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Schizotypal personality disorder (STPD) is a mental disorder that belongs to the group of mental illnesses called personality disorders. Therefore, like other personality disorders, it is characterized by a consistent pattern of thinking, feeling, and interacting with others and with the world that tends to cause significant problems for the sufferer.
Specifically, schizotypal personality disorder tends to be associated with a pattern of odd, eccentric feelings, unusual perceptual experiences, behaviors, and relating to other people that interferes with the individual's ability to function.
Individuals with this illness have a tendency to be loners and suffer from discomfort in social situations. They may also be paranoid, although their level of suspiciousness might not rise to the level of being completely out of touch with reality (delusional). As with other personality disorders, the person with schizotypal personality disorder is usually an adolescent or adult before they can be assessed as meeting the full symptom criteria for the diagnosis of this illness.
Schizotypal personality disorder tends to occur in almost 4% of adults, more often in males than in females. It is thought to be part of a continuum of illnesses related to schizophrenia, so in the current diagnostic manual by the American Psychiatric Association, the Diagnostic Manual of Mental Disorders, Fifth Edition (DSM-5), it is dually grouped with other personality disorders and with schizophrenia spectrum and other psychotic disorders. That is a bit different from how this illness is described by the World Health Organization (WHO) in the ICD-10, which calls this illness schizotypal disorder and associates it with schizophrenia only, rather than also with personality disorders.
What are causes and risk factors for schizotypal personality disorder?
- Although there is no specific cause for schizotypal personality disorder, like most other mental disorders, it is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model).
- Biologically, individuals with schizotypal personality disorder are thought to have less brain matter in certain areas and abnormalities of the neurotransmitter dopamine in the brain, with some similarities to the brain abnormalities found in individuals with schizophrenia.
- Neurodevelopmentally, people with schizotypal personality disorder have often been found to show differences in how they form new memories (prospective memory), as well as how their brains seem to respond when confronted with social situations.
- Having a family history of mental illness is a risk factor for developing schizotypal personality disorder. People who have a member of their immediate family (first-degree relative) with schizotypal symptoms (schizotypy) can be as much as 50% more likely to develop schizotypy compared to people without that family history. If a person has a close relative with schizophrenia, they are also more likely to develop schizotypal personality disorder and to have symptoms of similar severity to their schizophrenic relative.
- People who were born to a mother who smoked during pregnancy, had a lower birth weight, and had a smaller head circumference at the age of 12 months seem to develop symptoms of schizotypal personality disorder at higher rates than people of normal birth weight and head circumference at 1 year of age. Medical conditions like epilepsy can be a predisposing factor to developing schizotypy as an adult.
- Social risk factors for developing the suspiciousness and unusual perceptive symptoms of schizotypal personality disorder include birth during the winter or summer, higher birth order, being the victim of childhood physical or sexual abuse, or having a lower family socioeconomic status during childhood. It has also apparently been found to occur more often in black women compared to other women, independent of socioeconomic factors.
- Having parents who have difficult communication or a parent who tends to engage in magical thinking, like purporting to know what their children are thinking or doing, are other risk factors for children growing up to develop a schizotypal personality disorder. Children who use marijuana for the first time before 14 years of age or have been prematurely placed in the role of an adult can be predisposed to developing this illness as well.
What are schizotypal personality disorder symptoms and signs?
Signs and symptoms associated with schizotypal personality disorder can include the following:
- Ideas of reference (like feeling strangers are noticing or somehow communicating with oneself)
- Odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms (like superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents it may involve bizarre fantasies or preoccupations)
- Unusual perceptions
- Odd thinking and speech (like vague speech, or that which contains excessive detail, is in metaphors, is overly elaborate, or stereotyped)
- Suspiciousness or paranoid thoughts
- Inappropriate or constricted ways of expressing emotion (affect)
- Behavior or appearance that is odd, eccentric, or strange
- Lack of close friends or confidants other than close relatives
- Excessive social anxiety that does not decrease with familiarity and tends to be associated with paranoid fears rather than negative thoughts about oneself
Both of the most recent two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR and DSM-V) remain fairly consistent in how schizotypal personality disorder is defined.
What tests diagnose schizotypal personality disorder?
- There is no specific definitive test, like a blood test, that can accurately assess that a person has a schizotypal personality disorder. People who are concerned that they may suffer from this diagnosis might explore the possibility by taking a self-test, either an online or printable test, like the Schizotypal Personality Questionnaire, the Structured Interview for Schizotypy, the Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE), the Rust Inventory of Schizotypal Cognitions, the Community Assessment of Psychic Experiences, or the Schizotypal Personality Scale.
- To determine the presence of schizotypal personality disorder, health care professionals conduct a mental health interview that looks for the history and presence of the symptoms, also called diagnostic criteria, previously described. As with any mental health assessment, the health care professional will usually work toward ruling out other mental disorders, including screening for mood problems like depression and anxiety disorders, including anxiety attacks or generalized anxiety, obsessive-compulsive symptoms, types of other personality disorders like narcissistic personality disorder, antisocial personality disorder, schizoid personality disorder or histrionic personality disorder, drug-abuse problems as well as problems of being out of touch with reality, like schizophrenia or delusional disorder.
- Besides determining if the person suffers from a schizotypal personality disorder, the mental health professional may determine that while some symptoms (traits) of the disorder are present, the person does not fully qualify for the diagnosis. Since schizotypal personality disorder has most often been found to co-occur (termed being co-morbid) with borderline personality disorder, avoidant personality disorder, and paranoid personality disorder, the presence of those disorders will most likely be specifically explored as well.
- The health care professional will also likely try to ensure that the individual is not suffering from a medical problem that may cause emotional symptoms that mimic those of schizotypal personality disorder. The health care professional will therefore often inquire about when the person has most recently had a physical examination, comprehensive blood testing, and any other tests that a medical professional deems necessary to ensure that the individual is not suffering from a medical condition instead of or in addition to their emotional symptoms.
- Due to the use of a mental health interview in making the diagnosis and the fact that this condition, like any personality disorder, can be quite resistant to treatment, it is of great importance that the health care professional knows to conduct a thorough assessment. This is to assure that the person is not incorrectly assessed as having a schizotypal personality disorder when he or she does not.
- In determining the presence of schizotypal personality disorder, the evaluator will likely explore whether the person's symptoms indicate the presence of 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 aforementioned symptoms and signs (diagnostic criteria).
- The diagnosis is not to be assigned if it only occurs during the course of having schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or an autism spectrum disorder.
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What is the treatment for schizotypal personality disorder?
- Given the difficulties associated with schizotypal personality disorder, home remedies are not generally entertained as viable options for treating schizotypal personality disorder.
- Evidence-based treatments that have been found to be useful in helping the sufferer manage some of the symptoms of schizotypal personality disorder include both psychodynamic and cognitive-behavioral forms of talk therapy (psychotherapy).
- Cognitive-behavioral therapy, or CBT, is a form of psychotherapy that focuses on helping the person understand how their thoughts and behaviors affect each other. An emphasis on improving social skills is particularly important in addressing the long-standing social deficits that are part of schizotypal personality disorder.
- Psychodynamic psychotherapy, which is also called psychoanalytic therapy, seeks to help the individual understand and better manage his or her ways of defending against negative emotions.
- While medications do not "cure" personality disorders, including schizotypal personality disorder, they may be appropriate to address some of the mental health symptoms that can accompany it, like paranoia, odd behaviors, magical thinking, depression, or anxiety. The first antipsychotic medication was discovered by accident and then used for treatment of schizophrenia. This was chlorpromazine (Thorazine), which was soon followed by medications such as haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). These medications have become known as "neuroleptics" because, although effective in treating positive symptoms (for example, paranoia, magical thinking, mood swings/emotional lability), they can cause side effects, many of which affect the neurologic (nervous) system. Examples of such neurologic side effects include muscle stiffness or rigidity, painful spasms, restlessness tremors, and muscle twitches. These older medications are thought to be not as effective against so-called negative symptoms such as decreased motivation and lack of emotional expressiveness.
- Since 1989, a new class of antipsychotics (atypical or second-generation antipsychotics) has been used. At clinically effective doses, very few of the neurological side effects of traditional (first generation) antipsychotics are observed.
- Clozapine (Clozaril), the first drug of this new class, is the only medication that has been shown to be effective where other antipsychotics have failed. Its use is not associated with severe side effects, but it does produce other side effects, including a possible decrease in the number of white blood cells that can become dangerous in rare cases. Therefore, the blood needs to be monitored every week during the first six months of treatment and then every two weeks to identify this side effect early if it occurs.
- Other atypical antipsychotics include
- risperidone (Risperdal),
- olanzapine (Zyprexa),
- quetiapine (Seroquel),
- ziprasidone (Geodon),
- aripiprazole (Abilify),
- paliperidone (Invega or Sustenna),
- asenapine (Saphris),
- iloperidone (Fanapt),
- lurasidone (Latuda), and
- brexpiprazole (Rexulti).
- Although sometimes more effective and usually better tolerated, the use of the atypical antipsychotics is also associated with possible side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and monitoring for the emergence of complications. Most of these medications take two to three weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication is changed, or another medication is added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least four weeks (or even longer with clozapine).
- Since people with a schizotypal personality disorder are at increased risk of also developing depression, medications that address that symptom may be of great benefit as well. Serotonergic medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), vortioxetine (Trintellix), and vilazodone (Viibryd) are often prescribed because of their effectiveness and low incidence of side effects.
- Other often-prescribed antidepressant medications for the depression that can be associated with schizotypal personality disorder include
- venlafaxine (Effexor),
- duloxetine (Cymbalta),
- desvenlafaxine (Pristiq),
- levomilnacipran (Fetzima), and
- bupropion (Wellbutrin).
What are complications of schizotypal personality disorder? What is the prognosis of schizotypal personality disorder?
- People with schizotypal personality disorder are at risk for developing brief psychotic disorder, schizophreniform disorder, or delusional disorder. As many as half of individuals with this illness also suffer from major depression at the time the personality disorder is diagnosed and most have a history of suffering from at least one episode of major depression.
- People with schizotypal personality disorder also tend to suffer from an anxiety disorder, and many individuals who have this personality disorder in addition to another mental disorder have been found to be less responsive to treatment. Without treatment, individuals with this illness are at risk for having trouble getting and keeping relationships and employment over the long term, often due to symptoms like their odd behaviors and tendency toward paranoia.
Is it possible to prevent schizotypal personality disorder?
Societal interventions like prevention of child abuse and substance abuse in families can help decrease the occurrence of a number of very different mental health problems, including schizotypal personality disorder. More specifically, encouraging good prenatal care, discouraging women from smoking during pregnancy, and providing emotional support to women during pregnancy and the postpartum period may decrease those factors that have been linked to increased schizotypal symptoms in the children that come from those pregnancies.
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American Psychiatric Association
American Psychological Association
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National Institute of Mental Health (NIMH)
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