Currently, limited evidence exists for any psychotherapeutic treatment for schizotypal or paranoid personality disorders (SPD; PPD). However, schema therapy (ST) seems a promising candidate, focussing on ameliorating the consequences of childhood trauma through building a healing personal relationship and working on the integration and regulation of the total range of emotions with experiential exercises, e.g., imagery work.

The current case report presents a 38-year-old male with SPD, PPD, comorbid substance abuse, and an extensive trauma history. He initially presented with pronounced social isolation, emotional inhibition and avoidance, and a persistent sense of being different than other people. The patient received 63 sessions of individual ST over a course of 20 months.

Limited reparenting and empathic confrontation were the primary interventions, as the patient found it hard to engage in experiential exercises and activate emotion. When engaging with difficult emotions, the patient would often exhibit a swift sequence of schema modes, or even dissociate. This meant that the therapist would hold back in challenging or confronting the patient to more emotionally intensive work. The effect of therapy resulted only in small changes in schemas and modes during therapy, and some changes in the expression of anger, but no effect on personality disorder or symptom levels at the end of treatment and follow-up. However, the patient was adherent to the treatment and did not exhibit exacerbation of his condition.

ST seems safe and acceptable for this case of SPD and PPD. Should the treatment have been more effective, it might have been beneficial to insist on experiential work. We recommend extensive support and supervision when treating SPD and PPD. Further work is needed to adapt and handle the specific challenges this patient group poses, as well as studies on the effect of ST for these disorders.