Schizotypal personality disorder is characterized by difficulties in interpersonal relationships and the presence of social peculiarities or eccentricities in thought, perception, appearance, and behavior. The individual usually has strange, original ideas, sometimes a kind of magic that deviate from the typical environment and the culture of belonging, without acquiring the characteristics of a true delirium.

There may be a degree of distrust towards others and sensations of a hallucinatory or illusory type. A schizotypic person can present a strange, eccentric, or abstract language that can show significant unease in relationships, difficulties in integration, and adaptation to social norms.

Transient symptoms of anxiety or depression may occur, and, in case of particularly stressful situations, the individual may manifest transient psychotic symptoms. It can be considered as the premorbid personality of schizophrenia.

In Schizotypal personality disorder therapy, changing paranoid beliefs may be difficult if suspicious ideas about the therapist are not explicitly addressed at the beginning.

Case

Marta is a 35-year-old woman, lives with her 75-year-old father, has four cats, and three dogs, and she is single and has never had a serious relationship. She’s a cleaner at a private clinic and works early in the morning. She dresses in a very unusual way, in colorful clothes and always wears a hat, both in winter and in summer. Marta believes in magic, esotericism, and above all, the existence of civilizations from other parts of the universe.

She thinks that she is destined to receive the alien’s visit and is constantly waiting for messages and clues that will reveal to her when and where the spacecraft will land. She is fascinated by the theme of extracorporal experiences and describes frequent episodes of astral travel and esoteric rituals. She is also very superstitious and afraid that someone will cast the evil eye on her, which, she says, “is the worst of all.”

Despite her strange claims, Marta is not delusional and can recognize that her beliefs may be wrong. She often thinks that others talk about her when she leaves the house, but acknowledges that it may be because of her three dogs or her way of dressing. In social situations, she is shy and feels very uncomfortable, for this reason, she usually leaves her home at night, so she doesn’t have to talk to others. Marta’s paternal grandfather had schizophrenia and, since childhood, has always been very withdrawn and shy.

She has two older sisters but never took to them well. She’s never had great friends, not even the school period. Her mother died when Marta was 20. Her sisters are married and have children and often invite her to family meetings, although she did not usually attend. For the past nine years, he has lived in almost total isolation except for his father’s presence at home. These characteristics of Marta suggest that it may present a Schizotypal Personality Disorder.

Classification DSM-V & ICD-10

Classification

Schizotypal Personality Disorder (DSM V) is characterized by a dominant pattern of social and interpersonal deficiencies that is manifested by acute malaise and poor capacity for close relationships as well as cognitive or perceptual distortions and eccentric behavior, which begins at  the beginning of adulthood, is presented in different contexts, and is manifested by 5 or more of the following facts:

  1. Reference Ideas (excluding reference delusions) [a reference idea is an erroneous interpretation of events in the outside world as if they had a direct personal reference to oneself. In an idea of reference, the false belief is firmly not held as organized as a true belief, as in the case of a “delusional idea of reference”. More acutely, in the delusions of reference, we observe a belief well-structured and organized that certain events in the external world have a particular significance directly to one’s self (negative, derogatory, or grandeur)]
  2. Strange beliefs or magical thinking that influences behavior and does not conform to subcultural norms (e.g., superstitions, clairvoyance belief, telepathy or a “sixth sense”; in children and adolescents, extravagant fantasies or worries).
  3. Unusual perceptual experiences, including bodily illusions.
  4. Strange thoughts and discourse (e.g., vague, circumstantial, metaphorical, overworked, or stereotyped) [circumstantial thinking is characterized by the fact that shared information is excessive, redundant, and usually unrelated to the subject to what is desired].
  5. Suspicion or paranoid ideation [paranoid ideation consists of the suspicion or belief that you are being tormented, persecuted, or unfairly treated. Paranoid ideation is of lower proportions than a delusional and less firmly held idea.]
  6. Inappropriate or limited affection.
  7. Strange, eccentric or peculiar behavior or appearance.
  8. The person has no close friends or confidants other than his/her first-graders.
  9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about oneself.

The presence of these traits does not occur exclusively in the course of schizophrenia, bipolar disorder, or depressive disorder with psychotic characteristics, another psychotic disorder, or an autism spectrum disorder.

According to the International Classification of Mental Disorders and Behavior (ICD-10), Schizotypal Disorder (F21) is characterized by eccentric behavior or abnormalities of thinking and affectivity that resemble the schizophrenia, despite that the characteristic and definite anomalies of this disorder do not occur, nor present themselves.

They must be presented in a continuous or episodic manner for at least two years, three or four of the characteristic features listed below. Also, the person can’t compile guidelines for a diagnosis of schizophrenia. There are no predominant or characteristic symptoms, but some of the following may appear:

  1. Affectivity is cold and empty of content and is often accompanied by anhedonia (inability to experience pleasure, loss of interest, or satisfaction in almost all activities).
  2. Behavior or appearance is strange, eccentric, or peculiar.
  3. The impoverishment of personal relationships and a tendency towards social withdrawal.
  4. Reference ideas, paranoid or extravagant ideas, fantastic beliefs, and autistic concerns that do not form clear delusional ideas.
  5. Paranoid Ideas or suspicion.
  6. Obsessive ruminations without internal resistance, often on dysmorphic, sexual, or aggressive contents.
  7. Extraordinary perceptual experiences such as somatosensory bodily illusions or other illusions or manifestations of occasional depersonalization or derealization.
  8. Vague, circumstantial, metaphorical, extraordinarily elaborate, and often stereotypical thought and language, without reaching a clear incoherence or rambling of thought.
  9. Episodes, almost psychotic, occasional, and transient, with intense visual and auditory hallucinations and pseudo-delusional ideas, which are usually triggered without external provocation. This disorder has a chronic course with intensity fluctuations and occasionally evolves into clear schizophrenia.

Included: borderline schizophrenia. Latent schizophrenia. Latent schizophrenic reaction. Prepsychotic schizophrenia. Prodromic schizophrenia. Pseudoneurotic schizophrenia.  Pseudopsychopathic schizophrenia. schizotypal personality disorder.

Excluded: Asperger Syndrome (F84.5). Schizoid personality disorder (F60.1).

Although they are separate entities, schizoid and schizotypic personality disorder constitutes a continuum between themselves and with respect to schizophrenia (which would represent the symptomatological end in terms of social isolation and bizarre behaviors).

The distinction between schizotypic disorder and schizophrenia is largely supported by genetic studies, which shows the existence of a type of schizophrenia with an examination of the more or less preserved reality, difficulties in relationships, and slight disorders of thought.

In this way, the personality disorders Schizoid and Schizotypal are placed along a continuum since they both manifest signs of social distancing and emotional constriction.

  • While the patient with Schizotypic personality disorder presents bizarre ideas, rare beliefs, and unusual perceptual experiences (in addition to isolation and weak emotional expression)),
  • the patient with a schizoid personality disorder is more characterized by isolation and weak emotional expression.

The schizotypic exhibits more eccentricities in behavior and communication compared to the schizoid. They may have more attenuated symptoms (closer to schizoid disorder) or more exaggerated symptoms (closer, at the other end, to schizophrenia). People with Schizotypic disorder live on the margins of society, lead an isolated life, and are often labeled as “rare,” “touched,” “misfits.”

In a follow-up study, Fenton and McGlashn (1989) found that three key features of the disorder of Schizotypal Personality could predict schizophrenia at long-term:

  • Magical thinking
  • Suspicion or paranoid ideation
  • Social isolation.

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