Schizotypal Personality Disorder: Signs, Symptoms, & Treatments

What Is Schizotypal Personality Disorder?

Schizotypal personality disorder is categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a Cluster A personality disorder along with schizoid personality disorder and paranoid personality disorder. They are clustered due to their shared symptom presentation of what is considered eccentric behavior and difficulty connecting with others socially. Schizotypal personality disorder is often conceptualized as being a part of schizophrenia spectrum disorder. In this perspective, many psychotic disorders are viewed along a continuum or dimension in severity and functional impairment.

One primary difference in schizotypal personality disorder being that the individual can recognize or be made aware of the faulty logic in their thinking. If they experience brief episodes of psychosis or delusional thinking it is generally less severe and less frequent than episodes experienced by those diagnosed with schizophrenia. A small percentage of people diagnosed with schizotypal personality disorder will go on to develop schizophrenia or other psychotic disorders.¹

Schizotypal personality disorder is relatively rare with estimates in clinical samples ranging between 0-1.9 percent. Prevalence of schizotypal personality disorder in the general population is estimated to be 3.9 percent according to a National Epidemiological Survey on Alcohol and Related Conditions and it also found slightly higher prevalence in males at 4.2 percent versus females at 3.7 percent.^1,2

How Is Schizotypal Personality Disorder Diagnosed?

To meet DSM-5 criteria for diagnosis of schizotypal personality disorder at least five of the nine symptoms must be present since early adulthood and persistent in a variety of contexts:¹

1. Extreme social anxiety and interpersonal deficits that do not improve with time or familiarity
2. No friends or social support system and little interest or desire in making other social connections
3. Suspicion and paranoia typically directed at people
4. Ideas of reference (e.g. everyday occurrences have special meaning or directed specifically to them)
5. Eccentric appearance and behavior such as ill-fitting and unkempt clothing
6. Incongruent, inappropriate or flat emotional expression
7. Magical thinking or culturally odd beliefs
8. Unusual perceptions or experiences  (e.g. hearing someone call their name)
9. Odd, idiosyncratic speech and peculiar beliefs in context of their culture

These symptoms and behaviors do not occur exclusively during episodes of other mental health disorders or substance abuse. Personality disorders such as schizotypal personality disorder are consistent in presentation as are most personality traits, disordered or not.¹

Signs of Schizotypal Personality Disorder

According to DSM-5, personality disorder diagnoses are not given to children under 18 years of age, however schizotypal personality disorder symptoms will present in children and teens similarly as in adults. Research studies have found younger people score higher in odd beliefs, unusual bodily perceptions, peculiar behavior and odd speech.

Many children with these traits may appear socially awkward, isolated, may fall behind in school and may become victims of teasing and bullying. Socialization and adaptation as the youth develops could potentially help improve some of these symptoms and social consequences.³

In adult populations, males often present with more negative symptoms such as flat affect and disorganized symptoms such as emotional volatility and incongruent emotional responses, such as laughing when something bad happens. Females have been found to score higher on social anxiety symptoms and odd belief subscales.³ Adults with schizotypal personality disorder will often seek mental health treatment for comorbid mood or anxiety disorders, unaware of their personality disorder or that people may view them as odd or eccentric. Research has also found that people with schizotypal personality disorder often have difficulties in employment, frequently seeking positions that offer limited contact with others resulting in jobs that are menial or not challenging cognitively.⁴

Research has found that people with Cluster A personality disorders identified earlier in the article as schizotypal personality disorder, schizoid personality disorder and paranoid personality disorder tend to become worse as they get older.^3,5 Eccentric, paranoid and socially isolating behaviors can increase and in conjunction with cognitive decline impede the mind’s ability to regulate behavior. A “J shaped” relationship has been proposed with regards to this cluster of personality disorders, meaning that slightly worse symptoms start the disorder in youth, then it becomes better in adulthood and then markedly worsens (worse than in youth) with advancing age. Other research findings support a stable symptom presentation through adulthood with the worse symptom presentation being in adolescent years.^3,5

Symptoms of Schizotypal Personality Disorder

Schizotypal personality disorder may look at times like other disorders such as schizophrenia. What makes the disorder unique from schizophrenia is the severity and duration of psychotic symptoms.

Signs and symptoms commonly seen and experienced by those suffering from schizotypal personality disorder are:^1,2

• Avoidance of people and mistrust of people that does not decrease with time and familiarity
• Do not have close friends or confidants
• Anxious in social situations
• Magical thinking, such as, “Your phone number ends is 59 that’s my favorite number, so we were meant to meet each other today”
• Belief that they have magical control over some events or that certain rituals will prevent harm
• Unusual patterns of speech—idiosyncratic ways of describing people or things that make sense to them but are peculiar to others
• Spending a lot of time alone and not expressing loneliness or a desire for social interaction
• Unusual physical appearance by manners of dress and mannerisms
• Brief experiences of visual, tactile or auditory hallucinations
• Intense anxiety, particularly social anxiety
• Ignore social norms
• Flat affect or restricted range of facial expressions
• Difficulty maintaining employment
• Difficulty in school

Causes of Schizotypal Personality Disorder

There is no singular cause of schizotypal personality disorder. It is thought to be the product of one’s psychological, biological vulnerabilities and environmental stressors.

Known factors that make a person more likely to have schizotypal personality disorder include:^1,6

• First-degree relatives with schizophrenia
• Childhood trauma
  
• High stress living environment
• Low socio-economic status

Treatment of Schizotypal Personality Disorder

People with schizotypal personality disorder most commonly seek treatment for depression or anxiety disorders. It may not be apparent to the person or their loved ones that they have schizotypal personality disorder due to the rarity and lack of common knowledge of the disorder. A mental health professional will conduct a psychiatric evaluation to determine if the person meets DSM-5 criteria. This is typically done through clinical interview and through use of assessments such as the Schizotypal Personality Disorder Questionnaire (SPQ) or more recently the SPQ-Brief Response which is a 32-item revised version of the original, lengthier, 74 question questionnaire.

One of the most widely used measures is the Structured Interview for Schizotypy (SIS) or now the SIS-Revised (SIS-R). There are many adaptations of the assessment tools and varying types of measures for clinical use in diagnosing schizotypal personality disorder, many of which depend on the provider’s preference and specialized training, and/or the purpose of the assessment.^1,7,8

Therapy Options

Psychotherapies that may prove beneficial in treating schizotypal personality disorder include cognitive-behavioral therapy which can help by identifying unhelpful thought patterns and modifying maladaptive behaviors. People with schizotypal personality disorder often push people away and isolate, causing rifts between their families and loved ones, so family therapy can be beneficial in dealing with this and in helping the person and their family by providing psychoeducation, coping skills and improved communication strategies for dealing with the disorder. Supportive therapies can also provide skills in learning better socialization and re-learning more adaptive behaviors that help the person function more effectively in work, school and home environments.⁹

Medication

There are no medications approved by the Food and Drug Administration for treatment of schizotypal personality disorder however medications that target symptoms of depression and anxiety are often prescribed. Therapy in conjunction with medication is the most common and efficacious treatments for schizotypal personality disorder. Due to the seriousness of the role dysfunction and impairment commonly seen in schizotypal personality disorder those afflicted may be on medications and in therapy for many years or throughout their lifetime.

While symptoms may improve and behavioral modification may help, it is not a disorder that typically is cured but is more commonly managed and controlled. As stated earlier, many people experience improvement in their symptoms with age but personality is typically stable throughout one’s lifetime.⁹

Lifestyle Changes

As with most mental health disorders, a balanced diet and exercise may prove beneficial in treating schizotypal personality disorder along with proper treatment of any comorbid medical, mental health and substance abuse disorders. Having a support system of people that encourage positive change and personal growth rather than enable maladaptive behaviors is also enormously advantageous to people with Schizotypal personality disorder and other related mental health issues.⁹

Borderline personality disorder, a cluster B personality disorder, is also commonly diagnosed with schizotypal personality disorder. Some research studies have found a comorbidity ranging from 7 percent and higher, other research findings also indicate the presence of both disorders is more common in adolescent populations, indicating a wider range of symptom presentation during teen years. This is consistent with similar findings reported earlier indicating more severe symptom presentation in adolescence.¹¹

How to Get Help for Schizotypal Personality Disorder

If you believe you may have schizotypal personality disorder or know someone who does it is helpful to make a list of symptoms or behaviors that are troublesome. If you are unsure ask someone if they have noticed anything concerning. Discuss these concerns with your doctor or mental health professional. Bringing someone trusted to help advocate or reaffirm information provided to a doctor or provider may be useful.

If the person needing help is a child or teen, ask their teacher’s for information that may also help provide information and context for the behaviors and symptoms. Schizotypal personality disorder, like all DSM-5 personality disorders, is not technically diagnosed in people under the age of 18 years old, however if you suspect your child or teen is exhibiting early signs and symptoms of the disorder consult with your child’s paediatrician and determine if psychiatric intervention is indicated and could be of benefit to the youth.

If uncertain about which provider to obtain, consult with a primary care provider about referrals to a mental health professional another option is to inquire for a list of providers from an insurance company. Insurance providers typically will provide a list of in-and out-of-network specialists in a person’s geographic location.

Schizotypal Personality Disorder Statistics

Consider the following statistics about schizotypal personality disorder:

• Schizotypal personality disorder is relatively rare with prevalence estimates in the United States ranging from 1-3.9 percent of the population¹
• The disorder is more common in males (4.2%) than females (3.7%)¹
• Research has also found gender differences in symptom presentation with males suffering more often from flat affect and behavioral disorganization. Females typically displaying more social impairment and odd beliefs³
• Individuals with schizotypal personality disorder also have high rates of co-morbid depression with estimates ranging from 30- 50 percent¹

Coping With Symptoms of Schizotypal Personality Disorder

People with schizotypal personality disorder may go years or even their lifetime without being properly diagnosed. Those who are diagnosed often struggle with little knowledge of the disorder and may find it difficult to locate information due to its relative obscurity. Also, because of the persistent and pervasive nature of personality disorders, it may come as a surprise to someone that their personality, or essentially who they are is considered a disorder. They may think, “This is who I am, it’s my personality!” Many times, they will have other mental health diagnoses or are being treated for co-morbid mental health illness particularly social anxiety and depression.⁹

Individuals with schizotypal personality disorder may also experience brief episodes of psychosis, which may include auditory, sensory or visual hallucinations and delusions or false beliefs. These episodes typically do not last long enough to meet criteria for brief psychotic disorder, delusional disorder, schizophrenia or schizophreniform disorder. It is estimated that 30-50 percent will also experience major depressive disorder and there is significant comorbidity with other cluster A personality disorders (schizoid, paranoid and avoidant personality) and borderline personality disorder. They are also at a greater risk for developing schizophrenia and more severe psychotic disorders.¹

Schizotypal Personality Disorder vs. Schizoid Personality Disorder vs. Schizophrenia

While schizotypal personality disorder may present similar to other personality disorders or mental health concerns, there are some key differences.

Schizotypal Personality Disorder vs. Schizoid Personality Disorder

People with schizotypal personality disorder often have co-occurring personality disorders and other cluster A personality disorders are most common due to shared symptoms presentation. Specifically, schizotypal personality disorder is also seen as part of the schizophrenia spectrum along with other related disorders such as schizoid personality disorder. Both disorders share detachment from social relationships and have flat or blunted emotional affect but those with schizoid personality disorder will typically not have the odd or eccentric behaviors, mannerisms and language.¹

Schizotypal Personality Disorder vs. Schizophrenia

Schizotypal personality disorder as part of the schizophrenia spectrum is often conceptualized as a milder version of schizophrenia especially with regards to psychotic symptoms such as hallucinations and delusions. Another difference is that the hallmark features of schizotypal personality disorder persist in the absence of psychotic symptoms. And the psychotic features are less frequent and severe than those seen in schizophrenia and related disorders. Psychosis must not be better explained by a medical condition or substance abuse.¹

Schizotypal Personality Disorder vs. Autism Spectrum Disorder & Language Disorders

The eccentric behaviors, preference for solitude and idiosyncratic use of language may cause difficulty in distinguishing schizotypal personality disorder from autism and other language disorders. This is complicated further by the lack of common knowledge of schizotypal personality and the fact that it is not a childhood disorder. According to the DSM-5 language disorders are typically more severe than the language deficits present with schizotypal and the social deficits and inability to recognize emotion are more severe in autism than in schizophrenia, even in the milder forms of autism disorder.¹

Common Co-Occurring Disorders

Between 30-50% of people with schizotypal personality disorder will also develop major depressive disorder at least once in their life. Anxiety disorders are also common in this population, especially social anxiety and generalized anxiety disorder. Higher rates of PTSD have been commonly found in research studies as well, however prevalence rates are difficult to determine due to the lack of consistent research findings and paucity of studies with large sample sizes.^1,10

As stated earlier, schizotypal PD is a DSM-5 Cluster A personality disorder meaning it has a strong connection to other Cluster A disorders in presentation and pathology. Due to shared symptom presentation, they are often all considered during differential diagnosis.¹ When viewing disorders from a dimensional perspective, Schizotypal personality disorder is seen as on the schizophrenia spectrum along with Schizoid personality disorder. Conceptually, schizophrenia would be most severe followed by Schizotypal personality disorder and the mildest schizoid personality disorder.¹

Borderline personality disorder, a cluster B personality disorder, is also commonly diagnosed with schizotypal personality disorder. Some research studies have found a comorbidity ranging from 7 percent and higher, other research findings also indicate the presence of both disorders is more common in adolescent populations, indicating a wider range of symptom presentation during teen years. This is consistent with similar findings reported earlier indicating more severe symptom presentation in adolescence.¹¹