We will explore Otto Kernberg's perspective on schizotypal personality disorder through the lens of psychotherapeutic strategies, with a focus on its connections to schizophrenia.
Let us begin with the definition of schizotypal personality disorder.
How does the DSM-5 define Schizotypal Personality Disorder?
The DSM-5 the essential feature of schizotypal personality disorder is 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. This pattern begins by early adulthood and is present in a variety of contexts.
Individuals with schizotypal personality disorder often seek treatment for the associated symptoms of anxiety or depression rather than for the personality disorder features per se. Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in duration to warrant an additional diagnosis such as brief psychotic disorder or schizophreniform disorder. In some cases, clinically significant psychotic symptoms may develop that meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder, or schizophrenia. Over half may have a history of at least one major depressive episode.
From 30% to 50% of individuals diagnosed with this disorder have a concurrent diagnosis of major depressive disorder when admitted to a clinical setting.
There is considerable co-occurrence with schizoid, paranoid, avoidant, and borderline personality disorders.
What is Otto Kernberg's view on schizotypal personality disorder?
Otto Kernberg, MD, in his book “Severe Personality Disorders: Psychotherapeutic Strategies” (1984) describes the diagnosis of Schizotypal Personality Disorder is problematic. According to his observation, а careful evaluation of reality testing in the clinical situation may identify patients with actual loss of reality testing and psychotic personality structure in contrast to those in whom the maintenance of reality testing corresponds clearly to the diagnosis of Schizoid Personality. It is as if a tail end of schizophrenia has been inserted in the section on personality disorders, the counterpart of the remarkable restriction of schizophrenia to a psychosis of at least six months' duration, so that any schizophrenic illness lasting even a few days less than six months would be classified as a Schizophreniform Disorder. According to Otto Kernberg it would be preferable not to restrict schizophrenia so artificially and, from a clinical viewpoint, to be able to make the diagnosis even in cases who do not have the florid picture and where the treatment approach and the prognosis are different from those corresponding to personality disorders.
What are the challenges in defining schizotypal personality disorder according to Otto Kernberg?
According to Otto Kernberg, the criteria for Schizotypal Personality Disorder were developed to identify individuals who had been described as having Borderline Schizophrenia. There is evidence that Chronic Schizophrenia is more common among family members of individuals who were described as having Borderline Schizophrenia than in the general population.
Here is a clear theoretical bias; a category was created that would fit with a schizophrenia spectrum concept based upon research on genetic features in schizophrenia.
The evidence for the concept of a schizophrenia spectrum is convincing enough, but it should be kept in mind that some of the biological relatives of schizophrenic patients who present what called "pseudoneurotic schizophrenia," and others have called "borderline schizophrenia" or "ambulatory schizophrenia," may be suffering from milder or subclinical versions of schizophrenic illness rather than a personality disorder.”
"Borderline schizophrenia" — does it exist?
In fact, the entire contemporary literature on research on borderline conditions stemmed from an effort to clarify whether "borderline schizophrenia" exists and the extent to which one can differentiate this group into:
a) patients with "psychotic personality" structures or "atypical" or "latent" or "simple" or "residual" forms of schizophrenic illness
b) borderline personalities proper who are definitely not psychotic.
Epidemiological studies, including clinical interviews of biological relatives of schizophrenic probands, may not provide the kind of subtle discriminatory evidence that would answer these questions, in contrast to long-term, intensive diagnostic and therapeutic involvements with patient populations
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy