Early Historical Forerunners

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Some of the personality disorders were apparently known to the ancients, but the schizotypal personality is a relatively new construct. Its history begins with its relation to schizophrenia and progresses through efforts to say exactly where the two syndromes begin and end. In Chapter 1, we noted that the social sciences are fundamentally different from the hard sciences, their phenomena are intrinsically loosely boundaried, and, therefore, many symptoms and characteristics seem loosely related and almost impossible to capture adequately within a single diagnostic term.

Difficulties in classifying schizophrenics predate even the origin of the term. In the fifth edition of his text, Kraepelin (1896) concluded that catatonia and hebephrenia, as well as certain paranoid disturbances, were all variations of dementia praecox— Latin for "premature mental deterioration"—and displayed a common theme of early onset and incurability. Kraepelin thus brought order and simplicity to what had previously been diagnostic confusion. In line with the traditions of German psychiatry, he assumed that some biophysical defect must underlie this new coordinating syndrome. Among the major signs that he considered central, in addition to the progressive and inevitable decline, were discrepancies between thought and emotion, negativism and stereotyped behaviors, wandering or unconnected ideas, hallucinations, delusions, and a general mental deterioration. His solution was to be challenged and modified by Eugen Bleuler in Switzerland and Adolf Meyer in the United States.

After observing hundreds of dementia praecox patients in the early 1900s, Bleuler concluded that the complex, and often highly creative, reactions and thoughts of his subjects contrasted markedly with the simple and meandering thinking that Kraepelin had observed. Furthermore, not only did many of his patients display their illness for the first time in adulthood rather than in adolescence, but a significant proportion evidenced no progressive deterioration, both of which Kraepelin considered defining features of the syndrome. For Bleuler, dementia praecox assumed an age of onset and developmental course not supported by the evidence. Instead, the primary symptoms, he maintained, were disturbances in the associative links between thoughts, a breach between affect and intellect, ambivalence toward the same objects, and an autistic detachment from reality.

The diversity of cases displaying a fragmentation of thought, feeling, and action led Bleuler, in 1911, to coin the term schizophrenia, literally a schism in the phrenos, or mind, commonly misunderstood as "split personality." Although he referred to "the group of schizophrenias," he retained the Kraepelinian view that these disorders were caused by a single physiological disease process, a neurological ailment that produced their common primary symptoms. Secondary symptoms, such as hallucinations and delusions, were attributed to the distinctive life experiences of his subjects and to their efforts to adapt to their basic disease. He believed that although psychological factors could shape the particular character of the schizophrenic impairment, life experiences alone could not produce schizophrenia.

Bleuler further expanded on Kraepelin by recognizing both nondeteriorating and intermediary cases, a position that Kraepelin (1919) accepted in his later years when writing of "autistic personalities" and those whose dementia is "brought to a standstill short of its full clinical course" (p. 237). Bleuler (1911) termed these cases latent schizophrenia, which he regarded as being far more frequent than the psychotic form, though such subjects were seldom seen in treatment. Schizophrenia was thus conceptualized dimensionally, existing on a continuum with normality, with symptoms that might be expressed "within normal limits" (Bleuler, 1924, p. 437). Both Bleuler and his contemporaries noted that latent schizophrenia often occurred in the families of more severe schizophrenics, evidence supporting a common biological link.

After Bleuler's revisions, other writers advanced terminology recognizing a partially expressed form of the disease. Zilboorg (1941) referred to ambulatory schizophrenics, a designation that he believed captured the presence of a basic disease process while asserting its continuity with more severe cases. According to Zilboorg:

These patients seldom reach the point at which hospitalization appears necessary either to the relatives or to the psychiatrist, and appear "to walk about life " like any other "normal" person—although they remain inefficient, peregrinatory, casual in their ties to things and to people. Such individuals remain more or less on the loose in the actual or figurative sense, outwardly and inwardly. (p. 154)

Delusions, hallucinations, and flatness of affect were to be regarded as only the "terminal phenomena" of the schizophrenic process, affecting the unfortunate few in which the full process was expressed. Other authors wrote about a pseudoneurotic schizophrenia (P. H. Hoch & Polatin, 1949), in which neurotic symptoms were superimposed over a latent, but stable, variant of schizophrenia that sometimes precipitated into psychosis but usually retained its "ambulatory" status.

The specific term schizotype was coined by Rado (1956) as an abbreviation of schizophrenic phenotype. The name stuck. Schizotypes, according to Rado, possess an inherited potential to develop the observable symptoms of the disease, though this may never occur. The defect experienced by the schizotype is a fundamental deficiency in the ability to feel pleasurable emotions—including joy, affection, love, and pride—but no similar reduction in the negative emotions, the only emotions they are capable of feeling with any intensity. The net effect is to reduce motivation by reducing their ability to enjoy life activities, reduce the capacity for satisfying interpersonal relationships, reduce self-confidence and sense of security, attenuate sexual functioning, and even diminish the capacity for self-awareness.

Rado did not see the course of the schizotypal pattern as inevitably fixed, however, as did Kraepelin with dementia praecox, but instead as moving forward and backward among a compensated state, a decompensated state, a disintegrated state, and a deteriorated state. With luck, compensated schizotypes would go through life without ever experiencing a psychotic break. Decompensated schizotypes have become overtly schizophrenic, exhibiting the characteristic thought disorder that reduces the individual to functional incompetence, according to Rado, but might return to a compensated state given appropriate treatment.

Attracted to Rado's formulation, Meehl (1962, 1990b) constructed a brilliant, speculative theoretical model, ushering in the contemporary era of schizophrenic research. According to Meehl, a single dominant gene produces a basic cognitive and cognitive-emotional "slippage" by altering some function of the synapse at all points in the nervous system, but in an extremely subtle way. Meehl called this hypokrisia, meaning "insufficiency of separation, differentiation, or discrimination" (1990b, p. 15). The presence of the schizotaxic gene, however, does not mean that its owner will develop a schizophrenia. Only a minority, those unfortunate in possessing other genes such as those activating social introversion, dispositionally high levels of anxiety or low capacity for pleasurable experience, for example, or persons exposed to unfortunate trauma or repeated insult actually develop schizophrenia.

Because the gene is "silent" in most cases, its owners cannot be identified on the basis of hallucinations or delusions. Meehl was thus led to develop a new methodology called taxometrics, the purpose of which was to classify subjects on the basis of characteristics associated with schizophrenia but not necessarily specific to schizophrenic or even associated with it in an obvious way. Whereas the diagnostic categories of the DSM are defined through the consensus of experts in the field, taxometrics represents a mathematical means of identifying categories of mental disorder. Although the methodology has not yet been widely applied, researchers have now identified a schizotypy taxon and replicated their results (Korfine & Lenzenweger, 1995; Lenzenweger & Korfine, 1992).

A number of studies looking for subtle schizophrenic signs in the family members of schizophrenics followed. The most important were the Danish adoption studies, begun in 1963 by Kety, Rosenthal, Wender, and Schulsinger (1968) designed to separate the influence of genetic and environmental variables. Both schizophrenia and latent schizophrenia were found more often in the biological relatives of schizophrenic adoptees than in other subjects, also adopted, of the same age, gender, social class, and length of time with biological mother. These results strongly supported the hypothesis of a schizophrenic spectrum.

The borderline schizophrenic subgroup, closest to the contemporary schizotypal, was described as exhibiting a history of chronic maladaptation, including:

1. Cognitive difficulties, such as vague, illogical, unrealistic thoughts.

2. Affective abnormalities, namely anhedonia, defined as an incapacity to experience pleasurable feelings.

3. Interpersonal difficulties, including a deep ambivalence toward intimate relationships with others or intense dependent involvements.

4. The presence of psychopathology characterized by multiple neurotic features such as obsessions, phobias, psychosomatic concerns, generalized anxiety, and micro-psychotic episodes.

Despite these liabilities, such individuals were believed to persist without decompen-sating into a florid schizophrenic syndrome.

By the time work began on the DSM-III in 1980, a borderline schizophrenic syndrome was still regarded as somewhat ambiguous. The term borderline was widely used to refer not only to compensated schizotypes but also to the neurotic components of character disorder, the borderline personality organization of the psychodynamic perspective. To further clarify its boundaries with the psychoses and personality disorders, Spitzer, Endicott, and Gibbon (1979) developed provisional diagnostic criteria based on the results of the Danish adoption studies and their own literature review. A large sample of psychiatrists was then asked to rate each criterion in terms of how well it discriminated schizophrenia-like patients from those with an unstable, borderline condition or psychosis. On the basis of this study, the schizotypal personality disorder was officially born.

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