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.

Paranoid Personality Disorder

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.

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.

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.

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.

Schizoid Personality Disorder

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.

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.

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

Schizotypal Personality Disorder

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).

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:

• Cognitive-perceptual
  • (Criterion A1) ideas of reference, in which the person interprets ordinary events to have particular meaning for him or her (a milder form of referential delusions, described in Chapter 12);
  • (A2) odd beliefs or magical thinking, in which the person believes that he or she has control over external events, as occurs with superstitious beliefs;
  • (A3) unusual perceptual experiences, such as feeling “dislocated” from parts of one’s body or hearing a voice on the radio murmuring one’s name;
  • (A5) suspiciousness or paranoid ideation, which consists of paranoid beliefs that are less entrenched than paranoid delusions.
• Interpersonal
  • (A6) inappropriate or constricted affect, such as showing only a narrow range of emotions;
  • (A8) lack of close friends because of a preference for being alone;
  • (A9) excessive social anxiety that arises because of a general suspiciousness about other people.
• Disorganized
  • (A4) odd thinking and speech, such as being overly vague or elaborate or using words idiosyncratically (as in “My coworker isn’t talkable”);
  • (A7) behavior or appearance that is odd or eccentric, such as wearing mismatched or unkempt clothing, avoiding eye contact, or being unable to make conversation.

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.

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).

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.

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

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).

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).