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Case study: Behavioral Appearance Behavioral Appearance

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To those who find themselves in contact with schizotypal individuals' they often range appearing eccentric and aberrant to outright bizarre in their actions. Their behavior is clearly erratic. School and employment histories of these individuals show marked deficits and irregularities. Not only are they frequent dropouts, but they drift from one source of employment to another. If married, they are often separated or divorced.

At times, their behavior appears eccentric, that is, they prefer social isolation and may engage in activities that other find curious. In more severe cases, their behavior may seem clearly bizarre. The presence of odd speech patterns is an example. Schizotypal individuals may verbally digress or become metaphorical in their expressions. According to the DSM-III, "Often, speech shows marked peculiarities; concepts may be expressed unclearly or oddly or words used deviantly, but never to the point of loosening of associations or incoherence (American Psychiatric Association, 1980, p. 312)

Interpersonal Conduct

Interpersonally, schizotypals experience a life of isolation, with minimal personal attachment and obligations. As their lives progress it is not uncommon to find these individuals drifting into increasingly superficial and peripheral social and vocational roles. These individuals have virtually no close friends or confidants. They have great difficulty with face-to-face interaction. They commonly experience intense social anxiety at relatively minimal social challenge. For these reasons, we believe the interpersonal conduct of schizotypals may be categorized as ranging from being interpersonal detacted and secretive to inaccessible.

Cognitive Style

The cognitive style of schizotypal individuals may be ruminative and autistic in less severe variations to blatantly deranged in more severe forms of the disorder. The cognitive slippage and interference that characterize the thought processes of this disorder in its milder forms are simply amplified here. Schizotypals are frequently unable to orient their thoughts logically. They tend to become lost in a plethora of irrelevancies. Their thinking appears scattered and autistic as the disorder manifests itself in its more severe variations.

According to the DSM-III, these individuals may report "magical thinking" (i.e., clairvoyance, telepathy, a sixth sense, or just extreme superstitious behavior). Similarly schizotypals may experience recurrent illusions where they report the presence of a person or force not actually there. Psychotic thought, when it does occur, is transient and not indicative of a diagnosis of schizophrenia.

Affective Expression

The deficient or disharmonious affect of many of these patients deprives them of the capacity to relate to people, places, or things as anything but flat and lifeless phenomena. Their affective expression ranges from being apathetic to insentient and deadened. On the other hand, some schizotypal individuals seem in a constant state of agitation. Their affective expression ranges from being apprehensive, perhaps even frantic in their affective expression. We will present more on these clinical variations later.

Self-Perception

Schizotypal individuals often view themselves as forlorn and lacking meaning in life or, in more severe cases, on introspection, they may see themselves as vacant. They may experience recurrent feelings of emptiness or of estrangement. Experiences of depersonalization and dissociation may also be present in these patients. In sum, schizotypals appear virtually "self-less" as they look inward towards self-appraisal.

Primary Defense Mechanism

The schizotypal personality disorder is characterized by extreme social and affective isolation as well as autistic and bizarre cognitive functioning. The defense mechanism commonly used by individuals who possess this disorder is undoing.

Undoing is a self-purification mechanism in which individuals attempt to repent for some undesirable behavior or "evil" motive. In effect, undoing represents a form of atonement. In severly pathological forms, undoing may take the form of complex and bizarre rituals, or "magical" acts. These rituals, such as compulsive hand washing, are designed to cleanse or purify the individual. These compulsions not only cause these individuals discomfort, but they may also consciously recognize them as absurd. Nevertheless, individuals employing such a mechanism appear to have lost the ability to control these acts as well as the ability to see their real meaning.

Differential Personality Diagnosis

The schizotypal personality disorder is likely to be confused with another severe personality disorder, the borderline disorder. Both the schizotypal and the borderline patterns represent severe personality disorder. Furthermore, according to the present biosocial learning theory, they both emerge when the less severe personality variants decompensate. Yet, there are marked differences in these two disorders.

The schizotypal disorder features schizophrenic-like symptoms. These symptoms reflect disturbances in cognitive processes. Thus, the schizotypal is characterized by perceptual pathology as well as social withdrawal and isolation.

The most obvious feature of the borderline disorder, on the other hand, is instability of mood. The symptoms of the borderline reflect disturbances in affect rather than cognitive. Finally, the borderline individual is interpersonally dependent, unlike the socially isolated schizotypal.

A final note should be made regarding the schizotypal disorder in contrast to the Axiz I schizophrenic disorders. Axis I disorders are characteristically more severe and of relatively shorter duration. The Axis II schizotypal disorder represents the operation of internal, ingrained, and more enduring defects in the patient's personality. Although schizophrenic episodes often reflect a psychosocial stressor, the schizotypal disorder represents an underlying and persistent characterological pattern.

CLINICAL VARIATIONS

The description of the schizotypal personality disorder presented in the previous section portrays the generic aspects of this disorder. It is more common, however, to see the schizotypal pattern manifest itself in one of two major variations. The two major clinical variations of the schizotypal disorder are (1) the schizotypal-schizoid pattern and (2) the schizotypal-avoidant pattern.

Schizotypal-Schizoid Variation

Schizotypal-schizoid individuals are characteristically drab, sluggish, and inexpressive. They display a marked deficit in their affective expression and appear bland, untroubled, indifferent, and unmotivated by the outside world. Their cognitive processes seem obscure and vague. Such individuals seem unable to experience the subtle emotional aspects of social exchange. Interpersonal communications are often vague and confused. The speech pattern of these individuals tend to be monotonous, listless, or at times, inaudible. Most people consider these individuals as strange, curious, aloof, and lethargic. In effect, they become background people satisfied to live their lives in an isolated, secluded manner. Case 11.1 portrays such an individual.

Schizotypal-Avoidant Variation

Schizotypal-avoidant individuals are restrained and isolated. Similarly, they are apprehensive, guarded, and interpersonally withdrawing. As a protective device, they seek to eliminate their own desires and feeling for interpersonal affiliation, for they expect only rejection and pain from interacting with others. Thus, apathy, indifference, and impoverished thought, which we saw in the cognitive and affective insensitivity, is presented here as a result of an attempt to dampen an intrinsic oversensitivity. The case of Harold T. is a study of a schizotypal-avoidant individual.

SELF-PERPETUATION OF THE SCHIZOTYPAL PERSONALITY DISORDER

The prognosis for the schizotypal personality disorder is perhaps the least promising of all the personality disorder discussed in this text. Let us examine why.

The self-perpetuating spiral of deterioration that occurs in the schizotypal disorder is fostered by three major factors: (1) social isolation, (2) dependency training, and (3) self-insulation.

Social Isolation

Individuals who possess the schizotypal disorder are often segregated from social contact. They are kept at home or hospitalized with minimal encouragement to progress on a social basic. Social isolation such as this serves not to perpetuate the difficulties these individuals have with cognitive organization and social skills, but also serves to worsen the status of both. In many instances, the social isolation seems to stimulate a regression on the part of these individuals. They will tend to lose what cognitive and social abilities they may have had before the isolation. Jane W. was clearly capable of returning to society if she had been provided adequate social support. Without such support, the only option was to keep her institutionalized.

Dependency Training

Often found in conjunction with social isolation is the tendency on the part of those around schizotypal individuals to be overly protective. They will tend to patronize or coddle them. Such overprotection tends to reinforce dependent behavior on the part of the schizotypal. According to Millon (1981), "Prolonged guidance and shielding of this kind may lead to a progressive impoverishment of competencies and self-motivation, and result in a total helplessness. Under such ostensibly 'good' regimens, schizotypals will be reinforced to learn dependency and apathy" (p. 427).

Self-Insulation

Finally, not only through mismanagement and neglect will the schizotypal disorder be perpetuated, but also through the tendency of these individuals to insulate themselves from outside stimulation. As we described earlier, to protect themselves from painful humiliation, rejection, or excessive demands, schizotypals have learned to withdraw from reality and disengage themselves from social life. Even though exposed to active social opportunities, most of these individuals will participate only reluctantly. They prefer to keep to themselves-to withdraw. Without active social relationships, these individuals will simply recede further into social isolation, apathy, and dependency. Thus, the disorder is perpetuated.

The case of Harold T. demonstrates a condition in which his ability to insulate himself has served as an effective barrier to rehabilitation. His apathy, lack of verbal communication, and habit of drawing strange and religiouslike pictures has effectively insulated him from other and has removed any hope of improvement for almost 10 years.

So, in summary, we see that through social isolation, dependency training, and self-insulation, the schizotypal disorder is perpetuated. Although the motives for socially isolating and overprotecting these individuals are usually good, that is, with best interests of the patient in mind, the tactics are actually counterproductive for they deprive the patients of the opportunity to develop social skills while reinforcing dependency. The schizotypal's own tendency to insulate himself/herself from social contact serves to exacerbate the disorder even further. Such self-insulation serves to foster and further perpetuate the spiral of cognitive and social deterioration that typifies the schizotypal disorder.

Schizotypal Personality Disorder DSM-IV Criteria

A pervasive 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 accentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Ideas of reference (excluding delusions of reference)

Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)

Unusual perceptual experiences, including bodily illusions

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

Suspiciousness or paranoid ideation

Inappropriate or constricted affect

Behavior or appearance that is odd, eccentric, or peculiar

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

Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

Therapy

The schizotypal is perhaps one of the easiest personality disorders to identify but one of the most difficult to treat with psychotherapy. The thought disorder and accompanying paranoid ideation work to distort communication between therapist and client and inhibit the formation of a trusting therapeutic alliance. Moreover, because schizotypals are inherently isolative and nonrelational, the therapist may sometimes be experienced as an intrusive presence. Because the alliance is the very foundation of therapy, medication is often needed before lasting progress can be made, especially with subjects who express the disorder severely.

THERAPEUTIC TRAPS

The expectations of the therapist and their influence on therapy are particularly important and may require careful monitoring. Most schizotypals initially see the therapist as attacking or humiliating (Benjamin, 1996). As anxiety increases, they may retreat further behind a curtain of

disordered communication as a means of shielding themselves and confusing the intruder. Occasional retreats are universal. Therapists who become vexed when greeted with silence and emotional distancing only create an atmosphere that justifies such a reaction.

Instead, the need for distance must be respected, without conveying feelings of disapproval or inducing guilt, to which many subjects are especially sensitive. Not pushing too hard or too fast can prevent severe anxiety and paranoid reactions. Extraordinary patience may be required because schizotypals repeatedly misperceive aspects of the therapeutic relationship and then act on these misperceptions. Subjects who believe they have privileged access to information beyond the five senses sometimes apply their extrasensory powers to therapy and the therapist, believing that they can read the therapist's mind or arrive at conclusions about what the therapist secretly desires on the basic of tangential or irrelevant cues.

Accordingly, communication should be simple, straightforward, shorn of psychological jargon, and require a minimm of inference. Schizotypals find it difficult enough to bring order to their own thoughts, much less penetrate ambiguities and double messages carelessly introduced by others. The concrete is to be preferred over the poetic because the latter is naturally rich in connotations, which play havoc with schizotypal cognition. Special attention to the countertransference is in order, for unconscious feelings emitted by the therapist bring an unknown complexity to communication and are especially likely to be misconstrued by subjects.

STRATEGIES AND TECHNIQUES

What can be done in therapy often depends on the extent to which the thought disorder intrinsic to the syndrome can be controlled. Otherwise, every aspect of therapy becomes more complicated. Further, the appropriate goals and strategies for any particular subject depend on whether his or her symptoms most resemble an exaggerated schizoid pattern, an exaggerated avoidant pattern, or a mixture of the two. Strategies and techniques appropriate for the dominant underlying personality disorder can be used to supplement the primary goals of treating the schizotypal pattern (refer to the appropriate chapter).

Establishing a more normal pattern of interpersonal relationships is a primary goal of therapy. Social isolation intensifies cognitive deficits and allows social skills to atrophy. Contatc with a therapist can prevent further deterioration. Because patterns of disordered family communication typify the early developmental environment of these subjects, therapy offers the chance for a novel, corrective interpersonal relationship through steady support and euthenticity.

Accordingly, as emphasized by Benjamin (1996), the basic skills of humanistic therapy, including accurate empathy, mirroring, and unconditional positive regard, become particularly important. Benjamin states that the therapeutic alliance may represent a chance to experience a "nonexploitive protectiveness," one that eventually permits the schizotypal to give up management of the universe by magical means (p. 360). After an alliance has been established, subject can be encouraged to voice distortions of reality as they occur, and these can be discussed in the context of the therapeutic relationship.

Benjamin (1996) further stresses that many schizotypals are likely to belive that harm may come to the therapist through their association. As such ideas are voiced, they can be tested realistically and tactfully refuted. In general, interpersonal therapy should enhance subjects' sense of self-worth and encourage the realization of positive attributes, an important step in defeating detachment, rebuilding motivation, and providing confidence necessary to take the first steps toward constructive social encounters outside therapy. Because schizotypals have difficulty sorting the relevant and irrelevant in interpersonal relationships, therapists may find that much of their time is spent helping the schizotypal test interpersonal reality and gain perspective on which behaviors might be appropriate in whatever situations are current in the subject's life. Repeated discussions of essentially similar situations may be necessary, as many schizotypals fail to realize that these are but variations on a theme. Basic social skills training are often helpful. Modeling behaviors provides an example that even concrete subjects can imitate. The ability to appraise interpersonal realities appropriately is an important step in decreasing social anxiety and accompanying paranoid symptoms while creating a capacity for appropriate affect and a sense of reward.

From a cognitive perspective, psychotherapy must adapt to the schizotypal's limited attentional resources and tendency to intrude tangential factors. Because many schizotypals are either overly concrete or overly abstract, learning may be generalized to other settings and situations only with great difficulty. Simplicity and structure help prevent the lessons of therapy from being obscured by the discombobulating effects of thought disorder. Furthermore, cognitive techniques allow the content of thought to be identified and eventually modified. This suggests that the combination of medication and cognitive therapy should be particularly effective.

Writing in Beck et al. (1990), Ottaviani indicates that the first step is to identity characteristic automatic thoughts, such as, "I am a nonbeing," as well as patterns of emotional reasoning and personalization, reviewed previously. Moreover, she suggests that assumptions underlying social interaction present an especially profitable avenue for change, as schizotypals usually believe that other dislike them. Subjects must be taught to act as naïve scientists and test their thoughts against the evidence. Feelings do not make facts; instead, each cognition is a hypothesis and should be disregarded if found inconsistent with the objective evidence. Even bizarre thoughts can be dealt with in this way. The thought, "I am leaving my body," for example, can be countered with prepared countercognitions: "There I go again. Even though I'm thinking this thought, it doesn't mean that it's true" (p. 141)

Because an effective grasp of objective reality is the Catch-22 of the cognitive approach, Ottaviani further suggests that schizotypals also be taught methods for gathering contrary evidence. Subjects can list evidence inconsistent with their predictions, for example. Going beyond content, cognitive style interventions can also be made. Rambling can be countered by requests for summary statements, and global statements can be countered by asking for elaboration. Finally, where subjects are not too paranoid or bizarre, group settings can be used to practice social functioning and provide feedback about distorted cognitions.

Because classical psychodynamic therapy is inherently unstructured, its use is probably not advised. As noted by Stone (1985), the purpose of psychodynamic therapy should be to internalize the therapeutic alliance. Because the early home environment of most schizotypals is likely to feature fragmented and chaotic communications, the ego boundaries of the schizotypal subject are only poorly developed. The interpretation of conflict not only disregards their desire for distance but also plays into their fear of engulfment. Accordingly, silence should be accepted as a legitimate part of the personality (Gabbard, 1994). Once this acceptance is felt, the subject may then begin to reveal hidden aspects of the self that can be adaptively integrated. Analytic procedures such as free association, the neutral attitude of the therapist, and the focus on dreams may foster an increase in autistic reveries and social withdrawal.

Probably the most useful analytic suggestion comes from Rado (1959), who suggests that identifying and capitalizing on some source of pleasure, however small, is a superordinate therapeutic goal. Motivation develops from the capacity for pleasure, and ultimately, only this can balance the painful emotions, attach the schizotypal to the real world, and prevent the dissolution of the self and cognitive disintegration that results from autistic withdrawal.


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