A Case of Schizotypal Personality Disorder
By: THEODORE MILLON
et al.
Notes:
(1) Numbers mark aspects of the case most consistent with DSM
criteria as follow, and
do not necessarily indicate that the case
“meets” diagnostic criteria in this respect.
(2) Patient's name has been changed in respect to
confidentiality, and names mentioned are not of a real existent person.
Case of Matthew
Matthew, age 37, works the night shift for a large security
firm. Although he has guarded the same large food warehouse night after night for 13 years, he seldom
interacts with other employees, preferring instead to spend time alone.
Recently, however, his coworkers have been complaining of his strange behavior.
Matthew has been muttering incoherently and
“skulking” around corners. (7) After Matthew was seen cutting the skin on the back of his hand
with a pocketknife, his supervisor made arrangements for a psychological
evaluation.
During the clinical interview, Matthew answered questions
with either
one-word responses or very short phrases, usually waiting to be asked a second time before
responding and refusing to make eye contact with the examiner. (4) His answers were short and bizarre
and gave insight into a life devoid
of any human connectedness. (4) In fact, his only real personal contact is his older brother,
whom he
sometimes sees during the holidays. His only significant relationship, he
states, was with a girl in high school. “We graduated and I didn’t see her any more,” he says,
(8) beginning with almost no
emotion and then trailing off into
silence, with an occasional misplaced giggle. (6)
When asked why he likes his work, Matthew replies that the
night shift
spared him the crowds and noise of daytime. Moreover, he can be by himself during his patrols and
is not required to talk with anyone else. “People make me nervous,” he states,
smiling. When asked about
past employment, he notes that he has worked as a janitor and a driver but has been
homeless for a period of time, though it did not appear to worry him. (9) Throughout the interview, he shows neither understanding nor
curiosity about the events that led to the evaluation, instead answering questions mostly in
monotone. He seems
impervious to the world around him. (4)
After extensive probing and rephrasing, Matthew discloses
that he sometimes
fears that he is dead or nonexistent, that he feels more like a thing than a person. Accompanying
this revelation is his first genuine emotion of the interview. “I get terrified,” he
states. When these
feelings occur, he quiets the dread by cutting himself. If he truly did not exist, “the cuts would
not hurt, and he would not bleed.” (3) He is also helped by
“mind messages.” He calls out to the “protective spirits,” who answer his call, thus reaffirming his
existence. (2) Matthew seems undisturbed by the
peculiarity of his statements or by his idiosyncratic lifestyle. Although his
self-mutilation obviously
requires treatment, in his view, it is a positive force that contributes to his comfort.
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 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
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, or another Psychotic Disorder, and is not due to the direct physiological effects of a general medical condition.
Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g. “Schizotypal Personality Disorder (Premorbid).”
References
(1) Personality Disorders in Modern Life, second edition,
2000, 2004 by John Wiley & Sons, Inc.
(2)Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition. Copyright
1994 American Psychiatric Association.
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