Schizophrenia or Schizotypal Personality?

In 2013, personality disorder afficionados reviewing the newly released Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), noticed a unique classification. Schizoptypal Personality Disorder would be considered both as a personality disorder and as part of a non-personality category: Schizophrenia and Related Disorders. Recognized in some form since at least 1668 (Millon, 1996), it seems this puzzling condition has taxonomically come full circle, and it remains mysterious.

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Dementia Praecox to Schizophrenia Phenotype

Psychiatric researchers in the 1800s considered the appearance in adolescence of chronic, emotionally detached, eccentric-thinking presentations as indicative of a precocious onset of Dementia Praecox. This was an earlier term for Schizophrenia, which usually surfaces in the 20s to early 30s.

In the early 1900s, Eugen Bleuler realized most early-onset cases didn’t lead to progressive deterioration (Millon, 1996). This means there was no progression to full psychosis, with patterns of enduring hallucinations, well-formed delusions, gross disorganization, and/or catatonia, as in Schizophrenia.

The state of being these individuals remained in is reminiscent of the prodromal phase of Schizophrenia. This phase is considered “budding” psychosis when, months-to-years prior to a first florid psychotic episode, those with Schizophrenia display a turning-inward period. Detaching from relationships and emotions, they become interpersonally anxious, develop eccentric thought processes that may only make sense to them, and walk a thin line between delusional thinking and reality. Such thinking may include a fixation on apparent extrasensory perception (ESP) and ideas of reference. The latter is when someone wonders if certain occurrences in their environment, like coincidences, have a special connection to them.

Another difference is psychotic disorders tend to be episodic, and the symptoms in the precociously symptomatic youth remained static at baseline. It was as if they manifested a perpetual, latent manifestation of Schizophrenia. Such a sustained, inflexible, maladaptive psychological and behavioral architecture was pointing more towards a matter of personality disorder.

Long story short, researchers in the 1950s tackled this unwavering condition and decided it was best understood as “Schizophrenia phenotype.” This essentially means it seemed someone possessed a predisposition to developing Schizophrenia. From this, we gain the modern term “Schizotypal.”

Two disorders in one?

Not really. It is best left as a personality disorder given it's really a maladaptive interpersonal style, and fits the definition: a long-standing, pervasive, baseline pattern of inflexible, maladaptive inner experiences and exhibited behaviors as evidenced by the person’s thoughts, moods, impulses, and interpersonal relationships. However, as noted in the DSM-5, and by Millon (1996) and Yudofsky (2005), a common thread among Schizotypal Personalities is first-degree relatives with Schizophrenia spectrum illnesses.

Because of its significant resemblance/connection to Schizophrenia, the Schizotypal Personality is generally thought of as on the Schizophrenia spectrum and thus is included in that category. It's also noted in the DSM-5 that it’s rare that people with the condition eventually develop a mature psychotic disorder. Should someone with a Schizoptypal Personality develop an overlapping Schizophrenia, Schizophreniform Disorder, Brief Psychotic Disorder, or Delusional Disorder diagnosis, it's considered co-morbid and not a two-in-one. This makes sense, because it must be understood that once the psychotic episode remits, the person returns to the baseline Schizotypal Personality.

Genetics are at play, but can the environment influence etiology?

Personality is usually made up of a combination of inherited components and learned components. Schizoptypal Personality is further unique in that it’s generally believed to be largely inherited (Shannon, 2016), presumably given its relation to Schizophrenia, which has a significant genetic etiology. Despite the leanings towards a largely genetic etiology, in 2008, researchers found evidence that early childhood maltreatment is associated with developing the condition (Berenbaum et al., 2008).

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This research could point to learned behaviors in response to environmental stimuli. If abuse did occur, it would make sense that the child became suspicious and interpersonally anxious. The development of fantastic thinking as an escape mechanism is also a plausible hypothesis. Should the abuse include gross neglect, and the importance of close relationships was not taught, isolation could be learned; if physically abused, the child may have learned "others are dangerous, keep away." If development is not nurtured, unusual ways of trying to make sense of the world may arise, along with eccentric communication patterns. Perhaps the condition is another perfect storm of environmental conditions shaping genetic potential.

Lastly, is it possible symptoms are mostly learned? While no research supporting the idea was readily found, consider the good chance the child has someone in the home with Schizophrenia. Then imagine the influence on a developing child of a caregiver who is paranoid, expressing odd beliefs and has removed themselves from interpersonal relations. Is it not far-fetched to consider that the little one might develop core schema influenced by exposure to this, which become ingrained with age, but that genetic potential for florid psychosis is somehow never unlocked? Chances are, there are multiple roads to developing the condition.

Differentiating Schizotypal Personality From Schizophrenia

1. Shyness and eccentricities gain traction from childhood through adulthood and remain constant, however...
2. There are no past or present well-formed delusions, gross disorganization, hallucinatory activity, or catatonia.
3. The presentation is not episodic and there is no ebbing and flowing of symptoms.
4. Psychotic disorders tend to develop in the 20s to early 30s, whereas Schizotypal Personality “is the way the person has always been.”

Treatment implications

As discussed in Avoidant Personality or Social Phobia and OCD or OC Personality, many conditions share symptom overlap, but similar symptoms do not equate to similar care. It may seem particularly hair-splitting in the case of Schizoptypal Personality versus Schizophrenia, but very careful differential diagnosis is required.

Individuals with Schizotypal Personality often hold menial jobs, do their best to steer clear of close relationships, and end up alone for their suspiciousness and inability to relate well. It is not unusual that they become substance-dependent to manage their anxiety and end up on the street or in jail. I recall a pair of Schizotypal twins I attempted to work with at a correctional facility; they identified only with each other, and followed one another to legal demise. This occurred through substance use and threatening behavior towards people they saw as outside their "understanding circle," as they explained it.

Schizotypal people don’t readily seek treatment given their suspiciousness and interpersonal anxieties. If they do, treatment is more likely to be sought for depression, anxiety, or substance abuse, not due to any insight into their schizotypy. Other times they may arrive with their family, who are struggling to help.

Should Schizotypal people avail themselves of treatment, therapists must realize that, while improvement is possible—such as improving social skills or interpersonal trust—as with any personality disorder, there will always be some baseline pathology and any gains are cause for celebration. Even if they commit to psychotropic medications, pharmacology may help the quasi-delusional thoughts, disorganized ideas, and paranoid edge, but will not entirely erase the pathology as it often does in Schizophrenia episodes, where the person can regain a much higher-functioning baseline.

Given that people who have it often don't seek treatment, Schizotypal Personality is not readily encountered enough for most clinicians to gain a sense of it. Those interested in studying an insightful portrayal of the tendencies of a Schizotypal Personality are directed to the 1974 film Taxi Driver.