Schizotypy—Do Not Worry, It Is Not All Worrisome

Abstract

A long-standing tradition in personality research in psychology, and nowadays increasingly in psychiatry, is that psychotic and psychotic-like thoughts are considered common experiences in the general population. Given their widespread occurrence, such experiences cannot merely reflect pathological functioning. Moreover, reflecting the multi-dimensionality of schizotypy, some dimensions might be informative for healthy functioning while others less so. Here, we explored these possibilities by reviewing research that links schizotypy to favorable functioning such as subjective wellbeing, cognitive functioning (major focus on creativity), and personality correlates. This research highlights the existence of healthy people with psychotic-like traits who mainly experience positive schizotypy (but also affective features mapping onto bipolar disorder). These individuals seem to benefit from a healthy way to organize their thoughts and experiences, that is, they employ an adaptive cognitive framework to explain and integrate their unusual experiences. We conclude that, instead of focusing only on the pathological, future studies should explore the behavioral, genetic, imaging, and psychopharmacological correlates that define the healthy expression of psychotic-like traits. Such studies would inform on protective or compensatory mechanisms of psychosis-risk and could usefully inform us on the evolutionary advantages of the psychosis dimension.

Introduction

Schizotypy, in particular in a clinical context, is treated as a pathological condition. It is commonly assessed via self-report questionnaires comprising symptom dimensions known from schizophrenia, that is, positive, negative, and disorganized symptoms.^1–3 Individuals who score very high in such self-report questionnaires were found to have an enhanced risk for psychosis.^4,5 It is thus assumed that knowledge acquired from schizotypy research will also enlighten our knowledge of schizophrenia. Within this taxonomic tradition, it is no surprise that deficits and similarities with schizophrenia are highlighted.⁶ Sticking to a purely pathological perspective, however, seems one-sided when considering that scores in such self-report questionnaires vary widely in the general population.^4,7 Moreover, in longitudinal studies, the large majority of so-called “psychosis-prone” individuals (high in self-reported schizotypy), will never experience a psychiatric illness.^4,5 Thus, it is possible that individuals who score high in schizotypy might have some advantages, guaranteeing its persistence over generations and contributing to the richness of human experience and performance. Indeed, when taking that dimensional perspective, grounded in individual differences research, one can account for both the psychopathological and healthy personality potential of schizotypy.⁷ Our contribution to this special issue is, therefore, to provide a selective and brief overview on study domains in which schizotypy has been considered advantageous. In particular, we review studies on health/social wellbeing, flexible and unconventional thinking (in particular creativity) and psychological styles, and personality features. To also account for the likely important role of the multidimensionality of schizotypy, we report on results as a function of schizotypy subdimensions where possible. Alongside, we discuss the potential implications of these advantages and how they could influence and shape future studies on schizotypy, including its psychopathological expression.

Healthy Schizotypy

The years preceding the introduction of the new DSM, now in its fifth revision, has seen numerous contributions to the debate as to whether dimensional models of mental illnesses (including psychosis) should be included.⁸ Decades of research within a clinical and personality tradition have focused on markers (eg, cognitive and behavioral) that are present in both patients with schizophrenia and healthy schizotypal individuals from the general population.^6,9–11 In most studies, the link between schizotypy and the clinical condition is key. Markers are treated as indicators of psychopathology rather than as indicators of mental health. Yet, one could argue that these markers are simple by-products of the psychosis dimension devoid of any clinical relevance. In the end, these markers are present in completely healthy, fully functioning individuals from the general population without a past, current, and future history of a psychotic or related psychiatric history.^4,5 We obviously appreciate the possibility that these markers could be clinically relevant, in particular when of a certain magnitude. There is, however, a major caveat with this possibility; we lack information as to the necessary magnitude of cognitive deficits for those to be clinically predictive or selective. Commonly, we observe that deficits for given cognitive domains are evident in patients with schizophrenia as well as in the respective populations along the schizophrenia spectrum (including schizotypy). When taking a dimensional personality research perspective, we do not need to focus on impairments and disadvantages. We can focus on both potential psychopathological and beneficial markers. This approach equally facilitates the discussion of evolutionary advantages of the schizophrenia spectrum including schizotypy.^12–14

Schizotypy and Health/Wellbeing

Several studies have reported on comparisons in health and wellbeing between schizophrenia and schizotypy. For instance, patients with schizophrenia as compared to controls report a lower quality of life and life satisfaction.¹⁵ In the healthy population, schizotypal traits are often accompanied by lower life satisfaction and higher negative affect. Even when negative affect is accounted for, lower life satisfaction was most importantly associated with negative and disorganized schizotypy, but not with positive schizotypy.^16–18 Moreover, while all schizotypy dimensions (positive, negative, disorganization) related to lowered life quality, the relationship was most relevant to negative schizotypy, in particular when related to social activity.¹⁶ In another study, 3 groups were carefully selected, that is, they scored high only in negative schizotypy, positive schizotypy, or scored low in both dimensions.¹⁹ Results revealed negative health implications for the group that scored high in negative schizotypy. This study also showed that the group high in negative schizotypy was particularly stress susceptible (eg, perceived stress, avoidant coping). These studies indicate that negative schizotypy seems linked to lowered life quality, functioning, and wellbeing.

As indicated above, negative schizotypy is only part of the larger schizotypy concept, with positive schizotypy and cognitive disorganization representing frequently reported subdimensions.^1–3 In the case of positive schizotypy, studies link this subdimension to pleasant and enriching mental experiences. In a context in which participants were exposed to experimental settings facilitating altered states of consciousness, those scoring high as compared to low on positive schizotypy reported higher and more intense levels of altered perceptual experiences and visual imagery.²⁰ Importantly, these authors hinted that such settings (eg, shamanism) were associated with enhanced self-healing, raising the notion that positive schizotypy in the right context would be beneficial.

Several additional examples support this position, as shown by some recent studies on new religious movements (NRM). Positive schizotypal traits in members of NRM (eg, Hare Krishnas, Druids) were higher than those in both Christians and nonreligious control groups.²¹ In another study, higher delusional ideations were observed in members of NRM when compared with controls.²² This study also showed that NRM members had comparable delusional ideations to deluded patients.²² Importantly, however, NRM members seemed less distressed and preoccupied by their experiences than were patients.²³ Yet another study showed that individuals holding peculiar beliefs (eg, faith healing, angels, ESP) and who perceive them as being important to their lives consider these beliefs to have a positive impact enhancing their understanding of the world and themselves.²⁴ The more this relationship was observed, the less individuals experienced psychological distress. Finally, Farias et al²⁵ reported significant relationships between NRM and magical thinking (but not with paranoid ideation and perceptual ideation). NRM individuals reported a sense of connectedness and holistic experiences and showed an associative thinking style and emotional hypersensitivity. These authors suggested that such features offer a healthy way to cognitively organize thoughts and experiences, that is, reflect on a cognitive framework within which magical ideation and unusual experiences are given meaning.

Being able to cognitively organize thought and experiences might indeed reflect a crucial factor in how schizotypal features impact on mental health. Positive schizotypal features themselves, especially when accompanied by low negative schizotypy and/or low cognitive disorganization, might represent the healthy schizotype who can profit from positive schizotypal experiences by integrating positive schizotypal experiences into a coherent cognitive framework.^12,26–29 For instance, high positive schizotypy and low cognitive disorganization associated with the subjective evaluation of paranormal experiences being pleasant.²⁷ On the other hand, high negative schizotypy and high cognitive disorganization associated with the subjective evaluation of paranormal experiences being distressing.²⁷ In another study, schizotypy, psychological and subjective well-being as well as substance use was assessed in over 400 students.²⁸ Using a latent profile analysis, these authors reported that a group of individuals high in positive schizotypy (with average or below average scores on negative schizotypy and cognitive disorganization) showed favorable subjective and psychological wellbeing comparable to that of individuals with low schizotypy.

All in all, these studies indicate that negative schizotypy might link to lower overall wellbeing and mental health, while high positive schizotypy in itself might reflect healthy schizotypy which in the relative absence of negative schizotypy and cognitive disorganization is able to constructively integrate positive schizotypal beliefs and experiences into a meaningful and coherent cognitive belief framework. Very likely, this cognitive capacity is important to previous notions that schizotypy (in particular positive schizotypy) associates with enhanced openness to experience, fantasy-proneness and most importantly to the socially highly valued cognitive ability of creativity.^30–32

Schizotypy and Creativity

Ongoing debates link creativity with mental illness with most focusing on psychosis and the affective disorders.^33–36 Over many decades, reports mentioned links between “genius and madness” including “psychopathology causing creativity, creativity leading to psychopathology, a third variable causing both, and other plausible models involving multiple factors.”^{34 (p. 7)} While the exact nature and causality of a possible link remains open to debate, cognitive models have long proposed that such psychiatric patients suffer from deficient selective attention mechanisms disabling their ability to inhibit irrelevant information and leading to remote associations and an overgeneralization.³⁷ The generation of unusual, remote associations has been inferred from the behavior of patients with schizophrenia and mania³⁷ and has been observed experimentally from individuals showing schizotypal thoughts.^38,39 In the case of patients, few studies used laboratory creativity tests, or otherwise standardized scientific methods.^40,41 Yet, when such methods were applied, results indicated that patients do not show superior creative functioning when compared with controls or other psychiatric patient groups, but perform worse.⁴² This observation is not new. For instance, Jacobson questioned in 1926 that “geniuses are geniuses because they are insane”^{43 (p. 92)} arguing instead “that the great genius must be eminently sane when in action, if the works produced are to rank high.”^{43 (p. 94)} Creative individuals require periods of sane functioning despite potential psychopathological tendencies, conditions more likely being encountered in healthy relatives of patients and individuals high in schizotypy.^31,44,45

Schizotypy has indeed been instructive in this regard. A link between enhanced creativity and schizotypy has been confirmed in numerous studies using experimental creativity tests.^46–50 These experimental tests are mainly based on divergent and convergent thinking abilities⁵¹: in order to reach an original idea, a person must be able to diverge, exploring different ways in which a problem can be approached, and then converge upon an appropriate solution for the idea to be valued by others as creative. To test for divergent thinking abilities, researchers frequently apply tests such as the alternate uses task (AUT)⁵² in which participants list as many possible uses for common items (eg, tyre). To test for convergent thinking abilities, researchers frequently apply tests in which participants have to focus on a reduced number of possible solutions when given a large variety of stimuli. For instance, in Mednick’s⁵³ remote association task (RAT), participants are presented with 3 concepts (eg, “hair,” “stretch,” and “time”) and asked to find the concept that best fits with the 3 original concepts regarding association, meaning, or abstraction (solution to the current example would be “long”).

When such creativity tests are employed, it has been reported that schizotypy (mainly positive schizotypy)^39,54 as well as Eysenck’s Psychoticism scores⁵⁵ relate to enhanced convergent thinking abilities.⁵⁶ Similar conclusions have been drawn for divergent thinking abilities.^56,57 While these findings could now be taken as solid evidence for a link between positive schizotypy and creativity, other studies draw a less obvious picture. For instance, enhanced negative schizotypy was linked to divergent thinking, while no relationship emerged between divergent thinking and positive schizotypy.⁵⁰ Some have argued that the link between positive schizotypy and creative activities (eg, divergent thinking) can be explained by individuals’ professional choice.⁵⁸ Alternatively, factors such as openness, intelligence, and affective temperament might explain enhanced creative potentials in individuals high in positive schizotypy.^59,60 Also, it might be important to look at more varied creative expressions and professions. For instance, a recent study showed that comedians were paradoxically very high in both negative schizotypy (anhedonia) and impulsivity.⁶¹ Also, the creative potential seems important in high functioning autism and Asperger syndrome (notably the autism spectrum has been related to “outsider art,”⁶² science,⁶³ and music).⁶⁴ These observations help to rejuvenate ideas on genetic links between the autism and schizophrenia spectrum.⁶⁵

The creative, uncommon associations and solutions involved in creativity are thought to result from a person’s ability to browse remote semantic information within semantic networks.⁶⁶ Here, semantic concepts are represented as nodes. These nodes are located in proximity to one another with strong interconnections that represent closely related semantic concepts. Nodes that are located remotely to each other with weak interconnections represent weakly and indirectly related semantic concepts. Whenever a given node is activated, the surrounding nodes will be co-activated to a degree related to their closeness to the initially activated node. Consequently, during the creative process, the spreading activation within this semantic network proceeds along new lines reaching several widespread, remotely interconnected nodes. In schizotypy, individuals are not only found to produce more remote associations they also perceive remote associations to be more closely related to each other.^54,67,68 In neuropsychological terms, this bias for remote associative processing in positive schizotypes is thought to result from a bias toward right hemisphere processing, in particular for language functions,^68–71 probably because of an overall stronger right hemisphere activation^72,73 mediated by dopaminergic mechanisms.^70,74

It appears that schizotypy (in particular positive schizotypy) links, either directly or indirectly, to thinking styles (eg, divergent, convergent) favoring creativity. In addition, these thinking styles are enhanced in artistic professions.^35,36 By inference, individuals scoring high in (positive) schizotypy should be able to use their creative potential to their and others’ advantage, while this ability should be hampered for individuals at the clinical end of the psychosis continuum. Potentially, all populations along the psychosis continuum yield enhanced divergent thinking abilities, without necessarily being all able to again converge their remote associative thinking to a reasonable and usable thought. As Abraham et al⁵⁵(^{p. 531}), pointed out “Psychoticism then appears to only facilitate the ability to produce original, unusual or uncommon responses in a generative task and has little bearing on the usefulness or suitability of these responses.”

Here, previous notions on the role of generativity and consolidation in creativity are relevant,⁷⁵ because “generativity refers to the inspired creation of new forms, genres, or ideas, whereas consolidation refers to the more secondary process activities of refinement, editing, polishing, and communicating.”⁷⁶(p.107) Generativity might be as potent in psychiatric populations as it is in healthy schizotypes and/or conventionally trained creative populations, while the process of consolidation might be hampered in clinical populations only. Mapped onto the distinction between divergent and convergent thinking, one could likewise infer that both populations are comparable in their potential for divergent thinking, but that the convergent, consolidating process might be hampered in the most severely affected individuals. Thus the convergent facility might be fully functional in individuals such as those high in schizotypy or in individuals along the bipolar dimension.³⁴ The latter proposition seems indicated, because bipolar disorders might lie on the psychosis dimension between patients with schizophrenia and healthy controls.^77,78

We suggest that consolidation is intact in the healthy schizotype, while it is increasingly hampered along the psychosis dimension. The extent to which this suggestion might hold true is a topic for future studies accounting for subpopulation along the psychosis dimension; as well as different professions and other psychological dimensions, such as the autism spectrum. Moreover, future studies should more carefully consider the use of established and standardized creativity tasks to make it easier to compare across different studies. Indeed, a recent overview on creativity measures and psychopathology demonstrates how scattered the definitions, methods, and outcomes are.⁷⁹

As a final note here, such studies should also try to explain why patients, relatives, as well as individuals high in positive schizotypy show relative deficits in domains that would argue more or less directly against the notion of enhanced abilities to generate and to diverge along the schizophrenia spectrum. For instance, studies showed deficits in the appreciation of irony along the schizophrenia spectrum, with humor and metaphor processing being relatively intact in schizotypy.^80–85 Likewise, there have been reports on reduced word production along the schizophrenia spectrum such as assessed during conversational speech^86,87 or theory of mind tasks.⁸⁸ It is likely that symptom dimensions^{80,82,84,85,89} as well as performance levels⁹⁰ will at least partially determine how fluent, rigid, or varied thoughts and ideas are.

Problem Solving and Reasoning

Schizotypy studies on problem solving and reasoning are tightly linked to the creativity literature.^91–94 Creative insight might indeed be key to problem solving processes, whether people search individually or in groups. One study tested insight problem solving, in which a problem needs to be restructured (rather than found incrementally) until the solution suddenly arises (“aha experience”).⁹⁴ Insight (as compared to incremental) problem solving requires loosened associative thinking abilities to successfully restructure the problem. As shown above, individuals high in positive schizotypy show loose and unconventional associative thinking styles.^39,67,95 Thus, it does not come as a surprise that pre-selected high as compared to low scoring schizotypal individuals performed more correct solutions for insight problems with no group difference being observed for incremental problems.⁹⁴ Unfortunately, this study did not distinguish between different schizotypy dimensions. In another study, enhancing the ecological validity, individuals of varying schizotypy (total low, medium, high) scores performed a group-solving task.⁹¹ The low schizotypy group applied fewer strategies than the other 2 groups, with the latter 2 groups applying twice the number of problem solving strategies, with high schizotypy individuals being also efficient in speed.⁹¹

Concerning reasoning tasks, college students had to decide on the validity of logical reasoning statements.⁹³ While all schizotypy dimensions were associated with deficient reasoning abilities, it seemed that enhanced negative schizotypy caused these deficits. Using a different set of causal conditional statements, Sellen et al⁹² did not find reasoning deficits as a function of any schizotypy subdimension. The only relevant result to the present report was that slightly enhanced positive schizotypy was associated with less logic-like responses (ie, a lower logic index as calculated from performance in a conditional inference task). A final example used conditional reasoning about neutral and personally relevant statements.⁹⁶ Here, negative schizotypy associated with reasoning deficits. It was noted on page 128 of the author’s article that “it is interesting that neither the present results nor the evidence found by Sellen et al. implicates positive schizotypy.” Based on the presented literature, we agree with this conclusion: that positive schizotypy does not seem to be related to inferior or superior logical reasoning abilities, but propose intact or typical reasoning abilities with regards to healthy positive schizotypy.

Schizotypy and Creativity?

In line with independent reports in this special issue,^2,3 we have repeatedly noted the multidimensional nature of schizotypy and how acknowledging this helps us to disentangle associations with proneness to psychopathology, on the one hand, and the relationship to creativity (or lack of it), on the other. In constructing the debate we followed what has become the most widely accepted view of the structure of schizotypy: as 3 dimensions of positive schizotypy, negative schizotypy, and cognitive disorganization. However, it should be mentioned that this model can be challenged, on 2 grounds. Firstly, there is increasing evidence that the schizophrenias and bipolar disorder are overlapping clinical conditions, both descriptively and genetically, probably lying on a continuum,^77,78,97 although independent studies question the notion of a continuum idea.^98,99 Secondly, at the trait level, the domain of individual differences we have been accustomed to label “schizotypy” can also yield a 4 dimensions solution. This pattern of factor structure emerges when a sufficiently comprehensive set of psychotic trait scales is included in statistical analyses; as represented in the self-report O-LIFE schizotypy questionnaire.¹⁰⁰ Significantly, the fourth factor to emerge—impulsive nonconformity—unambiguously maps on to bipolar disorder; as evidenced by loadings both within the O-LIFE itself and in correlations between the impulsive nonconformity and bipolar symptoms.¹⁰¹

The current reasoning is highly relevant to the particular topic of this article: as discussed elsewhere¹⁰² and indeed as mentioned in passing here, in our own discussion of the role of psychotic traits in creativity. Both schizophrenic and bipolar (manic-depressive) traits are relevant to creativity.¹⁰³ This proposition was first debated in the “creativity/madness” literature as an either/or debate between Sass¹⁰⁴ and Jamison.¹⁰⁵ The latter argued that the creativity connection was mediated entirely by bipolar traits, while Sass disagreed and opted for the schizophrenia connection. As it turned out, both were partly right and interesting; Nettle¹⁰⁶ writing at the trait level, coined the term “thymotypy” to parallel “schizotypy” as the second of 2 routes to different forms or aspects of creativity.

Schizotypy and Thinking Style

A series of studies showed that certain subdimensions of schizotypy link to inner experiences and behavioral traits that give rise to individuals prone to unconventional (including creative) thinking and behavioral expression. Located within this domain are studies demonstrating that positive schizotypy links to enhanced dissociation, openness to experience, absorption, false memories, and fantasy-proneness as well as to reduced agreeableness.^30–32 All in all, it seems that positive schizotypy and hypomania, but less so negative schizotypy or cognitive disorganization seem related to the ability and ease with which one manipulates mental images and inner concepts.⁴⁷

Conclusions

The reviewed studies, while numerous but not exhaustive, support the notion that schizotypy is multidimensional.^1–3 This view has been supported by the reviewed literature showing that some psychotic trait features and their interaction might be disadvantageous while others are advantageous to an individual’s functioning. Thus, being high in positive schizotypy seems more likely to be beneficial, that is, associated with personal wellbeing, flexible and unconventional thinking (including creativity), and favorable personality traits and psychological features (eg, openness to experience, fantasy-proneness). On the other hand, studies that are concerned with the psychopathological markers of schizophrenia and psychosis more widely, seem to show that negative schizotypy and/or cognitive disorganization might be linked to psychopathological functioning.^107–110

To further our understanding of what might distinguish a healthy from a worrisome schizotypal profile we need studies that select individuals high in specific schizotypy dimensions,^19,28 examining their interactions in relation to individuals’ mental health and illness. In addition to considering variables of subjective wellbeing, cognitive functioning and personality, we would also profit considerably from distinguishing between healthy and worrisome schizotypy by (1) considering genetic and psychopharmacological correlates^70,111,112 and (2) searching for more variables that show a superior performance in high as compared to low scorers on schizotypy.^113–115 Knowing about behavioral, genetic, neuroimaging, and psychopharmacological correlates that differentiate healthy and worrisome schizotypy might shed light on potential protective or compensatory mechanisms at the healthy end of the schizophrenia spectrum.⁷⁰ Knowing about such correlates would also enrich the continuing discussions on evolutionary advantages of the schizophrenia spectrum including schizotypy.^12–14

Acknowledgment

The authors have declared that there are no conflicts of interest in relation to the subject of this study.