The Evolutionary Neurodevelopmental Perspective

Perspectives, by definition, yield only limited insight. The evolutionary theory of personality (Millon, 1990; Millon & Davis, 1996) maintains that the schizotypal exists on a continuum of severity with the passively detached schizoid and actively detached avoidant personalities, both of which gradually merge into the social detachment characteristic of normal introversion (see Figure 12.2). The distinction between the schizoid and avoidant as personality disorders thus appears at the threshold of normality and gradually becomes sharper as severity increases.

Thus, the schizoid appears behaviorally inert, interpersonally unengaged, remote, indifferent, cognitively impoverished or even vacant, and temperamentally unexcitable. The avoidant appears behaviorally fretful and hesitant, interpersonally fearful, cogni-tively distracted, and temperamentally anguished and tense. Because the disorders are really conceptual dimensions rather than discrete categories, as represented in the DSM, particular individuals may be located anywhere on the schizoid-avoidant continuum, thus sharing traits with either disorder. Some individuals, therefore, lack the fear of social humiliation that characterizes the avoidant, possess a measure of intact emotional

Personality Trait

Personality Disorder

Structural Personality Disorder

Psychotic Syndrome

' NormalN /Introversion\

Schizoid Passively Detached from Self and/Others: Behaviorally inert Interpersonally unengaged Cognitivew impoverished Temperamentally unexcitable

Avoidant Actively Detached from Self and Others: Behaviorally fretful interpersonally aversive Cognitively distracted Temperamentally tense

Insipid (Schizoid) Subtype

Schizotypal

Behaviorally eccentric interpersonally secretive Cognitively disorganized

Timorous (Avoidant) Subtype

Tempermentally insentient or distraught

Negative Symptoms e.g., anhedonia, catatonia

Schizophrenic Syndromes

Positive Symptoms e.g., delusions, hallucinations

FIGURE 12.2 The Schizoid, Avoidant, and Schizotypal Personalities and Their Relationship to Schizophrenia.

capacity characteristic of the avoidant, and enjoy a well-developed fantasy life but nevertheless prefer the solitary lifestyle of the schizoid. At moderate levels of pathology, the structural matrix of the personality is fundamentally sound, and its expressed traits are integrated into the needs and functioning of the total personality.

As the level of pathology increases, however, defects in the very structural matrix that supports psychological functioning begin to amplify, distort, and transform underlying personality traits. For most subjects, these defects will have a biological-genetic foundation but be expressed and perpetuated cognitively and interpersonally. According to the evolutionary theory, the negative symptoms of the schizotypal capture and exaggerate the social apathy of the more intact schizoid, and the positive symptoms capture and exaggerate the more intact avoidant (see Figure 12.2).

Alienated from others and marginal members of society, schizoid-based schizotypals turn increasingly to solitary thoughts. Over time, shared social behaviors become fully subordinate to private fantasy. Their thoughts are left to wander unchecked by the logic and control of reciprocal social communication and activity. What they find within themselves is hardly rewarding—a barren, colorless void that offers no basis for joyful fantasy. Their inner personal world proves to be as dead and ungratifying as objective reality. They have no choice, so it seems, but to turn to unreal fantasies. These, at least, might fill in the void and give their existence some substance. Interest moves toward the mystical and magical, to needed illusions and ideation that enables the person to become a central, rather than a peripheral and insignificant, figure.

In an effort to minimize their awareness of external discomfort, avoidant-based schizotypals turn inward to fantasy and rumination, but this also proves to be self-defeating. Not only are their inner conflicts intense, but they spend much of their reflective time reliving and duplicating the painful events of the past. Their protective efforts only reinforce their distress. Moreover, given their low self-esteem, their inner reflections often take the form of self-reproval. They not only fail to gain solace from themselves but also find that they cannot readily escape from their own thoughts of self-derogation, from feelings of personal worthlessness and the futility of being themselves. In an effort to counter these oppressive inner thoughts, they may seek to block and destroy their cognitive clarity, that is, to interfere with the anguish of their discordant inner emotions and ideas. This maneuver not only proves self-defeating, in that it diminishes their ability to deal with events rationally, but further estranges them from communicating effectively with others. Even more destructive self-reproval and cognitive interference alienate them from their own existence. Having no place to go, they begin to create a new, inner world—one populated by magical fantasies, illusions, telepathic relationships, and other odd thoughts that provide them with not only an existence but one that is more significant and potentially rewarding than that found in reality.

Feelings of being hollow, empty, decaying, or dead inside, for example, caricature the depersonalized passive-detachment of the schizoid pattern. Lacking energy and initiative, these individuals neither engage others nor generate anything to fill their own internal void, like Matthew. Eventually, they exist only as living absence. Likewise, individuals who claim access to special modes of information and privileged dimensions of reality caricature the active-detachment of the avoidant, for whom hypervigilance and the construction of a withdrawn fantasy life are core traits. As the structural defect becomes more profound, it finally destroys integration itself as the defining characteristic of personality. Only the negative and positive symptoms of schizophrenia remain, residuals of the passive and active detachment of the schizoid and avoidant personalities (see Figure 12.2). Table 12.1 summarizes the total schizotypal pattern in terms of eight clinical domains.

Contrast with Other Personalities

The schizotypal is necessarily similar to the schizoid and avoidant but shares surface characteristics with the other structurally defective personalities, the paranoid and borderline. Both schizotypal and paranoid experience ideas of reference, are deeply suspicious of others, and prefer social isolation, though for different reasons. In the schizotypal, ideas of reference include signs and omens specially intended to guide or benefit the person. What the normal person would consider an interesting coincidence, the schizotypal may consider a revelation. As these are part and parcel of cognition, they can occur in conjunction with mystical states, are not necessarily troubling, and may be welcomed.

TABLE 12.1 The Schizotypal Personality: Functional and Structural Domains

Functional Domains

Structural Domains

Expressive Behavior

Eccentric

Self-Image

Estranged

Exhibits socially gauche and peculiar mannerisms; perceived by others as aberrant; disposed to behave in an unobtrusively odd, aloof, curious, or bizarre manner.

Exhibits recurrent social perplexities and illusions as well as experiences of depersonalization derealization and dissociation; sees self as forlorn, with repetitive thoughts of life's emptiness and meaninglessness.

Interpersonal Conduct

Representations

Chaotic

Prefers privacy and isolation, with few, highly tentative attachments and personal obligations; has drifted over time into increasingly peripheral vocational roles and clandestine social activities.

Internalized representations consist of a piecemeal jumble of early relationships and affects, random drives and impulses, and uncoordinated channels of regulation that are only fitfully competent for binding tensions, accommodating needs, and mediating conflicts.

Cognitive Style

Autistic

Morphologic Organization

Fragmented

Capacity to "read" thoughts and feelings of others is markedly dysfunctional; mixes social communications with personal irrelevancies, circumstantial speech, ideas of reference, and metaphorical asides; often ruminative, appearing self-absorbed and lost in daydreams with occasional magical thinking, bodily illusions, obscure suspicions, odd beliefs, and a blurring of reality and fantasy.

Possesses permeable ego-boundaries; coping and defensive operations are haphazardly ordered in a loose assemblage of morphologic structures, leading to desultory actions in which primitive thoughts and affects are discharged directly, with few reality-based sublimations, and significant further disintegrations into a psychotic structural level, likely under even modest stress.

Regulatory Mechanism

Undoing

Mood/ Temperament

Distraught or Insentient

Bizarre mannerisms and idiosyncratic thoughts appear to reflect a retraction or reversal of previous acts or ideas that have stirred feelings of anxiety, conflict, or guilt; ritualistic or magical behaviors serve to repent for or nullify assumed misdeeds or "evil" thoughts.

Excessively apprehensive and ill at ease, particularly in social encounters; agitated and anxiously watchful, evincing distrust of others and suspicion of their motives that persists despite growing familiarity; or manifests drab, apathetic, sluggish, joyless, and spiritless appearance; reveals marked deficiencies in face-to-face rapport and emotional expression.

Note: Shaded domains are the most salient for this personality prototype.

Note: Shaded domains are the most salient for this personality prototype.

In contrast, ideas of reference in the paranoid are usually associated with a fierce defense of autonomy, namely, the fear that others are somehow spying on the person. Thus, knowledge is extracted for the schizotypal but from the paranoid. Moreover, schizotypals may believe they can use their special insights to control others, whereas paranoids believe that others are attempting to control them.

Not surprisingly, both schizotypals and paranoids are often socially isolated. However, schizotypals seek social isolation because of repeated, hostile demands that they reform cognitively or face marginalization for being weird or strange. In contrast, paranoids directly destroy friendly associations by attributing hostile motives to others, for example, by repeated accusations. Schizotypals cannot reform cognitively, feel a sense of separateness, and choose to reject the world (Benjamin, 1996), whereas paranoids are rejected by the world. Finally, the paranoid is usually perceived as being cold, stubborn, and rigidly autonomous, whereas the schizotypal is open to experience to the point of cognitive disintegration.

Because the schizotypal and borderline personalities were originally carved from the same diagnostic rock, their overlap is of particular concern. Both experience emotional difficulties and temporary psychotic episodes, though for different reasons. Schizotypals are emotionally constricted or inappropriate, whereas borderlines are emotionally labile. Emotions in schizotypals mirror their idiosyncratic construction of reality. Because their interpretations are cognitively eccentric, their affect is subjectively appropriate but objectively inappropriate. In contrast, emotions in the borderline are driven interpersonally through their dichotomous appraisals of themselves and their relationships. Borderlines shift suddenly from all good to all bad, all loving to all hating, with few intermediate shades of gray. Although the speed with which the borderlines vacillate and their totalis-tic appraisals suggest a cognitive disorder, these symptoms are a consequence of their early attachments, not a neurocognitive deficit. The most discriminating feature, however, is likely to be their response to social isolation. Schizotypals seek separateness from the world; borderlines crave intimacy and desperately avoid abandonment.

Pathways to Symptom Expression

The structurally defective personalities, particularly the schizotypal with its demonstrated relationship to schizophrenia, push the boundaries of the multiaxial system. Although personality is, by definition, the patterning of variables across the entire matrix of the person, the causal factors involved in creating and perpetuating the structurally defective patterns seem broader and more intricate than the syndromes of Axis I, which rests on the disease model, yet more narrow than those of Axis II. What we would normally think of as symptoms, then, seem closer to the core of the personality, caught somewhere between a consequence and a characteristic. The depersonalization of the insipid schizotypal, for example, is so logically connected to an exaggerated schizoid pattern that its separation as a symptom would diminish the subtype. Such distinctions have an artificial feel and remind us, as noted in the introductory chapters, that all taxonomies are limited social constructions. As you read the following paragraphs, try to identify the connection between personality and symptom.

Dissociative Episodes

Many individuals experience moments of detachment in which things seem strange or unreal, yet such estrangement and depersonalization are common in schizotypals. Observers of the passing scene, such persons remain uninvolved, sometimes even to the point of watching the course of events unfold from outside their physical bodies. In part, such feelings derive from a fundamental lack of affect, which promotes social detachment and prevents them from connecting meaningfully with others or from developing goals that might give meaning to their lives.

However, depersonalization may also reflect an attempt at self-desertion, an attempt to leave shameful and humiliating realities behind by fleeing existence itself. Alternatively, some schizotypals may seem to lose their personal identity in oceanic mystical states; these experiences are usually considered pleasurable, rather than terrifying.

Particularly for timorous schizotypals, recurrent illusions, magical thinking, and ideas of reference may be seen as an effort to supply some kind of content to the existential void, to anchor themselves to something substantial, to keep their boat afloat, even if that content is self-generated.

Psychotic Syndromes

As noted throughout this chapter, schizotypal personality disorder is believed to exist on a continuum with the schizophrenic syndromes. Although they exist on different axes, the difference appears to be one of degree rather than kind. Accordingly, the boundary between schizotypal personality and the schizophrenic syndromes is probably more arbitrary than objective. As a personality disorder, however, the schizotypal naturally assumes the presence of characteristics that stretch back to early adulthood.

In the absence of stress, then, during which many traits become more exaggerated or intense, schizotypals should be able to maintain their level of functioning. Should difficulties mount, however, or their coping efforts meet with failure, schizotypals may abandon their efforts to mobilize their resources or maintain reality contact and deteriorate into a psychotic disorder. In these severe states, they fail to discriminate between subjective experience and external reality; they become unable to carry out normal responsibilities or to behave in accord with conventional social expectations. Rational thinking disappears, previously controlled emotions erupt, and a disintegration and demoralization of self takes hold. For this reason, the DSM-IV stresses that the personality disorder can be diagnosed where it preexists the onset of a brief psychotic disorder, schizophreni-form disorder, delusional disorder, or schizophrenia and reasserts itself once the psychotic symptoms of these disorders have remitted.

Depression

Many schizotypals, those without substantial schizoid characteristics, retain the capacity to feel some measure of emotion. Unfortunately, that emotion is often depression. Many are also biologically anhedonic, unable to experience more than a minimum of pleasurable feeling. In consequence, they either do not enjoy relating to others or find such relationships painful. In the end, they are usually dismissed contemptuously by others as weird or strange and drift aimlessly at the edge of society. Schizotypals have little capacity for experiencing reinforcement and develop few opportunities to acquire reinforcers. Schizotypals have no life plan, no sense of accomplishment, no ongoing interests, and no cherished relationships.

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