Schizotypal personality disorder (StPD orSPD), also known asschizotypal disorder, is amental disorder characterized bythought disorder,paranoia, a characteristic form ofsocial anxiety,derealization, transientpsychosis, and unconventional beliefs.[4][5] People with this disorder often feel pronounced discomfort in forming and maintainingsocial connections with other people, primarily due to the belief that other people harbor negative thoughts and views about them.[6] People with StPD may react oddly in conversations, such as not responding as expected, or talking to themselves.[6] They frequently interpret situations as being strange orhaving unusual meanings for them;paranormal andsuperstitious beliefs are common. Those with the disorder often score high on measures forself-disorder.[7]
People with StPD usually disagree with the suggestion that their thoughts and behaviors are a 'disorder' and seek medical attention fordepression oranxiety instead. Schizotypal personality disorder occurs in approximately 3% of the general population and is more commonly diagnosed in males.[10]
People with StPD can feel intense paranoia.People with StPD can have abnormal sensory experiences (similar to the one pictured) in places or situations where others experience nothing unusual.
Odd andmagical thinking is common among people with StPD.[11][12][13] They are more likely to believe insupernatural phenomena and entities.[14][15][16][17] It is common for people with StPD to experience severesocial anxiety and haveparanoid ideation.[18][19]Ideas of reference are common in people with StPD.[20][21][22] They can feel as if expressing themselves is dangerous. They may also feel that others are more competent, and have deeply entrenched and pervasive insecurities. Strange thinking patterns may be adefense mechanism against these feelings.[23] People with StPD usually have limited levels ofself-awareness.[24] They may believe others think of them more negatively than they actually do.[25]
Patients with StPD can havedifficulties in recognizing their or others' emotions,[26][27] which can extend to difficulty expressing emotion.[28][29] They may have limited responses to others' emotions and can be ambivalent.[30] It is common for people with StPD to derivelimited joy from activities.[31][32][33] People with StPD are typically more socially isolated and uninterested in social situations than people without StPD,[34][35][36] although they are still likely to be socially active on the Internet.[37]Depersonalization,[38][39]derealization,[40]boredom,[41] and internal fantasies are common in patients with StPD. Abnormal facial expressions are also common in people with StPD, and they can have aberranteye movements and difficulty responding to stimuli.[42][43][44][45][46] They are often more prone to substance abuse orsuicidal ideation.[47][48] In an epidemiological study on suicidal behavior in StPD, even when sociodemographic factors were accounted for, people with StPD were 1.51 times more likely to attempt suicide.[49] StPD is also often characterized as having similar symptoms asschizophrenia, but with less severe cognitive deficits.[50]
People with StPD tend to havecognitive impairments.[51] They can have abnormal perceptional and sensory experiences such asillusions.[52][53] For example, someone with StPD may perceive colors as lighter or darker than others perceive them.[54]Facial perception may also be difficult for people with the disorder.[55][56][57][58] They may see others as deformed, misrecognize them, or feel as if they are alien to them.[54] People with StPD can have difficulty processing information such as speech or language.[59][60][61] They are more likely to speak slowly, with less fluctuation inpitch,[62] and long pauses between speech. Patients with StPD may have a lowerodor detection threshold,[63] and can have impairedauditory orolfactory processing.[64] It is also common for people with StPD to struggle withcontext processing,[65][66] which cause them to form loose connections between events.[67] In addition, people with StPD can have decreased capacities formultisensory integration orcontrast sensitivity,[68][69][70][71] either hyperreactive or impaired reactions to sensory input,[72][73][74] slower response times,[46] impairedattention,[75][76][77] poorerpostural control,[78] and difficulties with decision-making.[79][80] They can have difficulties inmemory,[81][82][83] and may have frequent intrusive memories of events.[84] It is common for people with StPD to feeldéjà vu or as if they can accurately predict future events due to abnormalities in the brain's memory storage.[85]
Exposure to influenza during week 23 ofgestation is associated with a higher likelihood of developing StPD. Poornutrition in childhood may also contribute to the onset of StPD by altering the course of brain development.[133]
Numerous areas of the brain are thought to be associated with StPD. Higher levels of dopamine in the brain,[134][135] possibly specifically theD1 receptor,[136][137][138] might contribute to the development of StPD. StPD is associated with heightened dopaminergic activity in thestriatum.[139][140][141][142] Their symptoms may also stem from higherpresynaptic dopamine release.[143][144][145][146]
StPD symptoms may also be influenced by reducedinternal capsule,[165][166][167] which carries information to thecerebral cortex.[168] People with StPD can also have impairments in theuncinate fasciculus, which connects parts of thelimbic system.[169] People with StPD have reduced levels of gray matter in theirmiddle frontal gyrus andBrodmann area 10,[170] although not as reduced as patients with schizophrenia,[170] possibly preventing them from developing schizophrenia.[171] Increased gyrification in gyri by the cerebellum may lead to dysconnectivity in the brain, and therefore, schizotypal symptoms.[172][173]
In people predisposed to schizophrenia spectrum disorders, the consumption ofcannabis can induce the onset of StPD or other disorders with psychotic symptoms.[184][185][186][187]
Unique environmental factors, which differ from shared sibling experiences, have been found to play a role in the development of StPD and its dimensions. There is evidence to suggest thatparenting styles, early separation,childhood trauma, and childhood neglect can lead to the development of schizotypal traits.[188][189][190] Neglect, abuse, stress,[191] trauma,[192][193][194] or family dysfunction during childhood may increase the risk of developing schizotypal personality disorder.[49][195][196] People with the most severe cases of StPD usually have a combination of childhood trauma and a genetic basis for their condition.[197][198]
During childhood, people with StPD may have seen littleemotional expression from their parents. Another possibility is that they were excessively criticized or felt like they were constantly under threat,[199] potentially resulting in the onset of social anxiety, strange thinking patterns,[200] and blunted affect present in StPD.[201][200][202]
Over time, children learn to interpret social cues and respond appropriately but for unknown reasons this process does not work well for people with this disorder.[203] Their difficulties in social situations might eventually cause the individual to withdraw from most social interactions, thus leading toasociality.[77] Children with schizotypal symptoms usually are more likely to indulge ininternal fantasies[204] and are more anxious, socially isolated, and sensitive to criticism.[205]
There is also evidence indicating that disruptions in brain development during the prenatal period could affect the development of StPD.[206]
TheDSM-5 includes two distinct diagnostic models for personality disorder (PD). TheDSM-5’s main body (Section II) retains a traditional, categorical model of 10 putatively distinct PDs, whereas itsSection III (Emerging Models and Methods) introduces an alternative, dimensional model for PD – namely, theAlternative DSM-5 Model for Personality Disorders (AMPD) – consisting of two main criteria—personality functioning and personality traits—both of which range from the adaptive to the maladaptive range.[208]
In its section II chapter on personality disorders, the latest edition of the DSM – namely theDSM-5-TR – defines STPD as "a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior".[209] Retained from theDSM-IV-TR,[209] the criteria require that at least five out of nine diagnostic criteria are met.[210] In addition to the aforementioned criteria, a diagnosis requires that the condition is not merely a part of the manifestation of adisorder causing psychosis, such asschizophrenia, nor ofautism spectrum disorder.[210]
The AMPD defines six specific personality disorders – one of them being STPD[211] – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathologicalpersonality traits associated with the disorder (criterion B).[212] While at least two of the elements of personality functioning must have a "moderate or greater impairment",[213] criterion B for Schizotypal PD requires four or more of six trait facets: Cognitive and Perceptual Dysregulation, Unusual beliefs and Experiences, Eccentric Perceptions (all three of which are facets of the Psychoticism domain), Restricted Affectivity, Withdrawal, and Suspiciousness.[208] Other traits can be included in the diagnosis as specifiers.[213] Five additional criteria (C through G) further define the two main criteria.[208]
Neither theICD-10 nor theICD-11 conceptualize StPD as being a personality disorder.[207][9] Instead, it is listed together with psychotic disorders as "Schizotypal disorder" in the ICD-11 (as6A22) and the ICD-10 (asF21).[9][207] In regards to personality disorders, theICD-11 classification of personality disorders has replaced the categorical classification ofpersonality disorders in the ICD-10 with adimensional model containing a unifiedpersonality disorder (6D10) with severity specifiers, along with specifiers forprominent personality traits or patterns (6D11).[214] While there is no specific PD diagnosis for StPD, schizotypal features – such as eccentricity and psychotic-like experiences – are considered indicators of severity, especially in severe cases involving impaired reality testing. These features are not coded as traits but inform the overall level of dysfunction.[215]
It should also be differentiated from other personality disorders; they can have symptoms similar to StPD. People with schizotypal personality disorder,paranoid personality disorder andschizoid personality disorder can also be socially detached and haveblunted affects, but without thecognitive or perceptual distortions of StPD. Individuals with StPD and people withavoidant personality disorder can have limited close relationships. However, people with AvPD rarely have the eccentric behaviour of StPD. Psychotic-like symptoms can also appear inborderline personality disorder, but those with BPD fear social isolation while those with StPD are comfortable with it. People with StPD are also usually less impulsive than people with BPD. Individuals withnarcissistic personality disorder may also appear socially alienated, however, this is due to fears of having flaws noticed by others.[219]
There are various methods ofscreening for schizotypal personality. The Schizotypal Personality Questionnaire (SPQ) measures nine traits of StPD using aself-report assessment.[223] The nine traits referenced are Ideas of Reference, Excessive Social Anxiety, Odd Beliefs or Magical Thinking, Unusual Perceptual Experiences, Odd or Eccentric Behavior, No Close Friends, Odd Speech, Constricted Affect, and Suspiciousness. A study found that of the participants who scored in the top 10th percentile of all the SPQ scores, 55% were clinically diagnosed with StPD.[224] It has been adapted into a computerized adaptive version, known as the SPQ-CAT.[225] A method that measures the risk of developing psychosis through self-reports is the Wisconsin Schizotypy Scale (WSS).[226] The WSS divides schizotypal personality traits into 4 scales for Perceptual Aberration, Magical Ideation, Revised Social Anhedonia, and Physical Anhedonia.[227][228] A comparison of the SPQ and the WSS suggests that these measures should be cautiously used for screening of StPD.[228]
When screening for StPD, it is difficult to distinguish between schizotypal personality disorder andautism spectrum disorder.[229] In order to develop better screening tools, researchers are looking into the importance ofipseity disturbance, which is characteristic ofschizophrenia spectrum disorders such as StPD but not of autism.[230][229]
Theodore Millon proposes two subtypes of schizotypal personality.[231][232] Any individual with schizotypal personality disorder may exhibit either one of the following somewhat different subtypes (note that Millon believes it is rare for a personality to show one pure variant, but rather a mixture of one major variant with one or more secondary variants):
Subtype
Features
Traits
Insipid schizotypal
A structural exaggeration of the passive-detached pattern. It includesschizoid,depressive anddependent features.
Sense of strangeness and nonbeing; overtly drab, sluggish, inexpressive; internally bland, barren, indifferent, and insensitive; obscured, vague, and tangential thoughts.
Timorous schizotypal
A structural exaggeration of the active-detached pattern. It includesavoidant andnegativistic features.
Warily apprehensive, watchful, suspicious, guarded, shrinking, deadens excess sensitivity; alienated from self and others; intentionally blocks, reverses, or disqualifies own thoughts.
Millon's typology of personality disorders was influential in the development of theDSM-III, particularly with respect to distinguishing between schizoid, schizotypal and avoidant personality disorders.[233] These had previously been considered different surface-level expressions of the same underlying personality structure, and some psychologists, particularly those working inpsychoanalytic orpsychodynamic traditions, still take these personality disorders to be essentially similar.[234][235]
StPD is rarely seen as the primary reason for treatment in a clinical setting, but it often occurs as a comorbid finding with other mental disorders. When patients with StPD have prescribed pharmaceuticals, they are usually prescribedantipsychotics.[236][237][238] However, the use of neuroleptic drugs in the schizotypal population is in great doubt.[239] The antipsychotics which show promise as treatments for StPD includeolanzapine,[240]risperidone,[241][242]haloperidol,[243] andthiothixene.[244] The antidepressantfluoxetine may also be helpful.[245][246] While people with schizotypal personality disorder and other attenuated psychotic-spectrum disorders may have a good outcome with neuroleptics in the short term, long-term follow-up suggests significant impairment in daily functioning compared to schizotypal and even schizophrenic people without antipsychotic drug exposure.[247] Positive, negative, and depressive symptoms were shown to be improved by the use of olanzapine, an antipsychotic.[245] Those with comorbid OCD and StPD were most positively affected by the use ofolanzapine and showed worse outcomes with the use ofclomipramine, an antidepressant.[242]Antidepressants are also sometimes prescribed, whether for StPD proper or for comorbid anxiety and depression.[239][242] However, there is some ambiguity in the efficacy of antidepressants, as many studies have only tested people with StPD and comorbidobsessive–compulsive disorder or borderline personality disorder. They have shown little efficacy for treatingdysthymia andanhedonia related to StPD.[5] Both of these medications are the most frequently prescribed medication for StPD, though the use and efficacy of them should be evaluated differently for every case.[245] The use of stimulants has also shown some efficacy, especially for those with worsened cognitive and attentional issues. Patients who have concurrent psychosis should be monitored more closely if stimulants are used as part of their treatment.[5] Other drugs which may be effective includepergolide,[248]guanfacine,[249][250][251][252] anddihydrexidine.[253][254][255]
According toTheodore Millon, schizotypal personality disorder is one of the most straightforward personality disorders to identify but one of the most difficult to treat withpsychotherapy.[231]Cognitive remediation therapy,[250][256][257]metacognitive therapy, supportive psychotherapy,[258] social skills training,[259] evolutionary systems therapy[260][261][262] andcognitive-behavioral therapy can be effective treatments for the disorder.[263][264] Increased social interaction with others may be able to help limit symptoms of StPD.[265] Support is crucial for schizotypal patients with predominantparanoid symptoms because they may have difficulties even in highly structured groups.[266] Persons with StPD usually consider themselves to be simply eccentric or nonconformist; the degree to which they consider their social nonconformity a problem differs from the degree to which it is viewed as a problem in psychiatry. It is difficult to gain rapport with people with StPD because increasing familiarity and intimacy often increase their level of anxiety and discomfort.[267] Therapy for StPD must be flexible to face emergencies or unique challenges.[258]
People with StPD usually had symptoms of schizotypal personality disorder in childhood.[217] Traits of StPD usually remain consistently present over time,[218][268] although can fluctuate greatly in severity and stability.[269][270] The two traits of StPD which are least likely to change are paranoia and abnormal experiences.[270] DSM characterizes StPD as having nine major symptoms: ideas of reference, odd/magical beliefs, social anxiety, not having close friends, odd or eccentric behavior, odd speech, unusual perceptions, suspiciousness, schizo-obsessive behaviors[271] andconstricted affect.[272]
There may begender differences in the symptomology of men and women with StPD.[157] Women with the disorder might be more likely to have less severecognitive deficits, and more severesocial anxiety andmagical thinking.[273][274][275] Symptoms ofdepression in women with StPD have a more negative impact on cognitive functioning than in males diagnosed with StPD and depression.[273] In males with the disorder, abstraction and verbal learning are more likely to be in deficit compared to women, who tend to be less vulnerable to verbal deficits.[273]
StPD tends to develop in adolescence and early adulthood, accompanied by a gradual decline in functioning and the increased development of StPD symptoms.[50] Adolescents with StPD were more likely to have performance deficits, especially inarithmetic,[50] and to display significantly lower levels ofexecutive functioning, similar to autism spectrum disorder.[50] Compared to those without StPD, adolescents with StPD spend more time socializing on the Internet, such as on forums, chat rooms and cooperative computer games, and spend less time socializing in-person.[276] People with StPD are more likely to only have ahigh school education, to be unemployed,[277] and to have significantfunctional impairment.[278]
Roughly 20-30% of those diagnosed with StPD will later develop schizophrenia.[279] One study found that substance use is a risk factor.[280] The same study found that older age presented a reduced risk, and that preexisting anxiety and depression disorders had protective effects.
The reported prevalence of StPD in community studies ranges from 1.37% in aNorwegian sample, to 4.6% in anAmerican sample.[219] A large American study found a lifetime prevalence of 3.9%, with somewhat higher rates among men (4.2%) than women (3.7%).[10] It may be uncommon in clinical populations, with reported rates of up to 1.9%.[219] It has been estimated to be prevalent among up to 5.2% of the general population.[281] Together with othercluster A personality disorders, it is also very common amonghomeless people who show up at drop-in centers, according to a 2008 New York study. The study did not address homeless people who do not show up at drop-in centers.[282] Schizotypal disorder may beoverdiagnosed inRussia and otherpost-Soviet states.[283]
Schizotypal can be diagnosed in early childhood, with diagnostic validity beginning at age five.[284] Though the prevalence is not yet established, one study found a prevalence of definite psychotic symptoms in children of 5.9% and 10.2%.[284]
StPD can be diagnosed alongside other disorders, includingborderline personality disorder (BPD),attention-deficit disorder,social anxiety disorder, andautism spectrum disorder.[285]Comorbidities such as these can influence and potentially interfere with an individual's diagnosis of StPD.[285] People who are treatment-resistant toobsessive–compulsive disorder (OCD) behavioral therapy and medication that also display odd or eccentric behaviors could contribute to the coexistence of obsessive–compulsive disorder with schizotypal disorder.[271] In the case that StPD precedes a diagnosis of schizophrenia, the StPD diagnosis is maintained but marked as premorbid.
StPD was introduced in 1980 in theDSM-III.[303] Its inclusion provided a new classification for schizophrenia-spectrum disorders and of personality disorders that were previously unspecified.[304][303] Its diagnosis was developed through differentiating the classifications ofborderline personality disorder, of which some of the diagnosed population demonstrated schizophrenia-spectrum traits.[304][303] When the separation of borderline personality disorder and StPD was originally suggested bySpitzer and Endicott,Siever andGunderson opposed the distinction.[305][304] Siever and Gunderson's opposition to Spitzer and Endicott was that StPD was related to schizophrenia.[306]Spitzer and Endicott stated "We believe, as do the authors, that the evidence for the genetic relationship between Schizotypal features and Chronic Schizophrenia is suggestive rather than proven".[304] StPD was included in theDSM-IV and theDSM-5 and saw little change in its diagnosis.[303]
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^abcKirchner SK, Roeh A, Nolden J, Hasan A (2018-10-03)."Diagnosis and treatment of schizotypal personality disorder: evidence from a systematic review".npj Schizophrenia.4 (1) 20:1–18.doi:10.1038/s41537-018-0062-8.ISSN2334-265X.PMC6170383.PMID30282970.For years, the International Classification of Diseases (ICD) from the World Health Organization (WHO) and other classification instruments, e.g., the DSM from the American Psychiatric Association (APA), have differed in their classification of STPD (referred to as schizotypal disorder in the ICD): In ICD-9 and -10, it is listed under schizophrenia spectrum disorders, whereas in DSM-III to -5 it is classified as a personality disorder.
^abAmerican Psychiatric Association, ed. (2022).Diagnostic and statistical manual of mental disorders: DSM-5-TR (Fifth edition, text revision ed.). Washington, DC: American Psychiatric Association Publishing. pp. 66–67, 747.ISBN978-0-89042-575-6.
^abAmerican Psychiatric Association, ed. (2022).Diagnostic and statistical manual of mental disorders: DSM-5-TR™ (Fifth edition, text revision ed.). Washington, DC: American Psychiatric Association Publishing. pp. 744–745.ISBN978-0-89042-576-3.
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^abAmerican Psychiatric Association, American Psychiatric Association, eds. (2013).Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, D.C: American Psychiatric Association. pp. 769–770.ISBN978-0-89042-554-1.
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^American Psychiatric Association, ed. (2022).Diagnostic and statistical manual of mental disorders: DSM-5-TR (Fifth edition, text revision ed.). Washington, DC: American Psychiatric Association Publishing. pp. 66-67, 747.ISBN978-0-89042-575-6.
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^Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington: American psychiatric association. 2013. p. 658.ISBN978-0-89042-554-1.There may be great difficulty differentiating children with schizotypal personality disorder from the heterogeneous group of solitary, odd children whose behavior is characterized by marked social isolation, eccentricity, or peculiarities of language and whose diagnoses would probably include milder forms of autism spectrum disorder or language communication disorders. Communication disorders may be differentiated by the primacy and severity of the disorder in language and by the characteristic features of impaired language found in a specialized language assessment.
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