Cluster A Personality Disorders

Personality disorders are ego-syntonic behaviors that begin in childhood or adolescence and are classified into 3 clusters: A, B, and C. They can considerably interfere with a patient’s adherence to medical treatment for a variety of reasons. It is important to rule out organic causes of a mental disorder (e.g., endocrine hormone imbalances, medication adverse effects, alcohol and/or substance use, other mental health co-morbidities) before ascribing a personality disorder to a patient. Cluster A includes paranoid, schizoid, and schizotypal personality disorders, which can be behaviorally described as being distrustful and/or detached from society.

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Paranoid Personality Disorder

Key features

  • Strong distrust of others and suspicions that others want to harm or deceive them, even when unfounded
    • E.g., spouse’s infidelity
    • E.g., not sharing personal information even with close relationships out of fear of being exploited or harmed
    • E.g., reads malicious intent or hidden meaning into everyday normal remarks or actions
  • Exaggerated reactions and holding grudges after harmless events

Risk factors

  • Family history of schizophrenia
  • Family history of delusional disorder (persecutory type)
  • Affects men more commonly than women

Management

  • Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, psychosis, mood instability)

Clinical associations

  • Projection is the predominant defense mechanism.
  • Should be differentiated from delusional disorder

Schizoid Personality Disorder

Key features

  • No interest in close relationships or intimacy → solitary, lack of close relationships other than parents or siblings
  • Inability to enjoy activities usually seen as pleasurable
  • Appears unemotional and indifferent to the opinion of others

Risk factors

  • Family history of schizophrenia or schizotypal personality disorder
  • Slightly higher prevalence in men

Management

  • It is unlikely that a physician will encounter a patient with schizoid personality disorder without any other reason for medical treatment, as these patients avoid interacting with people.
  • Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, psychosis, mood instability)

Clinical associations

  • Isolation of affect is the predominant defense mechanism.
  • Should be differentiated from:
    • The involuntary social withdrawal associated with avoidant personality disorder (Cluster C)
    • Autism spectrum disorder
    • Agoraphobia
    • Antisocial personality disorder (in the colloquial sense of the term; i.e., “He’s just being antisocial”)

Schizotypal Personality Disorder

Key features

  • Social anxiety and paranoia →  lack of close relationships
  • Odd beliefs and behavior, including:
    • Eccentric appearance
    • Magical thinking
    • Ideas of reference
    • Striking speech patterns, e.g., very vague or overly detailed

Risk factors

  • Family history of schizophrenia or schizotypal personality disorder
  • Slightly higher prevalence in men

Management

  • Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, psychosis, mood instability)

Clinical associations

  • Should be differentiated from:
    • Schizophrenia
    • Schizoaffective disorder
    • Delusional disorder (especially ideas of reference)

Summary

Cluster A disorderParanoidSchizoidSchizotypal
Key features
  • Suspicious
  • Distrustful
  • Hypervigilant
  • Voluntary social withdrawal
  • Detached
  • Unemotional
  • Eccentric thoughts, perceptions, and behavior
  • Uncomfortable in close relationships
Defense mechanismProjectionIsolation of affectN/A
DifferentialsDelusional disorder
  • Avoidant personality disorder
  • Autism spectrum disorder
  • Agoraphobia
  • Schizophrenia
  • Schizoaffective disorder
  • Social anxiety disorder
ManagementPsychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers)Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers)Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers, second-generation antipsychotics)
Epidemiology♂>♀♂>♀ (slightly)♂>♀ (slightly)
ExampleA man believes that his neighbors are sneaking into his house at night and are working together to get him kicked out of the neighborhood.A man lives in a remote village and has no known friends or family.A young man believes that the crystals he sells have magical healing properties and that the spirit gods are helping him find his fortune.

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