Personality Disorders 102: Schizotypal PD

Today we’re continuing on from where I left last week, at the edge dividing the schizophreniform disorders. As I mentioned before, Schizotypal Personality Disorder is similar to both Schizophrenia (shortened to Sz from now on) and Schizoid PD, though not the same as either. Schizotypal PD contains the thought-disordered aspects of Sz, and some degree of the hallucinatory experiences, without containing the depressive and pleasure-losing aspects.

For example, someone with schizoid PD may avoid social interaction between they feel no pleasure from participating, or because they don’t have any desire for relationships. Someone with schizotypal PD, however, will often want to be social, but will feel incredibly anxious in social situations regardless of how well they know the people they’re with.

They may have paranoid symptoms, such as believing that people can read their mind; alternately, their anxiety may be due to the pressure of trying to communicate to minds that don’t work on anywhere near the same wavelength as them. It can be generalised as (though obviously, this won’t always be the case) a schizoid person not wanting to try interaction, and a schizotypal person wanting to be social but not knowing how and eventually withdrawing through experiencing failure.

Schizotypal PD is another of those conditions that’s fairly hard to give a main character, usually being assigned to the generic “crazy person”, who generally is assumed to have Sz anyway. However, one mild example could be Luna Lovegood from the Harry Potter series: she holds many beliefs that others in her peer group don’t agree with, seems very detached from what others consider reality, and finds it very difficult to make friends with anyone until Harry’s group take her in. Yet once she is actually included, she is found to be just as capable as everyone else.
The diagnostic criteria for Schizotypal PD are:

  • Inappropriate or constricted affect (the individual appears cold and aloof)
  • Behavior or appearance that is odd, eccentric or peculiar;
  • Poor rapport with others and a tendency to social withdrawal;
  • Odd beliefs or magical thinking, influencing behavior and inconsistent with subcultural norms
  • Suspiciousness or paranoid ideas
  • Obsessive ruminations without inner resistance, often with sexual or aggressive contents
  • Unusual perceptual experiences including somatosensory (bodily) or other illusions, depersonalization or derealization;
  • Vague, circumstantial, metaphorical, over-elaborate or stereotyped thinking, manifested by odd speech or in other ways, without gross incoherence
  • Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations and delusion-like ideas, usually occurring without external provocation.

As you can see, the criteria for Schizotypal PD resembles the criteria for Sz itself .The ICD diagnostic manual mentions this, and clarifies that Schizotypal PD should be diagnosed when the person has “schizophrenia-like” issues that are not definitively Sz. For example, people with Schizotypal PD have quasi- (meaning “almost-“) psychotic episodes, rather than full psychotic breaks.

For example, someone with Schizotypal PD may experience smaller delusions such as believing that song lyrics are speaking directly to them, or people they walk past are talking about them, but they are unlikely to believe more-psychotic delusions such as being part of a government conspiracy or abducted by aliens. Also, their beliefs will not be as long-lasting, or have quite as much life impact, as full Sz.You could see it as similar to hypomania in bipolar disorders: Schizotypal PD can be seen as the hypomania to Sz’s mania.

Schizotypal PD doesn’t have one “hallmark feaure”; any of the symptoms above could be strongest and weakest in a person with it. Probably the most disturbing symptom, at least for others around the person, is disordered thoughts. These can make it very difficult to understand a person with Schizotypal PD, as they will jump between topics in conversation, possibly going into long chains of word salad (meaningless jumbled-up words) or clanging (linking words based on their sound, with no thought to coherence).

The prognosis for people with Schizotypal PD is fairly hard to get good data on, as it is a rare condition, affecting less than 2% of the population. Many of the people diagnosed will later go on to develop full Sz, while others will continue to have Schizotypal PD. In both cases, symptoms are worst in the early twenties, and gradually decrease over time. People with schizotypal PD are sometimes treated with antipsychotic medications (if they have a more sz-like profile with frequent thought problems) or sometimes with antidepressant medication (if they appear to have more social and emotional difficulties).

Psychological Criticisms of Schizotypal PD.

A downside with basing some criteria on thoughts and perceptions is it hinders getting an accurate picture of what the person is actually thinking or feeling, and how this translates to the criteria. There is no accurate way of working out if someone’s thinking is disordered, as their speech is the only way of interpreting their thoughts, so a speech disorder, mood disorder, or thought disorder can all produce similar effects.

Also, I don’t think it is ever a good idea to include “going against cultural norms” as a criteria, unless it represents a sudden and dramatic change from how the person normally is. This is especially the case with Schizotypal PD, a key area in the creativity and mental illness debate, because it is difficult to say where the eccentricity that often accompanies high intelligence or high creativity ends, and where a mental illness begins.

Finally, none of the symptoms of Schizotypal PD are unique, and none are essential. For example, magical thinking (believing your thoughts have direct influence over events) is strongest in Sz-related conditions, but is also present in depressive and anxiety-based disorders.  Social isolation is also not uniquely schizophrenic, and could be seen as a result of their inappropriate social behaviour rather than caused directly by the PD. So arguably Schizotypal PD itself is an unnessecary category, given that Sz, Schizoid PD and Schizoaffective disorders already exist.

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