Schizotypal Personality Disorder
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Schizotypal personality disorder (SPD) is characterized by a 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. Diagnostic criteria include odd beliefs or magical thinking, such as beliefs in clairvoyance or telepathy, unusual perceptual experiences, and a lack of close friends outside of first-degree relatives.
Schizotypal personality disorder (SPD) is a mental disorder consisting of persistent social difficulty, reduced capacity for close relationships, and cognitive or perceptual distortions and eccentricities. Estimates suggest a prevalence rate of approximately 0–2% of clinical populations and 4% of the general population (American Psychiatric Association (APA) 2013). SPD may first be apparent in childhood, as evidenced by extreme social anxiety, hypersensitivity, being teased for oddness, and peculiar thoughts and language. The long-term prognosis for SPD is worse than for other personality disorders, due to significant social and occupational isolation. Although the exact nature of its relationship to schizophrenia is not fully understood, recent empirical investigations of SPD patients have shed light on several important aspects of schizophrenia spectrum and other psychotic disorders. Individuals diagnosed with SPD often seek treatment in response to co-occurring symptoms, such as depression and anxiety, rather than due to features of their personality. These individuals are often misdiagnosed as having social anxiety disorder, dysthymia, or autism spectrum disorder (Rosell et al. 2014). Treatment studies examining psychotherapy for SPD are sparse, but many clinicians argue for longer-term psychotherapy for SPD focusing on psychoeducation and supportive interventions. This entry will provide an overview of the current diagnostic criteria for SPD as well as focus on the history of SPD in the DSM, review the characteristics of the disorder as well as highlight empirical evaluations of SPD, and conclude by highlighting recent debates surrounding the SPD diagnosis as well as important considerations for treatment.
Current Diagnostic Criteria for Schizotypal Personality Disorder
Schizotypal personality disorder (SPD) is defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5; APA 2013) as a mental disorder characterized by a pervasive pattern of interpersonal and perceptual deficits, including reduced capacity for close relationships, cognitive distortions, and eccentricities of behavior, usually beginning in early adulthood but first becoming apparent, in some cases, in childhood or adolescence. The indication of five or more of the following nine criteria may warrant the diagnosis of SPD: (1) ideas of reference, or the incorrect interpretation of incidents or events as having special significance to the individual (e.g., that a news headline may be intended just for them); (2) odd beliefs or magical thinking, superstition, or unusual preoccupation with paranormal phenomena, clairvoyance, telepathy, a “sixth sense,” or special powers; (3) unusual perceptual experiences, such as feeling a presence or hearing a voice murmuring their name; (4) speech that is unusual, vague, or digressive, although coherent; (5) suspiciousness and paranoid ideation; (6) restricted range of affect in social situations which may be perceived by others as stiff, inappropriate, or odd; (7) behavior or appearance that is odd, eccentric, or peculiar; (8) lack of close friends or confidents other than first-degree relatives; and (9) excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid beliefs rather than negative judgments about the self. In addition, the diagnosis of SPD may only be warranted if these symptoms do not correspond with a concurrent schizophrenic, bipolar, depressive, or autism spectrum condition. SPD is also mentioned in the Schizophrenia Spectrum and Other Psychotic Disorders section of DSM-5 because it is closely associated with schizophrenia and other psychotic disorders. Specifically, DSM-5 notes that if SPD symptoms are indicated prior to the onset of schizophrenia, then the diagnosis of schizotypal personality disorder (premorbid) may be warranted (APA 2013).
In addition, individuals with SPD may be prone to transient episodes of psychosis lasting minutes to hours when under duress (APA 2013). While these episodes are usually insufficient in duration to be captured by the additional diagnosis of a brief psychotic disorder or schizophrenia, clinically significant psychotic symptoms may occur that do indeed meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder, schizoaffective disorder, or schizophrenia. SPD can typically be distinguished from such disorders because these other psychotic disorders are characterized by periods of persistent psychotic symptoms (e.g., delusions and hallucinations), rather than the transient, relatively brief, cognitive and perceptual distortions that generally occur with SPD (e.g., odd beliefs and ideas of reference).
A Historical Overview of SPD in the DSM
Kendler (1985) describes that the origins of SPD draw heavily from the early twentieth century writing of Eugen Bleuler and Emil Kraepelin, who described schizophrenia-like symptoms in patients prior to the onset of their illness as well as in the first-degree relatives of schizophrenic patients. Kraepelin noted mild or subclinical psychotic symptoms as precursors to the development of dementia praecox (his term for schizophrenia). He also suggested that the psychotic-like experiences in first-degree relatives could suggest an arrested form of the illness. Bleuler also observed what he called “crazy acts” in the context of otherwise normal behavior and noted that these psychotic-like experiences often preceded the development of schizophrenia. Kendler (1985) noted that these early studies examining the relatives of individuals with schizophrenia found that an eccentric or odd personality style, irritability, social isolation, aloof or cold demeanor, and suspiciousness were the most commonly shared characteristics of these individuals.
Sandor Rado introduced the term schizotype in 1953 to describe what he called the schizophrenia phenotype, based on his clinical observations that there was a continuum of schizophrenic behavioral impairment. Rado described that the risk for developing schizophrenia was genetically driven and that this genetic vulnerability resulted in impairment ranging from mild to severe. Subsequently, Paul Meehl in 1962 argued that a single dominant gene, termed the schizogene, along with other genetic characteristics, such as introversion, anxiety, aggression, and diminished capacity for pleasure, exerts their influence on an individual during brain development, thus leading to an aberration in brain functioning that he referred to as schizotaxia. Thus, Meehl viewed schizotypy as the personality organization that resulted from schizotaxia and that conveyed the vulnerability for the development of schizophrenia. Meehl’s initial descriptions of schizotypy include many of the features eventually included in DSM descriptions of SPD, such as restricted affect, odd beliefs or magical thinking, and cognitive difficulties.
SPD was first introduced in the third edition of the DSM (DSM-III) and was initially conceptualized to capture the attenuated schizophrenia-like symptoms found in relatives of patients with schizophrenia. In addition, clinical observations of patients diagnosed with other personality disorders in the DSM, particularly borderline personality disorder (BPD), indicated that these individuals often manifested transient, psychotic-like symptoms. Accordingly, early research on DSM-defined SPD focused on confirming its utility in identifying nonclinical individuals carrying the genetic vulnerability for schizophrenia or clarifying its clinical validity in comparison to BPD and other personality disorders. A detailed examination of 36 transcripts from a study of schizophrenia conducted in Denmark in 1968 provided the initial criteria for SPD in the DSM-III: (1) magical thinking, (2) ideas of reference, (3) social isolation, (4) recurrent illusions, (5) odd speech, (6) inadequate rapport, aloof cold, (7) suspiciousness, (8) undue social anxiety-hypersensitivity (Kendler 1985; Widiger and Frances 1985).
Prior to DSM-III, the features of schizotypy were captured solely by the schizoid personality disorder diagnosis. In DSM-III, schizoid personality disorder was subdivided into three separate diagnoses: schizotypal personality disorder, schizoid personality disorder, and avoidant personality disorder. Cognitive peculiarities (e.g., magical thinking, suspiciousness, paranoid ideation) were used to distinguish between SPD and schizoid personalities. In addition, SPD was distinguished from BPD by the emphasis on cognitive symptoms for SPD as opposed to the emphasis on affective symptoms in BPD, such as affective lability, chronic feelings of emptiness, and inappropriate or intense anger. Interestingly, both SPD and BPD were thought to refer to the boundaries of distinct spectrums of disorders; the BPD diagnosis was regarded as representing the boundary between personality and affective disorders, whereas SPD represented the boundary between personality and schizophrenic conditions (Widiger and Frances 1985).
A subsequent revision of the DSM (DSM-IV) further refined the SPD criteria by broadening the diagnosis to five (or more) of nine criteria in order to improve the reliability and validity of the diagnosis (Widiger and Frances 1985). Specific revisions were made to include more behavioral observations, such as the inclusion of odd appearance or behavior, as well as to refine certain criteria, such as specifying that excessive social anxiety not be related to negative judgments of the self but rather due to paranoia. The criteria for SPD were not revised between DSM-IV and DSM-5.
Empirical Evaluations of SPD
The prevalence of SPD is estimated to be 0–2% in clinical populations and 4% in the general population (APA 2013). Findings from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal survey of psychopathology in US adults, suggested that rates of SPD have been found to be significantly greater among men than women (4.2% and 3.9%, respectively). The diagnosis was also found to be significantly more prevalent in Black individuals (specifically Black women), individuals in lower income brackets, and among those who were never married, divorced or separated, or who have been widowed (Pulay et al. 2009).
Etiology and Course
Evidence points to a significant genetic contribution to the development of SPD. Early studies of the genetic factors associated with SPD have shown that it is more common among the relatives of schizophrenic patients and that its symptoms have similarities with prodromal schizophrenic symptoms (Castonguay and Oltmanns 2013). The course of SPD is relatively stable, with only a small proportion of individuals ultimately developing schizophrenia or another psychotic disorder. Schizotypal personality features may be apparent first in childhood and adolescence with the characteristics of solitariness, poor relationships with peers (including being teased for their oddness), social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language, and unusual fantasies (APA 2013). The long-term prognosis for individuals with SPD has been found to be bleaker than that of other personality disorders; individuals with SPD have been found to remain socially isolated and occupationally impaired over time. It has been speculated that this may be the case because SPD poses a greater neurobiological vulnerability and is less likely to remit due to limitations in available treatment (Castonguay and Oltmanns 2013).
Co-occurrence with Other Mental Disorders
SPD has a high co-occurrence rate with major depressive disorder, obsessive-compulsive disorder, and Tourette disorder. It is important to note that because the presence of SPD is a rule-out criterion for schizophrenia, few studies report diagnostic overlap between SPD and schizophrenia, despite the two disorders sharing many characteristic features. SPD also has a high degree of co-occurrence with schizoid PD, paranoid PD, avoidant PD, as well as BPD. The most distinctive schizotypal characteristic is the presence of cognitive-perceptual distortions (e.g., magical thinking, ideas of reference). Although individuals diagnosed with SPD may resemble those diagnosed with schizoid PD, the social deficits associated with SPD are secondary to mistrust and paranoia rather than lack of pleasure or interest in relationships as would be the case for schizoid PD. Similar to those diagnosed with paranoid PD, individuals diagnosed with SPD display suspiciousness in their behavior; however, while suspiciousness significantly influences the behavior of individuals diagnosed with paranoid PD, those diagnosed with SPD hold less conviction regarding their suspiciousness and can take in alternative information about other’s motives and behaviors. Finally, psychotic-like symptoms observed in both SPD and BPD are distinguished as either transient or dissociative, respectively, and relative to BPD, psychotic symptoms are more common and unaccompanied by affective instability in SPD (Chemerinski et al. 2013).
Factor Structure of the DSM SPD Diagnosis
SPD has been shown to be a multidimensional construct. Analyses of the DSM-IV SPD criteria consistently reveal a three-factor solution: cognitive/perceptual (e.g., odd beliefs, perceptual disturbances, ideas of reference, and paranoia/suspiciousness), interpersonal (e.g., no close friends, social anxiety, restricted affect), and disorganized/oddness (e.g., odd speech/thought, odd behavior, and restricted affect). Interestingly, the assignment of restricted affect to either the interpersonal or oddness factor depends on whether the assessment was performed by self-report in nonclinical populations as opposed to semi-structured interviews of SPD or personality-disordered patients, with restricted affect more often belonging on the oddness factor in clinical populations (Rosell et al. 2014). Rosell et al. (2014) also noted that a four-factor solution for the SPD diagnostic criteria was recently identified among nonpsychotic family members of schizophrenia patients (e.g., negative schizotypy, positive schizotypy, interpersonal sensitivity, and social isolation/introversion). Thus, more research is needed to explore the factor structure of the SPD diagnosis.
Characteristics of SPD
Similar to schizophrenia, SPD is characterized by positive, or psychotic-like, symptoms and negative, or deficit-like, symptoms (Siever and Davis 2004). The positive symptoms of SPD include ideas of reference, cognitive or perceptual distortions, and magical thinking. Converging factor analyses have emphasized paranoid symptoms and cognitive disorganization as well (Bergman et al. 1996; Reynolds et al. 2000). Negative symptoms in SPD consist of constricted (or inappropriate) expressions of affect and social withdrawal. Unaffected relatives of schizophrenia patients present with elevated schizotypal traits overall (Zouraraki et al. 2015). Moreover, it has been found that negative schizotypal symptoms, such as social isolation, coldness, inadequate rapport, and poor functioning, represent more characteristic presentations among biological relatives of schizophrenic individuals than positive schizotypal symptoms (Siever and Davis 2004).
Trauma, maltreatment, and other psychosocial stressors can contribute to the development of SPD. In fact, an increasing body of research has demonstrated an association between early trauma exposure and an increased risk for adult psychotic symptoms. Specifically, childhood neglect and emotional abuse have been found to be associated with specific schizotypal symptoms, including ideas of reference, magical thinking, unusual perceptual experiences, and paranoid ideation (Berenbaum et al. 2008; Powers et al. 2011). Suboptimal parenting, including abuse and deviant parental communication, has also been reported to increase vulnerability to developing SPD (Zouraraki et al. 2015). In addition, those diagnosed with SPD have reported more experiences of physical attack in childhood than those diagnosed with other severe personality disorders (Yen et al. 2002). Moreover, pre- and perinatal factors, such as influenza exposure, low birth weight, and obstetric complications, have been associated with increased incidence of SPD (Zouraraki et al. 2015).
Cultural considerations play an important role in the assessment and diagnosis of SPD. For example, cognitive and perceptual distortions must be evaluated within the context of an individual’s cultural environment. Clinicians’ lack of familiarity with particular cultural experiences and customs may lead to the overestimation of SPD; for instance, among the Black community, premonitions, communications with ancestral spirits, or perceptions of experiences of discrimination or paranoid beliefs may actually characterize cultural beliefs or genuine reality-based experience (Pulay et al. 2009). Other religious beliefs and rituals, such as voodoo, speaking in tongues, belief in the afterlife, shamanism, mind reading, sixth sense, evil eye, and magical beliefs related to health and illness may also appear to be characteristic of the SPD diagnosis to the uninformed outsider (APA 2013). It is important for clinicians to be aware of their own cultural biases and blind spots when diagnosing SPD.
Skodol et al. (2002) found that individuals diagnosed with SPD report significantly more impairment in work, social relationships, and leisure than patients meeting criteria for other personality disorders (i.e., obsessive-compulsive personality disorder and avoidant personality disorder) as well as those with major depressive disorder. McClure et al. (2013) also noted significant functional impairments in individuals diagnosed with SPD, in that they were less likely to be living independently or to have been educated beyond a high school diploma as compared to individuals diagnosed with other severe personality disorders. Furthermore, Jahshan and Sergi (2007) found that individuals high in schizotypy were more impaired in their social, family, and academic functioning relative to a low-schizotypy comparison group.
Many of the cognitive impairments found in schizophrenic individuals in the domains of working memory, recognition memory, information processing, cognitive inhibition, episodic memory, and sustained attention are also present in individuals diagnosed with SPD, though to a lesser severity (Siever et al. 2002). This has been found to be the case even in direct comparison to individuals diagnosed with other personality disorders; specifically, individuals with SPD have been found to be more impaired in attentional vigilance, information processing, and other measures of executive function (Trestman et al. 1995). Individuals diagnosed with SPD also have significant working memory deficits as compared to those diagnosed with other personality disorders (Rosell et al. 2014). In addition, magnetic resonance imaging (MRI) studies have identified specific structural abnormalities in patients diagnosed with SPD that are like those associated with patients diagnosed with schizophrenia (Siever et al. 2002). For example, these abnormalities include frontotemporal white matter abnormalities, which have been found to be severe in schizophrenic groups yet intermediate in SPD patients (Lener et al. 2015). In addition, Chemerinski and colleagues (2013) reviewed relevant psychophysiological deficits relevant to SPD and found significant abnormalities in prepulse inhibition (PPI) – or the ability to inhibit reaction to or filter sensory information – to be associated with increased vulnerability to developing SPD symptoms.
A growing body of literature has also addressed the social or interpersonal dimensions of schizotypy and SPD. Studies of social cognition and emotion recognition in samples of individuals endorsing schizotypy have yielded mixed results. Investigations of theory of mind – or the ability to attribute and differentiate between one’s own and others’ mental states, including beliefs, intentions, and desires – in schizotypy have regularly demonstrated impairments. One study of emotion recognition accuracy in individuals diagnosed with and without SPD indicated that those diagnosed with SPD displayed deficits only in recognizing positive emotions but not negative emotions (Waldeck and Miller 2000). Impaired accuracy of facial affect recognition has been found to be associated with the endorsement of social anhedonia, constricted affect, and most prominently, social anxiety (Ripoll et al. 2011). Chemerinski and colleagues (2013) have suggested that many different symptoms of SPD contribute to social deficits, including excessive social anxiety, odd speech, constricted affect, and suspiciousness.
Moreover, schizotypal personality traits have been associated with deficits in empathic accuracy, the detection of deception, appreciation of irony, and processing information about the self (Jahshan and Sergi 2007; Ripoll et al. 2013). However, Jahshan and Sergi found that improved social cognition was significantly related to greater social functioning in their sample of high-schizotypy individuals. Another study suggested that individuals diagnosed with SPD demonstrated the most impairment in behavioral measures of social skills and social appropriateness (Waldick and Miller 2000). In addition, difficulties socializing effectively, concerns about basic safety, and the tendency to become easily overwhelmed in social situations may explain the trend of adolescents with schizotypal traits relying more heavily on the internet for social interaction as compared to control subjects without personality disorder features (Chemerinski et al. 2013).
Debates Surrounding the SPD Diagnosis
One of the main debates about the SPD diagnosis is the exact nature of its relationship with schizophrenia. Appels et al. (2004), for example, posited that parents of patients with a schizophrenia diagnosis endorsed more positive and negative schizotypal traits than parents without a family history of schizophrenia spectrum disorders because of an underlying familial or genetic vulnerability to schizophrenia. Moreover, Siever and Davis (2004) reviewed data supporting their hypothesis that schizophrenic and schizotypal personalities share a common genetic anomaly or diathesis that renders specific brain regions particularly vulnerable to environmental difficulties such as hypoxia (i.e., oxygen deficiency). Siever and Davis (2004) emphasized the importance of genetic predisposition for the diagnosis of SPD and proposed that certain features of the schizotypal brain (e.g., intact cognitive functioning) may serve as mitigating or buffering factors that diminish the impact of schizophrenia susceptibility. Therefore, these researchers suggested cognitive and behavioral strategies, some of which are discussed later in this entry, that could be used to spare genetically vulnerable schizotypal individuals from the severe social and cognitive deterioration that characterizes schizophrenia.
The assumption that the incidence of familial schizophrenia should be given primacy as a validating criterion for the SPD diagnosis, however, has been challenged (e.g., Frances 1985; McClure et al. 2013). Although empirically useful to narrow the SPD diagnostic criteria to be more like those for schizophrenia (e.g., differentiating between positive and negative symptoms and distinguishing between affective conditions, as with schizoaffective disorder), altering the SPD diagnostic criteria in this way may prove less useful clinically because it would ignore the personality characteristics associated with the disorder. Moreover, Frances (1985) has argued that individuals who meet the most characteristic familial schizotypal descriptions often do not willingly present for treatment, due to paranoia and social isolation.
Treatment Considerations for SPD
While there is no single, preferred treatment model for SPD, there are several important factors to consider in treatment planning and assessment. First, effective treatment planning is contingent on an adequate diagnosis and case formulation. It is important to note that SPD often co-occurs with mood disorders and other personality disorders, so SPD features may be overshadowed by symptoms of these other conditions. In addition, given that suspiciousness is a prototypical feature of SPD, efforts should be made to establish and maintain an alliance with this population to aid in treatment retention.
Common complaints among patients with SPD include eccentric social habits, anhedonia, hypersensitivity to criticism, humorlessness, the misinterpretation of the moods and statements of others, and inability to fit in socially. Moreover, individuals with SPD often seek treatment for their co-occurring symptoms of depression or anxiety rather than specific features of their personality (APA 2013). Patients with SPD are often misdiagnosed with attention deficit disorder (ADD), social anxiety disorder, dysthymia, or an autism spectrum disorder (Rosell et al. 2014).
The prescription of psychopharmacological medication can play a primary or supplementary role in the treatment of SPD. The treatment of positive symptoms such as magical thinking, ideas of reference, and suspiciousness with antipsychotic medication has been substantiated. Koenigsberg et al. (2003), for example, found that individuals with SPD randomly assigned to a risperidone treatment condition demonstrated reduced positive and negative symptoms, although this medication did not lead to significant changes in affect symptoms. Antipsychotics, stimulants, benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and neuroleptic medication may also prove helpful in addressing the mood dysregulation, social anxiety, and cognitive symptoms associated with the SPD diagnosis. McClure et al. (2013), who emphasized the cognitive impairments associated with SPD, argued for psychopharmacological treatments geared at cognitive enhancement. For example, research has shown that pharmacological enhancement of dopamine receptor functions has led to improvements in working memory without clinical worsening in patients with psychotic symptoms. However, unlike patients diagnosed with schizophrenia, patients diagnosed with SPD are rarely treated with psychiatric agents, in part because clinical trials for SPD and SPD symptoms are so rare (Chemerinski et al. 2013).
McClure et al. (2013) argued that cognitive remediation-oriented therapy or skills-based training may benefit individuals with SPD. Cognitive therapy for individuals with a personality disorder diagnosis generally emphasizes improving current functioning through increasing the patient’s repertoire and flexibility with compensatory strategies, developing and learning from a therapeutic relationship, understanding the historical development and maintenance of core beliefs, and modifying maladaptive beliefs to bring about enduring emotional and behavioral change through rational and experiential methods. Cognitive behavioral therapy (CBT) for psychotic disorders or for those with a high frequency of positive symptoms emphasizes the consideration of alternative explanations for various psychotic experiences (Beck 1995). Cognitive remediation or cognitive enhancement therapy is geared toward the improvement across neuropsychological domains, including information processing, working memory, attention, cognitive and social flexibility, problem solving, organization, and executive function.
Empirical studies of psychotherapy methods and outcome in individuals diagnosed with SPD are sparse, perhaps due to its relatively new classification and appearance in DSM-III or possibly because of the infrequency with which patients who meet criteria for SPD seek psychotherapy. Moreover, because individuals with schizotypal features are significantly less prone to overt suicidal gestures, as compared to other personality disorders, these individuals are more likely to present for treatment at outpatient clinics and private psychotherapy offices rather than to hospitals with funded research programs.
Because of the chronicity of SPD, Stone (1985) advocated for long-term psychotherapy incorporating elements of exploration, support, and social-educational measures for treatment. Group psychotherapy treatment may be less helpful for those diagnosed with SPD who are especially shy or mistrustful. Stone also argues against the use of traditional psychoanalysis for those with SPD due to the isolating nature of being analyzed “on the couch” and the associated inability of the SPD patient to attend to visual demonstrations of support and understanding from the therapist. However, he does note that those individuals diagnosed with SPD who are easily overwhelmed or distracted by gestures or sounds made by the therapist may be able to attend to auditory markers of therapeutic empathy and, therefore, may prefer to look away from the clinician. Ultimately, Stone argues for gearing treatment toward issues of identity disturbance, experiences of depersonalization, and anhedonia when working with individuals diagnosed with SPD.
McWilliams (2011) has long advocated for therapists to recognize the adaptive capacity of individuals diagnosed with both schizotypal and schizoid personality disorders. In particular, she notes that these individuals have an incredible capacity for creativity. She argues that the “sublimation of autistic withdrawal into creative activity” can be a productive goal for psychotherapy with these patients (p. 200). An additional aim may be to simply help the patient to have feelings, emotions, and experiences they were incapable of having before treatment began. Moreover, she argues that the therapeutic relationship may provide the schizotypal patient with a new experience of a safe and trusting bond, allowing for subsequent healing.
Some of the challenges faced by clinicians working with these individuals therapeutically may be difficulties or discontinuities with respect to time and person, hypersensitivity to interpersonal cues, and the patients’ fragility. These difficulties may lead the therapist to be overly permissive or may inhibit the patient’s motivation and his or her ability to continue treatment. Due to its chronic nature, psychotherapy with individuals diagnosed with SPD may require a longer treatment course than psychotherapy with other disorders based more in affective instability (such as those with mood disorders or BPD). For these reasons, Stone (1985) advocates for clinicians to use a structured and clear therapeutic frame, increased efforts at psychoeducation, careful attention to countertransference, as well as patience, when working with individuals diagnosed with SPD.
In sum, schizotypal personality disorder (SPD) is characterized by persistent social difficulty, eccentricities in appearance, beliefs, and speech, and cognitive or perceptual distortions. SPD is also marked by functional impairments across cognitive, social, and work domains. SPD is a challenging condition to diagnose and treat due to its phenomenological heterogeneity and the associated interpersonal difficulties and suspiciousness. Clinicians are encouraged to consider long-term psychotherapy approaches that emphasize psychoeducation and support.
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