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What are the characteristics of a diagnosis of “schizotypal disorder”, how does it differ from schizophrenia and how is schizotypal disorder treated – says Irina Valentinovna Shcherbakova, Doctor of Medical Sciences, Professor, Psychiatrist.
Until the nineties of the last century, schizotypal disorder was known as “sluggish schizophrenia” or “slow-onset” (“pre-schizophrenia”, “mild schizophrenia”, “pseudo-neurotic schizophrenia”). It is a relatively benign, slowly progressive endogenous process that occurs in one third of all patients with schizophrenia. In the current ICD-10 classification of mental disorders, schizotypal disorder is an independent diagnosis, isolated from schizophrenia. It includes a group of functional mental disorders that occupy an intermediate position between schizophrenia and personality pathology.
In the current ICD-10 classification of mental disorders, schizotypal disorder is an independent diagnosis, isolated from schizophrenia.
Schizotypal disorder includes individuals with impairments in interpersonal functioning, cognition, emotion, and behavioral control who exhibit a genetic predisposition to schizophrenia, so-called “hidden carriers.” The latter are family members of patients with schizophrenia and are distinguished by chronic peculiarities of thinking and communication, and low social activity.
The first signs of schizotypal disorder appear in childhood or adolescence. The provocation that triggers the disease can be psychological stress. Schizotypal disorder is characterized by a gradual, usually imperceptible onset, the absence of pronounced exacerbations and defined remissions, and is chronic and continuous.
As the disease progresses, there is a gradual decline in working capacity associated with a decline in intellectual activity and initiative, impoverishment of emotions and contacts, and deepening social isolation. At the same time, about 30% of patients with schizotypal disorder continue to work, choosing lighter, home-based types of work activities that are more acceptable to them; Some patients become dependents and disabled.
Main symptoms of schizotypal personality disorder
The clinical signs of schizotypal disorder are varied, but some of them are fundamental for diagnosis:
strange beliefs, speech;
strange or magical thinking;
unusual sensations and bodily illusions;
suspiciousness or paranoid thoughts (thoughts of persecution);
inappropriate emotions or lack of emotional response (constricted affect);
strange, eccentric or peculiar behavior or appearance;
lack of close friends or confidants other than first-degree relatives;
excessive social anxiety, which does not decrease after dating and is usually associated with paranoid fears.
These signs can be combined into three groups:
- Cognitive-perceptual deficits: strange beliefs, perceptual disturbances, paranoia or suspiciousness
- interpersonal deficits: lack of close friends, social anxiety, paranoia or suspiciousness
- disorganization: unclear speech or thinking, dulled affect, strange behavior
Additional signs
Along with the main above-mentioned signs of schizotypal disorder, the clinical picture also contains other symptoms in both men and women, which are usually found in neurotic diseases, mood, behavioral or personality disorders.
Neurotic manifestations. The most common disorders in schizotypal disorder include anxiety-phobic symptoms - fears, panic attacks, obsessive-compulsive symptoms; heightened introspection, increased reflection, somatoform phenomena, asthenia. There are often cases of painful concern about one’s physical or mental health (hypochondria) or “mysterious” symptoms and diseases that have not been confirmed by specialists.
Eating disorders. Eating disorders, such as anorexia or bulimia, are quite common.
Mood disorders (affective disorders). Concomitant mood disorders are the rule rather than the exception—long-term, shallow depressions or unreasonable mood elevations (euphoria), long-term or short-term, but without psychotic symptoms.
Behavioral disorders. Aggressive, antisocial behavior, absurd actions, and desire disorders in the form of vagrancy, sexual perversions, and alcohol and psychoactive substance abuse may be observed.
Some of the described disorders become permanent or “axial”; others can replace each other or join existing ones, becoming additional, aggravating the patient’s condition.
Depending on the predominance of certain symptoms, there are several main variants of schizotypal personality disorder:
- pseudoneurotic schizophrenia (external resemblance to neurosis)
- pseudopsychopathic schizophrenia (external resemblance to psychopathy)
- schizophrenia, poor in symptoms (characterized by increasing asthenia and decreased ability to work)
- schizotypal personality disorder
- latent schizophrenia
Comparative characteristics
First of all, a parallel is drawn between SPD and schizophrenia. The symptoms of the diseases are really similar, so with the naked eye it is difficult to distinguish one from the other. However, obvious differences are still present.
Although schizotypal disorder has many features similar to schizophrenic disorder, its course is more favorable.
Symptoms in patients with schizophrenia are more intense. Hallucinations and delusions are persistent, obsessive, and force a person to break away from reality. A persistent personality defect is formed. The intellectual sphere suffers to a greater extent, manifesting itself in illogicality and absurdity of thinking. The disease leaves a negative imprint on a person’s consciousness.
Schizoid and schizotypal personality disorders are very similar. The diseases can be called related. The distinctive criterion is still the same intensity of expression, only now the “blanket over itself” is pulled by the SPD. The disease includes illusory, mild hallucinatory manifestations, and other psychotic symptoms. In schizoid disorder, changes affect more the emotional sphere.
A common thread running through both disorders is emotional shifts: alienation and emotional coldness. Sensory disturbances stand out sharply against the background of both conditions, which makes diagnosis difficult.
But if schizoid disorder manifests itself in childhood, then the schizotypal personality appears at an older age.
A young man, 21 years old, tells his medical history: “Just recently, everything was fine with me. He had a great respect for physics and took part in Olympiads. He became interested in microbiology and entered medical school. At the same time, I played the guitar and studied foreign languages (I speak three). Suddenly everything stopped abruptly. I didn't want to do anything. I abandoned my studies and then my hobbies. Soon he dropped out of life.”
Since schizotypal disorder is accompanied by obsessive actions, it is differentiated from obsessive-compulsive disorder. Hallucinatory manifestations make it possible to compare the disease with paranoid states.
The disorder is similar to autistic diseases due to its detachment from social contacts and stereotypical behavior.
Due to its wide range of symptoms, SPD has been associated with many diseases. Experts do not recommend using the diagnosis everywhere, since its recognition is difficult.
To make a diagnosis, the International Classification of Diseases has approved criteria, of which a person must have at least 4 over the past two years:
- emotional detachment;
- pretentious behavior;
- avoidance of social contacts;
- magical thinking;
- paranoid tendencies;
- obsessive thoughts without attempts to resist on sexual, aggressive topics, dysmorphophobic thoughts;
- derealization, depersonalization;
- psychotic episodes: illusions, hallucinations, delusions without external intervention;
- detailed, stereotypical thinking, intricate speech.
Differences between schizotypal disorder and schizophrenia in psychiatry
The diagnosis of “schizotypal disorder” excludes severe psychotic disorders characteristic of schizophrenia, among them: delusional, hallucinatory, movement disorders (catatonia), clouding of consciousness.
In addition, with schizotypal disorder there are never such severe outcomes as with schizophrenia, for example, apathetic-abulic dementia.
In addition, with schizotypal disorder there are never such severe outcomes as with schizophrenia, for example, apathetic-abulic dementia.
Causes of schizotypal disorder
Genetic reasons. The external clinical similarity of schizotypal disorder with other mental illnesses may be explained by hereditary factors. Scientists have discovered a number of common genetic abnormalities with schizophrenia, bipolar affective disorder and personality disorders (psychopathy). For example, the genetic contribution explains the exceptionally high level of characteristics characteristic of patients: strange appearance and behavior, aloofness, and lack of close friends. The genetic commonality of schizotypal disorder and schizophrenia also causes some cognitive deviations that relate to attention and memory.
Environmental factors. The causes of schizotypal disorder are associated not only with heredity, but also with factors unfavorable for the development of the fetus, psychological trauma in early childhood, and chronic stress. In particular, maternal influenza during the sixth month of pregnancy was associated with higher levels of schizotypal symptoms in the adult male population. Serious risk factors for the development of schizotypal disorder in youth may include malnutrition of the pregnant mother and child under three years of age, a history of child abuse, emotional abuse (including bullying and post-traumatic disorder), neglect, and neglect, especially with a corresponding genetic background.
The combination of various adverse effects leads to disturbances in the neurochemical balance in the brain, hormonal and immune abnormalities, which determine the clinical picture and accompany schizotypal personality disorder.
First signs
First of all, it is worth noting that schizotypal disorder and schizophrenia are different conditions. In the first case, borderline pathology is observed, which actually has manifestations similar to schizophrenia. Experts often call schizotypal disorder one of the varieties of low-grade schizophrenia.
It is impossible to identify such a disorder using laboratory tests. They are carried out to identify the physical causes of “incomprehensible” behavior. If none are identified, the child may be referred for consultation to a psychotherapist or psychiatrist.
Children with schizotypal disorder may exhibit a wide variety of behaviors.
- Children are very categorical in their statements. They often make promises that include the words “never” or “always,” but they fail to fulfill their promises. Such violations of promises become chronic.
- Schizotypal disorder is often expressed in hypertrophied perception and resentment. There may be outbursts of anger towards parents and family members.
- Avoiding communication with other people is a kind of defensive reaction. In this way, children with mental problems reduce the level of responsibility for their actions and the likelihood of receiving criticism or rejection from others.
- With schizotypal disorder, people are prone to excessive “catastrophizing.” They assume the worst-case scenario, and as a result, they refuse to take any action.
- Children with schizotypal disorder are surrounded by chaos. They create chaos, destroy everything around them, and create conditions for risk.
- Cyclicity of reasoning. The flow of thoughts goes on endlessly, while speech contains patterns that repeat one after another.
- Denial of events from the past that have become painful or traumatic for the child.
- The inability to take care of oneself and painful dependence on an adult. This applies to both emotional well-being and physical condition, as well as the need to make decisions independently.
- Depression may also indicate the presence of a mental disorder.
- With schizotypal disorder, children undeservedly expect the people around them to create more favorable conditions. The perception of one's own rights is violated; as a result, the child may develop favoritism - the habit of receiving a special position in any environment.
- Rich imagination leads to the fact that the child begins to invent events and believe in them. This is how he creates a different, happier life for himself and escapes from reality.
- Sudden mood swings, especially often they occur during family holidays or other events that evoke strong emotional experiences and memories.
- When upset, the child begins to show hypervigilance. He shows interest in other people's comments and thoughts, as well as the behavior of others. In addition, there may be an overreaction to disappointing events. Such hysteria is a way to distract oneself and others from real problems.
Other alarming symptoms include low and inadequate self-esteem, perfectionism and pathological lying. In a child with schizotypal disorder, manifestations of pathology are periodic. In moments of clarity, he may feel the “wrongness” of his behavior and even try to make amends to others. But most often, patients with schizotypal disorder deny that they have problems.
But these signs are not diagnostic criteria - some of them may indicate pedagogical neglect, excessive spoiling of the child, or the presence of other mental problems. In any case, such behavior of the child should alert parents and become a reason to contact specialists to provide professional help.
Diagnosis of schizotypal disorder
The diversity and multicomponent nature of symptoms in men and women with schizotypal disorder in psychiatry creates difficulties in diagnosis. Outwardly, patients may exhibit anxiety or "neurotic conflicts" that are determined or aggravated by "hidden" magical ideas, strange beliefs, or overvalued ideas. Therefore, schizotypal patients are often initially diagnosed with attention deficit disorder, social anxiety disorder, autism, dysthymia, neuroses, bipolar disorder, depression, and psychopathy.
Only a psychiatrist can establish a diagnosis of “schizotypal disorder” and give a prognosis after appropriate clinical examinations of the patient, obtaining objective information regarding his behavior and manifestations of the disease from close relatives.
Only a psychiatrist can establish a diagnosis of “schizotypal disorder” after appropriate clinical examinations of the patient, obtaining objective information regarding his behavior and manifestations of the disease from close relatives.
Additional methods will improve the quality and reliability of diagnosis - pathopsychological, neurophysiological examinations, blood tests to identify markers of the activity and severity of a mental disorder (for example, Neurotest).
Thanks to a pathopsychological examination (conducted by a psychologist), the characteristics of cognitive processes, the emotional-volitional sphere, and personal characteristics are revealed, which form the psychological portrait of the patient along with pathological traits caused by schizotypal disorder. Neurophysiological examination gives an idea of the degree of damage or distortion of cognitive functions, the degree of reserve and compensatory capabilities of the brain.
The neurotest includes several indicators that reflect the state of the immune system involved in the formation of schizotypal disorder and other schizophrenia spectrum disorders. Certain combinations of deviations in indicators indicate a specific variant of the disease, suggest its prognosis, the degree of severity, severity of the condition and the effectiveness of the therapy.
Where does the disease begin?
Schizotypal disorder arose from schizophrenia, subsequently emerging as a separate illness. Bleuler, in addition to the vivid schizophrenic symptoms identified by Kraepelin, drew attention to milder forms of the disease, from which its primary names come: latent, sluggish, non-psychotic, sanatorium schizophrenia.
There is a close connection between the inheritance of schizotypal disorder from close relatives with schizophrenia. In this case, the risk of acquiring the disease increases significantly.
About 3% of our planet's population is affected by the disease. It occurs more often in men than in women.
The disease begins with banal apathy:
- prostration;
- increased drowsiness;
- fast fatiguability;
- lack of motivation to action;
- brokenness;
- lethargy.
Such a bouquet inevitably harms performance. First, the individual loses the desire for self-realization and interest in professional activities. He does everything through force - it costs him unimaginable emotional and intellectual effort. Broken by stress, a person loses his job.
The schizotypal person is deprived of aspirations, desires, and gives up his favorite activities. Becomes lack of initiative. It is really difficult for the patient to carry out any actions, even the most minimal ones. From the outside, such behavior is perceived as laziness. People around them can be angry with a person, encourage him to act, try to convict a schizotypal person of weak will, and call him a weakling. But everything is to no avail: the patient simply cannot work.
Asthenic disorders are accompanied by senesthesia and senestopathy. Senesthesia refers to non-standard sensations in the motor sphere that are difficult to interpret. The sufferer is observed to have an unnatural gait: swaying from side to side, legs tangling. Hands hang like whips, head drooping.
Senestopathies are unpleasant, indescribable sensations in the body. The patient draws them artistically:
- feet burn with fire;
- the head is boiling like in a frying pan;
- It’s hard to breathe, as if your throat is being squeezed in a vice.
When unusual sensations appear, physical pathologies are excluded.
Apathetic disorders contribute to the development of gentle behavior. In order not to waste energy, the schizotypal person gets rid of unnecessary actions. Gradually he adapts to a limited life, albeit at a lower social and professional level.
Another category of patients, on the contrary, exhibits overcompensation, finds an absorbing hobby, and plays sports to the point of exhaustion. Still others resort to drugs and alcohol. Everyone is looking for their own way of adaptation.
When pathological changes grossly change personality, a person becomes maladapted in society. In this case, he loses the ability for minimal productive functioning, even to the point of disability.
Treatment of schizotypal disorder
Treatment of schizotypal disorder should begin as early as possible and be comprehensive. Timely diagnosis and adequately selected therapy not only reduce painful symptoms, but also reduce the risks of developing complications in the form of loss of ability to work, social isolation, loneliness, the transition of a slow-moving disease process into more severe forms of schizophrenia, the emergence of addictions, and suicidal tendencies.
Complex therapy is an effective combination of psychotropic drugs and psychotherapeutic techniques. Remember! Only a qualified psychiatrist knows how schizotypal disorder is treated.
Drug therapy. Drugs of various pharmacological groups are used - antipsychotics, antidepressants, mood stabilizers, tranquilizers. Specific regimens are selected individually, taking into account the clinical picture, duration of the disease, and state of physical health. Treatment is long-term: after relief of current symptoms, maintenance therapy is carried out.
Psychotherapy. Supervision of the patient by a psychotherapist is mandatory to obtain a positive and stable result. Unlike schizophrenia, with schizotypal disorder the use of almost all known types of psychotherapeutic techniques is permitted. During sessions with a psychotherapist, the necessary skills are developed to cope with symptoms, maintain social connections, form attitudes to activate volitional and motivational impulses, and correct pathological personal characteristics. Psychotherapeutic sessions have an important psychoprophylactic value, helping to increase the stress resistance of patients and prevent self-aggressive behavior.
Unlike schizophrenia, treatment for schizotypal disorder involves the use of almost all known types of psychotherapeutic techniques.
Primary prevention of schizotypal disorder in children involves early environmental enrichment. This includes exercise, cognitive stimulation and improved nutrition between three and five years of age, which improves brain function and reduces the likelihood of developing the disease in youth.
