Objectives

• What are the DSM-IV criteria for the schizotypal personality?

• Explain what is meant by structurally defective personalities.

• Are there childhood behaviors that are precursors of the schizotypal personality?

• The idiosyncratic personality is a normal variant of the schizotypal. Describe its characteristics and relate them to the more disordered criteria of the DSM-IV.

• Explain how different personality styles combine to form each of the subtypes of the schizotypal personality.

• Explain the significance of the terms latent schizophrenia, pseudoneurotic schizophrenia, and ambulatory schizophrenics.

• Explain Meehl's theory of schizotaxia. Is there any evidence supporting it?

• Do the findings on neuroanatomical and neurotransmitter research on schizophrenia apply to schizotypal subjects also?

• What is the viral hypothesis for schizophrenia?

• How does the psychodynamic perspective explain the schizotypal personality?

• What factors sustain the eccentric and odd interpersonal behavior of the schizotypal?

• Explain the meaning of the term emotional reasoning.

• Schizotypals share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the schizotypal.

• List therapeutic goals for the schizotypal personality.

Others see them as eccentric, different, weird, odd, or strange. Excessively anxious around others, they keep themselves separated and isolated, even from those they have known for long periods of time. Some seem absorbed in stimulation that derives from their own internal world and may have difficulty expressing their thoughts and feelings coherently. When engaged interpersonally, they may seem distracted or unable to focus or even ramble from subject to subject. Emotions may have a constricted range or be completely inappropriate to objective events. They may have odd beliefs unsubstantiated by science; for example, they can communicate telepathically or somehow read the future. Some have perceptions that are equally odd; for example, they may think about long dead relatives, then suddenly get the feeling that these spirits are hovering in the room near them. Often, they are extraordinarily suspicious of the motives of others.

Such individuals are called schizotypal personalities, or schizotypals for the sake of convenience in this chapter. Given the preceding characteristics, it is not surprising that most researchers now believe that the schizotypal personality lies on a continuum with schizophrenia. As such, both schizotypals and schizophrenics are often referred to as schizotypes. The continuum that links the two disorders is called schizotypy. In line with schizophrenia research, schizotypal symptoms that suggest a surplus or exaggeration of normal functioning, such as delusions, hallucinations, and ideas of reference, are usually referred to as positive symptoms, and those that refer to interpersonal and motivational deficits are often referred to as negative symptoms.

Consider the case of Neal (see Case 12.1), a victim of unfortunate circumstances, who was arrested for possession of cocaine but later released on probation when urine tests prove negative for any illegal substance. Like many schizotypals, Neal experiences what are called ideas of references, meaning that he believes that other persons are referring to him or that he is somehow at the center of interpersonal events (see criterion 1). Rather than dismiss these happenings as bad luck, however, Neal instead concludes that he has been "set up." Moreover, he "knows" that the police officers are talking about him, simply because they keep looking at him and trying to hide it, as least from his perspective. Neal's referential ideas are probably related to the social anxiety reported by the police. Neal is uncomfortable around everyone, even though it appears he has no cause to be (see criterion 9). The more uncomfortable he feels, the more vigilant he becomes and the more likely he is to construe events so that they revolve around him.

Other unusual characteristics emerge during the clinical interview. Although Neal is asked simple biographical questions, the style and content of his responses are strange. He cannot connect with the purpose of the interview or the intent of the interviewer and is puzzled by basic questions, as if he and the interviewer were not sharing the same consensual social reality. Seemingly unambiguous inquiries lead to disconnected and somewhat tangential responses (see criterion 4), as if the main purpose of the question were lost, then recovered, then lost again. Whereas meaning and emotion are tightly coupled in the speech of most people, they are only loosely coordinated for Neal (see criterion 6). Sometimes, they are completely inappropriate to objective events, as if interpersonal interactions were being interpreted through frames of reference that are either wrongly applied or somehow emphasize trivial aspects of the interaction at the expense of those that are important or central.

Neal also reports unusual perceptual experiences reminiscent of schizophrenia. When he states that the true purpose of the interview has been "told to him," he is not speaking metaphorically. Instead, Neal is asserting that he has privileged access to information outside the realm of normal human experience (see criterion 2). He also reports unusual perceptual experiences that resemble hallucinations (see criterion 3). When Neal says that he has glimpsed the future, he literally believes that he has somehow looked ahead in time. When he claims that he can see what is happening in other

Neal was mandated to six months' mental health treatment as a condition of his probation.1 He had been found in possession of a small quantity of crack cocaine when the house he rents a room in was raided. After testing negative for drugs, he was released, given probation, and sent for counseling. "I've thought for some time they wanted to set me up," he noted. "They kept looking at me from outside the cell, although they tried to hide it, so I know they were talking about me." Police report that his neighbors state that Neal has no friends and that he seems frightened of people. No one came to bail Neal out of jail.

Neal is 32 years old and has a tall, almost emaciated frame. His eyes are deeply set, and he rarely meets the gaze of others. There is a disjointed quality to his movements, as though his body is not solely within his own control. From the start of the interview, he seemed incapable of responding to the simplest questions. Only after a long silence could some answer be produced, and even these were often rambling and only tangentially related to the inquiry, as if he were free-associating midway through his own responses. Moreover, his emotions seem at odds with the substance of his words, sometimes smiling at a sad story. He claims to know the "true purpose" of the interview; it was "told to him," and he has "glimpsed the future." Further inquiries designed to determine whether his responses might only seem pathological because of poor word choice or phrasing show instead that Neal is being literal: He believes that he can occasionally see the future in a visual form. He also claims that he can sometimes see what is going on in other places and what might happen if he were to go there.

Getting an accurate and full history from Neal is difficult. According to a neighbor, Neal was born when his mother was in her mid-to late-40s. The identity of his father is unknown, and, to the neighbor's knowledge, no male has ever come around their home. His mother's whereabouts are unknown, but a neighbor believes she may live somewhere in the city. She abandoned Neal at age 12. The neighbor states that he did well in school, at least before his mother left. Nevertheless, "Neal was never normal," she says. "After his mother left, he became stranger, twisting his body up into knots and having conversations with himself." No information is available concerning whether he received treatment for these behaviors. Also unclear is how Neal supports himself currently. He claims to have worked as a window washer for downtown shop owners until his bizarre hair and unkempt appearance began to frighten customers. Currently, Neal is fixated on his run-in with police, occasionally mumbling something under his breath about "busting heads." Therapy will be difficult, even if he finds it possible to keep a schedule.

1Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Schizotypal Personality Disorder DSM-IV Criteria

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 five (or more) of the following:

(1) ideas of reference (excluding delusions of reference)

(2) 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)

(3) unusual perceptual experiences, including bodily illusions

(4) odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)

(5) suspiciousness or paranoid ideation

(6) inappropriate or constricted affect

(7) behavior or appearance that is odd, eccentric, or peculiar

(8) lack of close friends or confidants other than first-degree relatives

(9) excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

places and what might happen should he go there, he is speaking perceptually, not in-ferentially. Interestingly, Neal's revelations and extrasensory information seem to serve a protective function, making him suspicious but also making it possible to keep himself safe. When Neal becomes socially anxious and construes events so that they somehow point to him, he at least has a means of guarding himself. That's why they have become a basis for action in the course of his everyday life. And because Neal's fears are mostly fictions anyway, his countermeasures always seem to work, thus reinforcing superstitious beliefs and exotic cognitive modes.

Finally, like many schizotypals, Neal exhibits behaviors that seem odd or peculiar (see criterion 7). His next-door neighbor reports that he has been known to twist his body up in knots and have conversations with himself. Likewise, Neal claims to have worked as a window washer until his appearance and bizarre behaviors began to frighten customers. Perhaps they also frightened Neal. Given his social anxiety and the unusual cognitive methods through which he protects himself, it is not surprising that Neal has no close friends (see criterion 8). Instead, he is pretty much on his own, pursuing a minimalist existence at the margins of society.

Given the portrayal of Neal, we are now in a position to consider other issues. Personality can be likened to an office building. The workers have their own jobs, and the building complements their activities. Internal traffic is not shunted down convoluted pathways, for example, or turned out into the street. All workers and visitors find their destination easily, without wasted effort or frustration. The entire structure, in fact, just naturally encourages efficient functioning. Each person naturally integrates with the others so that, ideally, the entire complex functions as a single harmonious whole.

In the schizotypal, borderline, and paranoid personalities, however, structural defects prevent the whole from operating smoothly. For the paranoid, the building is too rigid and constrictive, so much so that anyone who enters must conform to its specific, predetermined rules or be ejected. In the borderline, the building is structured so loosely that its insides hardly seem separated into rooms. Instead, contents spill from one compartment to the next, so the entire structure seems labile and vulnerable to splitting or heaving unpredictably. In the schizotypal, the overall design possesses an eccentric and indecipherable logic, by which the bizarre is made normal and the normal made bizarre.

These three are the structurally defective personalities. Personality style expresses a way of functioning in the world; personality structure refers to the actual substrates that undergird functioning. A hand, for example, is made to write, grasp, and manipulate. That's what it does. Structurally, however, a hand is formed of bone, muscle, nerve, and tendon; without these, no hand can function. In the same way, structural domains of personality support its functional aspects, thus forming the architecture of the mind. Cognitive schemata, for example, provide structural support for the expression of cognitive styles. Self-image provides yet another structural component to personality, one that influences interpersonal ways of relating, as well as the operation of defense mechanisms, which support and protect self-esteem. Thus, compulsives see themselves as conscientious and conform scrupulously to external standards to make absolutely sure this image is confirmed; minor errors are magnified into major mistakes, leading to self-condemnation. As this example shows, structural elements of personality are so deeply imprinted that they actively transform the nature of objective events. No matter how successful the compulsive may be at fending off error, a deep fear that something has slipped by remains. Every interpersonal interaction takes place under a black, solemn cloud.

Through their rigidity, lability, and eccentricity, the structurally defective group is set apart from other personality disorders. Temporary periods dominated by bizarre behavior, irrational impulses, and semidelusional thoughts are common. Such individuals may drift in and out of contact with consensual social reality, as if caught up in a momentary dream. Unable to grasp the illusory character of these inner stimuli, they may be driven to engage in erratic and hostile actions or embark on wild and chaotic sprees they may only vaguely recall later. Every so often, their intrapsychic world erupts and overwhelms them, blurring their awareness and releasing bizarre impulses, thoughts, and actions. Most have a checkered and erratic history of relationships, school, and work performance, as with Neal. Lack of judgment and foresight and failures to

Focus on Development

Childhood Precursors of Schizotypal Personality Disorder When Do Positive and Negative Symptoms Begin to Emerge?

Researchers have traditionally divided the symptoms of the schizophrenic syndromes into two types. First are the positive symptoms, mainly perceptual-cognitive in nature, which represent a surplus or exaggeration of normal functioning. These include suspi-ciousness, ideas of reference, odd beliefs, magical thinking, unusual perceptual experiences, and circumstantial and tangential speech. Second are the negative symptoms, mainly social-interpersonal in nature, which represent deficits in normal functioning. These include constricted or inappropriate affect, speech problems (i.e., poverty of speech, stilted speech), social indifference, social isolation, flatness of emotion, and odd behavior or appearance.

Because some children show schizoid-like behavior from early childhood, there has been some interest in determining if early behavioral manifestations of either the positive or negative symptoms might develop into full-fledged disorders later in life. S. Olin et al. (1997) studied teachers' ratings of adolescents who were subsequently diagnosed as schizotypal personalities and compared them with several groups, including a group of normal adolescents whose parents were both normal. They found that childhood analogs of adult schizotypal symptoms were evident as early as late childhood and early adolescence. When compared with children who later became healthy adults, children who later were diagnosed as schizotypal were more passive, more socially unengaged, more sensitive to criticism, and reacted more nervously. However, they were not rated as more anxious by their teachers. The preschizotypal children differed from children who later became schizophrenic, who were more disruptive and hyperexcitable. The results support a continuity of the negative symptoms from late childhood on into adulthood.

Unfortunately, no studies have yet addressed the positive symptoms of the schizotypal personality. Because it is developmentally normal for young children to believe in magic and to make attributions accordingly (Rosengren, Kalish, Hickling, & Gelman, 1994; Vikan & Clausen, 1993), it would be instructive to look at the development of these symptoms in schizotypal children. Perhaps a reluctance or inability to relinquish early magical thinking, which is developmentally normal and generally manifested by all children, may doom a child to some serious psychopathology later in life.

capitalize on native talents are common. Flashes of promise or achievement seldom endure without a highly tolerant and supportive social environment. Whereas other personality disorders often find a secure niche to match their habit systems, the structurally defective personalities repeat setbacks again and again. Nevertheless, most eventually manage to pull themselves together and gain enough of a foothold to prevent themselves from slipping into more serious, decompensated states.

With the portrait of Neal as an example, we now approach additional issues that form the plan of this chapter. First, we compare normality and abnormality; then we move on to variations on the basic schizotypal theme. After that, biological, psychodynamic, interpersonal, and cognitive perspectives on the schizotypal personality are described. These sections form the core of what is scientific in personality. By seeking to explain what we observe in character sketches like Neal's, the goal is to move beyond literary anecdote and enter the domain of theory. As always, we present history and description side by side, noting the contributions of past thinkers, each of whom tends to bring into focus a different aspect of the disorder. Developmental hypotheses are also reviewed but are tentative for all personality disorders. Next, the section "Evolutionary Neurodevelopmental Perspective" shows how the existence of the personality disorder follows from the laws of evolution. Also included are a comparison between the schizotypal and other theory-derived constructs and a discussion of how schizotypal personalities tend to develop Axis I disorders. Finally, we survey how the disorder might be treated through psychotherapy, again organizing our material mostly in terms of classical approaches to the field: the biological, interpersonal, cognitive, and psychodynamic perspectives. Along the way, we anchor abstract points in the text to case studies to provide concrete examples.

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