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Schizotypal Disorder
› The Schizophrenic Spectrum
› Diagnostic Criteria

ICD-10 Criteria for Schizotypal Disorder
DSM-IV Criteria for Schizotypal Personality Disorder
Differences in ICD-10 and DSM-IV
Complications

› Signs & Symptoms

Definition
Symptoms
Self-Image
View of Others: Relationships
Issues with Authority
Behavior
Affective Issues
Defensive Structure

› Causes

Genetic Causes
Social & Environmental Causes
Risk Factors

› Treatment

Prognosis
The Schizotypal Personality Disorder Coming into Treatment
Medication Issues
Countertransference Issues
Treatment Techniques
Treatment Goals

› History & Facts

History
Etiology
Epidemiology

› Links

The Schizophrenic Spectrum
Based on family inheritance and genetic studies, schizophrenia, schizotypal personality Disorder and schizoid personality disorder are considered to be part of a “schizophrenic spectrum” of mental illness. Although schizophrenia is categorized as a psychotic disorder and both schizoid and schizotypal are personality disorders [1], all three share several symptoms, including avoidance of social relations and flat emotional affect. An important distinction is that people with schizoid personality don’t typically experience the perceptual distortions, paranoia or illusions typical of schizotypal personality or the psychotic episodes of schizophrenia (Nakamura 2005, Questa 2001, Widiger 2007).[2]
Schizotypal personality disorder can easily be confused with schizophrenia, which is characterized by intense psychosis, a severe mental state characterized by a loss of contact with reality. While people with schizotypal personalities may experience brief psychotic episodes with delusions or hallucinations, they are not as pronounced, frequent or intense as in schizophrenia.[3]
Another key distinction between schizotypal personality disorder and schizophrenia is that people with the personality disorder usually can distinguish between their distorted ideas and reality. Those with schizophrenia generally can’t be swayed from their delusions.[4]
Both disorders, along with schizoid personality disorder, belong to what’s generally referred to as the schizophrenic spectrum. Schizotypal personality falls in the middle of the spectrum, with schizoid personality disorder on the milder end and schizophrenia on the more severe end.[5]

[1] This is true according to DSM-IV. In ICD-10, Schizotypal Disorder is considered a delusional disorder along with Schizophrenia
[2] Source: Suite101.com, ›The Schizophrenic Continuum
[3] Source: HealthyPlace.com, ›Schizotypal Personality Disorder
[4] Source: MayoClinic, ›Schizotypal Personality Disorder – Symptoms
[5] Source: HealthyPlace.com, ›Schizotypal Personality Disorder
Diagnostic Criteria
ICD-10 Criteria for schizotypal disorder
A disorder characterized by eccentric behaviour and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies occur at any stage. The symptoms may include:

A cold or inappropriate affect
Anhedonia
Odd or eccentric behaviour
A tendency to social withdrawal
Paranoid or bizarre ideas not amounting to true delusions
Obsessive ruminations
Thought disorder and perceptual disturbances
Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation

Excludes: Asperger’s syndrome, schizoid personality disorder. [6]

DSM-IV criteria for schizotypal personality disorder
For a diagnosis of schizotypal personality disorder, at least five of the following criteria must be met, according to criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.
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 following:

Ideas of reference (excluding delusions of reference)
Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations)
Unusual perceptual experiences, including bodily illusions
Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
Behavior or appearance that is odd, eccentric, or peculiar
Lack of close friends or confidants other than first-degree relatives
Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self [7]

Differences in ICD-10 and DSM-IV

Although the ICD-10 diagnostic criteria for schizotypal disorder differ in detail from the DSM-IV criteria for schizotypal personality disorder, they define essentially the same condition. ICD-10 does not consider the disorder to be a personality disorder, and it classes it with schizophrenia, schizotypal and delusional disorders.

Complications
Common behavioral outcomes include:

isolation and poor social support networks
employment difficulties (especially in jobs that require social skills)
marriage and relationship difficulties (misinterpretations, paranoia and ideas of reference are especially likely to complicate close relationships)

Patients with schizotypal personality disorder are less likely to attempt suicide than those with many other personality disorders.

Conditions which a commonly comorbid with schizotypal personality disorder:

Depressive disorders (with an incidence of 50% among those with schizotypal personality disorder)
Anxiety disorders
Another personality disorder (e.g. schizoid personality disorder, paranoid personality disorder, avoidant personality disorder, borderline personality disorder)

People with schizotypal personality disorder are at increased risk of:

Schizophrenia
Major depression
Anxiety disorder, characterized by prolonged worry or uneasiness
Dysthymia, a low-grade depressed mood that continues for more than two years
Panic disorder, characterized by sudden bouts of heart-pounding terror
Social phobia, characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations
Avoidant personality disorder, characterized by a pervasive pattern of social inhibition and feelings of ineptness
Obsessive-compulsive disorder, characterized by recurrent, unwanted thoughts and repetitive behaviors
Borderline personality disorder, characterized by a constant state of emotional turmoil

[6] Source: ICD-10 Online Version (F21)

[7] Source: Diagnostic and statistical manual of mental disorders: DSM-IV-TR

Signs & Symptoms
Definition
Schizotypal personality disorder is a serious condition in which a person usually has few to no intimate relationships. These people tend to turn inward rather than interact with others, and experience extreme anxiety in social situations.
People with schizotypal personality disorder often have trouble engaging with others and appear emotionally distant. They find their social isolation painful, and eventually develop distorted perceptions about how interpersonal relationships form. They may also exhibit odd behaviors, respond inappropriately to social cues and hold peculiar beliefs.
Schizotypal personalities are characterized by odd forms of thought, perception and beliefs. They may have bizarre mannerisms, an eccentric appearance, and speech that is excessively elaborate and difficult to follow. However, these cognitive distortions and eccentricities are only considered to be a disorder when the behaviors become persistent and very disabling or distressing.
In social interactions, schizotypals may react inappropriately, not react at all, or talk to themselves. They may believe that they have extra sensory powers or that they are connected to unrelated events in some important way. However, they tend to avoid intimacy and typically have few close friends (Dobbert 2007).

Symptoms
People with classic schizotypal personalities are apt to be loners, having few to no intimate relationships. They exhibit extreme anxiety in social situations, often associated more with distrust and an inability to communicate with others than with a negative self-image. They view themselves as alien or outcast, and this isolation causes pain as they disengage more and more from relationships and the outside world.
People with schizotypal personalities often have odd patterns of speech and ramble endlessly on tangents to a topic of conversation. They may dress in peculiar ways and have very strange ways of viewing the world around them. Often they harbor unusual ideas, such as believing in the powers of ESP or a sixth sense. At times, they believe they can magically influence people’s thoughts, actions and emotions.
In adolescence, signs of a schizotypal personality may begin as a gravitation toward solitary activities or a high level of social anxiety. The child may be an underperformer in school or appear socially out-of-step with peers, and as a result often becomes the subject of bullying or teasing.
Social impairment and isolation are common signs of schizotypal personality disorder. Individuals with the personality disorder do not desire social isolation; isolation results from continuously experiencing intense discomfort in social situations, and enduring the negative reactions to the unusual beliefs and behavior exhibited by so many schizotypal personality disorder sufferers.
Abnormal behavior patterns and beliefs vary in severity among people with schizotypal personality disorder. Severe cases may closely resemble schizophrenic delusions, including bizarre claims and paranoia (believing that dogs are government agents, for instance, or that news reporters are capable of mind control).
In most cases, people with schizotypal personality disorder act eccentrically, and have unusual (but not severely delusional) beliefs. An individual may have a strong belief in the paranormal or government conspiracy theories, for instance. These beliefs are deeply held, and when combined with social discomfort, have a negative impact on the individual’s career and relationships.
Ideas of reference” is a common symptom of schizotypal personality disorder. Ideas of reference is a clinical term describing the belief that the individual is the center and cause of all events. For instance, if someone laughs, the schizotypal personality disorder assumes that person laughs at him.
When diagnosing schizotypal personality disorder, certain life habits and signs are looked for. These include:

Inappropriate displays of emotion
Odd beliefs, ideas of reference, or fantasies
Odd or eccentric appearance
Social discomfort
Unusual speech patterns
Unusual, eccentric behavior.
Incorrect interpretation of events, including feeling that external events have personal meaning
Peculiar thinking, beliefs or behavior
Belief in special powers, such as telepathy
Perceptual alterations, in some cases bodily illusions, including phantom pains or other distortions in the sense of touch
Idiosyncratic speech, such as loose or vague patterns of speaking or tendency to go off on tangents
Suspicious or paranoid ideas
Flat emotions or inappropriate emotional responses
Lack of close friends outside of the immediate family
Persistent and excessive social anxiety that doesn’t abate with time

Self-Image
Millon and Davis state that individuals with StPD evidence an estranged self-image; they see themselves as forlorn and alienated from the world. They ruminate about life’s emptiness and meaninglessness. Many people with StPD see themselves as more dead than alive and threatened by nonbeing. To themselves, they seem insubstantial, foreign and disembodied (Millon & Davis, 1996, p. 626).
These individuals know that their relationships and their vocational experiences are prone to disruption and failure. They begin to isolate and increasingly see themselves as not fitting into the society in which they live. Feedback from others usually confirms that they do not experience the world as others do. They rarely can find affirmation or validation for themselves in their interactions with others.

View of Others: Relationships
Kantor notes that both the schizoid and schizotypal personality disorders show interpersonal reserve and semi-isolation. However, individuals with schizotypal personality disorder demonstrate strange and eccentric beliefs and habit patterns. The schizotypal personality disorder has a “schizoid” tree trunk with odd, quirky branches (Kantor, 1992, p. 75). Walker and Gale (Rain, editor, 1995, p. 57) note that the ideational and perceptual abnormalities of StPD must not cross the clinical threshold into delusions and hallucinations. However, the negative symptoms of social withdrawal and constricted affect may be as pronounced as those observed in many patients with schizophrenia.
Oldham describes individuals with StPD as shy, aloof, and withdrawn; they have difficulty communicating and are estranged from people (Oldham, 1990, p. 260). They are loners who experience intense social anxiety associated with distrust rather than a negative self-appraisal (Sperry, 1995, p. 191). These individuals fear being controlled by others but imagine that they can magically influence people directly or indirectly. They want to be left alone; their interpersonal baseline position is one of hostile withdrawal and self-neglect (Benjamin, 1993, p. 356).
Individuals with StPD have poorly regulated cognitive controls that are particularly vulnerable to disruption when experiencing affective interpersonal stimuli. Cognitive slippage can occur even with low levels of anxiety; when this happens, their speech becomes digressive, vague, and difficult to follow (Seiver, Lion, Editor, p. 49). Unable to achieve interpersonal comfort and satisfaction, they drift into isolation and increasingly peripheral vocational roles (Millon & Davis, 1996, pp. 624-625).
Interpersonal isolation and peculiarity become mutually exacerbating conditions. The more isolated persons with StPD are, the more peculiar they become. The more peculiar they become, the more they are interpersonally maladroit and isolated.

Issues with Authority
Because individuals with StPD are interpersonally more unusual, with eccentric mannerisms, unusual dress, peculiar behavior, and distrust of being controlled, they are less able to manage their behavior than are those with schizoid personality disorder. Accordingly, they are more likely to be able to function only in marginal jobs with limited oversight by anxiety-inducing supervisors. They are also more likely than the schizoid personality disordered individuals to be unable to manage their behavior in public settings and may find themselves in more difficulty with the police. Authority figures are distrusted and intensely anxiety-provoking; their presence may lead to even more bizarre and socially unacceptable behavior.

Behavior
Individuals with StPD show a variety of persistent and prominent eccentricities of behavior, thought, and perception that mirror, but fall short of, clinical schizophrenia (Millon & Davis, 1996, p. 613). They are socially gauche and are perceived by others as bizarre, odd, or aberrant. Many individuals with StPD dress in an unusual manner that attracts attention (sometimes bewilderment, sometimes amusement) (Millon & Davis, 1996, p. 624).
These individuals are unable to differentiate the salient from the tangential causing them to attend to a different aspect of an event or interpret events differently than others, e.g., they may digress into a discussion of Mexican political corruption when another guest compliments the hostess on the chili served for dinner. They will also ascribe special significance to incidental events, e.g. the Mexican dinner theme might indicate some significant event about to occur in that country. The overall impact of this variance in attention, interpretation, or attribution of meaning to everyday events renders them odd and peculiar to observers (Millon & Davis, 1996, p. 625).

Affective Issues
Sperry (1995, p. 193) describes the StPD emotional style as cold, aloof, and unemotional but hypersensitive to slights. They are generally suspicious and mistrustful. Millon & Davis (996, p. 627) state that individuals with StPD tend to display one of two predominant affective states. The first is insipid, drab, apathetic, sluggish, and joyless. The second is timorous, excessively apprehensive, ill at ease, agitated, and anxious (Millon & Davis, 1996, p. 627).
Kantor notes that StPD inappropriateness of affect may also result from missing a primary idea and reacting to a secondary or peripheral matter. As in the examples above, if an event is perceived or interpreted in a tangential manner, the accompanying affect will also be dislocated from the central point of what is taking place. The more irrelevant or peripheral the focus, the more unusual (and interpersonally disconcerting) the affective and cognitive responses will be (Kantor, 1992, pp. 78-84).

Defensive Structure
All of the personality disorders have an inherent tendency to live in the past, or in fantasy, with too little input from the here and now. This produces a characteristic infantile quality in these individuals (Kantor, 1992, p. 36). To this, in StPD, is added an inclination to create illogical theories that are wishful, capricious, magical, and mysterious. These odd beliefs are “soft&” delusions in that they are modest, trivial, low key, and surrealistic; they create a dreamy eccentricity in individuals with StPD (Kantor, p. 75). Oldham (1990, p. 260) suggests that people with StPD need to believe that they have extraordinary, supernatural powers in order to give meaning to their impoverished sense of self. Millon & Davis (1996, p. 626) propose that StPDs are overwhelmed by the dread of total disintegration and nonexistence; the self-made reality of superstition, suspicion, and illusion counter the threat of non-being.
Millon & Davis (1996, p. 626) describe individuals with StPD as ineffective and uncoordinated in regulating their needs, tensions, and goals. Their inadequate defenses lead to a disorganized and often direct discharge of primitive thoughts and impulses. They are unable to effectively sublimate their energy into reality-based activity and have few successful achievements in life. The disorganized and ineffective defenses further leave StPDs vulnerable to being overwhelmed by excess stimulation.

Causes
Genetic Causes
Although listed in the DSM-IV-TR on Axis II, schizotypal personality disorder is widely understood to be a “schizophrenia spectrum” disorder. If you look at the relatives of individuals who have been diagnosed with schizophrenia, rates of schizotypal PD will be much higher in those individuals than in the relatives of people with other mental illnesses or in the relatives of community controls with no mental illness. Technically speaking, schizotypal PD is an “extended phenotype” that helps geneticists track the familial or genetic transmission of the genes that are implicated in schizophrenia. There are dozens of studies showing that individuals with schizotypal PD look similar to individuals with schizophrenia on a very wide range of neuropsychological tests. Cognitive deficits in patients with schizotypal PD are very similar to, but somewhat milder than, those for patients with schizophrenia.
The DSM-IV™ indicates that StPD is more prevalent among the first-degree relatives of individuals with schizophrenia than among the general population (DSM-IV™, 1994, p. 643). Seiver also notes that many family members of schizophrenic patients are eccentric and socially isolated; he states that research supports the idea of familial transmission of schizotypal personality disorder similar to that of other schizophrenia-related disorders (Seiver, Livesley, ed., 1995, p. 77). StPD has a relatively stable course; only a small proportion of individuals with StPD go on to develop schizophrenia or other psychotic disorders (DSM-IV, 1994, p. 643).

Social & Environmental Causes
People with schizotypal PD, like patients with schizophrenia, may be quite sensitive to interpersonal criticism and hostility, and there is now evidence to suggest that parenting styles, early separation and early childhood neglect can lead to the development of schizotypal traits.
It has been speculated that the schizotypal individual develops a fear of, strong objection to, or incapacity for social interaction, due to the sum of their past social experiences being negative in nature. That as infants they do not learn how to interact with others, and as children and adults this inability quickly makes them a target for other people. Eventually, the individual learns (most often unconsciously) to see people as harmful and a source of negativity, suffering and ostracization. This leads to the development of “ideas of reference,” in which the schizotypal individual believes that events are of special relevance to them or that benign events are somehow related to them (e.g., sees two people laughing and believes that the people are laughing at them). The individual may realize that their ideas of reference are irrational, but maintains them nonetheless. This exacerbates the individual’s social anxiety, causing them to skew away from society and withdraw into their own world.
The exact reason or cause of this impairment is unknown. Some experts contend that childhood abuse, neglect or stress results in the brain dysfunction that gives rise to schizotypal symptoms. Both genetics and environmental circumstances appear to play a role in development of the disorder.
A family history — such as having a parent who has schizophrenia or schizotypal personality disorder — increases your chances of developing the condition. A number of environmental factors also may contribute, such as a neglectful or abusive childhood home.
Like most types of personality disorders, the cause of schizotypal personality disorder is unknown. Researchers have suggested that the personality disorder is closely related to schizophrenia, and schizotypal personality disorder is more common in families with a history of schizophrenia. This connection has suggested a genetic basis for schizotypal personality disorder, but definitive proof of a genetic cause has yet to be found.

Risk Factors
Personality development is mostly affected by genetic tendencies. Environmental factors, such as stressful childhood experiences, also may play a role. Factors that increase the risk of developing the schizotypal personality disorder include:

Having a relative who has schizophrenia
Living in a childhood environment of deprivation or neglect
Experiencing child abuse or mistreatment
Undergoing a childhood trauma
Having an emotionally detached parent

Treatment
Prognosis
Schizotypal personality disorder generally has a stable course.
Approximately 10-20% of patients go on develop schizophrenia or another psychotic disorder.
Schizotypal personality disorder typically begins in early adulthood and may endure throughout life. There’s no cure for schizotypal personality disorder, but psychotherapy and some medications may help. Some research suggests that positive childhood experiences may help reduce symptoms of schizotypal personality disorder in affected young people.
Until recently, doctors have generally believed that once a personality disorder has developed it will last throughout life. However, new research has suggested that the symptoms of conditions such as schizotypal personality disorder may improve significantly over time. Factors that appear most likely to reduce the symptoms of this disorder include positive relationships with friends and family as well as a sense of achievement at school, work and in extracurricular activities.
Researchers believe that these experiences may create a protective effect by fostering — among other positive traits — self-confidence, a belief in one’s ability to overcome difficulty and a sense of social support. These findings also indicate that early interventions such as youth programs that foster personal achievement and strong community relationships may help prevent personality disorders in at-risk children. The earlier these kinds of interventions reach a child in any challenging situation, the better his or her chances of doing well.

The schizotypal personality disorder coming into treatment
Few individuals with a Cluster A personality disorder are particularly inclined to seek treatment. They are often forced into therapy by family or the legal system. However, once there, individuals with StPD may respond positively to an environment structured to allow them greater personal and interpersonal success than they can achieve utside of the treatment setting. They are not inclined to prefer isolation; they frequently move to greater and greater isolation via social distress and rejection. They may value a setting where they can enjoy some connection to others.

Medication issues
Personality disorders are medicated for target symptoms rather than for the personality disorder itself. Joseph (1997, pp. 58-61) believes that, from a symptomatic approach, schizotypal personality disorder can be considered a mild form of schizophrenia with the same characteristics accompanied by mild perceptual and affective symptoms. The difference he describes is quantitative, not qualitative. Therefore, treatment employs similar medications in lower dosages. He notes that StPD can be effectively treated with risperidone, olanzapine, and sertindole for both positive and negative symptoms. SSRIs can improve obsessive, compulsive, and depressive symptoms. However, antidepressants in the absence of antipsychotic medication can make any underlying psychosis worse. Ellison & Adler (Adler, ed., 1990, p. 49) also note that individuals with StPD have responded positively to low dose neuroleptics which can reduce the tendency to blame others, unwarranted suspicion, outbursts of rage, and repeated interpersonal conflict. These individuals are inclined, however, to experience medication as causing odd side effects and compliance can become a problem (Ellison & Adler, Adler, ed., 1990, p. 59).
Psychopharmacological treatment may also be directed to dimensions that underlie the personality: cognitive/perceptual organization (low-dose antipsychotics); impulsivity and aggression (serotonin blockers); affective instability (cyclic antidepressants or serotonin blockers); and anxiety/inhibition (serotonin blockers and MAOI agents) (Sperry, 1995, p. 7).
For individuals with StPD, anxiolytics in small doses have been effective for anxiety; antipsychotics have been useful for psychotic symptoms; SSRIs have reduced symptoms of interpersonal sensitivity, anxiety, paranoid ideation, and self-injury (Sperry, 1995, p. 205).
Better functioning individuals with StPD who display oddities of speech but who do not have psychotic episodes may not require medication (Stone, Gabbard & Atkinson, editors, 1996, p. 955). Treatment Provider Guidelines Because of the autistic nature of StPD ideation and cognitive style, it is important to establish a sound psychotherapeutic relationship with these clients. This relationship can then serve as a basis for reality testing for individuals with StPD. Their impaired social interaction and lack of social connection results in ongoing loss of contact with reality. Their connection with treatment providers can serve as a corrective opportunity for their increasing eccentricity and bizarre thinking. Their peculiar thoughts can be treated as symptoms which they can identify and correct within the context of a therapeutic setting, e.g. individual or socialization group sessions (Will, Retzlaff, ed., 1995, p. 105).
One experienced clinician noted that working with clients with StPD requires flexibility and a focus on behavior. She described one StPD client who could not bring himself to speak to his therapist but was able to write her notes on envelopes or toilet paper. It was painful work but he was able to connect in his own unusual manner. He was described as a man who wore three-piece suits and appeared to be more intact than was actually the fact.

Countertransference issues
Clients with StPD are inclined to engage treatment providers in circuitous, belabored, odd, and meaningless discourses on subjects like: “artistic endeavor and the use of drugs” or “mental health treatment providers as agents of social control.”Treatment providers may become overwhelmed, bored, or frustrated and begin to withdraw. Individuals with StPD will not be able to structure treatment sessions; the focus and content will need to come from service providers so that the therapeutic tasks can be achieved and neither client nor clinician become overwhelmed and defeated.
Service providers, in response to these individuals’ tenuous boundaries, may begin to feel as if they do not exist in the clients’ reality. Clinicians may feel disconnected or, alternately, joined in an idiosyncratic insight that is not based in reality but in the clients’ defense system. Clinicians need to form a holding environment that can allow clients with StPD to integrate their feelings and perceptions without getting lost in the circuitous and disjointed cognitions expressed by these individuals (Kubacki & Smith, Retzlaff, ed., 1995, pp. 176-177).

Treatment Techniques
Zimmerman (1994, pp. 92-95) suggests the following questions when assessing for schizotypal personality disorder:

Have you ever found that people around you — who seem to be talking in general — are actually making comments meant for you? If so, how did you find out they were talking about you?
When you walk into a room, do people stop talking or begin acting differently? Does this happen often?
Have you ever experienced someone in charge changing the rules specifically because of you but would not admit it?
Do you sometimes feel like strangers in public places are looking at you or are talking about you? Why do you think they are taking particular notice of you?
Some people talk about having ESP or mental telepathy; they feel like they can sense what is in someone’s mind or predict the future. Have you had experiences like this? Very often? Have these experiences become important in your life?
Are you superstitious? In what way? Does this influence decisions you make? Do your friends or family share these superstitions?
Some people believe they can influence the weather or the outcome of ball games just by thinking about them. Do you believe that you can make things happen just by thinking about them?
Do you believe in curses, omens, hexes, voodoo, witchcraft, magic, or other similar things?
Have you ever sensed that there was some unusual force or presence close to you? What do you think caused this? Has it happened often?
Have you ever experienced the world around you looking different than it usually does? Can you describe what it was like? What do you think caused this to happen?
Do your eyes play tricks on you? For example, have you ever seen someone’s face or body suddenly change in shape or form?
Do you ever mistake noises for voices or shadows for people? Does this happen often?
Have you ever experienced people who pretended to be your friends taking advantage of you? What happened?
Do you find yourself trying to figure out what people really mean instead of taking what they said at face value?
Do people tell you that you read too much into things?
Do people tell you that you take offense at things that were not meant to be critical?
Not counting your immediate family, do you have any close friends in whom you can confide?
Do you generally feel anxious around people? What makes you nervous? How bad does it get for you?

In assessing individuals with StPD, consider possible psychotic processes; determine whether or not there is evidence of hallucinations, delusions, and/or a thought disorder. If symptoms of psychosis are present, treatment must be designed for the seriously mentally ill.
Even if there are no indications of psychosis, treatment is most effective when structured, supportive, and focused on teaching social skills. Individuals with StPD are in danger of increasing loss of contact with reality without social connection (Beck, 1990, p. 140). When these individuals relinquish their activities, they regress into an amotivated state; they often deteriorate and become increasingly less functional without the feedback process that accompanies interpersonal interaction (Millon & Davis, 1996, p. 640). Treatment providers must set limits on aberrant behavior and avoid placing too many demands on clients’ fragmented defenses. Instead, support must be provided for existing mechanisms for regulation and control; assistance should be provided to these individuals to order their thoughts by clarification and educative techniques (Dorr, Retzlaff, ed., 1995, p. 203).
Individuals with StPD often experience social isolation as painful; increasing their capacity to develop and maintain a social network is an effective therapeutic strategy (Beck, 1990, p. 140). Institutionalization, when necessary, should be brief; hospital settings breed isolation, reward withdrawal, and lead to increased detachment and bizarre preoccupations (Millon & Davis, 1996, p. 642).
Interviews with individuals with StPD usually elicit surprising statements and peculiar ideas; the clinician must be empathic and show understanding to share their secret and autistic world (Sperry, 1995, p. 199). One source of the cognitive peculiarity for individuals with StPD is what cognitive-behaviorists describe as emotional reasoning. This is a process wherein these individuals believe that a negative external situation exists because they have a negative emotion, e.g. if they are uncomfortable with another person that person must be hostile or dangerous (Sperry, 1995, p. 196). These individuals can be taught to recognize when they are distorting reality. Just because they “feel it” does not necessary mean “it” is true, e.g. feeling fear does not automatically mean danger exists (Beck, 1990, p. 141). They need to learn to evaluate their thoughts against environmental evidence, not against their feelings. This reduces emotional reasoning and the drawing of incorrect conclusions about interpersonal situations (Millon & Davis, 1996, pp. 640-641).
Individuals with StPD also personalize, i.e., they believe that they are responsible for external situations when this is not the case (Sperry, 1995, p. 196). Therapy time, then, is often spent in education and therapists find themselves functioning as the clients’ auxiliary ego (Stone, 1993, p. 187). Structured, focused reframing of environmental cues that normalize the interpretations these individuals make in regard to the behavior of others allows them to function with greater stability, both socially and vocationally. Hypochondriasis is another problem for people with StPD. However, if they can become more successful interpersonally, many of the bodily symptoms will diminish automatically (Stone, 1993, p. 189).
Not pushing individuals with StPD too hard in treatment can prevent their experiencing severe anxiety and having paranoid reactions. Group or individual sessions must be well structured; the rambling cognitive style of these individuals makes it difficult for them to focus. A supportive approach is often the only kind of therapeutic intervention that they can tolerate in early treatment (Millon & Davis, 1996, pp. 640-641). In fact, for many individuals with StPD, supportive interventions remain the mainstay of treatment. Supportive therapy utilizes sympathetic listening, education about the world, giving advice, problem solving, exhortation, and the quiet establishment of relatedness which relies upon regular contact and nonjudgmental acceptance. The most effective treatment is one in which service providers remain active and involved but avoid becoming overly ambitious or impatient. Expectations must be in harmony with the clients’ capabilities. . . even though these fall far short of an ideal life (Stone, Gabbard & Atkinson, editors, 1996, p. 955).

Treatment for individuals with StPD is most effective when family members are involved. Service providers should try to join with the family to engage them in the treatment process. There is the possibility that these clients are meeting pathological needs in the home environment and will not be able to make progress in their own lives without assistance to detach from their family. On the other hand, if the family is supportive, their help can make an enormous difference.

Treatment goals
Personality disorders derive in part from patterns of behavior and thought that would appear to be hard-wired into the central nervous system during the first six years of life. It is understandable that personality disorders are hard to modify and slow to change. However, studies suggest that positive changes can occur. The treatment goal in working with all of the personality disorders is the same: gradually exchanging new, more adaptive habits of thought and behavior for pre-existing, maladaptive habits (Stone, 1993, p. 152).
In treatment settings, it is most common to encounter schizotypal clients with some schizoid and paranoid features. Improvement is most likely in the occupational areas; it is much more difficult to see progress in social or intimate relationships (Stone, Gabbard & Atkinson, editors, 1996, p. 953). Millon & Davis propose that change is most likely for these individuals in nonintimate interactions, in reality testing, and participation in enjoyable activities. Treatment can help individuals with StPD identify those spheres of life toward which some positive inclination exists. While they may not be able to be enthusiastically involved, increased participation in activities can provide a window of reality-based experiences that may reduce the need for bizarre internal gratifications (Millon & Davis, 1996, pp. 639-640). Beck proposes that treatment should teach individuals with StPD that bizarre thoughts are symptoms and do not have to be responded to behaviorally or emotionally (Beck, 1990, p. 141).
Another treatment objective for individuals with StPD is to develop and maintain social relationships through social skills training, cognitive reorientation, and environmental management (Millon & Davis, 1996, p. 640).
In an outpatient treatment setting, this author has seen individuals with StPD develop connections to others that, while impoverished and rather fragile, were of considerable value to the individuals involved. Their investment in the social contact provided the impetus needed for them to learn and practice social skills and appropriate interpersonal behavior.

History & Facts
History

The schizotypal personality disorder was introduced in the DSM-III in 1980. The term schizotype was first used by Sandor Rado in 1953 as a combination of schizophrenic and genotype. The concept came from the awareness that there were nonpsychotic but eccentric and dysfunctional personalities who were considered to have attenuated expressions of the constitutional defect that underlay schizophrenia (Akhtar, 1992, pp. 260-261). Rado hypothesized that these schizotypal individuals had the same two constitutional defects that were found in schizophrenia, i.e., deficiency in integrating pleasurable experiences and a distorted awareness of the bodily self. The symptoms of StPD came from these two defects and included: chronic anhedonia and poor development of the pleasurable emotions; continual engulfment in emergency emotions, e.g. fear and rage; extreme sensitivity to rejection and loss of affection; feelings of alienation; a rudimentary sexual life; and, a propensity for cognitive disorganization under stress (Akhtar, 1992, p. 263).

Etiology
The precise etiology of schizotypal personality disorder is not known. It has some biological markers in common with schizophrenia, including:

lateral ventricular enlargement
reduced prefrontal cortical mass
increased levels of homovanillic acid in both cerebrospinal fluid and plasma
impaired smooth-pursuit eye-tracking movement

There are also prefrontal and left hemispheric neuropsychological performance deficits on neuropsychological testing.
Adoptive and family studies have found a higher prevalence of schizotypal personality disorder among first-degree relatives of those with schizophrenia. Similarly, schizophrenia and other psychotic disorders are more prevalent among the relatives of those with schizotypal personality disorder.

Links
ICD-10 (F21)
DSM-IV-TR
Wikipedia’s article on schizotypal personality disorder
Eccentric/Schizotypal Personality, Functional and Structural Domains
Dual Diagnosis and the schizotypal personality disorder (pdf)
Cluster A: Schizotypal personality disorder (pdf)
The Scizophrenic Spectrum
Mayo Clinic’s article on schizotypal personality disorder
Schizotypal personality disorder: Mild schizophrenia?
Schizoid and schizotypal personality disorders introduction

2011
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