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Schizotypal personality disorder

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Template:Cs1 config Template:Distinguish Template:Infobox medical condition (new) Template:Personality disorders sidebar Schizotypal personality disorder (StPD or SPD), also known as schizotypal disorder, is a cluster A personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, derealization, transient psychosis, and unconventional beliefs as described by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=":0">Template:Cite journal</ref> Personality disorders that are classified as cluster A are grouped based on traits such as odd and eccentric behavior, which is contrary to cluster B and cluster C personality disorders, which are known for dramatic and anxious behavior.<ref>Template:Cite journal</ref> In the International Classification of Diseases, the latest edition of which is the ICD-11, schizotypal disorder is not classified as a personality disorder, but among psychotic disorders.

People with this disorder often feel pronounced discomfort in forming and maintaining social connections with other people, primarily due to the belief that other people harbor negative thoughts and views about them.<ref name="Schacter">Template:Cite book</ref> People with StPD may react oddly in conversations, such as not responding as expected, or talking to themselves.<ref name="Schacter" /> They frequently interpret situations as being strange or having unusual meanings for them; paranormal and superstitious beliefs are common. People with StPD usually disagree with the suggestion that their thoughts and behaviors are a 'disorder' and seek medical attention for depression or anxiety instead. Schizotypal personality disorder occurs in approximately 3% of the general population and is more commonly diagnosed in males.<ref name="pulay">Template:Cite journal</ref>

Signs and symptomsEdit

File:Paranoia (158822147).jpeg
People with StPD can feel intense paranoia.
File:Rotating snakes illusion.svg
People with StPD can have abnormal sensory experiences (similar to the one pictured) in places or situations where others experience nothing unusual.

Magical thinkingEdit

Odd and magical thinking is common among people with StPD.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> They are more likely to believe in supernatural phenomena and entities.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> It is common for people with StPD to experience severe social anxiety and have paranoid ideation.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Ideas of reference are common in people with StPD.<ref>Template:Cite encyclopedia</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> They can feel as if expressing themselves is dangerous. They may also feel that others are more competent, and have deeply entrenched and pervasive insecurities. Strange thinking patterns may be a defense mechanism against these feelings.<ref>Template:Cite journal</ref> People with StPD usually have limited levels of self-awareness.<ref>Template:Cite journal</ref> They may believe others think of them more negatively than they actually do.<ref>Template:Cite journal</ref>

AffectEdit

Patients with StPD can have difficulties in recognizing their or others' emotions,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> which can extend to difficulty expressing emotion.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> They may have limited responses to others' emotions and can be ambivalent.<ref>Template:Cite journal</ref> It is common for people with StPD to derive limited joy from activities.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> People with StPD are typically more socially isolated and uninterested in social situations than people without StPD,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> although they are still likely to be socially active on the internet.<ref>Template:Cite journal</ref> Depersonalization,<ref>Template:Cite journal</ref><ref>Template:Citation</ref> derealization,<ref>Template:Cite book</ref> boredom,<ref name=":5">Template:Cite journal</ref> and internal fantasies are common in patients with StPD. Abnormal facial expressions are also common in people with StPD, and they can have aberrant eye movements and difficulty responding to stimuli.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="Sensory gating deficits assessed by">Template:Cite journal</ref> They are often more prone to substance abuse or suicidal ideation.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> In an epidemiological study on suicidal behavior in StPD, even when sociodemographic factors were accounted for, people with StPD were 1.51 times more likely to attempt suicide.<ref name=":3" /> StPD is also often characterized as having similar symptoms as schizophrenia, but with less severe cognitive deficits.<ref name=":15">Template:Cite journal</ref>

CognitionEdit

People with StPD tend to have cognitive impairments.<ref>Template:Cite journal</ref> They can have abnormal perceptional and sensory experiences such as illusions.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> For example, someone with StPD may perceive colors as lighter or darker than others perceive them.<ref name="Fonseca-Pedrero_2015">Template:Cite journal</ref> Facial perception may also be difficult for people with the disorder.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> They can see others as deformed, may misrecognize them, or can feel as if they are alien to them.<ref name="Fonseca-Pedrero_2015" /> People with StPD can have difficulty processing information such as speech or language.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> They are more likely to speak slowly, with less fluctuation in pitch,<ref>Template:Cite journal</ref> and long pauses between speech. Patients with StPD may have a lower odor detection threshold,<ref>Template:Cite journal</ref> and can have impaired auditory or olfactory processing.<ref>Template:Cite journal</ref> It is also common for people with StPD to struggle with context processing,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> which cause them to form loose connections between events.<ref>Template:Cite journal</ref> In addition, people with StPD can have decreased capacities for multisensory integration or contrast sensitivity,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> either hyperreactive or impaired reactions to sensory input,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> slower response times,<ref name="Sensory gating deficits assessed by" /> impaired attention,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="Roitman" /> poorer postural control,<ref>Template:Cite journal</ref> and difficulties with decision-making.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> They can have difficulties in memory,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> and may have frequent intrusive memories of events.<ref>Template:Cite journal</ref> It is common for people with StPD to feel déjà vu or as if they can accurately predict future events due to abnormalities in the brain's memory storage.<ref>Template:Cite journal</ref>

HistoryEdit

StPD was introduced in 1980 in the DSM-III.<ref name=":1">Template:Cite journal</ref> Its inclusion provided a new classification for schizophrenia-spectrum disorders and of personality disorders that were previously unspecified.<ref name=":22">Template:Cite journal</ref><ref name=":1" /> Its diagnosis was developed through differentiating the classifications of borderline personality disorder, of which some of the diagnosed population demonstrated schizophrenia-spectrum traits.<ref name=":22" /><ref name=":1" /> When the separation of borderline personality disorder and StPD was originally suggested by Spitzer and Endicott, Siever and Gunderson opposed the distinction.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=":22" /> Siever and Gunderson's opposition to Spitzer and Endicott was that StPD was related to schizophrenia.<ref>Template:Cite journal</ref> Spitzer and Endicott stated "We believe, as do the authors, that the evidence for the genetic relationship between Schizotypal features and Chronic Schizophrenia is suggestive rather than proven".<ref name=":22" /> StPD was included in the DSM-IV and the DSM-V and saw little change in its diagnosis.<ref name=":1" />

EpidemiologyEdit

The reported prevalence of StPD in community studies ranges from 1.37% in a Norwegian sample, to 4.6% in an American sample.<ref name="DSM 5">Template:Cite book</ref> A large American study found a lifetime prevalence of 3.9%, with somewhat higher rates among men (4.2%) than women (3.7%).<ref name="pulay"/> It may be uncommon in clinical populations, with reported rates of up to 1.9%.<ref name="DSM 5" /> It has been estimated to be prevalent among up to 5.2% of the general population.<ref name=":12">Template:Cite journal</ref> Together with other cluster A personality disorders, it is also very common among homeless people who show up at drop-in centers, according to a 2008 New York study. The study did not address homeless people who do not show up at drop-in centers.<ref>Template:Cite journal</ref> Schizotypal disorder may be overdiagnosed in Russia and other post-Soviet states.<ref>Быкова А. Ю., Беккер Р. А., Быков Ю. В. О трудностях дифференциальной диагностики между первичным деперсонализационно-дереализационным расстройством и шизотипическим расстройством // Siberian Journal of Life Sciences & Agriculture. — 2022. — Т. 14. — №. 1.</ref>

PrognosisEdit

People with StPD usually had symptoms of schizotypal personality disorder in childhood.<ref name=":7">Template:Cite journal</ref> Traits of StPD usually remain consistently present over time,<ref name=":8">Template:Cite journal</ref><ref>Template:Cite encyclopedia</ref> although can fluctuate greatly in severity and stability.<ref>Template:Cite journal</ref><ref name="Two-year prevalence and stability o">Template:Cite journal</ref> DSM characterizes StPD as having nine major symptoms: ideas of reference, odd/magical beliefs, social anxiety, not having close friends, odd or eccentric behavior, odd speech, unusual perceptions, suspiciousness, schizo-obsessive behaviors<ref name=":11">Template:Cite journal</ref> and constricted affect.<ref>Template:Cite journal</ref> StPD can be diagnosed alongside other disorders, including borderline personality disorder (BPD), attention-deficit disorder, social anxiety disorder, and autism spectrum disorder.<ref name=":14">Template:Cite journal</ref> Comorbidities such as these can influence and potentially interfere with an individual's diagnosis of StPD.<ref name=":14" /> There may be gender differences in the symptomology of men and women with StPD.<ref name="An MRI study of superior temporal g">Template:Cite journal</ref> Women with the disorder might be more likely to have less severe cognitive deficits, and more severe social anxiety and magical thinking.<ref name=":9">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Symptoms of depression in women with StPD have a more negative impact on cognitive functioning than in males diagnosed with StPD and depression.<ref name=":9" /> In males with the disorder, abstraction and verbal learning are more likely to be in deficit compared to women, who tend to be less vulnerable to verbal deficits.<ref name=":9" /> People with StPD are more likely to only have a high school education, to be unemployed,<ref>Template:Cite journal</ref> and to have significant functional impairment.<ref name=":10">Template:Cite journal</ref> The two traits of StPD which are least likely to change are paranoia and abnormal experiences.<ref name="Two-year prevalence and stability o"/>

StPD tends to develop in adolescence and early adulthood, accompanied by a gradual decline in functioning and the increased development of StPD symptoms.<ref name=":15" /> Adolescents with StPD were more likely to have performance deficits, especially in arithmetic,<ref name=":15" /> and to display significantly lower levels of executive functioning, similar to autism spectrum disorder.<ref name=":15" /> Compared to those without StPD, adolescents with StPD spend more time socializing on the Internet, such as on forums, chat rooms and cooperative computer games, and spend less time socializing in-person.<ref>Template:Cite journal</ref> People who are treatment-resistant to obsessive–compulsive disorder (OCD) behavioral therapy and medication that also display odd or eccentric behaviors could contribute to the coexistence of obsessive–compulsive disorder with schizotypal disorder.<ref name=":11" />

EtiologyEdit

GeneticEdit

Although environmental factors likely play an important role in the onset of the disorder, people who have relatives with schizotypy,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="A brief questionnaire measure of mu">Template:Cite journal</ref> mood disorders,<ref>Template:Cite journal</ref> or other disorders on the schizophrenia spectrum are at a higher likelihood of developing StPD.<ref>Template:Cite journal</ref><ref name="A brief questionnaire measure of mu"/><ref>Template:Cite journal</ref> The COMT Val158Met polymorphism and its Val or Met allele are suspected to be associated with Schizotypal personality disorder.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> These genes affect dopamine production in the brain,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> a neurochemical thought to be associated with schizotypal traits.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> The gene may also contribute to decreased levels of gray matter in the prefrontal cortex.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> This may lead to impaired capacities for decision-making,<ref>Template:Cite journal</ref> speech,<ref>Template:Cite journal</ref> cognitive flexibility,<ref>Template:Cite journal</ref> and altered perceptual experiences.<ref>Template:Cite journal</ref> The rs1006737 polymorphism of the CACNA1C gene is also believed to have a part in schizotypal symptoms.<ref>Template:Cite journal</ref> It may lead to a significantly increased physiological response to stress through the cortisol awakening response in the brain.<ref>Template:Cite journal</ref><ref>Template:Cite thesis</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> It may also negatively affect reward processing in the brain and lead to anhedonia or depression in patients.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> These factors possibly lead to the development of Schizotypal traits.<ref>Template:Cite journal</ref> The zinc-finger protein ZNF804A likely affects the levels of paranoia, anxiety, and ideas of reference in StPD.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> This gene is also thought to negatively impact attention in people with StPD.<ref>Template:Cite journal</ref> It may lead to an increased level of white matter volume in the frontal lobe.<ref>Template:Cite journal</ref> Another gene, the NOTCH4 is thought to relate to Schizophrenia spectrum disorders.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> It can lead to disruptions in the occipital cortex, and therefore symptoms of schizotypy.<ref>Template:Cite journal</ref> The GLRA1 and the p250GAP genes are also potentially associated with StPD.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> It may lead to abnormally low levels of Glutamic acids in the NMDA receptors, which impairs memory and learning.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> StPD may stem from abnormalities in Chromosome 22.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

NeurologicalEdit

Exposure to influenza during week 23 of gestation is associated with a higher likelihood of developing StPD. Poor nutrition in childhood may also contribute to the onset of StPD by altering the course of brain development.<ref>Template:Cite journal</ref> Numerous areas of the brain are thought to be associated with StPD. Higher levels of dopamine in the brain,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> possibly specifically the D1 receptor,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> might contribute to the development of StPD. StPD is associated with heightened dopaminergic activity in the striatum.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Their symptoms may also stem from higher presynaptic dopamine release.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> People with StPD may also have decreased volumes of grey or white matter in their caudate nucleus,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> which leads to difficulties in speech.<ref>Template:Cite conference</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> People with StPD likely have a reduced volume in their temporal lobes,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> possibly specifically the left hemisphere. The reduced levels of gray matter in these areas may be linked to their negative symptoms.<ref>Template:Cite journal</ref> Reduced volume of gray or white matter in the superior temporal gyrus or the transverse temporal gyrus are thought to lead to issues with speech,<ref name="An MRI study of superior temporal g"/><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> memory, and hallucinations.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Deficits in the gray matter volume of the temporal lobe and prefrontal cortex are likely associated with impairments in cognitive function, sensory processing, speech, executive function, decision-making, and emotional processing present in people with StPD.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> StPD symptoms may also be influenced by reduced internal capsule,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> which carries information to the cerebral cortex.<ref>Template:Cite journal</ref> People with StPD can also have impairments in the uncinate fasciculus, which connects parts of the limbic system.<ref>Template:Cite journal</ref> People with StPD have reduced levels of gray matter in their middle frontal gyrus and Brodmann area 10.<ref name=":4">Template:Cite journal</ref> Although, not as reduced as patients with Schizophrenia.<ref name=":4" /> Possibly preventing them from developing schizophrenia.<ref>Template:Cite journal</ref> Increased gyrification in gyri by the cerebellum may lead to dysconnectivity in the brain, and therefore, schizotypal symptoms.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> They may also have a hyporeactive,<ref>Template:Cite journal</ref> or hyperreactive amygdala.<ref>Template:Cite journal</ref> As well as hyperactive pituitary glands and putamens.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> It is also possible that lower capacities for prepulse inhibition plays a role in StPD.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Research has suggested that people with StPD can have higher concentrations of Homovanillic acids.<ref>Template:Cite journal</ref> Abnormalities in the cave of septum pellucidum may also be present.<ref>Template:Cite journal</ref> In people predisposed to the development of Schizophrenia spectrum disorders, the consumption of cannabis can induce the onset of StPD or other disorders with psychotic symptoms.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

EnvironmentalEdit

Unique environmental factors, which differ from shared sibling experiences, have been found to play a role in the development of StPD and its dimensions. There is evidence to suggest that parenting styles, early separation, childhood trauma, and childhood neglect can lead to the development of schizotypal traits.<ref>Template:Cite journal</ref><ref>Deidre M. Anglina, Patricia R. Cohenab, Henian Chena (2008) Duration of early maternal separation and prediction of schizotypal symptoms from early adolescence to midlife, Schizophrenia Research Volume 103, Issue 1, Pages 143–150 (August 2008)</ref><ref>Howard Berenbaum, Ph.D., Eve M. Valera, Ph.D. and John G. Kerns, Ph.D. (2003) Psychological Trauma and Schizotypal Symptoms, Oxford Journals, Medicine, Schizophrenia Bulletin Volume 29, Number 1 Pp. 143–152</ref> Neglect, abuse, stress,<ref>Template:Cite journal</ref> trauma,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> or family dysfunction during childhood may increase the risk of developing schizotypal personality disorder.<ref name=":3">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> There is also evidence indicating that disruptions in brain development during the prenatal period could affect the development of StPD.<ref>Template:Cite journal</ref> Over time, children learn to interpret social cues and respond appropriately but for unknown reasons this process does not work well for people with this disorder.<ref name="Schizotypal personality disorder">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> During childhood, people with StPD may have seen little emotional expression from their parents. Another possibility is that they were excessively criticized or felt like they were constantly under threat,<ref>Template:Cite journal</ref> potentially resulting in the onset of social anxiety, strange thinking patterns,<ref name="The differential effects of child a">Template:Cite journal</ref> and blunted affect present in StPD.<ref>Template:Cite journal</ref><ref name="The differential effects of child a"/><ref>Template:Cite journal</ref> Their difficulties in social situations might eventually cause the individual to withdraw from most social interactions, thus leading to asociality.<ref name="Roitman">Template:Cite journal</ref> Children with schizotypal symptoms usually are more likely to indulge in internal fantasies,<ref>Template:Cite journal</ref> more anxious, socially isolated, and more sensitive to criticism.<ref>Template:Cite journal</ref> People with the most severe cases of StPD usually have a combination of childhood trauma and a genetic basis for their condition.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

DiagnosisEdit

DSMEdit

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, namely the DSM-5-TR, defines STPD as "a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior" in the section II chapter on personality disorders.<ref name=":16">Template:Cite book</ref> The diagnosis is based on at least five out of nine diagnostic criteria being met.<ref name=":17">Template:Cite book</ref> The criteria have been retained from the DSM-IV-TR.<ref name=":16" /> In addition to the aforementioned criteria, a diagnosis requires that the condition is not merely a part of the manifestation of a disorder causing psychosis, such as schizophrenia, nor of autism spectrum disorder.<ref name=":17" />

StPD is characterized by five or more of the following:<ref name="Merck Manuals">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

  • Ideas of reference (but not delusions of reference)
  • Odd beliefs or magical thinking (e.g. the supernatural or special connection or bond to an abuser)
  • Unusual perceptional experiences (hearing a voice, dissociative experiences, illusions, etc.)
  • Odd thought and speech (e.g. jumping from one topic to another)
  • Eccentric behavior and/or appearance
  • Paranoid ideation
  • Moods and facial expressions that don't match each other or the situation
  • Few to no close supports
  • Excessive social anxiety that remains even with familiar people

These symptoms must have begun by early adulthood.

Alternative modelEdit

Template:Further Section III of both the DSM-5 and DSM-5-TR contains the Alternative DSM-5 Model for Personality Disorders (AMPD). The AMPD defines six specific personality disorders – one of them being STPD – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); a listing and description of the pathological personality traits associated with the disorder (criterion B); and a section dedicated to specifiers.<ref name=":18">Template:Cite book</ref>

General personality impairment in individuals with STPD, according to the AMPD, involves a fragmented sense of self and difficulty distinguishing personal identity from others. Emotional expression may appear unusual or disconnected from the situation. They often lack clear goals or consistent personal values. Understanding social dynamics is challenging, leading to frequent misinterpretations of others' intentions. Close relationships are difficult to maintain due to suspicion and discomfort in social settings. A diagnosis requires impairment in at least two of these areas. At least two of these elements must have a "moderate or greater impairment".<ref name=":19">Template:Cite book</ref> The AMPD lists six pathological traits, from the domains of detachment and psychoticism for STPD. Any four or more of these are required for a diagnosis to be made. Other traits can be included in the diagnosis as specifiers.<ref name=":19" />

The patient must also meet the general criteria C through G for a personality disorder, which state that the traits and symptoms being displayed by the patient must be stable and unchanging over time with an onset of at least adolescence or early adulthood, visible in a variety of situations, not caused by another mental disorder, not caused by a substance or medical condition, and abnormal in comparison to a person's developmental stage and culture/religion.<ref name=":18" />

ICDEdit

Personality disorders can also be diagnosed in accordance with the International Classification of Diseases, the latest edition of which is the ICD-11. The ICD-11 personality disorder section differs substantially from the previous edition, ICD-10. All distinct PDs have been merged into one: personality disorder (6D10), which can be coded as mild (6D10.0), moderate (6D10.1), severe (6D10.2), or severity unspecified (6D10.Z). As such, there is no specific PD diagnosis for STPD.

On the other hand, neither the ICD-10 nor the ICD-11 conceptualize STPD as being a personality disorder. Instead, it is listed together with psychotic disorders as "Schizotypal disorder" (6A22) in the ICD-11, and as (F21) in the ICD-10.

Differential diagnosisEdit

Diagnosis Details
Other mental disorders with psychotic symptoms Unlike delusional disorder, schizophrenia, or mood disorders with psychotic features, StPD is not characterized by a persistent period of psychotic symptoms. StPD symptoms must also persist when psychotic symptoms are not present.<ref name=":7" /><ref name=":8" />
Personality change due to another medical condition Symptoms similar to those of StPD can appear due to other medical conditions that affect the central nervous system or substance use disorders.
Other personality disorders Other personality disorders can have symptoms similar to StPD. People with schizotypal personality disorder, paranoid personality disorder and schizoid personality disorder can also be socially detached and have blunted affects, but without the cognitive or perceptual distortions of StPD. Individuals with StPD and people with avoidant personality disorder can have limited close relationships. However, people with AvPD rarely have the eccentric behaviour of StPD. Psychotic-like symptoms can also appear in borderline personality disorder, but those with BPD fear social isolation while those with StPD are comfortable with it. People with StPD are also usually less impulsive than people with BPD. Individuals with narcissistic personality disorder may also appear socially alienated, however, this is due to fears of having flaws noticed by others.<ref name="DSM 5" />

Differential diagnosis with the following disorders should also be considered:

  • Other disorders with psychotic symptoms: (e.g., schizophrenia, bipolar disorder, or depressive disorder with psychotic features)<ref name="Merck Manuals" />
  • Paranoid, schizoid, or avoidant personality disorders<ref name="Merck Manuals" />
  • Dissociative identity disorder (DID)Template:Citation needed
  • Communication disorders<ref>Template:Cite book</ref>

ScreeningEdit

There are various methods of screening for schizotypal personality. The Schizotypal Personality Questionnaire (SPQ) measures nine traits of StPD using a self-report assessment.<ref>Template:Cite journal</ref> The nine traits referenced are Ideas of Reference, Excessive Social Anxiety, Odd Beliefs or Magical Thinking, Unusual Perceptual Experiences, Odd or Eccentric Behavior, No Close Friends, Odd Speech, Constricted Affect, and Suspiciousness. A study found that of the participants who scored in the top 10th percentile of all the SPQ scores, 55% were clinically diagnosed with StPD.<ref>Template:Cite journal</ref> It has been adapted into a computerized adaptive version, known as the SPQ-CAT.<ref>Template:Cite journal</ref> A method that measures the risk of developing psychosis through self-reports is the Wisconsin Schizotypy Scale (WSS).<ref>Template:Cite journal</ref> The WSS divides schizotypal personality traits into 4 scales for Perceptual Aberration, Magical Ideation, Revised Social Anhedonia, and Physical Anhedonia.<ref>Schizotypal Disorder Template:Webarchive in ICD-10: Clinical descriptions and guidelines. Template:Webarchive</ref><ref name=":04">Template:Cite journal</ref> A comparison of the SPQ and the WSS suggests that these measures should be cautiously used for screening of StPD.<ref name=":04" />

When screening for StPD, it is difficult to distinguish between schizotypal personality disorder and autism spectrum disorder.<ref name="zaq">Template:Cite journal</ref> In order to develop better screening tools, researchers are looking into the importance of ipseity disturbance, which is characteristic of schizophrenia spectrum disorders such as StPD but not of autism.<ref>Template:Cite journal</ref><ref name="zaq" />

Millon's subtypesEdit

Theodore Millon proposes two subtypes of schizotypal personality.<ref name="Millon 11">Template:Cite book</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Any individual with schizotypal personality disorder may exhibit either one of the following somewhat different subtypes (note that Millon believes it is rare for a personality to show one pure variant, but rather a mixture of one major variant with one or more secondary variants):

Subtype Features Personality traits
Insipid schizotypal A structural exaggeration of the passive-detached pattern. It includes schizoid, depressive and dependent features. Sense of strangeness and nonbeing; overtly drab, sluggish, inexpressive; internally bland, barren, indifferent, and insensitive; obscured, vague, and tangential thoughts.
Timorous schizotypal A structural exaggeration of the active-detached pattern. It includes avoidant and negativistic features. Warily apprehensive, watchful, suspicious, guarded, shrinking, deadens excess sensitivity; alienated from self and others; intentionally blocks, reverses, or disqualifies own thoughts.

Millon's typology of personality disorders was influential in the development of the DSM-III, particularly with respect to distinguishing between schizoid, schizotypal and avoidant personality disorders.<ref name="Livesley West 1986 pp. 59–62">Template:Cite journal</ref> These had previously been considered different surface-level expressions of the same underlying personality structure, and some psychologists, particularly those working in psychoanalytic or psychodynamic traditions, still take these personality disorders to be essentially similar.<ref name="McWilliams 2011 p199">Template:Cite book</ref><ref>Template:Cite book</ref>

Common comorbiditiesEdit

author = {Šram, Zlatko}, year = {2018}, month = {03}, title = {Childhood Trauma, the Occult, Dissociative Identity Disorder, and Schizotypal Personality Disorder: Relations on a Sample of Psychiatric Outpatients} }https://www.researchgate.net/publication/323526162_Childhood_Trauma_the_Occult_Dissociative_Identity_Disorder_and_Schizotypal_Personality_Disorder_Relations_on_a_Sample_of_Psychiatric_Outpatients</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

TreatmentEdit

MedicationEdit

File:Risperidone-3D-balls.png
Ball-and-stick model of Risperidone, a drug used to treat StPD
File:Cognitive behavioral therapy - basic tenets.svg
Model of Cognitive behavioral therapy, a type of therapy used to treat StPD

StPD is rarely seen as the primary reason for treatment in a clinical setting, but it often occurs as a comorbid finding with other mental disorders. When patients with StPD have prescribed pharmaceuticals, they are usually prescribed antipsychotics.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> However, the use of neuroleptic drugs in the schizotypal population is in great doubt.<ref name="Livesley 012">Template:Cite book</ref> The antipsychotics which show promise as treatments for StPD include olanzapine,<ref>Template:Cite journal</ref> risperidone,<ref>Template:Cite journal</ref><ref name="Diagnosis and treatment of schizoty">Template:Cite journal</ref> haloperidol,<ref>Template:Cite journal</ref> and thiothixene.<ref>Template:Citation</ref> The antidepressant fluoxetine may also be helpful.<ref name=":13"/><ref>Template:Cite journal</ref> While people with schizotypal personality disorder and other attenuated psychotic-spectrum disorders may have a good outcome with neuroleptics in the short term, long-term follow-up suggests significant impairment in daily functioning compared to schizotypal and even schizophrenic people without antipsychotic drug exposure.<ref>Template:Cite journal</ref> Positive, negative, and depressive symptoms were shown to be improved by the use of olanzapine, an antipsychotic.<ref name=":13">Template:Cite journal</ref> Those with comorbid OCD and StPD were most positively affected by the use of olanzapine and showed worse outcomes with the use of clomipramine, an antidepressant.<ref name="Diagnosis and treatment of schizoty"/> Antidepressants are also sometimes prescribed, whether for StPD proper or for comorbid anxiety and depression.<ref name="Livesley 012" /><ref name="Diagnosis and treatment of schizoty"/> However, there is some ambiguity in the efficacy of antidepressants, as many studies have only tested people with StPD and comorbid obsessive-compulsive disorder or borderline personality disorder. They have shown little efficacy for treating dysthymia and anhedonia related to StPD.<ref name=":0" /> Both of these medications are the most frequently prescribed medication for StPD, though the use and efficacy of them should be evaluated differently for every case.<ref name=":13" /> The use of stimulants has also shown some efficacy, especially for those with worsened cognitive and attentional issues. Patients who have concurrent psychosis should be monitored more closely if stimulants are used as part of their treatment.<ref name=":0" /> Other drugs which may be effective include pergolide,<ref>Template:Cite journal</ref> guanfacine,<ref>Template:Cite journal</ref><ref name=":2">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> and dihydrexidine.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

TherapyEdit

According to Theodore Millon, schizotypal personality disorder is one of the most straightforward personality disorders to identify but one of the most difficult to treat with psychotherapy.<ref name="Millon 11" /> Cognitive remediation therapy,<ref name=":2" /><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> metacognitive therapy, supportive psychotherapy,<ref name=":6">Template:Citation</ref> social skills training<ref>Template:Cite journal</ref> and cognitive-behavioral therapy can be effective treatments for the disorder.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Increased social interaction with others may be able to help limit symptoms of StPD.<ref>Template:Cite journal</ref> Support is crucial for schizotypal patients with predominant paranoid symptoms because they may have difficulties even in highly structured groups.<ref name="Oldham 1">Template:Cite book</ref> Persons with StPD usually consider themselves to be simply eccentric or nonconformist; the degree to which they consider their social nonconformity a problem differs from the degree to which it is viewed as a problem in psychiatry. It is difficult to gain rapport with people with StPD because increasing familiarity and intimacy often increase their level of anxiety and discomfort.<ref>Template:Cite journal</ref> Therapy for StPD must be flexible to face emergencies or unique challenges.<ref name=":6" />

See alsoEdit

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ReferencesEdit

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External linksEdit

Template:Medical resourcesTemplate:ICD-10 personality disorders

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