individual lives life from “the inside of the bottle,” peering at others as if watching a different species, worried that someone may poke a finger or two into his or her private world.

Schizotypal personality disorder

SPD is a condition that stems from two areas of research: (1) borderline personality conditions, which incorporates a series of pervasive disturbances in function, cognition, affect and behavioral control and (2) studies of nonpsychotic family members who exhibited chronic peculiarities of thought and communication (Lenzenweger, 2018; McClure, Harvey, Bowie, Iacoviello, & Siever, 2013; Racioppi et al., 2018; Rosell, Futterman, McMaster, & Siever, 2014). The diagnosis of schizotypal personality disorder follows a categorical approach as a minimum threshold of symptoms must be met in order to be diagnosed with the disorder. Furthermore, it is conceptualized along three constructs: interpersonal (social anxiety), cognitive-perceptual (perceptual disturbances), and disorganized-oddness (odd speech and affect) (Rosell et al., 2014). The diagnostic of SPD consists of ideas of reference, odds beliefs, or magical thinking; unusual perceptual experiences and bodily illusions; odd thinking and speech; suspiciousness or paranoid ideation; inappropriate affect; eccentric behavior and a lack of close friends, as well as excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears. Five of nine criteria are required for a diagnosis (Kirchner et al., 2018). Moreover, individuals must demonstrate multi-contextual impairments in areas such as work or social environments (APA, 2013). Studies found that relatives of individuals with schizophrenia show increased rates of schizotypal personality traits and were at a greater risk for the development of schizophrenia (Barch et al., 2004; Callaway, Cohen, Matthews, & Dinzeo, 2014; Tarbox, Almasy, Gur, Nimgaonkar, & Pogue-Geile, 2012). However, when compared to schizophrenia symptomology, SPD individuals experience less magical thinking, ideas of reference, as well as perceptual distortions such as illusions (Lener et al., 2015). Many SPD individuals show adequate personal and community functioning without any treatment (Debbané & Mohr, 2015).

Epidemiology

For schizotypal personality disorder, the estimated prevalence is approximately 3.9% of the overall US population. The global prevalence of this disorder ranges between 0.6% and 4.6%. This disorder is believed to be slightly more common in males. Comorbidities are common. Over 50% of patients have had one or more episodes of major depressive disorder. Between 30% and 50% have the major depressive disorder when schizotypal personality disorder is diagnosed, and substance use disorders are common. There has been an insufficient study on the racial or ethnic differences for schizotypal personality disorder, but one study indicated that the highest rates of the disorder occurred in African-Americans compared to Caucasians and Hispanics.

Diagnostic Considerations

Schizotypal PD is marked by static interpersonal deficits, cognitive or perceptual disturbances and unusual behavior. According to the DSM-IV-TR, in order to diagnose an individual with schizotypal PD at least five of the following symptoms must be present: (1) ideas of reference; (2) evidence of magical thinking or odd beliefs that are not subculturally determined; (3) unusual perceptual experiences, including bodily illusions; (4) odd thinking and speech; (5) suspicions or paranoid ideation; (6) inappropriate or constricted affect; (7) odd, eccentric, or peculiar behavior or appearance; (8) lack of close friends or confidantes other than first-degree relatives; and (9) excessive, nonhabituating social anxiety that tends to be associated more with paranoid fears than with negative judgments about self.

A family history of schizophrenia is not unusual. If symptoms of schizophrenia begin to emerge, the schizophrenic diagnosis takes precedence and the schizotypal diagnosis is considered ‘premorbid.’

7.3 Schizotypal Personality Disorder

The schizotypal personality disorder is characterized by strong deficits in establishing interpersonal contact. Persons with schizotypal personality disorder show a pronounced fear of social situations and actively avoid them. They do not have close friends or confidants. Their interpersonal deficits are marked by acute discomfort with close relationships, constricted affect, cognitive and perceptual distortions, and eccentricities of behavior, as in their choice of dress and movement. Persons with this disorder often develop magical thinking and a belief in the occult, and sometimes ideas of reference or paranoid ideation may influence their behavior. Regarding language, there are unclear, strange, or stereotyped expressions and incorrect use of words, though not to the point of associative loosening and incoherence.

Phenomenological, biological, genetic, and outcome data (e.g., the Danish adoption studies) show a relation between schizotypal personality disorder and schizophrenia. Therefore, it is often considered a schizophrenia-spectrum disorder.

Schizotypal Personality Disorder

Patients with schizotypal personality disorder also can appear aloof, apprehensive, and suspicious. They may be hypersensitive or hostile if they are distressed. However, they generally appear interpersonally inhibited. These patients show evidence of cognitive distortions, for example, nondelusional ideas of reference. They show a lack of social skills and are not able to accurately perceive social discourse. In addition, the clinician will note that their thinking is odd, their speech is peculiar, and they often are characterized by eccentric and bizarre behavior and appearance.

As with schizoid personality disorder patients, these patients are difficult to engage, and one must attend to appropriate boundaries and interpersonal distance. Their odd speech and behavior may be off-putting, and you may need to monitor your own responses to such behavior. However, once these patients are engaged, they tend to form a strong dependent relationship with their clinician.