A 62-year-old woman comes to the office for follow-up of worsening hypertension. The patient admits to not taking her antihypertension medication as prescribed. She says she feels fine and adds, "I always listen to my bodily rhythms when deciding whether to take medication on a particular day." The patient explains that her crystal jewelry has healing powers, and she maintains an online forum about the health benefits of crystals. The patient does not trust most people and believes that she can predict the weather based on the number of birds in her yard. She lives alone, has few friends, and is unemployed. On examination, the patient makes limited eye contact and appears mildly anxious. She has no auditory hallucinations, and no specific delusions are elicited. Which of the following is the most likely explanation for this clinical presentation?
DSM-5 personality disorders | |
Cluster A Odd/eccentric |
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Cluster B Dramatic/erratic |
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Cluster C Anxious/fearful |
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This patient's eccentric behavior, odd thoughts, perceptual distortions (eg, "bodily rhythms"), and social anxiety are consistent with schizotypal personality disorder. Patients with this disorder typically exhibit magical thinking (eg, superstitiousness, clairvoyance) and odd perceptual disturbances that are subthreshold for a psychotic disorder. They do not experience the persistent, fixed delusions or frank hallucinations seen in schizophrenia (Choice F). Individuals with schizotypal personality disorder rarely sustain close interpersonal relationships due to excessive social anxiety that does not decrease with familiarity.
(Choice A) Social anxiety is common in patients with both schizotypal and avoidant personality disorders. However, individuals with avoidant personality disorder desire relationships but fear rejection and do not exhibit the eccentric behaviors of schizotypal personality disorder.
(Choice B) Borderline personality disorder is characterized by unstable relationships, impulsivity, mood lability, and self-harm.
(Choice C) Obsessive-compulsive personality disorder is a lifelong pattern of preoccupation with orderliness, perfectionism, and control.
(Choices D and E) Although individuals with paranoid and schizoid personality disorders also have difficulty sustaining trusting relationships, they do not exhibit the overt eccentricity or perceptual distortions seen in schizotypal personality disorder. Patients with paranoid personality disorder exhibit a pattern of pervasive distrust and suspicion; those with schizoid personality disorder are socially detached and tend to prefer solitary activities.
Educational objective:
Schizotypal personality disorder is characterized by a long-standing pattern of eccentric behavior, odd beliefs, perceptual distortions, and social anxiety despite familiarity.