Schizotypal personality disorder JLC

Schizotypia is a controversial term in psychiatry. The term was used by Kretschmer(l0) to denominate the phenotypic characters that antedated the development of schizophrenia. Nevertheless, the term schizotypal personality disorder was not included in psychiatric classifications until the publication of DSM-IIIR in 1987. (U.) Before that date, schizotypal individuals were allocated either with schizoids or with schizophrenics, and were usually labelled as latent schizophrenics or pseudoneurotic schizophrenics. However, the validity of this nosological entity is still controversial and, despite its acceptance in DSM-IV, ICD-10 does not recognize it as a separate personality disorder. Instead, ICD-10 includes the schizotypal syndrome among the psychotic disorders and not as a personality disorder, based on the biological affinities of schizotypal individuals with other schizophrenic patients. DSM-IV diagnostic criteria are shown in Tab—3.

Table 3 DSM-IV diagnostic criteria for schizoid personality disorder

Epidemiology

Schizotypal personality disorder is present in 0.5 to 3 per cent of the general population, with no demonstrated differences between sexes. It is more commonly diagnosed in relatives of schizophrenic patients, and the incidence is much in monozygotic than in dizygotic twins (33 per cent versus 4 per cent). (4) Clinical picture

The essential feature of schizotypal individuals is a pattern of peculiarity and oddness in interpersonal relationships with resulting social detachment and lack of close relationships. Because of their distorted reality processing schizotypal individuals feel intensely uncomfortable in the presence of others. Conversely, others feel uneasy in the presence of schizotypals because of their unusual ways of thinking and expressing emotions.

Like schizoids, schizotypals have a decreased desire for intimate contacts, although they may sometimes express unhappiness about their lack of relationships. As a consequence they do not have close friends or confidants other than relatives. They experience intense anxiety in social situations with unfamiliar people. They can interact if necessary, but they prefer to keep aloof because they feel different and are not interested in the concerns of others. Their anxiety in these situations is not based on feelings of inadequacy or fear of humiliation. Rather, it is due to suspicion of the motivation of others, and therefore it is not alleviated as time pases and the situation becomes more familiar. Thus schizotypals feel progressively worse and more reluctant to confide in other people.

Individuals with schizotypal personality disorder often have ideas of reference, i.e. interpretations of casual events as having specific and unusual meanings related to themselves. However, these ideas do not achieve the pathological conviction of delusions. Similarly, these individuals may be preoccupied with superstitions or paranormal phenomena. They may feel that they may read other people's thoughts or influence their behaviour by the power of thought. Their magical thinking is often manifested by ritualized behaviours aimed at avoiding harmful events.

Perceptual disturbances are frequent in schizotypal personality disorder. An experience of a sixth sense is typical, with the 'ability' to notice someone's presence. Distorted perceptions are present in the form of sounds perceived as calling voices or shadows transformed into figures and faces.

Thought processing and speech are characteristically affected. Speech may be constructed in an unusual and idiosyncratic way—generally loose, digressive, or vague, but without actual derailment or incoherence. Responses may be either excessively concrete or far too abstract, and words may be used in unusual ways.

The interpersonal relationships of schizotypal individuals are primarily affected by paranoid and suspicious ideation. They may believe that colleagues at work want to damage their reputation. In addition to the social anxiety of these individuals, this leads to a stiff and constricted contact and affect. They are considered odd and eccentric by others: they have peculiar mannerisms, dress in an unusual and unkempt manner, adopt extravagant postures and clothing combinations, do not obey normal social conventions, and generally avoid eye contact.

Course

Schizotypal features may be present in childhood and adolescence in the form of solitariness, academic underachievement, hypersensitivity, and bizarre fantasies. Schizotypals do not seek treatment because of their personality disorder, but rather because of the presentation of associated depression, dysphoria, and anxiety. In response to stressful situations, these patients may experience transient psychotic episodes lasting from minutes to hours. In some cases, clinical symptoms and duration reach the degree of brief psychotic disorder, schizophreniform disorder, or schizophrenia, with the schizotypal personality disorder as the premorbid state. The prevalence of major depressive episodes is notoriously high, as is co-diagnosis with paranoid, schizoid, avoidant, and borderline personality disorders.

Differential diagnosis

Delusional disorder, schizophrenia, and mood disorder with psychotic symptoms have to be excluded based on the greater intensity and persistence of psychotic symptoms.

In childhood, it can be difficult to distinguish schizotypal personality disorder from other forms of disorders characterized by odd behaviour, isolation, eccentricity, and peculiarities of language. These include autistic disorder, Asperger's disorder, and some language disorders. The differentiation with communication disorders is based on the prominence of language symptoms in these children and the compensatory efforts to communicate by gesture and other means. Autism and Asperger's disorder present an even more intense social isolation and indifference, and stereotyped behaviours and interests.

Paranoid and schizoid personality disorders lack the perceptual and speech impairment of schizotypal personality disorder, as well as the marked eccentricity and oddness. Avoidant personality disorder, while including social anxiety and isolation, differs from schizotypal personality disorder in that avoidants have an intense desire for closeness which is constrained by fear of rejection. Schizotypals do not have a desire for relationships. Borderline personality disorder has a high rate of co-occurrence with schizotypal personality disorder and frequently the two disorders cannot be differentiated. Brief psychotic episodes in people with borderline personality disorder are more dissociative-like and generally follow affective shifts in response to stress or frustration. Social isolation in borderline personality patients is generally due to repeated interpersonal failures rather than a persistent lack of desire for relationships and intimacy.

Finally, schizotypal personality disorder must be diagnosed in the cultural context of the patient. It should be noted that some perceptual peculiarities and magical beliefs may be due to culturally determined characteristics. For example, mind reading, voodoo, shamanism, evil eye, and so on should not be considered as personality disorders in some cultural areas.

Treatment

Low-dose antipsychotic medication may be useful for ideas of reference, perceptual disturbances, and other psychotic-like symptoms. Antidepressants are effective when depressive states are associated.

The psychological management of schizotypals should include a prolonged period of gaining the confidence of the patient. However, a particularly careful approach must be adopted owing to the peculiar thought processing of these patients.

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