13.2 Odd/Eccentric Personality Disorders

Cluster A personality disorders involve odd or eccentric behaviors and ways of thinking. Patients who have a Cluster A personality disorder are also likely to develop another psychological disorder that involves psychosis, such as schizophrenia or delusional disorder (Oldham et al., 1995; see Chapter 12). The three personality disorders in this cluster—paranoid, schizoid, and schizotypal personality disorders—are on the less severe end of the spectrum of schizophrenia-related disorders; of these three, only schizotypal personality disorder is considered to be on the schizophrenia spectrum in DSM-5. We’ll examine each of the three Cluster A personality disorders in turn and then discuss what is known about the factors that give rise to them and about how to treat them. Rachel Reiland did not exhibit symptoms characteristic of this group of personality disorders.

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Paranoid Personality Disorder

Paranoid personality disorder A personality disorder characterized by persistent and pervasive mistrust and suspiciousness, accompanied by a bias to interpret other people’s motives as hostile.

The essential feature of paranoid personality disorder is persistent and pervasive mistrust and suspiciousness, accompanied by a bias to interpret other people’s motives as hostile (see TABLE 13.3). Someone with this personality disorder may distrust coworkers and family members and may even (incorrectly) believe that his or her partner is having an affair, despite the partner’s denials. The patient’s accusations create a difficult situation for the partner who is not having an affair but can’t “prove” it to the patient’s satisfaction.

Table : TABLE 13.3 • DSM-5 Diagnostic Criteria for Paranoid Personality Disorder
  1. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
    2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
    3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
    4. Reads hidden demeaning or threatening meanings into benign remarks or events.
    5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
    6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
    7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
  2. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013). American Psychiatric Association. All Rights Reserved.

People with paranoid personality disorder are better able to evaluate whether their suspicions are based on reality than are people with paranoid schizophrenia. Moreover, the sources of their perceived threats are not likely to be strangers or bizarre types of signals (such as radio waves), as is the case with paranoid schizophrenia, but rather known individuals (Skodol, 2005). If the symptoms arise while a person is using substances or during a psychotic episode of schizophrenia or a mood disorder, then paranoid personality disorder is not diagnosed. As you’ll see in Case 13.2, about Ms. X., it may not be immediately apparent from a patient’s report what is “true” and what is a paranoid belief.

CASE 13.2 • FROM THE OUTSIDE: Paranoid Personality Disorder

Ms. X. is a middle-aged African-American woman who has lived in the area all of her life. She began seeking treatment…after her family members had noted that, to them, she was acting strangely. Ms. X. stated that she believed that her family members were out to make her crazy and convince her neighbors of the same. She stated the reason for this was because she was the “darkest one” in her family. Ms. X. was a fair-skinned black woman. She was born to a dark-skinned black mother and a white father. She was the darkest sibling of her family. Because of this, she felt that her family had treated her and her mother unjustly. She stated that as a child, she was instructed to look after her lighter-skinned older sisters, whom the family held in high regard. She stated that she did not complete high school because she had to care for her older sister’s children. She described that she would be instructed to “cook and clean” for them, as though she were their slave, and be available to them whenever they needed her…. Because of this, [she claimed] she was not able to have a social life. After Ms. X. married, she continued to receive the same treatment from her sisters. She stated that her children were treated unfairly, because of their darker skin as well…. As she got older, Ms. X. stated that her sisters, who were part of the elite society, would “embarrass” her while around their socialite friends. She believed this to be due to her darker skin color. She stated that her sisters convinced her neighbors that she was a “bad” person, and because of this, her neighbors would do “evil” things to spite her.

Ms. X. met with her sisters to discuss this issue. When confronted, the sisters denied that they were treating her negatively. They acknowledged that their skin was fairer than hers but denied that they were treating her in such a way. They believed that their sister was “delusional.” Ms. X. refused to believe her sisters, and when confronted with the idea that her family was not in any way harming her, she would shift the conversation to another topic.

(Paniagua, 2001, pp. 135–136)

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For most people, this kitchen scene would be an unpleasant but infrequent conflict between parent and child. But for people with paranoid personality disorder, such conflict may not be occasional. People with paranoid personality disorder distrust others and tend to interpret other people’s remarks or behaviors as having malevolent intent. They are likely to maintain these interpretations despite evidence to the contrary.
Buccina Studios/Getty Images

As was the case with Ms. X.’s refusal to believe her sisters, people with paranoid personality disorder cannot readily be persuaded that their paranoid beliefs do not reflect reality. However, such people can recognize that there are multiple ways to interpret other people’s reactions and behaviors.

Although less obvious in the case of Ms. X., other common characteristics of people with this personality disorder include a strong desire to be self-sufficient and in control, which stems from a distrust of others, and a tendency to be critical of others and blame them for problems that arise. People with this disorder may also be unable to accept criticism from others. In response to stress, they may become briefly psychotic, with their paranoid beliefs reaching delusional proportions.

In addition, people with paranoid personality disorder tend to be difficult to get along with because their suspiciousness frequently leads them to be secretive or “cold,” argumentative, complaining, or to bear a grudge. These behaviors often elicit hostility or anger in others, which then confirms the person’s suspicious beliefs. TABLE 13.4 provides additional information about paranoid personality disorder.

Table : TABLE 13.4 • Paranoid Personality Disorder Facts at a Glance
Prevalence
  • Between 2.3% and 4.5% of the general population is estimated to have paranoid personality disorder.
Comorbidity
  • People with paranoid personality disorder may also have another personality disorder, usually another Cluster A (odd/eccentric) personality disorder (schizoid or schizotypal) or narcissistic, avoidant, or borderline personality disorder.
Onset
  • Symptoms can first appear in childhood or adolescence, when the person appears hypersensitive, has difficulties with peers, and has odd thoughts or fantasies or uses language unconventionally.
Course
  • The symptoms of paranoid personality disorder are relatively stable over time (Seivewright et al., 2002).
Gender Differences
  • Based on surveys in the general population, there is no clear gender difference in the prevalence of paranoid personality disorder. However, among people with this disorder, men are more likely than women to come to the attention of mental health professionals (Morey, Alexander, & Boggs, 2005).
Source: Unless otherwise noted, the source is American Psychiatric Association, 2000, 2013.

To summarize, paranoid personality disorder involves a chronic pattern of suspiciousness and mistrust that often creates interpersonal problems because of the guarded ways in which the patient interacts with others. Little is known about the specific factors that give rise to this personality disorder.

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Schizoid Personality Disorder

Schizoid personality disorder A personality disorder characterized by a restricted range of emotions in social interactions and few—if any—close relationships.

Schizoid personality disorder is characterized by a restricted range of emotions in social interactions and few—if any—close relationships (American Psychiatric Association, 2013). TABLE 13.5 lists the DSM-5 diagnostic criteria. People with schizoid personality disorder often lack social skills and may not pick up on or understand the normal social cues required for smooth social interactions—for instance, they may return someone’s smile with a stare. Such difficulties with social cues can lead to problems in jobs that require interacting with others; people with this personality disorder generally are not interested in developing personal relationships.

Table : TABLE 13.5 • DSM-5 Diagnostic Criteria for Schizoid Personality Disorder
  1. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. Neither desires nor enjoys close relationships, including being part of a family.
    2. Almost always chooses solitary activities.
    3. Has little, if any, interest in having sexual experiences with another person.
    4. Takes pleasure in few, if any, activities.
    5. Lacks close friends or confidants other than first-degree relatives.
    6. Appears indifferent to the praise or criticism of others.
    7. Shows emotional coldness, detachment, or flattened affectivity.
  2. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013). American Psychiatric Association. All Rights Reserved.

In addition, people with schizoid personality disorder may react passively to adverse events. They may seem to lack initiative and drift through life. People with this disorder appear to be emotionless and often don’t express anger, even when provoked. And, in fact, they often report that they rarely experience strong emotions such as joy and anger (Livesley, 2001). In contrast to those with paranoid personality disorder, people with schizoid personality disorder generally aren’t suspicious and are indifferent to other people (Skodol, 2005). Case 13.3 on the next page describes one woman with schizoid personality disorder, and TABLE 13.6 presents some additional facts about schizoid personality disorder.

Table : TABLE 13.6 • Schizoid Personality Disorder Facts at a Glance
Prevalence
  • Approximately 3% of the general population is estimated to have schizoid personality disorder (Grant, Hasin, et al., 2004).
Comorbidity
  • Common comorbid personality disorders are the other Cluster A (odd/eccentric) personality disorders and avoidant personality disorder. Half of the people diagnosed with schizoid personality disorder will also be diagnosed with schizotypal personality disorder (McGlashan et al., 2000).
Onset
  • Those who develop schizoid personality disorder were often socially isolated underachievers who were teased by their classmates as children and adolescents.
Course
  • Schizoid personality disorder is relatively stable over time (Seivewright et al., 2002).
Gender Differences
  • This personality disorder tends to be diagnosed more often in men than in women.
  • Men with this personality disorder are often more impaired than their female counterparts.
Source: Unless otherwise noted, the source is American Psychiatric Association, 2013.

In sum, schizoid personality disorder involves a chronic pattern of limited emotional expression and diminished social understanding, few relationships, and little desire for relationships.

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CASE 13.3 • FROM THE OUTSIDE: Schizoid Personality Disorder

A 33-year-old woman with three children became a cause of concern to social services because of her limited caring abilities. Investigations led to two of her children being taken into [foster] care and, after a further period of 2 years, her third child was also taken away. At this time she was referred to psychiatric services because she was felt to be isolated from society and had such poor social function. It proved very difficult to engage her as she would go to great lengths to avoid contact and it was uncertain to what extent she required compulsory treatment. Eventually, she was admitted under a compulsory order after threatening a community worker…. After discharge from [the] hospital she was transferred to supportive housing but resented the frequent monitoring of her progress, which she perceived as intrusion and tried to avoid contact…. She functioned better with no contact and so a transfer was agreed to a supported [apartment] where she would be left undisturbed apart from one visit each week from a support worker and a full review every 6 months. After 2 years she remains well on no treatment and is very happy with her life, which despite little interaction with other people now includes regular contact with her family.

(Tyrer, 2002, p. 470)

Schizotypal Personality Disorder

Schizotypal personality disorder A personality disorder characterized by eccentric thoughts, perceptions, and behaviors, in addition to having very few close relationships.

People with schizotypal personality disorder have eccentric thoughts, perceptions, and behaviors, in addition to having very few close relationships, like those with schizoid personality disorder (American Psychiatric Association, 2013).

What Is Schizotypal Personality Disorder?

According to the DSM-5 diagnostic criteria, schizotypal personality disorder has nine symptoms (see TABLE 13.7). These symptoms can be organized into three distinct groups (Calkins et al., 2004; Raine, 2006; Reynolds et al., 2000) although DSM-5 does not do so:

Table : TABLE 13.7 • DSM-5 Diagnostic Criteria for Schizotypal Personality Disorder
  1. 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 eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. Ideas of reference (excluding delusions of reference).
    2. 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).
    3. Unusual perceptual experiences, including bodily illusions.
    4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
    5. Suspiciousness or paranoid ideation.
    6. Inappropriate or constricted affect.
    7. Behavior or appearance that is odd, eccentric, or peculiar.
    8. Lack of close friends or confidants other than first degree relatives.
    9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
  2. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.
Note: Cognitive-perceptual symptoms are in green, interpersonal symptoms are in blue, and disorganized symptoms are in red.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013). American Psychiatric Association. All Rights Reserved.

IK, in Case 13.4, had symptoms that represent all three groups highlighted in TABLE 13.7. This personality disorder is on the schizophrenia spectrum (see Chapter 12). Additional facts about schizotypal personality disorder are listed in TABLE 13.8.

Table : TABLE 13.8 • Schizotypal Personality Disorder Facts at a Glance
Prevalence
  • Approximately 0.6–4.6% of the general population has schizotypal personality disorder.
Comorbidity
  • Common comorbid personality disorders include other Cluster A personality disorders (McGlashan et al., 2000), as well as borderline, avoidant, and obsessive-compulsive personality disorders (Raine, 2006).
  • Common comorbid psychological disorders are major depressive disorder, social phobia, and panic disorder (Raine, 2006).
Onset
  • Symptoms emerge by early adulthood.
  • In childhood and adolescence, symptoms may include social isolation and social anxiety, academic underachievement, hypersensitivity, odd fantasies and thoughts, and idiosyncratic use of language.
Course
  • Although schizotypal personality disorder most commonly is stable over time, symptoms may improve for some people (Fossati et al., 2003). In fact, for almost one quarter of patients, symptoms improve to the point where they no longer meet all the diagnostic criteria (Grilo et al., 2004).
  • Among other patients with this disorder, the opposite is true: A small percentage go on to develop schizophrenia or another psychotic disorder (Grilo et al., 2004).
Gender Differences
  • Schizotypal personality disorder is slightly more common among men than women.
Source: Unless otherwise noted, the source is American Psychiatric Association, 2013.

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CASE 13.4 • FROM THE OUTSIDE: Schizotypal Personality Disorder

IK is a 33-year-old man who had both schizotypal personality disorder and obsessive-compulsive disorder (OCD) for at least 17 years. His schizotypal symptoms included poor interpersonal relatedness, ideas of reference (not delusional), social anxiety, unusual perceptual experiences (such as seeing things in the periphery, but not there when viewed directly), constricted affect, and some paranoid ideation (in particular with regard to police officers, but his father reported that this was unrealistic).

IK’s social skills deficits were primarily conversation skills, inappropriate affect, poor assertion skills, and lack of eye contact with the therapist and family members. He was also prone to aggressive outbursts in the home, often breaking objects due to frustration.

(McKay & Neziroglu, 1996, pp. 190–191)

Schizotypal personality disorder differs from schizoid personality disorder in that the former includes cognitive-perceptual symptoms—such as IK’s ideas of reference and seeing things with peripheral vision that could not be seen with a direct gaze—and odd behavior. Nevertheless, research suggests that these two disorders may not be distinct from each other; half of those with schizoid personality disorder are also diagnosed with schizotypal personality disorder (McGlashan et al., 2000). Some researchers propose that schizoid personality disorder may simply be a subtype of schizotypal personality disorder (Raine, 2006).

Understanding Schizotypal Personality Disorder

We focus on understanding schizotypal personality disorder, the most researched of the Cluster A personality disorders. As noted in Chapter 12, schizotypal personality disorder includes less intense manifestation of features of schizophrenia: delusions and unusual perceptions.

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Neurological Factors in Schizotypal Personality Disorder

Most of the neurological factors that contribute to schizophrenia have also been found to contribute to schizotypal personality disorder: genes and prenatal environment, such as maternal illness and malnourishment, and birth complications (Raine, 2006; Torgersen et al., 2000). In both disorders, researchers have documented similar abnormalities in brain structure and in neural function (activity of dopamine, serotonin, and glutamate). These abnormalities are generally not as severe in people with schizotypal personality disorder as in people with schizophrenia (Buchsbaum et al., 2002; Siever & Davis, 2004).

Neurological factors that are associated with schizophrenia are associated with schizotypal personality disorders, such as maternal illness or malnourishment during pregnancy.
AJ Photo/BSIP/SuperStock

Genes also play a role: The rates of schizotypal personality disorder are higher among family members of people with schizophrenia than among the general population (Siever & Davis, 2004; Tienari et al., 2003).

Psychological Factors in Schizotypal Personality Disorder

Like people with schizophrenia, those with schizotypal personality disorder tend to have specific cognitive deficits. These include problems with attention (distinguishing relevant from irrelevant stimuli), memory, and executive function (used in problem solving, planning, and judgment) (Voglmaier et al., 2000). According to Beck and colleagues (2004), schizotypal personality disorder is unusual among the personality disorders in that the primary distortions are in mental processes (e.g., perceptions) rather than in mental contents. However, problems with social interactions can arise from the cognitive deficits: People with this personality disorder tend to have an impaired theory of mind—and thus have difficulty recognizing emotions in others (Waldeck & Miller, 2000) and in taking another’s point of view or recognizing another’s mental state (Langdon & Coltheart, 2001; Miller & Lenzenweger, 2012). Although people with schizotypal personality disorder have cognitive deficits, they generally have better cognitive skills than do people with schizophrenia (Trestman et al., 1995).

People with this personality disorder also often behave in unusual ways, which can make other people more likely to mistreat them, intentionally or not. Such mistreatment may thus confirm their beliefs about themselves and other people. People with this disorder also pay attention to, remember, and interpret stimuli in ways that are consistent with their beliefs—and that thus reinforce their isolation from, and avoidance of, other people.

Social Factors in Schizotypal Personality Disorder

Certain social factors appear to play a relatively large role in the onset of schizotypal personality disorder, in contrast to their lesser role in schizophrenia. These social factors include physical abuse or neglect, insecure attachment to parents, and discrimination (Berenbaum et al., 2008; Raine, 2006; Wilson & Constanzo, 1996)—all stressful events. In fact, some of these social factors may be related to each other: Insecure attachment may, at least in part, result from abuse or neglect. Children who develop schizotypal personality disorder are more likely to have experienced trauma, abuse, and neglect than are those who develop most other personality disorders (Yen et al., 2002). These negative childhood experiences influence patients’ views of other people as untrustworthy and having malevolent motives.

Feedback Loops in Understanding Schizotypal Personality Disorder

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With schizotypal personality disorder, as with schizophrenia, neuropsychosocial factors create feedback loops. For instance, early social stressors such as neglect and trauma can contribute to brain abnormalities, particularly if a genetic or other neurological vulnerability exists before birth. The neurological changes, in turn, contribute to disturbances in cognitive and emotional functioning (Raine, 2006). These cognitive and emotional disturbances then can lead to problems in social interactions, which in turn produces stress (Skodol, Gunderson et al., 2002)—and the stress can then affect neurological functioning. Moreover, trauma, neglect, and insecure attachment may give rise to a paranoid attributional style and discomfort with others (Raine, 2006).

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Treating Odd/Eccentric Personality Disorders

Very little research has been conducted to evaluate treatments for odd/eccentric personality disorders. People with any of these sorts of personality disorders tend not to be interested in treatment and, if urged or coerced into it, are often reluctant participants at best. Treatment may create significant anxiety for the patient. Thus, the particular challenge of treating people with odd/eccentric personality disorders is their tendency not to collaborate with the therapist to develop goals for treatment (Beck et al., 2004; Farmer & Nelson-Gray, 2005).

Nevertheless, when such patients do participate in CBT, they can develop more adaptive strategies, such as improved social skills (which makes them less likely to be conspicuous and in turn leads them to feel safer with others). CBT may also employ relaxation techniques, exposure to avoided social situations, and cognitive restructuring of distorted views of self and others, and of dysfunctional beliefs (Beck et al., 2004; Farmer & Nelson-Gray, 2005).

Most of the medications that effectively treat symptoms of schizophrenia can also treat symptoms of schizotypal personality disorder, although the medications are often taken at lower doses (Koenigsberg et al., 2003; Raine, 2006; see Chapter 12).

Thinking Like A Clinician

Shawna has few friends; most of the time she’s quiet and shy, avoiding eye contact. Occasionally, she mentions that her troubles—work, social, and financial—are because of the radiation coming out of the computer. She says it with a straight face, but it’s hard to tell whether she’s joking. When asked whether she’s being serious, she reluctantly says that she’s not, but it’s not clear whether she’s being honest. If you were asked to determine whether she has a personality disorder, what kinds of questions would you ask? Based on what you have read, what types of answers would distinguish quirky behavior from the truly odd behavior that characterizes a Cluster A personality disorder? If you determined that her behavior was odd enough to merit a diagnosis of a Cluster A (odd/eccentric) personality disorder, what would you look for in order to decide which of those disorders might be the best diagnosis?