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Day # 131: Schizotypal Personality Disorder

Today we will continue our current theme of cluster A personality disorders as we discuss schizotypal personality disorder.

Introduction 1

  • Individuals with schizotypal personality disorder (SPD) have a lifelong pattern of eccentric behavior and odd thought patterns.

  • They may experience derealization, body illusions, ideas of reference, and display magical thinking (odd beliefs inconsistent with cultural norms).

  • Common traits/symptoms may include being -> peculiar, odd, strange, eccentric, suspicious, withdrawn.

Diagnostic Criteria 2

  • The diagnosis of schizotypal personality disorder requires a pervasive pattern of eccentric behavior, discomfort with close relationships, and cognitive or perceptual disturbances, beginning by early adulthood and present in a variety of contexts.

  • ≥ 5 of the following must also be present: Mnemonic "PECULIARS"

  • Paranoid - suspicious

  • Eccentric - odd behavior or appearance

  • Cultural norms - odd beliefs or magical thinking that are inconsistent with cultural norms.

  • Unusual perceptual experiences - such as bodily illusions

  • Lacks - few close friends or confidants

  • Ideas of references - excluding delusions of reference

  • Anxiety - excessive anxiety in social situations

  • Restricted or inappropriate affect

  • Speech / thinking - unusual speech/thinking such as vague, stereotyped, etc.

  • Symptoms do not occur exclusively during the course of another mental illness such as schizophrenia, bipolar disorder, depressive disorder with psychotic features, or the effects of another medical condition. If criteria are met prior to the onset of schizophrenia, add "premorbid" as a specifier to the diagnosis.

Epidemiology/Pathogenesis 3, 4, 5

  • Prevalence is estimated to be 3-5% of the general population, however this is difficult to study since those with the disorder rarely seek treatment and it is uncommon in clinical settings.

  • The ratio of men to woman is unknown, however DSM-5 suggest the disorder may be slightly more common in males. There is also an association in females with fragile x syndrome.

  • Relatives of patients with schizophrenia show a higher incidence of schizotypal PD than among control participants, especially when schizotypal features were not associated with comorbid mood symptoms. There is also a higher incidence among monozygotic twins than among dizygotic twins (33 percent vs. 4 percent in one study).

  • Other factors that may increase risk include prenatal insults such as influenza exposure, childhood trauma, chronic stress, and certain genetic factors (COMT Val158Met polymorphism).

  • Prognosis: May be first apparent in childhood with poor peer relationships, social anxiety, peculiar thoughts and language, and bizarre fantasies. Due to their odd or eccentric beliefs and behaviors they may attract teasing. Typically has a chronic course with lifelong marital/relational and job-related problems, with a small minority developing schizophrenia.

Clinical Pearls 6

  • Those with schizotypal personality disorder rarely seek treatment themselves. If they are referred to treatment by a spouse or an employer, they can often present themselves as put together and appear undistressed, however may appear odd or eccentric and the diagnosis is based on their peculiarity of thinking, behavior, and appearance.

  • "Magical thinking" may include belief in fantasies, superstitions, clairvoyance, telepathy, etc. Odd behaviors may include involvement in cults or strange religious practices.

  • Mental status exam: taking a history may be difficult because of the patients unusual way of thinking and communicating. They will likely look, act, and speak in a way that is perceived as peculiar or eccentric. They may speak in a way that has meaning only to them and often needs interpretation. They may have difficulty identifying their mood or feelings, however they are often sensitive to negative affects of others. These individuals may be superstitious or believe they have special powers of thought and insight. Some premises of their beliefs may be false, however thoughts should not technically reach the level of delusional thinking. They may experience perceptual disturbances such as body illusions or macropsia (condition in which visual objects are perceived to be larger than they are objectively sized).

  • Optional personality questionnaires: Schizotypal Personality Questionnaire (SPQ); Personality Assessment Inventory (PAI); Minnesota Multiphasic Personality Inventory (MMPI).

  • Differential diagnosis: consider and rule out schizophrenia, delusional disorder, or other psychotic disorders (patients with schizotypal PD are not frankly psychotic, although they may have transient psychosis under stressful situations but these are usually brief). Differentiating schizotypal PD and neurodevelopmental disorders such as mild forms of autisim spectrum disorder (ASD) or language communication disorders can be challenging in some cases. ASD may be differentiated by stereotyped behaviors and interests and more severely impaired social interactions. Communication disorders may be differentiated by the characteristic features of impaired language. Also consider other personality disorders in the differential diagnosis, particularly other cluster A disorders (schizoid, paranoid). The cluster A disorders have certain shared features, however paranoid PD exhibit more social engagement and greater tendency to project their feelings onto others and schizoid PD do not display the same eccentric behavior and magical thinking seen in schizotypal PD. The social isolation of schizotypal PD can be distinguished from that of avoidant PD, which is attributable to fear of being embarrassed and excessive anticipation of rejection. Patients with schizotypal PD may show some features of borderline personality disorder, and some studies show a high rate of co-occurrence between the two disorders. Shared features may include transient psychotic-like symptoms in response to stress (borderline PD usually more related to affective shifts such as intense anger or disappointment and are usually more dissociative) and social isolation (isolation in borderline PD usually secondary to repeated interpersonal failures to due to frequent mood shifts, angry outburts, or impulsivity rather than than the lack of social contacts or desire to be alone).

Treatment 7, 8

  • General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

  • Psychotherapy: Psychotherapy is the treatment of choice for schizotypal PD, however little is known about effective psychotherapeutic approaches for this condition. The principles of treatment of schizotypal PD do not differ from those of schizoid PD. Treatments options are limited and insufficiently studied. Cognitive behavioral therapy (CBT) has been advocated for and case studies support its potential effectiveness, however systematic data is lacking. Other approaches that have been used include psychodynamic therapy and social skills training. It may take considerable time to slowly develop trust and rapport with these patients. These patients have odd patterns of thinking and some are involved strange practices and it is important for therapists to remain non-judgmental about these beliefs or activities.

  • Pharmacotherapy: There are no FDA approved medications for schizotypal PD. In clinical trials, the most frequently studied drug is risperidone, and the most frequently studied class of drugs is the antipsychotics, followed by the antidepressants. Some patients have benefited from small dosages of antipsychotics which has been shown to reduce general symptoms, particularly illusions, ideas of reference, paranoid ideation, anxiety, and quasi-delusional thinking or transient psychosis during stress. Serotonergic antidepressants have been used for rejections sensitivity or when a depressive component of the personality is present. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment. Comorbid anxiety and depressive disorders should be treated accordingly (see treatment of depression; treatment of anxiety).


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