Schizophrenia Spectrum Personality Disorders

What is Personality?

Personality is not about what disorders you have. Rather, personality is about who you are and how you are, over the course of your life.

Typical personality patterns have been named (e.g., avoidant personality); but these are not disorders. You can imagine someone with a depressive personality might be more likely to have a depressive disorder, but it doesn’t necessarily mean that they are clinically depressed.

“It refers to a person’s characteristics patterns of thought, feeling, behaviour, motivation, defense, interpersonal functioning, and ways of experiencing self and others.”

Shedler

Personality Disorders

No personality type is inherently bad/disordered/abnormal/problematic. Each exists on a continuum of functioning from healthy to severely disturbed.

  • If you think of something like narcissistic personality, we don’t generally think of that as a good thing: however, there are healthy versions of a narcissistic personality!

    • It is when a person becomes manipulative, sees themselves as better than others, or boosts their confidence in a way that can harm other people that they would be moving towards narcissistic personality disorder

Personality disorders — as defined in the DSM — are the most pathological versions of identified personality patterns.

Personality Disorders and Schizophrenia

Personality disorders have been grouped into clusters. For this class, we’re concerned with Cluster A, which describes odd/eccentric personality traits or patterns. Cluster A personality disorders include:

  • Schizotypcal PD

  • Schizoid PD

  • Paranoid PD

It is unsurprising that Cluster A PDs and schizophrenia have some symptom and genetic overlap.

Cluster A Personality Disorders

You’ll see that there is significant overlap across not only the three disorders, but with these disorders and schizophrenia. They can occur before the full-blown psychotic symptoms of SZ appear (e.g., may indicate risk for developing SZ). Schizotypal PD is especially a risk factor for developing SZ. Additionally, schizophrenia spectrum personality disorders:

  • Are more common in family members of people with SZ

  • May have similar genetic and environmental risk factors

  • Are more common in males

  • Tend to be stable across the lifespan

    • E.g., if there has been no progression to true psychosis, as they get older, they will be less likely to develop SZ

  • Are less commonly hospitalized and prescribed anti-psychotics

    • Insight is less common in people with personality disorders

    • These people don’t necessarily seek out treatment

      • In part because they are reluctant to make social contact or are actively mistrustful of other people

Paranoid Personality Disorder

What does Paranoid Personality Disorder Look Like?

People with paranoid personality disorder:

  • Are often cold, distant, and unable to form close, interpersonal relationships

  • Are often overly suspicious of their surroundings without good reason

  • Generally can’t see their role in conflict situations

  • Project their feelings of paranoia as anger onto others

You can see how this would potentially impact a person who then may experience a psychotic episode (e.g., experience more severe delusions)

Paranoid personality disorder is mostly centred around paranoia, seen in people such as cult leaders or conspiracy theorists. Individuals with this disorder are typically more functional that those with schizotypal personality disorder, but still experience impaired relationships with others.

The DSM-5 Criteria for Paranoid Personality Disorder

As the name suggests, paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others that impact all aspects of the person’s life. To be diagnosed with this, an individual must meet at least four of the following DSM-5 criteria:

  • Groundless suspicions that others are exploiting, harming, or deceiving them

    • The keyword here is groundless; this includes things that are clear to friends, family, or the person giving the diagnosis as being unjustified or exaggerated (e.g., no reasonable rationale to be suspicious)

  • Unjustified doubts about the trustworthiness of friends or family

    • This can manifest as conflictual relationships with friends/family

  • Reluctance to confide in others because of unwarranted fear that the information will be used against them

    • Reluctance is not driven by fear of judgement, but rather because they think the information will be used against them

  • Reads hidden negative meanings into benign remarks or events

    • Slight remarks, tones of voice, or random events

    • An example could be an individual thinking that they were gonna be left out from a friend’s party after they receive their invitation a day late

  • Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights)

  • Perceives attacks that are not apparent to others and is quick to react angrily or to counterattack

  • Has recurrent unjustified suspicions about the fidelity of a spouse or partner

The differential diagnosis here is with…

  • Schizophrenia

  • A delusional disorder

  • Drug abuse

    • E.g., amphetamine-induced psychosis

  • PTSD

    • They may become paranoid, but usually have trauma-specific paranoia

  • Bipolar

    • E.g., paranoid delusions in the manic phase

  • Borderline

    • E.g., paranoid ideation

  • Dementia

    • E.g., paranoid ideation; often things like thinking that people are hiding things on them or that their spouses are cheating on them

Paranoid personality disorder is pretty uncommon, occurring in about only 2-4% of the population, and there is commonly co-morbid alcohol and substance abuse.

Schizoid Personality Disorder

What does Schizoid Personality Disorder Look Like?

People with schizoid personality disorder:

  • Are often cold, distant, and introverted, and have an intense fear of intimacy and closeness

  • Absorbed in their own thinking and daydreaming

    • And thereby exclude themselves from attachment to people and reality

You can see that there seems to be a stronger presence of negative symptoms here, especially with social reclusion. You can also imagine a non-pathological version of this, that might consist of someone who avoids social situations and has few friends. Additionally, individuals with this disorder are typically more functional that those with schizotypal personality disorder.

An example of someone with schizoid personality disorder could be someone who runs a junk shop, and spends the majority of their time in the store, and whose only friend is their cat.

The DSM-5 Criteria for Schizoid Personality Disorder

Schizoid personality disorder is mainly characterized by restricted relationships and range of emotions, in addition to shallow relationships and a lack of intimacy or closeness with others. To be diagnosed with this, an individual must meet at least four of the following DSM-5 criteria:

  • Does not desire or enjoy close relationships, including family (e.g., a loner)

  • Almost always chooses solitary activities

  • Has little or no interest in sexual experiences with another person

  • Takes pleasure in few activities

    • Might have a couple of activities they take pleasure in, but don’t express much active pleasure in them

  • Lack close friends or confidants other than first-degree relatives

  • Appears indifferent to the praise or criticism of others

    • Can make them limited employees — they lack the motivation to please others or work as a team, so they tend to do solitary occupations (e.g., night shifts or truck driver)

  • Shows emotional coldness, detachment, or flattened affect

The differential diagnosis here is with…

  • Schizophrenia

  • Depression with psychotic features

  • Autism spectrum disorder

Schizoid personality disorder occurs only in about 3-5% of the population, and there is occasional co-morbid depression — it is less common because most people in isolation would be depressed if isolated, but it doesn’t seem to impact schizoids that much.

Schizotypal Personality Disorder

What Does Schizotypal Personality Disorder Look Like?

People with schizotypal personality disorder:

  • Are often cold, distant and introverted, and have an intense fear of intimacy and closeness

  • Show disordered thinking, perception, and ineffective communication skills.

  • Many symptoms of schizotypal personality disorder look like schizophrenia, but are less intense and intrusive.

An example of someone with schizotypal personality disorder could be a fervent believer in crystals and auras, so much so that they let those beliefs guide their life. This person might:

  • Appear hesitant or uninterested in relationships with other people

  • Exhibit a variety of both positive (e.g., beliefs that are close to delusions) and/or negative symptoms (social disengagement and cognitive limitations).

  • Have a family member with schizophrenia

    • Schizotypal personality disorder is often seen in family members of those with schizophrenia

  • Might later develop schizophrenia, especially if they’re already at risk

    • Schizotypal personality disorder may be a precursor to SZ

This Cluster A personality disorder is generally considered to be the closest to schizophrenia; something that will be examined more closely later in the lesson.

The DSM-5 Criteria for Schizotypal Personality Disorder

Schizotypal personality disorder is characterized by social and interpersonal deficits (e.g., few close friends and reduced interaction with family); cognitive or perceptual distortions (symptoms on the delusional spectrum, but not meeting the full criteria for a delusion), and odd behaviours and beliefs. In terms of genetic and environmental factors, it is considered to be the closest of the Cluster A personality disorders to schizophrenia. This is especially the case because they show the same cognitive deficits as people with SZ. To be diagnosed with this, an individual must meet at least five of the following DSM-5 criteria:

  • Ideas of reference (not true delusions)

    • Such as messages are coded in tv just for them

  • Odd beliefs, or magical thinking that are inconsistent with cultural norms (e.g., belief in ghosts, telepathy, UFOs; bizarre fantasies or preoccupations)

  • Unusual perceptual experiences, including bodily illusions

    • For instance, someone who has ideas of reference, let’s say in things they read, may believe that the letters they read pulsate to indicate that the message is just for them

  • Odd thinking and speech (e.g., vague, circumstantial, overelaborate, repetitive, or stereotyped)

    • Somewhat like thought disorder in SZ, but not to the level of incoherence

  • Suspiciousness or paranoia

  • Inappropriate or constricted affect

    • Silly/paranoid/angry affect

  • Behaviour or appearance that is odd, eccentric, or peculiar

    • Appearance is odd (hairdo, clothing, etc.)

  • Lack of close friends

    • Discomfort in social situations

    • Strange idea about other people

The differential diagnosis for schizotypal personality disorder excludes:

  • Taking place exclusively during the course of SZ

  • Bipolar disorder

  • Depression with psychotic features

  • A different psychotic disorder

  • Autism spectrum disorder

The prevalence is 1-4% of the population, and the most common co-morbid disorder is depression.

Genetics and Environment

Here is some important information about SZ spectrums PDs:

  • They are more common in the offspring of people with SZ    

    • Especially true of those with schizotypal PD

  • Those with schizotypal PD are more likely to have children with SZ

  • Paranoid and schizoid PD are less common in families of people with SZ

  • Some of the same genes associated with SZ are associated with schizotypal personality disorder

  • Similar environmental factors as SZ (such as prenatal stress, maternal illness, birth complications and chronic stress) make it more likely for people to develop SZ spectrum PDs

    • Especially true of schizotypal PD

Cognitive Deficits

Some of the same cognitive deficits we see in SZ are present in schizotypal PD:

  • Many of the same frontal-lobe-related executive function issues like working memory, attention span, and planning deficits

    • Poor performance on…

      • Wisconsin card sorting

      • Verbal fluency

      • Continuous performance tasks

      • Theory of mind tasks

  • This may be linked to dysregulation of frontal dopamine systems similar to that seen in SZ

Brain Changes

Temporal and Frontal Changes (Hazlett, 2008)

In one of the first studies that looked at structural brain changes in schizotypal personality disorder, directed by Elizabeth Hazlett, researchers looked globally at volumes of grey and white matter in the frontal and temporal lobes.

What they found was the following:

  • Temporal Lobe

    • schizotypal PD and SZ individuals showed significantly smaller volumes of grey matter but no significant changes in white matter

  • Frontal Lobe

    • SZ individuals had significant deficits in grey matter, schizotypal PD individuals also showed grey matter deficits but to a lesser extent

Temporal Lobe Volume and Psychotic Symptoms (Goldstein, 2009)

In this study looking at the same group, researchers found that increased positive symptom severity in schizotypal PD individuals is associated with reduced grey matter in the temporal lobe. We saw earlier in the lesson that disruptions in the temporal lobes, or in the dopamine circuits of the temporal lobes relates to positive/psychotic symptoms of SZ; this study focusing on SZ-PD finds a similar association, specifically related to symptom severity.

Spatial Memory (Goldstein et al., 2011)

Another study looked at the idea of spatial memory and executive control deficits in SZ-PD and compared them to individuals with bipolar disorder.

  • The Task: People saw array of squares, and had to keep tapping them until one of them hid a dark blue square, and then had to move that dark blue square into bin. The task involved spatial working memory, but also response selection and inhibition.

  • Groups:

    • Controls

    • Bipolar individuals

    • SZ individuals

  • Measure: They measured the performance of individuals on the task by measuring the errors they made on the task

  • Results:

    • Controls and bipolar individuals has similar scores, whereas schizotypal individuals had more errors

    • Poorer task performance related to a smaller volume of area 44 of the frontal lobe, suggesting executive functioning deficits are indeed present in schizotypal individuals

White Matter Connections in SZ-PD (Lener, 2010)

This study showed that individuals with schizotypal personality disorder had poorer connectivity in the genu of the corpus callosum — the part of the brain that connects the frontal lobes of each hemisphere — which is associated to more positive symptoms on the scale of psychotic-like symptoms in this disorder.