Schizotypal Personality Disorder (StPD)

Schizotypal Personality Disorder (StPD)

Schizotypal Personality Disorder (StPD)

From an early age, patients with schizotypal personality disorder (StPD) have lasting interpersonal deficiencies that severely reduce their capacity for closeness with others. They also have distorted or eccentric thinking, perceptions, and behaviors, which can make them seem odd. They often feel anxious when with strangers, and they have almost no close friends. They may be suspicious and superstitious; their peculiarities of thought include magical thinking and belief in telepathy or other unusual modes of communication. Such patients may talk about sensing a “force” or “presence,” or have speech characterized by vagueness, digressions, excessive abstractions, impoverished vocabulary, or unusual use of words.

Patients with StPD may eventually develop schizophrenia. Many of them are depressed when they first come to clinical attention. Their eccentric ideas and style of thinking also place them at risk for becoming involved with cults. They get along poorly with others, and under stress they may become briefly psychotic. Despite their odd behavior, many marry and work. This disorder occurs about as often as schizoid PD.

ORDER COMPREHENSIVE SOLUTION PAPERS ON Schizotypal Personality Disorder (StPD)

Essential Features of Schizotypal Personality Disorder

In many situations, these patients tend to be isolated and exhibit a narrow emotional range with other people. They will have paranoid or suspicious ideas, even ideas of reference (which, however, are not held to a delusional extent). Their dress or mannerisms may give them an odd appearance, with affect that is inappropriate or constricted; speech can be vague, impoverished, or overly abstract. They may report strange perceptions or physical sensations, and their peculiar behavior may be affected by magical thinking or other odd beliefs (superstitions, a belief in telepathy). With severe social anxiety (which doesn’t improve with acquaintance), they tend to have no intimate friends.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, psychotic disorders, mood disorders with psychotic features, autism spectrum disorder and other neurodevelopmental disorders, paranoid and schizoid PDs)

Coding Note

If StPD precedes the onset of schizophrenia, add the specifier (premorbid).

Timothy Oldham

“But it’s my baby! I don’t care what he had to do with it!” Hugely pregnant and miserable, Charlotte Grenville sat in the interviewer’s office and wept with frustration. She was there at the request of the presiding judge in a battle over visitation rights with her yet-unborn child.

The identity of the father was never in doubt. The week after her second missed period, Charlotte had visited a gynecologist and then called Timothy Oldham with the news. She had considered threatening to sue him for child support, but that hadn’t been necessary. He made good money installing carpets and had no dependents. He offered her a generous monthly stipend, beginning immediately. But he wanted to help rear their child. Charlotte had rejected that idea out of hand and then filed suit. With a crowded court docket, the case had dragged on nearly as long as Charlotte’s pregnancy.

“I mean, he’s really weird!”

“What do you mean, ‘weird?’ Give me some examples.”

“Well, I’ve known him for the longest time—several years, anyway. He had a sister who died; he talks about her like she’s still alive. And he does weird things. Like, when we were making love, right in the middle he started this babble about ‘holy love’ and dedicating his seed. It put me right off. I told him to stop and get off, but it was too late. I mean, would you want your kid growing up with that for a father?”

“If he’s so peculiar, how did you get involved with him?”

She looked abashed. “Well, we only did it once. And I might have been a little bit drunk at the time.”

Timothy was not only sedate, but nearly immobile. He sat quietly in the interview chair, a gangly blond whose hair swept across his forehead nearly to his eye brows. He told his story in a dull monotone that didn’t reveal the slightest trace of emotion.

Timothy Oldham and his twin sister, Miranda, had been orphaned when they were 4 years old. He had no memory of his parents, other than a vague impression that they might have made their living from a marijuana farm in northern California. The two children had been taken in by an aunt and uncle—Southern Baptists who, he said, made the farm couple in Grant Woods’s American Gothic look cheerful by comparison. “That painting, it’s really them. I have a copy of it in my bedroom. Sometimes I can almost see my uncle moving the pitchfork back and forth to signal me.”

“Is it really your uncle, and does the pitchfork really move?” the interviewer wanted to know.

“Well, it’s more of a feeling I get . . . not really . . . a sign of my Christian endeavor . . . ” Timothy’s voice trailed off, but he kept gazing straight ahead.

The “Christian endeavor,” he explained, meant that everyone was put on earth for some special purpose. His uncle always used to say that. He thought his own purpose might be to help raise the baby growing inside Charlotte. He knew there had to be more to life than laying carpets all day.

Timothy had only a few friends, none of them close. He and Charlotte had spent no more than a few hours together. In response to a question, he talked about his sister. Miranda and he had been understandably close; she was the only real friend he had ever had. She died of a brain tumor when they were 16, and Timothy was devastated. “We were webbed together when we were born. I swore at her graveside it would never be undone.”

With still no inflection in his voice, Timothy explained that being “webbed together” was something you were born with. He and Miranda still were webbed. It was a Christian endeavor, and she was directing him from beyond the grave to have a baby girl. He said that it would be having Miranda back again. He knew that the baby wouldn’t actually be Miranda, but said he knew it would be a girl. “It’s just one of those feelings. But I know I’m right.”

Timothy responded in the negative to the usual questions about hallucinations, delusions, abnormal moods, substance use, and medical problems such as head injury and seizure disorders. Then he arose from his seat and left the room without another word.

That evening Charlotte Grenville gave birth—to a healthy boy.

Evaluation of Timothy Oldham

Charlotte’s testimony suggested that Timothy’s peculiarities had been present for years. Although we don’t know much about his school career or work, his symptoms would seem likely to affect most areas of his life. This point should be more fully explored.

Timothy’s schizotypal symptoms included odd beliefs (his conviction that the baby would be his sister returned to earth; there is no evidence that he came from a subculture where this sort of thinking was the norm—criterion A2), illusions (the farmer in the picture waving his pitchfork—A3), constricted affect (A6), and absence of close friends (A8). His words (“webbed together,” “Christian endeavor”) seemed metaphorical and odd (A4). Unexplored by the interviewer were the presence of ideas of reference, paranoid ideas, odd behavior, and excessive social anxiety. Cognitive, affective, and interpersonal symptoms were represented here, however (see the Essential Features for a general PD earlier in this chapter).

This evaluation turned up no indications of another mental disorder. Timothy specifically denied the actual psychotic symptoms necessary to support a diagnosis of delusional disorder or schizophrenia. Other conditions that could entail psychotic symptoms include mood disordersand cognitive disorders, but we’ve seen evidence against both (B).

Other PDs to consider would include schizoid and paranoid PDs. Each of these implies some degree of social isolation, but not the eccentric thinking of StPD. Patients with any of these three Cluster A disorders can decompensate into brief psychoses—a trait held in common with borderline PD. Some patients may qualify for two diagnoses simultaneously: borderline PD and one of the Cluster A PDs. Patients with avoidant PD are socially isolated, but they suffer from it and lack odd behavior and thinking. Of course, a personality change due to another medical condition must be considered in those who have a severe or chronic illness; Timothy didn’t.

As of this evaluation, Tim would receive a GAF score of 75. He hadn’t developed schizophrenia, so we wouldn’t use the qualifier (premorbid).