Schizotypal personality disorder belongs to Cluster A personality disorders, which also include schizoid personality disorder and paranoid personality disorder. Schizotypal personality disorder is characterized by deficits in social and interpersonal skills, highlighted by a reduced ability to form close relationships, occurring in the setting of eccentric behavior and cognitive or perceptual distortions. Symptoms such as restricted affect and social isolation in schizotypal personality disorder may share similarities with those found in schizoid personality and paranoid personality disorders. The symptoms of schizotypal personality disorder must be distinguished from neurodevelopmental disorders, personality changes due to another medical condition, substance use disorders, and other mental disorders with psychotic symptoms.
The following factors should be carefully considered in the psychiatric evaluation, including the mental status examination, of individuals suspected of having schizotypal personality disorder.
Appearance: May appear unkempt, disheveled, or eccentric appearance with odd attire.
Behavior: May be inappropriate, stiff, peculiar, socially detached, hypervigilant, suspicious, or overtly paranoid.
Speech: Speech abnormalities include odd, vague, metaphorical, or stereotyped speech. In addition, individuals tend to have more pauses, slower speech, and less pitch variability.
Affect: Ranges from constricted to expansive and may be inappropriate to the circumstances.
Thought Content: May be suspicious or have paranoid ideation with magical thinking, fixation on the supernatural or paranormal, odd beliefs, overvalued ideas, or ideas of reference. Suicidal and homicidal ideation should be assessed at each encounter.
Thought Process: Ranges from logical and goal-directed to vague and rambling, without actual derailment.
Perceptions: Likely to describe unusual perceptual experiences, including bodily illusions or sensing that another person is present. These experiences are generally not at the level of overt hallucinations, which suggest a schizophrenia spectrum disorder.
Cognition: General cognition and orientation are not impaired in schizotypal personality disorder. However, assessment is necessary to rule out other psychiatric conditions, such as schizophrenia, where cognitive impairment is common.
DSM 5, criteria: A pervasive pattern of social and interpersonal deficits characterized by acute discomfort with, and reduced capacity for, close relationships, as well as cognitive or perceptual distortions and eccentricities of behavior, typically beginning in early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following:
- Ideas of reference (excluding delusions of reference).
- Odd beliefs or magical thinking that influence behavior and are inconsistent with subcultural norms, such as superstitious, belief in clairvoyance, telepathy, or sixth sense; in children and adolescents, bizarre fantasies or preoccupations.
- Unusual perceptual experiences, including bodily illusions.
- Odd thinking and speech, such as vague, circumstantial, metaphorical, overelaborate, or stereotyped.
- Suspiciousness or paranoid ideation.
- Inappropriate or constricted affect.
- Behavior or appearance that is odd, eccentric, or peculiar.
- Lack of close friends or confidants other than first-degree relatives.
- Excessive social anxiety does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic characteristics, another psychotic disorder, or autism spectrum disorder.
If criteria are met prior to the onset of schizophrenia, premorbid can be added, for example, schizotypal personality disorder (premorbid).
The DSM-5-TR alternative diagnostic model for schizotypal personality disorder outlines two main criteria—Criterion A and Criterion B.
Criterion A: This criterion denotes a requirement for moderate or greater impairment in personality functioning. Individuals must demonstrate significant challenges in 2 or more of the following 4 areas.
Identity: Confused boundaries between self and others; distorted self-concept; emotional expression often not congruent with context or internal experience.
Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
Empathy: Pronounced difficulty understanding the impact of own behaviors on others; frequent misinterpretations of others’ motivations and behaviors.
Intimacy: Marked impairments in developing close relationships associated with mistrust and anxiety.
Criterion B: This criterion outlines 6 pathological personality traits, and diagnosis requires 4 or more of these traits.
Cognitive and perceptual dysregulation (an aspect of psychoticism): Odd or unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or stereotyped thought or speech; odd sensations in various sensory modalities.
Unusual beliefs and experiences (an aspect of psychoticism): Thought content and views of reality that are viewed by others as bizarre or idiosyncratic; unusual experiences of reality.
Eccentricity (an aspect of psychoticism): Odd, unusual, or bizarre behavior or appearance; saying unusual or inappropriate things.
Restricted affectivity (an aspect of detachment): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.
Withdrawal (an aspect of detachment): Preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
Suspiciousness (an aspect of detachment): Expectations of, and heightened sensitivity to, signs of interpersonal ill-intent or harm; doubts about loyalty and fidelity of others; feelings of persecution.