Psychodynamic Model and Treatment of Schizotypal Personality Disorder

This paper concerns the psychotherapeutic treatment of patients who meet DSM criteria for schizotypal personality disorder (SPD). Perhaps, because it is the least treated of all the personality disorders listed in the DSM-IV-TR (APA, 2000; Gabbard, 2005), there is a shortage of useful theoretical models and treatment approaches for working with individuals diagnosed with SPD. I present a psychodynamic model for the treatment of SPD from the perspective of modern structural theory (Druck, 2011). I argue that psychodynamic supportive psychotherapy (Winston, Rosenthal, & Pinsker, 2004) is indicated for individuals diagnosed with SPD as a useful way to improve their ego functioning and reality testing. I also suggest that the effort to maintain an attitude of analytic neutrality can help clinicians manage their expectable intense and sometimes disorienting countertransference reactions, and can minimize the ego-boundary confusion commonly observed in individuals diagnosed with SPD (Stone, 1985). I particularly focus on some of the disorganized and cognitive-perceptual symptoms of SPD, such as paranoia, odd thinking and speech, and magical thinking (Raine et al., 1994). First, I highlight the importance of emotions in schizotypy deficits and explore how emotions are related to the cognitive-perceptual and disorganized features of the syndrome (Kerns, 2005). I argue that understanding the emotions of individuals with schizotypal tendencies can help improve their abilities to assess reality. Second, to better understand their compromised reality testing, I describe the role of conflict, defense and “weak ego boundaries” seen in patients diagnosed with SPD. Third, I analyze the cognitive and disorganized features of SPD with reference to the psychodynamic concepts of primary process thinking and primitive defense mechanisms. Finally, I argue that modern structural theory (Druck, 2011), which is based on the assumption that both deficits and conflicts explain psychopathology, is an effective way to understand and treat individuals diagnosed

with SPD. In this context, I present the long-term treatment of a woman with significant schizotypal features.