The cluster of “odd” personality disorders consists of the paranoid, schizoid, and schizotypal personality disorders. People with these disorders typically have odd or eccentric behaviors that are similar to but not as extensive as those seen in schizophrenia, including extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things. Such behaviors often leave the person isolated. Some clinicians believe that these personality disorders are related to schizophrenia (Rosell et al., 2014). In fact, schizotypal personality disorder is listed twice in DSM-5—as one of the schizophrenia spectrum disorders (see page 386) and as one of the personality disorders (APA, 2013). Directly related or not, people with an odd cluster personality disorder often qualify for an additional diagnosis of schizophrenia or have close relatives with schizophrenia (Chemerinski & Siever, 2011).

Clinicians have learned much about the symptoms of the odd cluster personality disorders but have not been so successful in determining their causes or how to treat them. In fact, as you’ll soon see, people with these disorders rarely seek treatment.

425

As you read earlier, people with paranoid personality disorder deeply distrust other people and are suspicious of their motives (APA, 2013). Because they believe that everyone intends them harm, they shun close relationships. Their trust in their own ideas and abilities can be excessive, though, as you can see in the case of Eduardo:

Ever on guard and cautious and seeing threats everywhere, people like Eduardo continually expect to be the targets of some trickery (see Figure 13.2 below). They find “hidden” meanings, which are usually belittling or threatening, in everything. In a study that required people to role-play, participants with paranoia were more likely than control participants to read hostile intentions into the actions of others (Turkat et al., 1990). In addition, they more often chose anger as the appropriate role-play response.

Quick to challenge the loyalty or trustworthiness of acquaintances, people with paranoid personality disorder remain cold and distant. A woman might avoid confiding in anyone, for example, for fear of being hurt, or a husband might, without any justification, persist in questioning his wife’s faithfulness. Although inaccurate and inappropriate, their suspicions are not usually delusional; the ideas are not so bizarre or so firmly held as to clearly remove the individuals from reality (Millon, 2011).

426

People with this disorder are critical of weakness and fault in others, particularly at work (McGurk et al., 2013). They are unable to recognize their own mistakes, though, and are extremely sensitive to criticism. They often blame others for the things that go wrong in their lives, and they repeatedly bear grudges (Rotter, 2011). As many as 4.4 percent of adults in the United States experience this disorder, which is apparently more common in men than in women (APA, 2013; Sansone & Sansone, 2011).

How Do Theorists Explain Paranoid Personality Disorder? The theories that have been proposed to explain paranoid personality disorder, like those about most other personality disorders, have received little systematic research (Triebwasser et al., 2013). Psychodynamic theories, the oldest of these explanations, trace the pattern to early interactions with demanding parents, particularly distant, rigid fathers and overcontrolling, rejecting mothers (Caligor & Clarkin, 2010; Williams, 2010). (You will see that psychodynamic explanations for almost all the personality disorders begin the same way—with repeated mistreatment during childhood and lack of love.) According to one psychodynamic view, some people come to view their environment as hostile as a result of their parents’ persistently unreasonable demands. They must always be on the alert because they cannot trust others, and they are likely to develop feelings of extreme anger. They also project these feelings onto others and, as a result, feel increasingly persecuted (Koenigsberg et al., 2001). Similarly, some cognitive theorists suggest that people with paranoid personality disorder generally hold broad maladaptive assumptions, such as “People are evil” and “People will attack you if given the chance” (Beck & Weishaar, 2014; Weishaar & Beck, 2006).

Biological theorists propose that paranoid personality disorder has genetic causes (APA, 2013; Bernstein & Useda, 2007). An early study that looked at self-reports of suspiciousness in 3,810 Australian twin pairs found that if one twin was excessively suspicious, the other had an increased likelihood of also being suspicious (Kendler et al., 1987). Once again, however, it is important to note that such similarities between twins might also be the result of common environmental experiences.

Treatments for Paranoid Personality Disorder People with paranoid personality disorder do not typically see themselves as needing help, and few come to treatment willingly (Millon, 2011). Furthermore, many who are in treatment view the role of patient as inferior and distrust and rebel against their therapists (Kellett & Hardy, 2014). Thus it is not surprising that therapy for this disorder, as for most other personality disorders, has limited effect and moves very slowly (Piper & Joyce, 2001).

Object relations therapists—the psychodynamic therapists who give center stage to relationships—try to see past the patient’s anger and work on what they view as his or her deep wish for a satisfying relationship (Caligor & Clarkin, 2010). Cognitive and behavioral techniques have also been used to treat people with paranoid personality disorder and are often combined into an integrated cognitive-behavioral approach. On the behavioral side, therapists help clients to master anxiety-reduction techniques and to improve their skills at solving interpersonal problems. On the cognitive side, therapists guide the clients to develop more realistic interpretations of other people’s words and actions and to become more aware of other people’s points of view (Kellett & Hardy, 2014). Antipsychotic drug therapy seems to be of limited help (Birkeland, 2013).

427

People with schizoid personality disorder persistently avoid and are removed from social relationships and demonstrate little in the way of emotion (APA, 2013). Like people with paranoid personality disorder, they do not have close ties with other people. The reason they avoid social contact, however, has nothing to do with paranoid feelings of distrust or suspicion; it is because they genuinely prefer to be alone. Take Eli:

People like Eli, often described as “loners,” make no effort to start or keep friendships, take little interest in having sexual relationships, and even seem indifferent to their families. They seek out jobs that require little or no contact with others. When necessary, they can form work relations to a degree, but they prefer to keep to themselves. Many live by themselves as well. Not surprisingly, their social skills tend to be weak. If they marry, their lack of interest in intimacy may create marital or family problems.

People with schizoid personality disorder focus mainly on themselves and are generally unaffected by praise or criticism. They rarely show any feelings, expressing neither joy nor anger. They seem to have no need for attention or acceptance; are typically viewed as cold, humorless, or dull; and generally succeed in being ignored. This disorder is present in 3.1 percent of the adult population (APA, 2013; Sansone & Sansone, 2011). Men are slightly more likely to experience it than are women, and men may also be more impaired by it.

How Do Theorists Explain Schizoid Personality Disorder? Many psychodynamic theorists, particularly object relations theorists, propose that schizoid personality disorder has its roots in an unsatisfied need for human contact (Caligor & Clarkin, 2010). The parents of people with this disorder, like those of people with paranoid personality disorder, are believed to have been unaccepting or even abusive of their children. Whereas people with paranoid symptoms react to such parenting chiefly with distrust, those with schizoid personality disorder are left unable to give or receive love. They cope by avoiding all relationships.

428

Cognitive theorists propose, not surprisingly, that people with schizoid personality disorder suffer from deficiencies in their thinking. Their thoughts tend to be vague, empty, and without much meaning, and they have trouble scanning the environment to arrive at accurate perceptions (Kramer & Meystre, 2010). Unable to pick up emotional cues from others, they simply cannot respond to emotions. As this theory might predict, children with schizoid personality disorder develop language and motor skills very slowly, whatever their level of intelligence (APA, 2013; Wolff, 2000, 1991).

Treatments for Schizoid Personality Disorder Their social withdrawal prevents most people with schizoid personality disorder from entering therapy unless some other disorder, such as alcoholism, makes treatment necessary (Mittal et al., 2007). These clients are likely to remain emotionally distant from the therapist, seem not to care about their treatment, and make limited progress at best (Colli et al., 2014).

Cognitive-behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interactions (Beck & Weishaar, 2011; Beck et al., 2004). On the cognitive end, their techniques include presenting clients with lists of emotions to think about or having them write down and remember pleasurable experiences. On the behavioral end, therapists have sometimes had success teaching social skills to such clients, using role-playing, exposure techniques, and homework assignments as tools. Group therapy is apparently useful when it offers a safe setting for social contact, although people with schizoid personality disorder may resist pressure to take part (Piper & Joyce, 2001). As with paranoid personality disorder, drug therapy seems to offer limited help (Silk & Jibson, 2010).

People with schizotypal personality disorder display a range of interpersonal problems marked by extreme discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities (APA, 2013). Anxious around others, they seek isolation and have few close friends. Some feel intensely lonely. The disorder is more severe than the paranoid and schizoid personality disorders, as we see in the case of 41-year-old Kevin:

As with Kevin, the thoughts and behaviors of people with schizotypal personality disorder can be noticeably disturbed. These symptoms may include ideas of reference—beliefs that unrelated events pertain to them in some important way—and bodily illusions, such as sensing an external “force” or presence. A number of people with this disorder see themselves as having special extrasensory abilities, and some believe that they have magical control over others. Examples of schizotypal eccentricities include repeatedly arranging cans to align their labels, organizing closets extensively, or wearing an odd assortment of clothing. The emotions of these individuals may be inappropriate, flat, or humorless.

People with schizotypal personality disorder often have great difficulty keeping their attention focused. Correspondingly, their conversation is typically vague, even sprinkled with loose associations (Millon, 2011). Like Kevin, they tend to drift aimlessly and lead an idle, unproductive life (Hengartner et al., 2014). They are likely to choose undemanding jobs in which they can work below their capacity and are not required to interact with other people. Surveys suggest that 3.9 percent of adults—slightly more males than females—display schizotypal personality disorder (Rosell et al., 2014; Sansone & Sansone, 2011).

How Do Theorists Explain Schizotypal Personality Disorder? Because the symptoms of schizotypal personality disorder so often resemble those of schizophrenia, researchers have hypothesized that similar factors may be at work in both disorders. A wide range of studies have supported such expectations (Hazlett et al., 2015; Rosell et al., 2015). Investigators have found that schizotypal symptoms, like schizophrenic patterns, are often linked to family conflicts and to psychological disorders in parents. They have also learned that defects in attention and short-term memory may contribute to schizotypal personality disorder, just as they apparently do to schizophrenia. For example, research participants with either disorder perform poorly on backward masking, a laboratory test of attention that requires a person to identify a visual stimulus immediately after a previous stimulus has flashed on and off the screen. People with these disorders have a hard time shutting out the first stimulus in order to focus on the second. Finally, researchers have linked schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high activity of the neurotransmitter dopamine, enlarged brain ventricles, smaller temporal lobes, and loss of gray matter (Lener et al., 2015; Ettinger et al., 2014). As you read in Chapter 12, there are indications that these biological factors may have a genetic base.

430

Although these findings do suggest a close relationship between schizotypal personality disorder and schizophrenia, the personality disorder also has been linked to disorders of mood (Lentz et al., 2010). More than half of people with schizotypal personality disorder also suffer from major depressive disorder at some point in their lives (APA, 2013). Moreover, relatives of people with depression have a higher than usual rate of schizotypal personality disorder, and vice versa. Thus, at the very least, this personality disorder is not tied exclusively to schizophrenia.

Treatments for Schizotypal Personality Disorder Therapy is as difficult in cases of schizotypal personality disorder as it is in cases of paranoid and schizoid personality disorders. Most therapists agree on the need to help these clients “reconnect” with the world and recognize the limits of their thinking and their powers. The therapists may thus try to set clear limits—for example, by requiring punctuality—and work on helping the clients recognize where their views end and those of the therapist begin. Other therapy goals are to increase positive social contacts, ease loneliness, reduce overstimulation, and help the individuals become more aware of their personal feelings (Colli et al., 2014; Sperry, 2003).

Cognitive-behavioral therapists further combine cognitive and behavioral techniques to help people with schizotypal personality disorder function more effectively. Using cognitive interventions, they try to teach clients to evaluate their unusual thoughts or perceptions objectively and to ignore the inappropriate ones (Beck & Weishaar, 2011; Weishaar & Beck, 2006). Therapists may keep track of clients’ odd or magical predictions, for example, and later point out their inaccuracy. When clients are speaking and begin to digress, the therapists might ask them to sum up what they are trying to say. In addition, specific behavioral methods, such as speech lessons, social skills training, and tips on appropriate dress and manners, have sometimes helped clients learn to blend in better with and be more comfortable around others (Farmer & Nelson-Gray, 2005).

Antipsychotic drugs have been given to people with schizotypal personality disorder, again because of the disorder’s similarity to schizophrenia. In low doses the drugs appear to have helped some people, usually by reducing certain of their thought problems (Rosenbluth & Sinyor, 2012).