Schizotypal Personality Disorder

Primer

Schizotypal Personality Disorder is a personality disorder characterized by pervasive patterns of “strange” or “odd” behavior, appearance, or thinking. These peculiarities are not so severe that they can be diagnosed as schizophrenia, and there is no history of actual psychotic episodes. Individuals will often have ideas of reference, but not to a delusional quality. Symptoms may be first apparent in childhood, when the individual has peculiar thoughts, unusual language, and/or bizarre fantasies.

Epidemiology
  • The prevalence for schizotypal personality disorder ranges from 0.6 to 4.6%.[1]
  • Schizotypal personality disorder is more common in male than females
Prognosis
  • Most individuals generally have a stable course, but a small proportion of individuals may later be diagnosed with schizophrenia or another psychotic disorder.
    • The phenotype of schizotypal personality disorder is closer to the phenotype seen in schizophrenia.
  • There may be an elevated risk for suicide in schizotypal personality.[2]
Comorbidity
Risk Factors
  • Schizotypal personality disorder is more prevalent amongst first-degree biological relatives of individuals with schizophrenia.[3]

DSM-5 Diagnostic Criteria

Criterion A

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 5 (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. - superstitiousness, 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, overelaborate, or stereotyped)
  5. Suspiciousness or paranoid ideation
  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
Criterion B

Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g. - “schizotypal personality disorder (premorbid).“

Mnemonic

The memory aid SchizoTypal can be used to remember there is magical Thinking. Where as schizoiD personality is Distant.

Psychopathology

Differential Diagnosis

  • Variations in adolescent development and associated stressors
    • Schizotypal features that emerge adolescence can also be due to transient emotional stresses during adolescence, rather than an enduring personality disorder.
  • Other mental disorders with psychotic symptoms
    • Schizotypal personality disorder can be distinguished from schizophrenia, and a bipolar or depressive disorder with psychotic features because these disorders all have discrete periods of persistent psychotic symptoms (e.g. - delusions and hallucinations). To diagnose schizotypal personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and persist even when the psychotic symptoms are in remission.
  • Delusional disorder
    • Unlike in delusional disorder, individuals with schizotypal personality disorder are likely to consider alternative explanations for their odd beliefs.
  • Neurodevelopmental disorders
    • Differentiating neurodevelopment disorders from schizotypal personality disorder can be challenging, especially since neurodevelopmental disorders are a heterogeneous group that can present similarly with solitary behaviours, social isolation, eccentricity, or peculiarities in language.
    • Autism spectrum disorder
      • Individuals with even mild autism have greater lack of social awareness and emotional reciprocity and more stereotyped behaviors and interests.
    • Communication disorders
      • Communication disorders may be differentiated by severity of the language deficits and by the characteristic features of impaired language found in a specialized language assessment.
  • Personality change due to another medical condition
    • Schizotypal personality disorder must be differentiated from personality change due to another medical condition (e.g. - traumatic brain injury), in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.
  • Substance use disorders
    • Schizotypal personality disorder should also be distinguished from symptoms related to persistent substance use.
  • Paranoid personality disorder
    • Although paranoid and schizoid personality disorders both have social detachment and restricted affect, schizotypal personality disorder is dominated by cognitive or perceptual distortions and eccentricity or oddness.
  • Avoidant personality disorder
    • Close relationships are limited in both schizotypal personality disorder and avoidant personality disorder. In avoidant personality disorder, however, individuals have an active desire for relationships, but are paralyzed by a fear of rejection. Compare this to schizotypal personality disorder, where there is a lack of desire for relationships in the first place.
  • Narcissistic personality disorder
    • Individuals with narcissistic personality disorder may also display suspiciousness, social withdrawal, or alienation, but in narcissistic personality disorder these qualities derive primarily from fears of having one's imperfections or flaws revealed.
  • Borderline personality disorder
    • It is important to note that there is a high rate of co-occurrence between schizotypal and borderline personality. However, there are some discriminating characteristics. For example, while social isolation can also be seen in borderline personality disorder, this is usually secondary to repeated interpersonal failures from emotional dysregulation, rather than from the lack of desire for intimacy. Individuals with schizotypal personality disorder do not usually demonstrate the impulsive or manipulative behaviors in borderline personality disorder. Additionally, while individuals with borderline personality disorder may have transient, psychotic-like symptoms, these are usually connected to affective shifts in response to stress (e.g. - intense anger) and usually dissociative (e.g. - derealization, depersonalization). In contrast, individuals with schizotypal personality disorder are more likely to have ongoing psychotic-like symptoms that may worsen under stress but are less likely to be associated with affective disturbances.

Treatment

Treatment of personality disorders is primarily with psychotherapy such as cognitive behavioural therapy or psychodynamic therapy.[4] The approach is generally similar to that for other cluster A personality disorders, including paranoid personality and schizoid personality disorder. Medications should be limited in use, and the evidence is lacking. Some small studies have suggested the use of antipsychotics such as risperidone may be useful in reducing symptom severity.[5][6]

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References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) Teraishi, T., Hori, H., Sasayama, D., Matsuo, J., Ogawa, S., Ishida, I., ... & Kunugi, H. (2014). Relationship between lifetime suicide attempts and schizotypal traits in patients with schizophrenia. PLoS One, 9(9), e107739.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) Matusiewicz, A. K., Hopwood, C. J., Banducci, A. N., & Lejuez, C. W. (2010). The effectiveness of cognitive behavioral therapy for personality disorders. Psychiatric Clinics, 33(3), 657-685.
5) Koenigsberg, H. W., Reynolds, D., Goodman, M., New, A. S., Mitropoulou, V., Trestman, R. L., ... & Siever, L. J. (2003). Risperidone in the treatment of schizotypal personality disorder. The Journal of clinical psychiatry, 64(6), 628.
6) Jakobsen, K. D., Skyum, E., Hashemi, N., Schjerning, O., Fink-Jensen, A., & Nielsen, J. (2017). Antipsychotic treatment of schizotypy and schizotypal personality disorder: a systematic review. Journal of Psychopharmacology, 31(4), 397-405.