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Schizotypal Personality Disorder
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Schizotypal personality disorder is characterized by magical thinking, peculiar notations, ideas of reference, illusions and derealization. Three percent of the population have this disorder and its prevalence increased in families of schizophrenic probands and women with fragile X syndrome (Sadock et al., 2017). This disorder shows deficits in social and interpersonal realms with reduced capacity for close relationships and cognitive or perceptual distortions and eccentricities of behavior beginning by early adulthood and present with 5 or more of the following:
1) ideas of reference
2) odd beliefs or magical thinking that influences behavior and is inconsistent with su cultural norms (clairvoyance, telepathy, etc)
3) unusual perceptual experiences including bodily illusions
4) odd thinking and speech
5) suspiciousness or paranoid ideation
6) inappropriate or constricted affect
7) odd behavior or peculiar appearance
8)lack of close friends
9) excessive social anxiety that doesn’t diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about themselves.
These patterns do not occur during the course of schizophrenia, bipolar, or depressive disorder with psychotic features, another psychotic disorder or autism spectrum disorder (American Psychiatric Association, 2013).
Diagnostically, these patients can look like someone with ASD. One distinction that helps me to remember the difference is that those with SPD generally have no sense of humor (this is related to the concrete way they see the world). SPD patients can also have more ego-boundary problems and discontinuity between time and person (Stone, 1985).
Psychotherapy and Psychotherapeutic Treatment
Typically, long-term psychodynamically-informed psychotherapy is indicated. Poorly functioning patients may benefit from supportive therapy while higher functioning patients may benefit from more exploratory psychotherapy (Stone, 1985; Wheeler, 2014). There are no trials comparing different psychotherapeutic approaches in patient with SPD, though the therapist can become a “reality organ” for a patient (Stone, 1985).
Low dose antipsychotics can be beneficial for those with perceptual symptoms or those with significant impairment or distress and/or thoughts that are highly ego-dystonic (McClure et al., 2009).Although SSRI’s are usually first line for social anxiety, in patients with schizotypal personality disorder, they are usually not effective. Low dose daily clonazepam has show some promise as well as a Gabapentin. Stimulants can be beneficial with those who have cognitive challenges (Siegel et al., 1996).
I have taken care of a 27 year old inpatient who believed she was Sparkle Pony from the My Little Pony (MLP) universe. She had to have glitter on her to calm her anxiety and believed if people sat too close to her, that they would steal her sparkle. She worked from home as a call center tech and had a few other online MLP friends but no “IRL” friends. She rarely left the house and her home was covered in glitter. Her admission was precipitated by a 911 call; the client was expected a big batch of glitter via amazon and it was delayed due to COVID and she called 911 in hysterics. She met criteria for SPD because she had the bizarre beliefs, perceptual disturbances (could “feel” presence or lack of sparkle), odd behavior, lack of close friends, and social anxiety. She was admitted to rule out psychosis and did not stay long on the unit. When we dug a bit deeper, she was the victim of some horrific sexual abuse as a child and developed this personality disorder to cope with the abuse. Ironically, when she was discharged, we referred her to a female therapist who had ASD who actually watched anime and MLP. I’m hoping they connected and she was able to help her work through her past trauma and develop some supportive relationships.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
McClure, M. M., Koenigsberg, H. W., Reynolds, D., Goodman, M., New, A., Trestman, R., Silverman, J., Harvey, P. D., & Siever, L. J. (2009). The effects of risperidone on the cognitive performance of individuals with schizotypal personality disorder. Journal of Clinical Psychopharmacology, 29(4), 396–398. https://doi.org/10.1097/JCP.0b013e3181accfd9
Siegel, B. V., Jr, Trestman, R. L., O’Flaithbheartaigh, S., Mitropoulou, V., Amin, F., Kirrane, R., Silverman, J., Schmeidler, J., Keefe, R. S., & Siever, L. J. (1996). D-amphetamine challenge effects on Wisconsin Card Sort Test. Performance in schizotypal personality disorder. Schizophrenia Research, 20(1-2), 29–32. https://doi.org/10.1016/0920-9964(95)00002-x
Stone M. (1985). Schizotypal personality: psychotherapeutic aspects. Schizophrenia bulletin, 11(4), 576–589. https://doi.org/10.1093/schbul/11.4.576
Sadock, B., Sadock, V. and Ruiz, P. (2017). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.