Abstract
Psychotic disorders and schizophrenia-spectrum personality disorders (PD) with psychotic/psychotic-like symptoms are considerably linked both historically and phenomenologically. In particular with regard to schizotypal and schizotypal personality disorder (SPD), this is evidenced by their placement in a joint diagnostic category of non-affective psychoses in the InternationaI Classification of Diseases 10th Revision, (CD-10) and, half-heartedly, the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, (DSM-5). Historically, this close link resulted from observations of peculiarities that resembled subthreshold features of psychosis in the (premorbid) personality of schizophrenia patients and their biological relatives. These personality organizations were therefore called “borderline (schizophrenia)” in the first half of the 20th century. In the 1970s, they were renamed to “schizotypal” and separated from psychotic disorders on axis-I and from other PD on axis-II, including modern borderline PD, in the DSM. The phenomenological and historical overlap, however, has led to the common assumption that the main difference between psychotic disorders and SPD in particular was mainly one of severity or trajectory, with SPD representing a latent form of schizophrenia and/or a precursor of psychosis. Thus, psychosis proneness and schizotypy are often assessed using SPD questionnaires. In this perspective-piece, we revisit these assumptions in light of recent evidence. We conclude that schizotypy, SPD (and other schizophrenia-spectrum PD) and psychotic disorder are not merely states of different severity on one common but on qualitatively different dimensions, with the negative dimension being predictive of SPD and the positive of psychosis. Consequently, in light of the merits of early diagnosis, the differential early detection of incipient psychosis and schizophrenia-spectrum PD should be guided by the assessment of different schizotypy dimensions.
Highlights
Specialty section: This article was submitted to Psychopathology, a section of the journal Frontiers in Psychiatry
schizotypal personality disorder (SPD) and psychotic disorder are not merely states of different severity on one common but on qualitatively different dimensions, with the negative dimension being predictive of SPD and the positive of psychosis
SPD, and psychotic disorder are rather manifestations of discrete profiles of schizotypy or SPD dimensions than merely states of different severity on only one dimension
Summary
SPD as a diagnostic entity was not formulated until 1979 [24], historically, its close link to schizophrenia-spectrum psychoses was earlier established by observations on two levels [25]:. The clinical level: observations of patients with attenuated forms of Bleuler’s fundamental symptoms of schizophrenia without positive psychotic symptoms or severe personality deterioration These personality organizations were commonly called “borderline or latent schizophrenia” in the first half of the 20th century; with focus on their pathological and dysfunctional aspects (including its function as a risk indicator for psychosis), the difference between manifest psychotic disorders and their latent forms ( SPD) has commonly been (mis-) assumed to be one of severity or trajectory. Both Kraepelin [26] and E. SPD assessments based on this disorderoriented view, formulate items conflating schizotypy with aspects of clinical relevance and distress [31]
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