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
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.
Comorbidity
More than half of individuals will have a history of at least one major
depressive episode
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Risk Factors
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:
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
Criterion B
Psychopathology
Differential Diagnosis
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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.
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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.
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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. 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.
Recommended Reading
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Resources
For Patients
Articles
Research
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.
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.