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Schizotypal Personality Disorder

By Robert M. A. Hirschfeld, MD, DeWitt Wallace Senior Scholar and Professor, Department of Psychiatry, Weill Cornell Medical College

Schizotypal personality disorder is characterized by a pervasive pattern of intense discomfort with and reduced capacity for close relationships, by distorted ways of thinking and perceiving, and by eccentric (odd) behavior.

  • People with schizotypal personality disorder may prefer not to interact with people because they feel like they are different and do not belong.

  • Doctors diagnose schizotypal personality disorder based on specific symptoms, including intense discomfort with close relationships, distorted ways of thinking and perceiving, and odd behavior.

  • Treatment includes antipsychotic drugs, antidepressants, and cognitive-behavioral therapy.

Personality disorders are long-lasting, pervasive patterns of thinking, perceiving, reacting, and relating that cause the person significant distress and/or impair the person's ability to function.

People with schizotypal personality disorder are less in touch with reality, and their thought and speech are more disorganized than occurs in other personality disorders. However, thoughts and behavior are not as unusual and out of touch with reality as in schizophrenia.

Schizotypal personality disorder occurs in about 1 to 2% of the general population. It is less likely to resolve or lessen as people age than most personality disorders.

Other disorders are often also present. Over half of people with schizotypal personality disorder have had at least one episode of major depressive disorder, and 30 to 50% of them have major depressive disorder when schizotypal personality disorder is diagnosed. These people often also have a substance abuse disorder.

Causes

Genes are thought to have an important role in the development of schizotypal personality disorder. It is more common among first-degree relatives (parents, siblings, and children) of people who have schizophrenia or another psychotic disorder.

Symptoms

Effect on relationships

People with schizotypal personality disorder do not have close friends or confidants, except for first-degree relatives. They are very uncomfortable relating to people. They interact with people if they have to but prefer not to because they feel like they are different and do not belong. However, they may say their lack of relationships makes them unhappy. They are very anxious in social situations, especially unfamiliar ones. Spending more time in a situation does not ease their anxiety.

People with this disorder may ignore ordinary social conventions (eg, not make eye contact), and because they do not understand usual social cues, they may interact with others inappropriately or stiffly.

Odd thinking and behavior

People with schizotypal personality disorder have odd ways of thinking, perceiving, and communicating. The following are examples:

  • Ideas of reference: People with these ideas think that ordinary occurrences have special meaning just for them.

  • Magical thinking: People think that they have magical control over others. For example, they may think that they cause other people to do ordinary things (such as feed the dog) or that they can perform magical rituals to prevent harm (such as washing their hands 3 times to prevent illness).

  • Paranoia: People are suspicious and mistrustful and wrongfully think that other people are out to get them or intend to harm them.

  • Paranormal powers: People think they have paranormal powers, enabling them to sense events before they happen or to read other people's minds.

Speech may be odd. It may be excessively abstract or concrete or contain odd phrases or use phrases or words in odd ways. They often dress oddly or in an unkempt way (eg, wearing ill-fitting or dirty clothes) and have odd mannerisms.

Perception of reality

In people with schizotypal disorder, perceptions (what they see, hear, or sense) may be distorted. For example, they may hear a voice whispering their name.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Doctors usually diagnose personality disorders based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5—see Classification and Diagnosis of Mental Illness), published by the American Psychiatric Association.

For doctors to diagnose schizotypal personality disorder, people must be intensely uncomfortable with and have very few close relationships. They must also have at least five of the following:

  • Ideas of reference

  • Odd beliefs or magical thinking

  • Distorted perceptions

  • Odd thought and speech

  • Suspicions or paranoid thoughts

  • Inappropriate or limited expression of emotion

  • Odd, eccentric, or peculiar behavior and/or appearance

  • Lack of close friends or confidants, except first-degree relatives

  • Excessive social anxiety that does not lessen with familiarity and is related mainly to paranoid fears

Also, symptoms must have begun by early adulthood.

Doctors must distinguish schizotypal personality disorder from schizophrenia, which causes similar, but more severe, bizarre, and persistent symptoms.

Treatment

  • Antipsychotic drugs and antidepressants

  • Cognitive-behavioral therapy

General treatment of schizotypal personality disorder is the same as that for all personality disorders.

The main treatment for schizotypal personality disorder is drugs. Antipsychotic drugs (used to schizophrenia) lessen anxiety and other symptoms. Antidepressants may also help lessen anxiety in people with schizotypal personality disorder.

Cognitive-behavioral therapy that focuses on acquiring social skills and managing anxiety can help. Such therapy can also make people more aware of how their own behavior may be perceived.

Doctors try to establish an emotional, encouraging, supportive relationship with people who have this personality disorder and thus help them learn to relate to others in more appropriate ways.