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Schizotypal personality disorder and suicide: problems and perspectives

Published online by Cambridge University Press:  08 July 2021

Leo Sher Open the ORCID record for Leo Sher [Opens in a new window]
Leo Sher*
Affiliation:
James J. Peters VA Medical Center, Bronx, NY, USA Icahn School of Medicine at Mount Sinai, New York, NY, USA
*
Author for correspondence: Leo Sher, Email: leo.sher@mssm.edu
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Abstract

Schizotypal personality disorder (SPD) is classified in DSM-V as a cluster A personality disorder. Cluster A personality disorders are described as odd or eccentric conditions. SPD is associated with significant disability and many psychiatric comorbidities. Several studies have shown that SPD and schizotypal traits are associated with suicidal ideation and behaviour. Suicide prevention interventions in individuals with SPD are impeded because (1) SPD is frequently not diagnosed; (2) SPD is difficult to treat; and (3) there are no guidelines for suicide screening or suicide prevention interventions in individuals with SPD. Suicide prevention in persons with SPD consists of (1) diagnosing SPD; (2) providing appropriate treatment for SPD; and (3) providing suicide screening and suicide prevention. Interventions aiming at reduction of depressive symptoms, improvement of self-esteem, and interpersonal skills may be effective at reducing suicide risk amongst individuals with SPD. Studies of suicidality in persons with SPD are needed and may be an important area of suicide research. It is to be hoped that future studies of the pathophysiology of suicidality in individuals with SPD will help to develop strategies for suicide screening and suicide prevention interventions in persons with SPD and improve suicide prevention in this challenging patient population.

Keywords

schizotypal personality disorderschizotypal traitssuicidedepression
Type
Perspective
Information
Acta Neuropsychiatrica , Volume 33 , Issue 5 , October 2021 , pp. 280 - 282
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Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of Scandinavian College of Neuropsychopharmacology

Summations

  • Schizotypal personality disorder (SPD) is understudied, under-recognised, and can be difficult to diagnose.

  • SPD is associated with significant disability, many psychiatric comorbidities, suicidal ideation, and behaviour.

  • There are no guidelines for the diagnosis and management of suicidal ideation and behaviour in individuals with SPD.

Perspectives

  • Improvements in the diagnosis and treatment of SPD may reduce suicide risk.

  • Family interventions may be important in preventing suicidal behaviour in persons with SPD.

  • Strategies to diagnose and treat suicide risk in individuals with SPD need to be developed.

Schizotypal personality disorder: diagnostic criteria, prevalence, and comorbidities

Schizotypal personality disorder (SPD) is classified in DSM-V as a cluster A personality disorder (American Psychiatric Association, 2013). Cluster A personality disorders are described as odd or eccentric conditions and include schizotypal, schizoid, and paranoid personality disorders. The term ‘schizotype’ was first proposed by a Hungarian psychoanalyst Sandor Rado in 1956 as an abbreviation of ‘schizophrenic phenotype’ (Millon et al., Reference Millon, Millon, Meagher, Grossman and Ramnath2004).

According to the DSM-V, for a diagnosis of (SPD), patients must have (1) a persistent pattern of intense discomfort with and decreased capacity for close relationships and (2) cognitive or perceptual distortions and eccentricities of behaviour (American Psychiatric Association, 2013). At least five of the following nine diagnostic criteria are required for a diagnosis of SPD: ideas of reference; odd beliefs or magical thinking; unusual perceptual experiences and bodily illusions; odd thinking and speech; suspiciousness or paranoid ideation; inappropriate or constricted affect; behaviour or appearance that is odd, eccentric, or peculiar; lack of close friends or confidants, other than first-degree relatives; and excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears.

Studies of SPD indicate that there are three symptom domains in SPD: (1) cognitive-perceptual symptoms (odd beliefs, perceptual disturbances, ideas of reference, and paranoia/suspiciousness), (2) interpersonal symptoms (no close friends, social anxiety, restricted affect), and (3) disorganisation/oddness (odd speech/thought, odd behaviour, restricted affect) (Rosell et al., Reference Rosell, Futterman, McMaster and Siever2014). Patients with SPD are less in touch with reality, and their thoughts and speech are more disorganised than in other personality disorders. SPD is regarded as a schizophrenia spectrum disorder (SSD) (Battaglia and Torgersen, 1996).

Considerable evidence suggests that there are significant associations between childhood hardships and SPD (Berenbaum et al., Reference Berenbaum, Valera and Kerns2003; Lentz et al., Reference Lentz, Robinson and Bolton2010; Fung and Raine, Reference Fung and Raine2012). Neglect, physical, and sexual abuse during childhood predisposes both men and women to meet the criteria for SPD at some point in their lifetime. It is important to note that childhood adversities also predispose to non-suicidal self-injury and suicidal behaviour (Braquehais et al., Reference Braquehais, Oquendo, Baca-García and Sher2010; Serafini et al., Reference Serafini, Canepa, Adavastro, Nebbia, Belvederi Murri, Erbuto, Pocai, Fiorillo, Pompili, Flouri and Amore2017).

The lifetime prevalence of SPD in the United States of America has been estimated to be around 4%, with somewhat higher rates amongst men (4.2%) than women (3.7%) (Pulay et al., Reference Pulay, Stinson, Dawson, Goldstein, Chou, Huang, Saha, Smith, Pickering, Ruan, Hasin and Grant2009). A study in Oslo, Norway, showed that the prevalence of SPD was 0.6% (Torgersen et al., Reference Torgersen, Kringlen and Cramer2001).

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study found that patients with SPD had high rates of co-occurring mental disorders: (1) substance use disorders – 67.5%; (2) mood disorders – 67.6%; (3) anxiety disorders – 72.3%; (4) personality disorders – 82.7% (Pulay et al., Reference Pulay, Stinson, Dawson, Goldstein, Chou, Huang, Saha, Smith, Pickering, Ruan, Hasin and Grant2009). SPD is significantly associated with bipolar I and II disorders, post-traumatic stress disorder (PTSD), borderline, and narcissistic personality disorders (Pulay et al., Reference Pulay, Stinson, Dawson, Goldstein, Chou, Huang, Saha, Smith, Pickering, Ruan, Hasin and Grant2009; Rosell et al., Reference Rosell, Futterman, McMaster and Siever2014).

Studies of SPD and suicidality

Several studies have shown that SPD and schizotypal traits are associated with suicidal ideation and behaviour (Joiner et al., Reference Joiner, Gencoz, Gencoz, Metalsky and Rudd2001; Lentz et al., Reference Lentz, Robinson and Bolton2010; Teraishi et al., Reference Teraishi, Hori, Sasayama, Matsuo, Ogawa, Ishida, Nagashima, Kinoshita, Ota, Hattori and Kunugi2014; Jahn et al., Reference Jahn, DeVylder and Hilimire2016; Gong et al., Reference Gong, He, Wang and Liu2020; O′Hare et al., Reference O’Hare, Poulton and Linscott2021). A nationally representative study of the non-institutionalised adults in the United States of America demonstrated that a diagnosis of SPD forecasts the occurrence of lifetime suicide attempts after adjusting for significant risk factors, including childhood hardship, co-occurring psychiatric disorders, and sociodemographic parameters (Lentz et al., Reference Lentz, Robinson and Bolton2010). A recent study showed that schizotypal traits in early adolescence predict subsequent suicidal ideation and attempts from the age of 18 to 38 years (O′Hare et al., Reference O’Hare, Poulton and Linscott2021)

Joiner et al. (Reference Joiner, Gencoz, Gencoz, Metalsky and Rudd2001) found that SPD symptoms were associated with suicidality after adjusting for symptoms of depression in a big cohort of young adult individuals referred to a management programme for persons with elevated suicide risk. A recent investigation found that depression mediated the association between schizotypal traits and suicidality (Gong et al., Reference Gong, He, Wang and Liu2020). Another investigation suggests that symptoms of depression and low self-esteem explain an association between interpersonal schizotypy and lifetime most severe suicide ideation (Jahn et al., Reference Jahn, DeVylder and Hilimire2016)

Teraishi et al. (Reference Teraishi, Hori, Sasayama, Matsuo, Ogawa, Ishida, Nagashima, Kinoshita, Ota, Hattori and Kunugi2014) administered the Schizotypal Personality Questionnaire (SPQ) to a large group of patients with schizophrenia with or without a history of suicide attempts and controls. The authors found that high schizotypy is associated with lifetime suicide attempts and that the total SPQ score might be useful to assess the risk of suicide attempts in patients with schizophrenia.

Suicide prevention interventions in individuals with SPD are impeded because:

  1. a) SPD is frequently not diagnosed.

  2. b) SPD is difficult to treat.

  3. c) There are no guidelines for suicide screening or suicide prevention interventions in individuals with SPD.

Diagnostic issues

SPD is under-recognised and understudied. SPD can be difficult to diagnose:

  1. (1) Mental health and especially non-mental health clinicians frequently are not sufficiently educated/trained to recognise SPD.

  2. (2) SPD may be difficult to diagnose even for competent mental health professionals. Identifying SPD or schizotypal traits in the clinical setting can be challenging because SPD symptoms overlap with symptoms of many better-known psychiatric conditions (Pulay et al., Reference Pulay, Stinson, Dawson, Goldstein, Chou, Huang, Saha, Smith, Pickering, Ruan, Hasin and Grant2009; Rosell et al., Reference Rosell, Futterman, McMaster and Siever2014). SPD may be attributed to more familiar diagnoses. Frequent complaints of individuals with SPD are related to attentional/cognitive difficulties, social anxiety, dysthymia, troubles relating to others, and long-lasting interpersonal difficulties due to mistrust or paranoid ideation. Schizotypal individuals are commonly diagnosed with attention-deficit disorder (inattentive type), social anxiety disorder, autism spectrum disorder, or depression.

  3. (3) An individual with SPD or schizotypal traits may be described in colloquial words (e.g. loner) without a diagnostic designation (Rosell et al., Reference Rosell, Futterman, McMaster and Siever2014; Nazario, Reference Nazario2020).

  4. (4) Studies of SPD are frequently focused on schizophrenia spectrum issues, and there has been comparatively less stress on SPD as a clinical syndrome on its own (Battaglia and Torgersen, 1996; Rosell et al., Reference Rosell, Futterman, McMaster and Siever2014).

Suicide prevention in individuals with SPD

Improvements in the diagnosis and treatment of SPD may reduce suicide risk. Education of mental health and non-mental health clinicians about symptoms of SPD may help to identify SPD in different clinical settings. To diagnose SPD, a clinician needs to complete the patient’s history, review psychiatric and medical records, and, if possible, get collateral information. Psychological tests such as the Structured Clinical Interview for DSM-5 (SCID-5) or SPQ may help to establish the diagnosis of SPD. Some SPD symptoms are easier to recognise than the others. Psychometric studies demonstrated that the cognitive-perceptual (‘positive’) traits are stronger than interpersonal (‘negative’) traits in recognising SPD in clinical settings (Widiger et al., Reference Widiger, Frances and Trull1987).

There is presently only limited data on which to base treatment choices in patients with SPD (Kirchner et al., Reference Kirchner, Roeh, Nolden and Hasan2018). Most of the medication treatment investigations were performed in individuals with SPD and a co-occurring disorder, which restricts our capability to make conclusions. Moreover, some studies included only a few patients.

SPD is frequently treated using a combination of medications and psychotherapy (Koenigsberg et al., Reference Koenigsberg, Reynolds, Goodman, New, Mitropoulou, Trestman, Silverman and Siever2003; Kirchner et al., Reference Kirchner, Roeh, Nolden and Hasan2018; Nazario, Reference Nazario2020). There are no medications approved by the US Food and Drug Administration specifically for the treatment of SPD. Antipsychotic medication treatment is common in SPD patients (Koenigsberg et al., Reference Koenigsberg, Reynolds, Goodman, New, Mitropoulou, Trestman, Silverman and Siever2003; Rosell et al., Reference Rosell, Futterman, McMaster and Siever2014; Kirchner et al., Reference Kirchner, Roeh, Nolden and Hasan2018). Sometimes, antidepressants or anti-anxiety medications are prescribed for individuals with SPD to relieve or reduce depressive or anxiety symptoms (Rosell et al., Reference Rosell, Futterman, McMaster and Siever2014; Kirchner et al., Reference Kirchner, Roeh, Nolden and Hasan2018; Nazario, Reference Nazario2020). Psychotherapeutic interventions in SPD include cognitive behavioural, supportive, supportive-expressive, and family therapy (Stone, Reference Stone1985; Nazario, Reference Nazario2020). People with SPD may find psychotherapy hard because, as part of the condition, they tend to be uneasy in relationships. Individuals with SPD may be more capable of performing work that is structured and requires limited social interaction.

There are no evidence-based recommendations for the diagnosis and management of suicidal ideation and behaviour in SPD. Clinicians need to be educated on how to perform suicide assessments of and manage suicidal patients with SPD using available knowledge and tools. Thorough suicide risk assessments of patients with SPD are a cornerstone of suicide prevention in individuals with SPD. Suicide screening/assessment of individuals with SPD may be challenging because many people with SPD are paranoid/suspicious. Individuals who want to kill themselves may knowingly withhold their intentions. Suicide risk assessment of SPD patients should consist of both direct and indirect questions. The assessment of proximal risk factors for suicide including depressive symptoms may help with a more precise suicide risk evaluation.

Suicide prevention amongst individuals with SPD should include engaging hard-to-reach and no-show patients, following up with patients who were discharged from inpatient settings, and working to ensure that patients are safe from the means for suicide at home and at work (Layman et al., Reference Layman, Kammer, Leckman-Westin, Hogan, Goldstein Grumet, Labouliere, Stanley, Carruthers and Finnerty2021). Periodic reviews of knowledge and skills in suicide assessments amongst clinicians may help to prevent suicides in persons with SPD as well as in patients with other psychiatric disorders. Interventions aiming at reduction of depressive symptoms and improvement of self-esteem may be effective at reducing suicide risk amongst individuals with SPD. Psychotherapeutic treatment aimed at improving interpersonal skills may also reduce suicidality in this patient population.

Family interventions may be important in preventing suicidal behaviour in individuals with SSD including persons with SPD (Caqueo-Urízar et al., Reference Caqueo-Urízar, Rus-Calafell, Craig, Irarrazaval, Urzúa, Boyer and Williams2017; Sher and Kahn, Reference Sher and Kahn2019). It is crucial to educate families of individuals with SPD that how they behave towards the patient can facilitate or inhibit recovery. Families of people with SPD should also be educated about signs and symptoms of suicide risk and what to do if the SPD individual becomes suicidal.

Studies of suicidality in persons with SPD are needed and may be an important area of suicide research. Strategies to diagnose and treat suicide risk in individuals with SPD need to be developed. It is to be hoped that future studies of the pathophysiology of suicidality in individuals with SPD will help to develop guidelines for suicide screening and suicide prevention interventions in persons with SPD and improve suicide prevention in this challenging patient population.

Conflict of interest

None.

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