Schizotypal personality disorder

Schizotypal personality disorder is a pathological condition that belongs to schizophrenic spectrum disorders and is a severe form of borderline psychopathology. The disorder has a negative impact on the social adaptation of patients and entails regular hospitalization in a psychiatric clinic. It is included in the International Classification of Diseases (ICD-10) in the same category as delusional disorders and schizophrenia. [1]

Epidemiology

The prevalence of schizotypal personality disorder can range from 3 to 4% (according to different authors). More often men than women suffer from the pathology. The first signs mainly debut at the age of 15 to 25 years.

In most cases, schizotypal disorder occurs among close relatives (hereditary predisposition).

The disorder is perceived not only as a milder "pre-schizophrenic" state, but also as a pathology underlying the development of schizophrenia. Statistics indicate that the disorder is much more common in schizophrenic patients than in people with any or no other psychiatric pathology.

Experts note that schizotypal personality disorder is a phenotype that allows tracing the chain of genetic inheritance of genes involved in the formation of schizophrenia. [2]

The most common comorbidities are depression, social phobia, dysthymia, and obsessive-compulsive disorders. [3]

Causes of the schizotypal personality disorder

The exact causes of the development of schizotypal personality disorder are unknown. Specialists identify several factors that contribute to the start of pathological changes:

• hereditary predisposition, the presence of relatives with a similar disorder;
• Dysfunctional family atmosphere, alcoholic or drug-addicted parents, etc;
• severe psychological trauma;
• intrauterine disorders, fetal hypoxia or intoxication, birth trauma, and severe labor;
• A characteristic or temperamental tendency to develop such disorders.

Risk factors

The development of schizotypal personality disorder is associated with risk factors such as:

• male gender;
• Aggravated hereditary history, especially on the maternal side (both schizophrenia and other psychopathologies, especially affective disorders). [4]

Additional factors also increase the risks of schizotypal disorder:

• life in the city (in rural residents the pathology occurs much less frequently);
• childhood psychological traumas;
• migration (especially forced migration);
• head injuries;
• drug abuse, taking psychoactive drugs, alcoholism.

Pathogenesis

Presumably, schizotypal personality disorder can be categorized as a disorder with an inherited predisposition. The accumulation of psychotic and personality anomalies in individual families can be traced, although the type of inheritance is still unclear. At the same time, the unfavorable influence of external factors, as well as biological failures due to somatic pathologies, age and endocrine problems, cannot be ruled out.

The specific pathogenetic mechanism has not yet been established, although there is a theory of a primary disorder of neurotransmitter metabolism. At the moment, a number of biological defects have been practically clarified, which consist in the production in the body of certain antibodies that damage brain tissue, although this assumption is still at the stage of hypothesis. It is possible that the neurochemical balance in brain structures is disturbed, the hormonal balance is disturbed and the immune system is not working properly. [5]

Biological reactions can be compared to those that occur in patients with schizophrenia. Structural brain changes may include the following processes:

• the anterior hippocampus is shrinking;
• shrinks the cerebral cortex;
• all the cerebral sections are reduced, and the ventricles, on the contrary, are enlarged.

Additionally, neurochemical shifts are detected - in particular, glutamate and dopamine transmissibility is impaired. [6]

Symptoms of the schizotypal personality disorder

Schizotypal personality disorder is accompanied by multiple symptomatology. Which of these symptoms will be manifested to a greater or lesser extent depends on individual characteristics and personality organization. The main manifestations of pathology are as follows:

• inferences that are extremely difficult or impossible for a healthy person to comprehend;
• strange speech, answers that are far from the question asked, statements that have nothing to do with the subject of the conversation;
• A penchant for mystical explanations of what is going on, magical rituals and endeavors;
• paranoid thoughts, a tendency toward delusions of persecution;
• inappropriate emotions (inappropriate sobbing, sudden unexplained laughter, etc.);
• eye-catching social behavior, flamboyant clothing;
• preference for solitude, avoidance of friendly contacts.

When communicating with a psychotherapist or psychiatrist, one notices an anxious state, the presence of illusory and imaginary feelings.

The first signs may be noticed long before the main symptoms appear.

• Neurosis-like states, periodic panic and asthenic attacks, phobias. The patient may overly "listen" to his self-perception, pathologically worry about his health, invent the existence of any diseases, hypertrophy symptoms and complaints.
• Eating disorders, the emergence of food addictions, attacks of anorexia and bulimia.
• Mood instability, frequent "jumps" of depressive and euphoric states, without connecting psychotic manifestations.
• Unpredictable behavior, bouts of aggression, antisociality, attempts of sexual perversion and vagrancy, tendency to drug abuse, use of psychostimulants.

It is not always possible to detect all symptoms of an emerging schizotypal personality disorder at once. Moreover, the clinical picture can change, some manifestations are replaced by others, combined, appear or disappear. [7]

Schizotypal personality disorder in children

It is difficult to diagnose schizotypal personality disorder in early childhood. It is often mistaken for autism. The probability of making the correct diagnosis increases with age - closer to puberty, when more specific characteristic signs appear. Parents are advised to pay attention to such manifestations:

• The baby tries to eat or drink only from certain utensils. When parents try to change the cup or plate, a panic attack or tantrum occurs.
• The child adheres only to the strict order of things established by him. If parents rearrange furniture or move toys, it will lead to an attack of aggression, strong irritation, anger.
• If in a familiar game are used unusual for the child actions, he will immediately respond to it with panic, aggression, sharp refusal to participate.
• The baby's motor coordination is poorly developed: the infant often falls, walks clumsily, etc.
• Seizures in a child last for a long time, it is quite difficult to calm him down. Almost all attempts of an adult to improve the situation are perceived "in the back", which is accompanied by crying or a new attack.

You should not expect repeated attacks of schizotypal disorder. At the first suspicion, you should consult a specialist.

Schizotypal personality disorder in adolescents

To consider schizotypal personality disorder in a teenager is somewhat easier than in an infant, but even here there can be considerable problems. It is possible to diagnose the pathology only as the behavioral changes increase, and it does not manifest itself immediately and not in everyone.

Typical signs become:

• Limiting socialization, avoiding peers and other familiar and unfamiliar people;
• A preference for an observational stance in lieu of participation in activities;
• visiting only famous places.

Early manifestation of the disease leads to the fact that children suffering from schizotypal disorder become objects of ridicule, and later even rejected by society, which further aggravates the situation. As a result of the lack of self-defense skills - there are attacks of aggressive behavior, irritability, anger, isolation, alienation.

Schizotypal personality disorder in men

Schizotypal personality disorder is much more common in males than in females. The initial symptomatology is more often detected already in childhood and especially in adolescence. At the same time, due to the gender-specific features of the mental warehouse "male" disorder is always more pronounced. The patient closes in on himself, immersed in his inner world. Outwardly looks little emotional, does not empathize and does not worry about other people. Sociophobia dominates among phobias.

In addition to insufficient socialization, men have early difficulties with their personal life and employment. An increased tendency to suicide, drug and alcohol addiction is formed. In some cases, full-blown schizophrenia develops, and then the patient may already pose a danger to society and surrounding people.

Schizotypal personality disorder in women

In childhood, the formation of schizotypal personality disorder is less noticeable in girls, in contrast to boys. Girls in most cases are fully developed, cognitive and intellectual deficiency is expressed little. In some cases, reticence and aloofness are mistaken for excessive shyness and timidity.

The first pathological signs are detected as they grow older, closer to adolescence, when the hormonal background begins to fluctuate. Most patients are diagnosed with the disorder only after 16-17 years of age.

Deterioration of the condition is usually observed:

• after a lot of stress;
• with pregnancy, postpartum;
• with somatic illnesses;
• after undergoing surgery;
• with the onset of menopause.

Many women develop severe depression over time, and in 20% of cases there is an addiction to alcohol or drugs.

Stages

Schizotypal personality disorder can go through three stages in its course:

1. Initial (latent, not showing any obvious symptoms).
2. Acute (accompanied by pronounced symptomatology).
3. Persistent or residual (characterized by persistent personality degradation with permanent impairment).

Degradation of personality in schizotypal disorder occurs gradually but persistently. The patient becomes indifferent, loses the ability to experience any feelings, ceases to orient in space. Possible attacks of aggression, during which he poses a threat to people nearby. Since the disease progresses slowly, the patient approaches complete degradation only when the disorder begins to develop rapidly from early childhood. Timely treatment makes it possible to achieve a stable remission. [8]

Complications and consequences

There is a certain correlation between the probability of the development of adverse effects and the age of manifestation of schizotypal disorder. If the pathology first manifested in childhood (before adolescence), the most frequent delayed complications are alcohol and drug addiction. The formation of behavioral deviancy is also possible: a person avoids social norms and rules, does not try to establish a personal life, does not realize himself in the professional sphere, does not know how and does not want to adapt to the social environment and engage in any work. Often such people become criminals, vagabonds, adventurers, swindlers.

However, if we compare schizotypal personality disorder and schizophrenia, the former has a more favorable prognosis: many patients have a chance of partial recovery of social function, although there is no stable complete cure. A series of schizotypal attacks may cease, the condition normalizes, but it is usually not possible to preserve personality changes. In some cases, schizotypal disorder transforms into schizophrenia. [9]

Diagnostics of the schizotypal personality disorder

It is quite difficult to diagnose schizotypal personality disorder, primarily due to the variety of symptoms. To make the correct diagnosis, the specialist has to spend a lot of effort and time. The main areas of diagnostic expertise:

• Assessment of complaints and painful manifestations (complaints of both the patient and his/her environment are assessed);
• study of the patient's life history, as well as that of his relatives;
• The patient and his/her family and friends (if any) are examined and talked to.

The specialist performs testing and instrumental diagnostics as clarifying measures:

• Neurophysiologic procedures (electromyography - stimulation, needle, and electroencephalography).
• Neurotesting, psychopathologic studies (application of tests aimed at assessing the likelihood of forming mental disorders).

Laboratory tests can be performed as part of the diagnosis of the consequences of perinatal lesions of the central nervous system in young children. With the help of certain technologies, it is possible to assess the severity of destructive intracerebral processes, to determine the effectiveness of therapy. These diagnostic measures include finding out certain immunologic values of blood plasma, including leukocyte elastase activity, alpha1-proteinase inhibitor and indices of idiotypic and anti-idiotypic autoantibodies to protein structures of nervous tissue. Comprehensive evaluation of these values makes it possible to determine the degree of destructive process in brain tissue and is a valuable addition to the general clinical neuropsychiatric examination of children. [10]

Differential diagnosis

Schizotypal personality disorder has to be distinguished from other similar pathological conditions:

• attention deficit hyperactivity disorder;
• symptomatic phobic disorders;
• some varieties of autism;
• of neuroses and neurosis-like conditions;
• of bipolar disorder;
• of depressive states;
• psychopathic personality change.

If you compare schizoid and schizotypal personality disorder, the differences are quite obvious:

For schizoid personality disorder: the patient is emotionally cold, distances himself from others; is not able to express either warm and tender feelings or anger towards others; outwardly indifferent to both praise and criticism; shows no sexual interest; prefers privacy; Does not build or seek trusting relationships; does not adhere to social norms and rules.

For schizotypal personality disorder: the patient looks strange, eccentric, characterized by mannerisms; can talk to himself, is extremely superstitious, often confident in his own powers of divination and telepathy; communicates only with his immediate family, has no friends; Speech is poor, abstract, incomprehensible to others, without definite associations and connections; There are manifestations of obvious anxiety in forced contact with strangers; tends to be extremely suspicious and paranoid.

Previously, specialists identified schizotypal and borderline personality disorder, which was defined as borderline schizophrenia. Today, these concepts are considered separately from each other. Thus, for schizotypal disorder is more characterized by such criteria as restraint and inadequacy of affect, unusual perceptual phenomena. For the term borderline disorder, impulsiveness, tension and instability of relationships, and violation of self-identity are more relevant.

Schizotypal personality disorder or anxiety disorder is often confused with such a disorder as sociopathy. The problem represents a banal disrespect for social norms and rules, but excludes social withdrawal. Dependent personality disorder also has a similar symptomatology. The difference is that the "dependent" patient feels a phobia of separation, and "anxious" on the contrary, a phobia of establishing contact. Patients with schizotypal personality disorder may additionally suffer from social anxiety, listening carefully to their own feelings during social contact. This results in an extreme degree of tension, and speech becomes even more incomprehensible. [11]

Treatment of the schizotypal personality disorder

Treatment for schizotypal personality disorder usually includes drug therapy and psychotherapy.

Medication is predominantly symptomatic. It consists in the use of low doses of neuroleptics, tranquilizers and antidepressants, which together alleviate symptoms, contribute to the stabilization of thought processes and normalize mood.

Individual and group sessions with a psychotherapist help to acquire skills to build trusting relationships with others, reduce the degree of emotional coldness, contain pathological manifestations.

It should be taken into account that patients with schizotypal personality disorder almost never realize the fact that they have a disorder. Therefore, in most cases, treatment begins with the involvement of close relatives, parents. The therapeutic activities begin with individual conversations with a psychotherapist, and then - trainings, practices to form the necessary communication skills, the ability to make decisions and perform tasks. [12]

Patients with schizotypal personality disorder are prescribed the same medications as for schizophrenia.

If the patient has periodic subpsychotic attacks, then low doses of such drugs are used:

• Haloperidol in a daily amount of 2-5 mg (exceeding the dosage is fraught with the development of psychosis, hallucinations, intensification of psychotic disorders);
• Diazepam in daily amounts of 2-10 mg (may cause dry mouth, heartburn, nausea, decreased blood pressure, tachycardia);
• Risperidone - up to 2 mg per day (prolonged use may cause insomnia, anxiety, headache, drowsiness, less often - extrapyramidal symptoms).

If a depressive state develops, it is appropriate to prescribe antidepressants - in particular, Amitriptyline, Fluoxetine.

Pergolide (a _{dopamine-D1-D2-receptor} agonist) and Guanfacine (an alpha2A-adrenoreceptor agonist) are indicated to improve cognitive function.

In apathetic states, increased fatigue, lack of initiative, impaired concentration of attention may be prescribed psychostimulants.

The use of increased doses of neuroleptics is inadmissible, as it may provoke the development of a secondary symptom complex.

Do not "self-prescribe" medications, as well as stop taking antipsychotic drugs or change dosages without consulting a doctor. Treatment should be canceled only after the doctor's instructions, gradually reducing the dose. It is inadmissible to abruptly stop taking such drugs.

Prevention

Preventive measures, first of all, should concern people who have an aggravated heredity. An important etiologic factor is various brain injuries, including at the stage of intrauterine development. Taking this into account, it is necessary to take sufficient care of the health, nutrition, emotional calmness of the pregnant woman, which helps to avoid increased vulnerability of the central nervous system in the process of fetal development.

Various infectious diseases, especially those that occur in the 5th-7th month of pregnancy, have an unfavorable effect on brain development. Infections such as rubella, influenza and poliomyelitis are particularly dangerous.

Among obstetric factors that increase susceptibility to schizotypal personality disorder, the leading ones are Rh incompatibility, hypoxia and trauma during labor, low birth weight, and preeclampsia.

It is important to avoid drugs and alcohol during adolescence.

Social skills should be developed from childhood, social isolation should be avoided, adequate relationships with people should be developed and life should be viewed from a positive perspective.

In families whose members are susceptible to the development of such disorders, it is necessary to build calm and stable relationships, without excessive emotional outbursts, physical violence, and uncontrollability. It is necessary to devote time to the formation of conflict resolution skills in children.

The most important areas of prevention:

• The child's acceptance of self as an individual;
• active time;
• Emotion and stress management;
• non-use of drugs, stimulants, abstinence from alcohol;
• an opportunity to speak out, to express yourself;
• The ability to ask for help and to help.

Forecast

Schizotypal personality disorder is an unpredictable pathology, and it is practically impossible to predict its course in advance. With a mild, shallow disorder, the patient may live a long life, almost unaware of the problem, and the disorder itself will not worsen and will not manifest itself fully. Surrounding people will perceive such a patient as an unusual or simply uncommunicative person.

It is not uncommon for the period of initial symptomatology to pass, the disorder does not worsen, and a persistent remission occurs (under favorable conditions).

However, an acute course, without any period of precursors, with regular exacerbations, increasing and progressive symptomatology, up to the subsequent development of schizophrenia, is not excluded.

Timely competent diagnosis and the right approach to treatment can curb the pathology and subsequently establish control over it.

Disability

It is quite difficult for patients with schizotypal personality disorder to receive disability. In fact, this issue is resolved positively only in extremely difficult cases, when a person has almost no chance to live a relatively normal life and get a job. However, not everyone can acquire the status of a disabled person. The following grounds for assigning disability to a patient with schizotypal disorder are possible:

• The disorder is complicated by schizophrenia that persists for more than 3 years with no signs of improvement;
• There are frequent relapses with hospitalization;
• lacks any kind of self-criticism;
• is hypersensitive to sound and light effects;
• outbursts of aggression occur, and the person is capable of harming themselves or others;
• the patient is completely withdrawn, aloof, doesn't communicate with anyone;
• the person loses all or part of their ability to care for themselves.

The question of assigning a particular disability group to patients with schizotypal personality disorder is decided on a strictly individual basis.

Army

Schizotypal personality disorder often does not require constant medication and psychotherapeutic treatment, so in many cases it does not exclude the possibility of military service. Only in the presence of obvious and severe pathological conditions is it possible to decide on incapacity.

If the psychiatrist in the military enlistment office assumes the presence of pathology, he issues a referral for inpatient diagnostics. However, this can happen only if the symptoms are very pronounced, which is not very often. If the conscript by the time of the visit to the military recruitment center is already registered in the psycho-neurological dispensary, then the issue is solved individually, in the course of joint consultation with the attending physician. In such a situation, the guardians must first of all provide the military recruitment center with medical documentation with the diagnosis and the court decision on the incapacity of the conscript. It should be understood that without the appropriate documentation, the diagnosis of "schizotypal personality disorder" alone is not a reason for exemption from military service for health reasons.