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mental health mondays :: puttin on the schizo

for part two of the mental health mondays look at personality disorders [whaddya mean you didn't read part one?!?!?!?!?], i've decided to take on probably the most frustrating post first. today, we're going to look at the various schizo- disorders and trust me, if your brain doesn't feel addled yet, by the end of this post, it definitely will.

now, there is one important exclusion to be made here, which is that schizophrenia is not one of the aforementioned disorders. what? no, my friends, while there are a host of personality disorders that start with the same letters, schizophrenia isn't included because it's a psychotic disorder. what's the difference? sigh. i was hoping that wouldn't come up. anyway, i'll defer to expert opinion, so here is the definition of schizophrenia given by the mayo clinic:

Schizophrenia is a severe brain disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior.
Contrary to popular belief, schizophrenia isn't a split personality or multiple personality. The word "schizophrenia" does mean "split mind," but it refers to a disruption of the usual balance of emotions and thinking.
Schizophrenia is a chronic condition, requiring lifelong treatment.

well that seems fairly specific now, doesn't it. schizophrenia is characterised by hallucinations, delusions and disordered thinking and by the abnormal interpretation of reality. i mean, one could debate the exact parameters of abnormality and reality, but let's just set that aside for the moment.

so now, let's look at the mayo clinic's definition of personality disorders:

A personality disorder is a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving. A person with a personality disorder has trouble perceiving and relating to situations and to people. This causes significant problems and limitations in relationships, social encounters, work and school.
In some cases, you may not realize that you have a personality disorder because your way of thinking and behaving seems natural to you. And you may blame others for the challenges you face.
Personality disorders usually begin in the teenage years or early adulthood. There are many types of personality disorders. Some types may become less obvious throughout middle age.

ok, so a personality disorder is related mostly to patterns of thinking and behaviour, in particular when it comes to interactions with others. there seems to be something almost sinister about being told that you might not realise that you have a disorder and that you blame others for your challenges, because it is just possible that you're surrounded by dickheads. but leaving that aside, the distinctions seem clear enough, considering that we're dealing with something as complex as the brain. [except the bits about the age of onset of the disorder. schizophrenia is thought to be lifelong most of the time once you have it, but it doesn't usually present until the teenage years or early adulthood. so, exactly like a personality disorder. i know that because it's on the mayo clinic page about schizophrenia symptoms, which comes right after the page with the definition i've quoted above. but it's not like they could have gotten anything else confused, of course.]

prior to 2013 and the publication of the diagnostic and statistical manual of mental disorders, version 5, psychiatric disorders of all kinds were split into different axes, with personality disorders occupying a separate quadrant of crazy than things like schizophrenia and bipolar disorder. now, everything is treated as one giant screwed up swimming pool, with more general guidelines about who's in the deep or shallow end.

however, personality disorders as a group still exist within that swimming pool, and within those groups are the schizo-based disorders. i have to admit that this might be a record for how long it's taken me to get to the point.

there are officially two [but kind of three] of these personality disorders: schizoid personality disorder and schizotypal personality disorder. i say "kind of three", because there's also schizoaffective disorder, which is where one has symptoms of both schizophrenia and a mood disorder [either bipolar or depression], but doesn't meet the full criteria for either one individually. in addition, there's also something called schizophreniform disorder, which is when symptoms of schizophrenia manifest for at least one, but less than six months. [at six months, you've crossed the border into actual schizophrenia.] schizophreniform disorder is almost more of a holding pen before you find out whether you'll be treated for a limited duration psychotic episode or full-blown schizophrenia. but it's not a personality disorder, so we'll move on.

schizotypal personality disorder is characterised by suspiciousness with regards to other people, unconventional beliefs or perceptions, odd or eccentric dress style, peculiar patterns of speech, and/ or emotional reactions inappropriate to the situation. in teenagers, the mayo clinic adds that the schizotypal child "may be an underperformer in school or appear socially out of step with peers, and as a result is often bullied or teased".

schizoid personality disorder, on the other hand, is linked to social withdrawal and disinterest or anxiety with regards to other people. people with schizoid personality disorder generally have few friends and aren't very socially adept, often struggling to form deep or long-lasting relationships. they are perceived as independent, or as loners and often have a rich interior life to which they prefer to retreat. schizoid individuals tend to do very well in creative pursuits and in general do better when they are allowed to work alone. many find it difficult to experience pleasure in the "real" world. there is a subgroup of the schizoid set who are referred to as "secret schizoids": these are people who appear to function with more ease in public, but still have the other symptoms of the disorder.

if those definitions seem problematic, it's because they are. even if you start from the belief that these are three points on the same spectrum, it's troubling to associate the eccentric artist who prefers her own thoughts and company with a person in the grips of full-blown psychosis. and, indeed, these definitions, particularly that of schizoid disorder, have been criticized for being laden with cultural bias. most discussions of schizoid personality disorder note that many people who "suffer" from it are completely unaware, because they are high functioning and don't seem troubled by their disordered thought.

schizotypal disorder is hampered by being vague: is it really a good idea to lump eccentric dress style in with occasionally believing that the television is talking to you directly? well, a psychiatrist would say that it's the cumulative effect that's important: no, an offbeat sense of fashion doesn't mean that you have a problem. but walking around downtown in an evening dress in the middle of winter might be a sign of something a little more worrying.

either way, it's a scary thing to be told that you're suffering with something that's in the same ballpark as schizophrenia. what's worse, people with schizotypal disorder are considered to be in danger of developing schizophrenia if their condition is left untreated, which puts a greater pressure on them to seek help.

but wait, it gets worse...

if you're too confused about the differences between schizoid and schizotypal disorder, don't worry, you can have both at once. if you primarily suffer from schizoid disorder, there is a form of it called depersonalised schizoid personality disorder, which includes "schizotypal features". that's where the isolation and alienation of the principal disorder actually starts to make you feel fundamentally detached from the world, as if you were not participating in it at all. but if that's too confusing, the two conditions can be comorbid, which means you get all the fun of both disorders, and all of the confusion about when it's time to call a doctor. [which you might not do, since you might just think you're lovably eccentric, or you might just be lovably eccentric and not need any help and it's the definitions that are wrong.]

schizotypal personality disorder can also shack up with paranoid, avoidant and borderline personality disorders pretty well, and with mood disorders like depression, social anxiety disorder and obsessive-compulsive disorder. oh, and if you have it in combination with that last one, it tends to make treating the ocd a lot harder. sorry.

if you haven't yet slammed your head into your desk so hard that you've suffered permanent brain damage, congratulations. i firmly believe that the schizoid/ schizotypal/ schizoaffective/ schizophreniform axis of evil [can an axis have four points? or is that just part of my fantasy world?] is the root of many people's problems with psychiatry. while it may be a given that people who do not conform in certain ways to societal norms are going to face a distinct set of problems dealing with the rest of the world, it is a big leap to say that this means they are broken and need to be psychologically fixed. furthermore, the undeniably vagaries of the associated definitions seem like an attempt to keep any sense of comfort or understanding out of the hands of people who are suffering.

of course, one of the problems with these disorders is that having a "schizophrenia spectrum" is predicated on a solid understanding of schizophrenia, which most psychiatrists will admit they don't have. unlike in economics, the confusion over schizophrenia trickles down throughout its loosely associated family of disorders, until the spectrum seems to go from treating the most critically ill to forcing people to conform to a societal stereotype.

and no, this does not mean i'm trying to say that schizotypal or schizoid or any other schiz- disorders don't exist. i don't have anything like the qualifications to do that and what seems like doublespeak to a non-professional [me] reflects necessary differences in categorization to someone in the field. what i would say is that we all need to be open about the fact that, when it comes to the entire schizophrenia spectrum, we're on extremely tenuous ground. proceed with caution.

p.s. :: the images used here are all poster art created for the 1976 british horror film schizo, which is actually about dissociative identity disorder in which the mind becomes split- into different personalities, or realities, etc. it's a completely unrelated condition, however. it's a mystery how people keep getting these things confused.

p.p.s. :: in case you were curious, the prefix "schizo" comes from the greek "schízein" meaning "to part or split".  

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