Individuals with this disorder are characterized as bizarre or eccentric with odd perceptions and cognitions. Their eccentricities are typically not confined to an isolated area; rather, schizotypal people often combine a peculiar style of dress or appearance, strange uses of language, unusual behaviors, and odd thought patterns. Their hygiene may be also poor. As such, schizotypal people are often identified easily and quickly by others, even nonclinicians. The schizotypal type is the classic oddball often fitting the characterization from relatively early in life as "marching to the beat of a different drummer."
People with Schizotypal Personality Disorder experience extreme discomfort with interpersonal relationships, lack close friends or confidants apart from relatives, and appear socially inept and withdrawn. They may be drifters and rarely date or marry. They often have ideas of reference, peculiar superstitions, and magical thinking that are so extreme as to be inconsistent with their culture or subculture. They may report beliefs in magical powers such as clairvoyance or telepathy, bizarre fantasies, and mystical experiences. Whereas some normal people may endorse some of these beliefs, those held by the schizo-typal are often more extreme and interfere with typical social and occupational functioning. Perceptual and somatic distortions are also common, but are not as extreme as those experienced by people with a psychotic disorder. Importantly, people with Schizotypal Personality Disorder do not evidence overt psychosis and have less deterioration of their functioning, which further discriminates the personality disorder from a psychotic disorder.
Emotionally, people with Schizotypal Personality Disorder are likely to show a restricted range of expression and in some cases, inappropriate affect. They have high levels of social anxiety with the themes of suspiciousness and paranoia contributing largely to the social deficits. Striking examples of unusual thought processes and emotions were shown in one of our patients, an 80-year-old woman, who during a relatively non-threatening part of the initial intake suddenly burst into tears and sobbed uncontrollably for several minutes. When asked what prompted her intense feelings, she replied that she was not sad, but rather that her sister (who was her only close relationship and who was living in another state) was crying at that very moment and the patient could always "feel her sister's feelings." Later in the same interview, the patient began laughing hysterically and reported that "her sister was having a good time" at that moment. Table 2.5 provides the DSM-IV-TR diagnostic criteria for Schizotypal Personality Disorder.
Table 2.5 DSM-IV-TR, Diagnostic Criteria for Schizotypal Personality Disorder (Code: 301.22)
A. 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
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.
Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.
Like the problems associated with criteria for Schizoid Personality Disorder, Criterion A6 (inappropriate or constricted affect) and Criterion A8 (lacks close friends or confidants other than first-degree relatives) may confound normal aging with illness because people become less affectively charged with age, and they are more likely to experience catastrophic but real social losses with advanced age, which can severely limit their social network beyond immediate family.
Theorized Pattern in Later Life and Possible Impact of Aging Like the schizoid, the central aging issue for the schizotypal personality is increased dependency on others. Because of acute social anxiety, older schizotypal patients will likely become agitated if physical infirmities force them to endure relationships with health care professionals, staff, and residents in congregate living settings or long-term care facilities. Their bizarre behaviors and beliefs will likely make the schizotypal older adult an easy target for social rejection in communal living settings. Like the paranoid type, schizotypal older adults may react to declines in hearing and vision by becoming even more paranoid and suspicious, further lowering their social effectiveness.
Another aging issue affecting the Schizotypal Personality Disorder has to do with the way people perceive bizarre behaviors in others across the life span. Among younger people, particularly adolescents, there is often a period when they try out a host of beliefs and styles of dress and appearance, some of which may be unusual or socially nonconforming. Some young adults intensify their eccentricities as a way of expressing themselves and perhaps making a social statement. Picture a young person with multiple body piercings, a Mohawk haircut, and bright tattoos. Now imagine an 85-year-old man with the same appearance. It is likely that his social standing would be greatly diminished compared with that of the younger person.
A problem facing schizotypal older adults is that their eccentricities are often perceived as more pathological than among younger adults. Individuals with this personality disorder are also at risk for being marginalized and discounted by others, being easily dismissed due to the overt "weirdness." One of our patients, an elderly schizotypal woman, was easily identified by others as being unusual (e.g., she wore a large fur hat, even indoors, and ill-fitting biker shorts). When she complained to her family doctor about having miniseizures throughout the day, he was dismissive, possibly attributing her experience to her psychiatric disorder (he was very familiar with her history and problems). Over time, her seizures worsened and played a role in an accident in which she wrecked her car and injured herself and two passengers in the other car. Only after that accident was a seizure disorder diagnosed and treated properly.
An interesting pattern is that of the older adult with Schizotypal Personality Disorder who is found by a visitor (e.g., utility company worker, health department worker) to be living in a deteriorating house (inside and out). Numerous neglected pets often cause putrescent conditions (e.g., one of our patients had 40 uncaged ferrets who urinated and defecated throughout the home). In the absence of an organic condition such as dementia or a history of psychotic disorder, an older adult who has a constellation of eccentricities (e.g., is unkempt, dressed inappropriately, malodorous, suspicious, paranoid, bizarre, and has few friends) likely is suffering from Schizotypal Personality Disorder.
Finally, a more optimistic view of aging and the Schizotypal Personality Disorder is offered by Butler et al. (1998) who propose a context in which the schizotypal type may do somewhat better in later life. They suggest that because such individuals are "insulated against the experiences of life" (p. 109), they may be less unnerved about some of the isolation and difficulties common in later life. However, these authors also note a competing pattern of increased reclusivity and isolation with age. We have seen this latter pattern in many cases, with the detrimental consequence of increased bizarreness due to the complete or near-complete lack of social contact.
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