Personality Disorders 101: Schizotypal PD

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Previously, I talked about the relationship between schizophrenia, Schizoid PD (SPD) and Schizotypal PD (SzPD). Continuing on from that, today’s topic is SzPD.

Schizotypal PD (SzPD) overlaps with some symptoms of schizophrenia, such as disordered thoughts and perceptions. However, someone with SzPD will not experience reduced motivation or catatonia, and they will have fewer difficulties in thinking and working than someone with schizophrenia. Instead, many SzPD symptoms link back to social situations and social performance. While people with SzPD desire social interaction, they are often anxious in social situations regardless of who they are with. Delusional or paranoid beliefs, such as that others can hear their thoughts, may be behind their anxiety. Alternately, their anxiety may be from the pressure of communicating with minds which work on very different wavelengths to their own.

The DSM-5 describes SzPD as a long-term pattern of being uncomfortable with and unsuccessful at maintaining close relationships, as well as experiencing distorted thoughts and perceptions and odd behaviors. To be diagnosed with SzPD, someone must meet 5 of the following criteria:

  • Their behaviour is influenced by odd beliefs or magical thinking which does not match typical cultural beliefs.
  • They experience ideas of reference (such as the belief that song lyrics or news items are sending a specific personal message or discussing their life).
  • They experience unusual perceptual experiences, including bodily illusions.
  • They think in a vague, metaphorical or clichéd way, which is reflected in their speech.
  • They are often suspicious or paranoid
  • They have a reduced range of emotions, or inappropriate emotions in response to situations
  • They appear odd, eccentric, or peculiar to others
  • They lack close friends or confidants outside of close family
  • They have social anxiety with both familiar and unfamiliar people. The anxiety is
  • associated with paranoia rather than through fear of judgement.

A long list of other conditions- schizophrenia, psychotic disorders, mood disorders with psychotic elements, and autism spectrum conditions- must be ruled out before someone can be diagnosed with SzPD. The general personality disorder criteria must also apply: “a person needs to have a collection of unusual behaviours and traits which affect a large portion of their everyday life. Those behaviours and traits must start before early adulthood. They need to cause negative consequences for the person, who should be upset by or annoyed at those behaviours.”

The ICD and DSM specifiy that SzPD should be used when someone has “schizophrenia-like” experiences which are not severe enough to be schizophrenia. For example, SzPD features quasi-psychotic (“nearly-psychotic”) episodes but not full psychotic breaks. Someone with SzPD could experience small-scale delusions like believing people they walk past are gossiping about them, but not larger delusions such as of being part of a government conspiracy or having been abducted by aliens. Also, these beliefs will not be as persistent or as life-affecting as for someone with schizophrenia.

Communicating with someone with SzPD may be difficult as they may jump between conversation topics, add meaningless words to sentences (word salad), or speak in rhymes and auditory patterns (clanging). However, someone with SzPD will experience less of these speech symptoms than someone with schizophrenia.

SzPD is rarely found in media; it would be very difficult to assign to a main character, as protagonists are expected to be relatable and understandable to the audience. SzPD traits are more likely to be part of a generic “crazy” side character, but even then the audience may just assume the character reflects schizophrenia instead. However, one character who reflects a few traits of SzPD is Luna Lovegood from the Harry Potter series. Luna holds many beliefs which are seen as unusual. She seems very detached from what others consider reality, and she struggles to make friends until meeting Harry’s group. Yet her capability is never called into question.

Because SzPD can either stay the same or develop into full schizophrenia, establishing a clear prognosis is difficult. Like other personality disorders, people’s symptoms are strongest in their early twenties then gradually decrease over time. Some people with SPD seek help due to their social difficulties, which can be helped by antidepressant medication. Others who have less anxiety and more thought-based symptoms may be helped by antipsychotic medications.

Psychological Criticisms of Schizotypal PD.

Many SzPD symptoms are based on a person’s disordered thoughts and perceptions. However, we cannot see thoughts in isolation to understand them; we can only understand someone’s thoughts through how they communicate about their thoughts. Someone with a communication disorder, who has no cognitive issues but cannot organise words into full sentences, will appear similar at first to someone who thinks in a jumbled way but can convey it accurately in words. Diagnosing conditions which include thought-based symptoms has to be carried out incredibly carefully as a result.

SzPD doesn’t have one “hallmark feature”, and none of its symptoms are unique. Magical thinking can be part of mood disorders and anxiety disorders, while many mental health conditions affect emotional expression. Disordered thoughts and perceptions also feature in multiple conditions. Research articles on SzPD often struggle to accurately pin down where SzpD can be separated from a large number of associated conditions. Similarly, descriptions often need to refer to SzPD by what it is not rather than what it is.

The DSM and ICD also feature another related category, schizoaffective disorders. A schizoaffective disorder diagnosis is used when someone experiences an equal amount of mood disorder symptoms (mania, hypomania, or depression) and psychotic symptoms (hallucinations and delusions). It represents that rather than “a mood disorder with a side of psychotic symptoms” or “a psychotic disorder with a side of mood symptoms”, someone is experiencing both aspects equally and simultaneously.

Given that the schizophrenia spectrum, schizoid PD and schizoaffective disorders all exist, SzPD could be seen as splitting hairs. So many other conditions share symptoms with SzPD that it seems to represent precision at the expense of practicality, especially as it relies so heavily on a symptom which cannot be directly seen.

SzPD can be seen as one example of over-labelling within psychiatry. Western psychiatry aims to form a comprehensive catalogue of every symptom a patient experiences, so that the patient can receive all the treatments they need. However, this approach can lead to patients receiving many overlapping diagnoses to make sure that every symptom is covered; in one study of patients with personality disorders and mood disorders, each person had a mean of 3.4 diagnoses. This approach is part of why mental health diagnoses have increased so rapidly, and it may cause issues for our understanding of mental health conditions.

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