ABSTRACT
“Cluster A” personality disorders comprise paranoid personality disorder (PPD), schizoid personality disorder (SPD), and schizotypal personality disorder (StPD). Patients who fall within these diagnostic categories are the least likely to present for individual psychoanalytic therapy because of the inflexibility and severity of the conditions, the comparatively poor response to treatment and, not infrequently, inaccurate diagnosis. However, the growth in public expectation from the talking therapies and the slow but steady progress made by researchers into the origins and prevalence of these disorders has led more Cluster A patients to seek out psychotherapeutic help than was the case in the past, although the number remains small relative to the treatment of borderline personality disorder. Demographically, Cluster A disorders affect 0.5%–2.5% (PPD), slightly less than 1% (SPD), and approximately 3% (StPD) of the U.S. population (with comparable rates in Europe), and the consequences for individuals affected can be highly disabling (Elkin, 1999). The incidence of each category appears to be higher in men than in women, and in describing this cluster of conditions emphasis has tended to be placed on odd, eccentric, or “cold” behavior. These characteristics are most evident in SDP and StPD. It is thought that a biological relationship may exist between the disorders and the schizophrenias, although of the three, StPD can be more demonstrably linked to schizophrenia phenomenologically and genetically (McGlashan, 1986). SPD and StPD are sometimes grouped as part of a continuum, given the similarity of certain symptoms. There remains no distinctive set of psychotherapeutic theories applicable to these conditions. More research is required into the developmental and psychic structural aspects of the illnesses before generally accepted psychological theories for the conditions can be established. There is, in fact, strikingly little research into Cluster A disorders compared with other personality disorders (notably borderlines), and more is needed if the conditions are to become better understood. Psychodynamic researchers have noted the stability of diagnosis and treatment outcomes (e.g., McGlashan, 1986; Sandell, et al., 1997; Stone, 1985, 1993). Clinical investigation into Cluster A–type personalities tends to study the nature of internal object relationships, defenses, psychotic anxieties, and transference-countertransference phenomena. * Attention to psychotic anxieties is of particular importance to those who study and treat Cluster A disorders. Psychotic elements occur in severe neuroses, psychosomatic disorders, sexual perversions, and personality disorders alongside neurotic constellations, and this is particularly the case with Cluster A. Such patients are not psychotic per se, but are vulnerable to psychotic thinking and compromised ego functioning that create confusion between internal and external realities.
