Etiological and therapeutic aspects of schizoid and schizotypal personality disorder

Following the introduction to the history of the concepts of abnormal personality, with regard to the schizoid and schizotypal forms, we present their systematic assessment in the modern classification systems.Both, the schizoid and schizotypal forms, are usually considered as schizophrenia-spectrum disorders. Biological and clinical data indicate relations to other axis-I disorders as well. However there are few systematic and strictly controlled studies on the psychotherapeutic and pharmacological treatment of schizotypal and schizoid personality disorders. Basic theoretic assumptions concerning both treatment concepts - for personality disorders in general, and especially in schizoid and schizotypal personality disorder - are given. Finally the role of neuroleptics and antidepressants for schizophrenia-spectrum disorders is discussed. New possibilities may emerge from the use of the recently developed atypical drugs, but further research in randomised studies is needed. Current prospective studies on early detected schizophrenia-spectrum disorders will broaden our knowledge about prevention and therapy.     

Personality disorder traits: prevalence and effects on health status in primary care patients.

OBJECTIVE: Previous work in an academic setting has found that scoring in the higher ranges for selected personality disorders on an objective assessment tool was associated with increases in psychiatric co-morbidities, decreased satisfaction with health care, and diminished health related functional status. This study examines how often patients in primary care practices exhibit traits consistent with these selected disorders and what impact this has on their health related functional status and use of health care resources. METHODS: Thirteen family practices agreed to distribute questionnaires to 50 consecutive patients in the spring of 1997. Questionnaires contained instruments that assess risk for personality disorders, health related functional status, health resource use, demographics, and depression. The relationships between four specific personality disorders (borderline, dependent, schizoid and schizotypal) and other assessed variables were explored. RESULTS: Of the 250 patients returning completed survey instruments, 80 (32%) scored in the high range for traits consistent with one of the four target personality disorders. Patients in the high risk group also were noted to have more outpatient, emergency, and inpatient visits in the previous six months. Those in the high risk group also had significantly lower scores on seven of eight measures of health related functional status. CONCLUSIONS: Patients who have several traits for borderline, dependent, schizoid, and schizotypal personality disorders are common in primary care practices. These patients utilize services at higher rates than others and are more likely to screen in the positive range for depressive symptoms and have overall lower health related functional status.     

Personality and personality disorders among patients with major depression in combination with dysthymic or cyclothymic disorders

Personality traits and personality disorders in 298 consecutive outpatients with pure major depression, major depression with dysthymic or cyclothymic disorder, pure dysthymic or cyclothymic disorder and other disorders were investigated. Patients with dysthymic or cyclothymic disorders alone or in combination with major depression showed more self-doubt, insecurity, sensitivity, compliance, rigidity and emotional instability. They were more schizoid, schizotypal, borderline and avoidant according to MCMI and had a higher prevalence of DSM-III Axis II diagnoses, and more borderline, avoidant, and passive-aggressive personality disorders, as measured by SIDP. All in all, dramatic and anxious clusters of personality disorders were more frequent among patients with dysthymic-cyclothymic disorders in addition to major depression than among patients with major depression only. The findings elucidated the close connection between the more chronic affective disorders and the personality disorders, irrespective of any concomitant diagnosis of major depression.     

Child and adolescent psychiatric disorders predicting adult personality disorder: a follow-up study

The objective of this study was to examine associations between childhood and adolescent psychiatric disorders and adult personality disorders in a group of former child psychiatric inpatients. One hundred and fifty-eight former inpatients with a mean age of 30.5 +/- 7.1 years at investigation had their childhood and adolescent Axis I disorders, obtained from their medical records, coded into DSM-IV diagnoses. Personality disorders in adulthood were assessed by means of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). The predictive effects of child and adolescent Axis I disorders on adult personality disorders were examined with logistic regression analyses. The odds of adult schizoid, avoidant, dependent,borderline and schizotypal personality disorders increased by almost 10, five, four, three and three times, respectively, given a prior major depressive disorder. Those effects were independent of age, sex and other Axis I disorders. In addition, the odds of adult narcissistic and antisocial personality disorders increased by more than six and five times, respectively, given a prior disruptive disorder, and the odds of adult borderline, schizotypal, avoidant and paranoid personality disorders increased between two and three times given a prior sub-stance-related disorder. The results illustrate an association between mental disorders in childhood and adolescence and adult personality disorders. Identification and successful treatment of childhood psychiatric disorders may help to reduce the risk for subsequent development of an adult personality disorder.     

Comparison between personality disorder diagnoses in DSM-III and DSM-III-R: reliability, diagnostic overlap, predictive validity

97 nonpsychotic consecutive day patients were diagnosed by the axis 1 and 2 in the DSM-III and DSM-III-R system, and their treatment response during their stay was measured by the Health Sickness Rating Scale. The interrater reliability was equally good for both diagnostic systems. On axis 1, there were only minor differences between DSM-III and DSM-III-R. On axis 2, the frequency of schizotypal disorder was reduced by 40% and the frequency of histrionic disorder by two-thirds. The number of schizoid disorders increased from zero to five. Of the DSM-III schizotypals who lost this diagnosis in DSM-III-R (n = 8), 4 got a new diagnosis of schizoid personality and 4 maintained their borderline diagnoses. In DSM-III-R there was a sharper demarcation between patients with severe and nonsevere personality disorder with regard to treatment outcome, indicating an increased validity of these categories. There was also a sharper demarcation between borderline versus histrionic and schizotypal, and between schizotypal and schizoid diagnoses.     

Personality disorders related to schizophrenia]

Personality disorders related to schizophrenia were described since Kraepelin's works. According to the DMS III-R those disorders are gathered into the A cluster of personality disorders consisting in: schizotypal, schizoid and paranoid personality disorders. Schizotypal and paranoid personalities are biologically linked to schizophrenia and support the concept of "schizophrenia spectrum". Until now such a link is not found between schizoid personality and schizophrenia. Future research in the field of those personality disorders will bring a better knowledge in the pathogenesis of schizophrenia.     

Auditory P300 does not differentiate borderline personality disorder from schizotypal personality disorder

The P300 response to an auditory two-tone discrimination task has previously been reported to have prolonged latency and reduced amplitude in schizophrenia and borderline personality disorder. In this study, P300 was recorded from 23 subjects with borderline personality disorder, 12 subjects fulfilling criteria for both borderline and schizotypal personality, and 11 subjects with schizotypal personality. The mean P300 latency was similar in each of these groups and was significantly longer than in 32 patients with neuroses and other personality disorders and 74 nonpatient controls. These findings suggest that borderline and schizotypal patients share a similar abnormality in auditory stimulus evaluation and question whether or not these disorders are separate.     

Familial transmission of schizotypal and borderline personality disorders

The authors determined the risk for psychiatric disorders in the first-degree relatives of 36 probands with schizotypal personality disorder (13 definite, 23 probable), 17 probands with borderline personality disorder (two definite, 15 probable), and 90 normal control probands. The relatives of probands with schizotypal personality disorder without a concurrent diagnosis of borderline personality disorder had a significantly greater risk for schizotypal personality disorder than the relatives of normal control probands, borderline probands, or schizotypal probands with coexisting borderline personality disorder. The relatives of borderline probands had a significantly greater risk for definite and probable borderline personality disorder than the relatives of normal control probands.     

Differential perception of parental bonding in schizotypal and borderline personality disorder patients.

Fifty-four patients with schizotypal and/or borderline personality disorders were compared with 165 patients with other personality disorders and 52 patients with no personality disorders as to their perception of parental behavior in childhood. Both schizotypals and borderlines reported low care; however, schizotypals remembered underprotection and borderline overprotection. The study suggests parental neglect in the childhood memory of schizotypals and negative over-involvement for borderlines.     

Borderline personality disorder: symptomatology and MMPI characteristics

Using the Schedule for Interviewing Borderlines and the MMPI, 20 subjects diagnosed as borderline and/or schizotypal personality disorder were examined to determine 1) whether having one diagnosis affected the likelihood of having the other, 2) the amount of diagnostic overlap between the two diagnoses, and 3) whether different MMPI profiles could be found. The results indicated some overlap but also some differentiation between the borderline and schizotypal disorders. The modest overlap in diagnostic criteria was consistent with other studies and justifies the continued separation of the two diagnoses. The MMPI may be used as an initial screen to identify persons who warrant further evaluation for a borderline personality disorder but would not be appropriate as a screen for a schizotypal personality disorder.     

Differentiation between schizoid and avoidant personalities: an empirical test

A number of authors have questioned the rationale for subdividing the DSM-II schizoid diagnosis into three separate personality disorders in DSM-III, the schizoid, avoidant, and schizotypal. The present study was designed to explore differences between psychiatric patients with schizoid and avoidant personalities as compared to psychiatric controls with no personality disorder. Differences were examined on demographic data, self-report measures, and clinical information. A Multivariate Analysis of Variance (MANOVA) revealed a significant overall effect for groups across MMPI subscales. However, subsequent univariate Analyses of Variance (ANOVA's) revealed that almost all differences were between the two personality disorder groups as compared to the psychiatric controls. Contrary to expectations, schizoid and avoidant personalities were found to display equivalent levels of anxiety, depression, and psychotic tendencies as compared to psychiatric control patients. No meaningful distinctions were found between the avoidant and the schizoid personalities. Results are discussed in terms of problems with the assessment methods and the diagnostic criteria.     

Personality disorders and accentuations in at‐risk persons with and without conversion to first‐episode psychosis

Aim: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Cluster A personality disorders (PDs), particularly schizotypal PD, are considered a part of the schizophrenia spectrum and a risk factor of psychosis. The role of PDs and personality accentuations (PAs) in predicting conversion to psychosis was studied in patients symptomatically considered at risk, assuming a major role of the schizotypal subtype. Methods: PDs and PAs, assessed at baseline with a self‐report questionnaire, were compared between risk‐, gender‐ and age‐matched at‐risk patients with (n = 50) and without conversion to psychosis (n = 50). Results: Overall, Cluster A‐PDs were the least frequent cluster (14%), and schizotypal PD was rare (7%). Yet, PDs in general were frequent (46%), especially Cluster B‐ (31%) and C‐PDs (23%). Groups did not differ in frequencies of PDs, yet converters tended to have a higher expression of schizoid (P = 0.057) and Cluster A‐PAs (P = 0.027). In regression analyses, schizoid PA was selected as sole but weak predictor of conversion (OR = 1.685; 95% CIs: 1.134/2.504). Conclusions: Unexpectedly, schizotypal PD was infrequent and did not predict conversion. Conversion was best predicted by schizoid PA, indicating more severe, persistent social deficits already at baseline in later converters. This corresponds to premorbid social deficits reported for genetic high‐risk children and low social functioning in at‐risk patients later converting to psychosis. Further, PDs occurred frequently in at‐risk patients irrespective of conversion. As psychopathology and personality relate closely to one another, this result highlights that, beyond the current narrow focus on schizotypal PD, personality‐related factors should be considered more widely in the prevention of psychosis.     

Borderline children: a closer look at diagnosis and treatment

In a follow-up study, children who met research criteria for childhood borderline personality disorder were examined for vulnerability to the affective, personality, and anxiety disorders as defined in DSM-III. In addition to provisional borderline, antisocial, or schizotypal personality diagnoses, many subjects had chronic affective conditions, the symptoms of which resembled those typically associated with borderline personality disorder.     

Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders

OBJECTIVE: This study tracked the individual criteria of four DSM-IV personality disorders-borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders-and how they change over 2 years. METHOD: This clinical sample of patients with personality disorders was derived from the Collaborative Longitudinal Personality Disorders Study and included all participants with borderline, schizotypal, avoidant, or obsessive-compulsive personality disorder for whom complete 24-month blind follow-up assessments were obtained (N=474). The authors identified and rank-ordered criteria for each of the four personality disorders by their variation in prevalence and changeability (remission) over time. RESULTS: The most prevalent and least changeable criteria over 2 years were paranoid ideation and unusual experiences for schizotypal personality disorder, affective instability and anger for borderline personality disorder, feeling inadequate and feeling socially inept for avoidant personality disorder, and rigidity and problems delegating for obsessive-compulsive personality disorder. The least prevalent and most changeable criteria were odd behavior and constricted affect for schizotypal personality disorder, self-injury and behaviors defending against abandonment for borderline personality disorder, avoiding jobs that are interpersonal and avoiding potentially embarrassing situations for avoidant personality disorder, and miserly behaviors and strict moral behaviors for obsessive-compulsive personality disorder. CONCLUSIONS: These patterns highlight that within personality disorders the relatively fixed criteria are more trait-like and attitudinal, whereas the relatively intermittent criteria are more behavioral and reactive. These patterns suggest that personality disorders are hybrids of traits and symptomatic behaviors and that the interaction of these elements over time helps determine diagnostic stability. These patterns may also inform criterion selection for DSM-V.     

An open, noncomparative study of amoxapine in borderline disorders

Five patients with borderline personality disorder (BPD) and 5 patients with schizotypal personality disorder (SPD) completed at least 3 weeks of treatment with amoxapine. The patients fulfilled DSM-III criteria for borderline disorders and scored 7 points or more in Gunderson's Diagnostic Interview for Borderlines (DIB). The final median medication in patients with BPD was 200 mg amoxapine/day and 42 mg oxazepam/day. Duration of treatment averaged 28 days. In patients with SPD the corresponding figures were 250 mg amoxapine/day, 36 mg oxazepam/day and 39 days. The study suggests that amoxapine improves schizophrenic-like and depressive symptoms in patients with schizotypal personality disorders (SPD). No effect could be shown in patients with borderline personality disorders (BPD).     

The comorbidity of multiple personality disorder and DSM-III-R axis II disorders

Our ability to differentiate MPD from DSM-III-R Axis I disorders has become increasingly refined. Differentiation of MPD from the Axis II personality disorders is an area of more recent clinical investigation. MPD can be found comorbidity with many other psychiatric conditions. It is found in association with each of the DSM-III-R personality disorders. At the present time, however, we lack research data that define the prevalence of the comorbidity of MPD with the personality disorders. Objective study of this area is complicated by the paucity of instruments available to assess personality dimensions in the presence of a DD. In addition, the currently available personality inventories tend to overdiagnose BPD in patients with a high level of distress and acuity of symptoms. The diagnosis of a personality disorder in a patient with MPD is made on the basis of the assessment of the "whole" human being. It is based on the presence of a pervasive and relatively inflexible pattern of behaviors that reflects the individual predominant mode of being. The diagnosis of a personality disorder is not made on the basis of personality traits contained within any single alternate personality or groups of personalities. The personality disorders defined by DSM-III-R are a heterogeneous group of conditions whose individual etiologies reflect a complex interplay of constitutional, genetic, environmental, interpersonal, and psychodynamic factors. The interplay is variable and diverse between these determinants of the personality disorders and the traumatic forces that result in the development of a DD. For the Cluster A personality disorders (schizoid, schizotypal, paranoid), there is evidence supporting a relationship with specific psychotic illnesses. The combination of dissociative pathology with these personality disorders commonly results in a greater impairment of reality testing than in either condition alone. The Cluster B personality disorders (histrionic, narcissistic, borderline, antisocial) and Cluster C personality disorders (avoidant, compulsive, dependent, passive-aggressive) are believed to be primarily developmental disturbances. Comorbidity of these personality disorders with MPD involves consideration of the interaction of many developmental processes with the psychological impact of severe childhood trauma. Many MPD patients present with an apparent mixed personality profile consisting of an array of avoidant, compulsive, borderline, narcissistic, dependent, and passive-aggressive features. Although this article explores comorbidity of MPD with each of the personality disorders defined in DSM-III-R individually, it seems likely that a number of posttraumatic personality organizations can be defined that commonly coexist with MPD.(ABSTRACT TRUNCATED AT 400 WORDS)     

Prototypicality ratings of DSM-III criteria for personality disorders

Although DSM-III personality disorder criteria have demonstrated acceptable reliability, the question of validity has not been adequately addressed. A first step in establishing the validity of diagnoses is to establish the validity of the criteria used to assess each diagnosis. The content validity of diagnostic criteria was investigated in relation to the larger set of potential criteria culled from the psychiatric literature. For each DSM-III axis II diagnosis, a panel of clinicians rated how prototypical each potential criterion was of the diagnosis in question. The results reveal problems with the organization and content of the criteria for most diagnoses. Many DSM-III criteria are composed of several statements linked by conjunctions or disjunctions. These component statements often received markedly different ratings, suggesting that criteria should be single statements. For most diagnoses, traits not included in DSM-III received higher ratings than did some DSM-III criteria. Suggestions are made to improve the distinctiveness and content validity of paranoid, schizoid, antisocial, borderline, avoidant, dependent, and compulsive personality disorders. The results for schizotypal personality disorder suggest that many clinicians are uncertain about this diagnosis. These findings provide a systematic way to modify definitions that contrasts with the more arbitrary ways in which diagnoses have previously been defined and redefined.     

Familial association of schizotypal traits with psychotic and affective disorders

The criteria for schizotypal personality disorder were developed on the basis of traits observed in biologic relatives of schizophrenic and borderline schizophrenic probands from the Danish adoption studies. In this review, the relationship between schizotypal personality disorder and the schizophrenic spectrum, affective disorders, and psychotic disorders is explored. A dimension of psychosis may overlap with the schizophrenia spectrum to yield chronic schizophrenia, with the affective disorders spectrum to yield psychotic affective disorder, or by itself lead to other psychotic disorders. Schizotypal personality disorder in this model is posited to represent schizophrenia spectrum disorder that does not overlap with psychosis, whereas nonpsychotic affective disorders represent the affective disorders that do not overlap with psychosis. Delusional disorder represents another psychotic disorder that is not specifically related to either schizophrenia or the affective disorders. Evidence suggests that the schizotypal personality disorder criteria, particularly those emphasizing the negative symptoms or deficit-like symptoms of this disorder, specifically identify a unique relationship to the schizophrenia spectrum.     

Personality disorder in the families of depressed, schizophrenic, and never-ill probands

In a blind family study of 176 probands with nonpsychotic major depression, psychotic major depression, schizophrenia, or no history of DSM-III disorders, only the relatives of depressed probands with mood-incongruent psychotic features had a risk for personality disorders higher than that for the relatives of never-ill probands. The authors did not find a high rate of borderline personality in relatives of depressed probands or of schizotypal personality disorder in relatives of probands with schizophrenia or any psychosis. However, depressed probands with normal dexamethasone test results had a significantly higher familial loading for the DSM-III cluster of histrionic, antisocial, borderline, and narcissistic personality disorders.