Aripiprazole in Schizotypal Personality

Abstract

Sir: Schizotypal personality disorder (SPD) is characterized by odd, eccentric behavior; inappropriate or constricted affect; odd beliefs or magical thinking; circumstantial, metaphorical, or stereotyped thinking manifested by odd speech; anxiety in social situations; and cognitive or perceptual distortions.1 Studies have been conducted on the efficacy of haloperidol,2 thiothixene,3 olanzapine,4 and risperidone5 in SPD. However, efficacy of aripiprazole in SPD has not been reported. Aripiprazole is a novel antipsychotic with a unique mechanism of action. It is a partial agonist of D2 and D3 dopamine receptors and 5-HT1A serotonin receptors, which are, respectively, responsible for its efficacy on positive, negative, and cognitive symptoms of schizophrenia and its antidepressant and antianxiety actions.6–8 Hence, it is called a dopamine-serotonin system stabilizer.9,10 Aripiprazole has been approved by the U.S. Food and Drug Administration in the treatment of schizophrenia. A search of English-language publications in PubMed using the keywords schizotypal personality disorder and aripiprazole retrieved no published reports or articles. Herein, we describe a patient with SPD of 5 years’ illness duration who had never been treated with any medications and who responded to treatment with aripiprazole. Case report. Mr. A, a 22-year-old engineering student of middle-class socioeconomic status and urban background, presented to our hospital in August 2007 with an insidious onset and continuous course of illness of 5 years’ duration characterized by odd and eccentric behavior, oddities in speech, avoidance of social situations, deteriorating academic performance, idiosyncratic repetitive behaviors, and magical thinking. His family members were concerned about his odd and eccentric behavior, social dysfunction, and academic decline. The above symptoms could not be attributed to any clear-cut psychotic disorders, mood disorders, substance use disorders, or general medical conditions. He had never received treatment for the symptoms. The patient's history and family history were noncontributory. Structured assessment conducted at baseline using the Structured Clinical Interview for DSM-IV Axis I Disorders11 and Structured Clinical Interview for DSM-IV Axis II Personality Disorders12 revealed that Mr. A had schizotypal personality disorder. The Schizotypal Personality Questionnaire (SPQ)13 revealed social anxiety, odd beliefs, odd behaviors, blunted affect, suspiciousness, lack of close friends, and magical thinking. A baseline score of 4 on the Clinical Global Impressions-Severity of Illness scale (CGI-S)14 was noted. Other baseline psychodiagnostic assessments were also conducted, such as the Object Sorting Test, Thematic Apperception Test, and Rorschach Inkblot Test, which revealed the absence of pathognomonic signs of psychosis. After giving informed consent, Mr. A was started on treatment with aripiprazole 10 mg at night. At 2-month (week 8) follow-up, the patient reported a 70% decrease in his symptoms, started attending his engineering college regularly, and showed interest in his studies. His family members reported marked improvement in his social and academic functioning. They also reported that his odd ideas, eccentric behaviors, magical thinking, and suspiciousness were reduced to minimal. His interaction with friends and his mood also improved. His CGI-S score was 3 (mildly ill), and his CGI-Improvement score was 2 (showing much improvement). This patient with SPD had a 5-year duration of untreated illness and was assessed with structured instruments. He responded to treatment with 10 mg of aripiprazole. Currently, thiothixene, haloperidol, risperidone, and olanzapine have been documented to be effective in treatment of SPD. This case report assumes importance in the light of the paucity of aripiprazole studies in SPD. However, the choice of antipsychotic medications is largely based on side effect profile. Available data on aripiprazole reveal that it is an effective medication with a benign adverse effect profile.9,10 Aripiprazole, being a dopamine- serotonin system stabilizer, is hence an ideal drug to target the odd and eccentric behavior, stereotyped thinking, social anxiety symptoms, and obsessive symptoms of SPD. Future double-blind, placebo-controlled studies examining the effectiveness of aripiprazole in the treatment of SPD are needed. Ajay Kumar, M.Phil. Ravikant Pinjarkar, M.Phil. Nitin Anand, M.A., M.Phil. M. Manjula, M.Phil., Ph.D. Department of Mental Health and Social Psychology Suresh Bada Math, M.D., D.N.B., P.G.D.M.L.E. Department of Psychiatry, National Institute of Mental Health and Neurosciences, (Deemed University), Bangalore, India