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DSM-II

In DSM-II, this disorder is called Schizophrenia, simple type

For more information, see Schizophrenia

This psychosis is characterized chiefly by a slow and insidious reduction of external attachments and interests and by apathy and indifference leading to impoverishment of interpersonal relations, mental deterioration, and adjustment on a lower level of functioning. In general, the condition is less dramatically psychotic than are the hebephrenic, catatonic, and paranoid types of schizophrenia. Also, it contrasts with schizoid personality, in which there is little or no progression of the disorder.

DSM-III

Diagnostic Criteria

The following are characteristic of the individual's current and long-term functioning, are not limited to episodes of illness, and cause either significant impairment in social or occupational functioning or subjective distress.

A. At least four of the following:

  1. magical thinking, e.g., superstitiousness, clairvoyance, telepathy, "6th sense," "others can feel my feelings" (in children and adolescents, bizarre fantasies or preoccupations)
  2. ideas of reference
  3. social isolation, e.g., no close friends or confidants, social contacts limited to essential everyday tasks
  4. recurrent illusions, sensing the presence of a force or person not actually present (e.g., "I felt as if my dead mother were in the room with me"), depersonalization, or derealization not associated with panic attacks
  5. odd speech (without loosening of associations or incoherence), e.g., speech that is digressive, vague, overelaborate, circumstantial, metaphorical
  6. inadequate rapport in face-to-face interaction due to constricted or inappropriate affect, e.g., aloof, cold
  7. suspiciousness or paranoid ideation
  8. undue social anxiety or hypersensitivity to real or imagined criticism

B. Does not meet the criteria for Schizophrenia.

Differential Diagnosis

Schizophrenia

In Schizophrenia, Residual Type, there is a history of an active phase of Schizophrenia with psychotic symptoms. When psychotic symptoms occur in Schizotypal Personality Disorder, they are transient and not severe.

Schizoid and Avoidant Personality Disorders

In Schizoid Personality Disorder and Avoidant Personality Disorder, there are no oddities of behavior, thinking, perception, and speech as are present in Schizotypal Personality Disorder.

Borderline Personality Disorder

Frequently, individuals with Borderline Personality Disorder also meet the criteria for Schizotypal Personality Disorder; in such instances, both diagnoses should be recorded.

Depersonalization Disorder

In Depersonalization Disorder, oddities of thought, speech, and behavior are not present, although in rare cases both disorders may coexist.

DSM-IV

Diagnostic Criteria

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. ideas of reference (excluding delusions of reference)
  2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)
  3. unusual perceptual experiences, including bodily illusions
  4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotypes)
  5. suspiciousness or paranoid ideation
  6. inappropriate or constricted affect
  7. behavior or appearance that is odd, eccentric, or peculiar
  8. lack of close friends or confidants other than first-degree relatives
  9. excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.

Note: If criteria are met prior to the onset of Schizophrenia, add "Premorbid," e.g., "Schizotypal Personality Disorder (Premorbid)."

Differential Diagnosis

Psychotic Disorders

Schizotypal Personality Disorder can be distinguished from Delusional Disorder, Schizophrenia, and Mood Disorder With Psychotic Features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of Schizotypal Personality Disorder, the Personality Disorder must have been present before the onset of psychotic symptoms and persist when the psychotic symptoms are in remission. When an individual has a chronic Psychotic Disorder (e.g., Schizophrenia) that was preceded by Schizotypal Personality Disorder, Schizotypal Personality Disorder should be recorded followed by "Premorbid" in parentheses.

Autistic Disorder, Asperger's Disorder, and Communication Disorders

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 Autistic Disorder, Asperger's Disorder, and Expressive and Mixed Receptive-Expression Language Disorders. Communication Disorders may be differentiated by the primacy and severity of the disorder in language accompanied by compensatory efforts by the child to communicate by other means (e.g., gestures) and by the characteristic features of impaired language found in a specialized language assessment. Milder forms of Autistic Disorder and Asperger's Disorder are differentiated by the even greater lack of social awareness and emotional reciprocity and stereotyped behaviors and interests.

Personality Change Due to a General Medical Condition and symptoms related to substance use

Schizotypal Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).

Other Personality Disorders

Other Personality Disorders may be confused with Schizotypal Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Schizotypal Personality Disorder, all can be diagnosed.

Paranoid and Schizoid Personality Disorders

Although Paranoid and Schizoid Personality Disorders may also be characterized by social detachment and restricted affect, Schizotypal Personality Disorder can be distinguished from these two diagnoses by the presence of cognitive or perceptual distortions and marked eccentricity or oddness.

Avoidant Personality Disorder

Close relationships are limited in both Schizotypal Personality Disorder and Avoidant Personality Disorder; however, in Avoidant Personality Disorder an active desire for relationships is constrained by a fear of rejection, whereas in Schizotypal Personality Disorder there is a lack of desire for relationships and persistent detachment.

Narcissistic Personality Disorder

Individuals with Narcissistic Personality Disorder may also display suspiciousness, social withdrawal, or alienation, but in Narcissistic Personality Disorder these qualities derive primarily from fears of having imperfections or flaws revealed.

Borderline Personality Disorder

Individuals with Borderline Personality Disorder may also have transient, psychotic-like symptoms, but these are usually more closely related to affective shifts in response to stress (e.g., intense anger, anxiety, or disappointment) and are usually more dissociative (e.g., derealization or depersonalization). In contrast, individuals with Schizotypal Personality Disorder are more likely to have enduring psychotic-like symptoms that may worsen under stress but are less likely to be invariably associated with pronounced affective symptoms. Although social isolation may occur in Borderline Personality Disorder, this is usually secondary to repeated interpersonal failures due to angry outbursts and frequent mood shifts, rather than a result of a persistent lack of social contacts and desire for intimacy. Furthermore, individuals with Schizotypal Personality Disorder do not usually demonstrate the impulsive or manipulative behaviors of the individual with Borderline Personality Disorder. However, there is a high rate of co-occurrence between the two disorders, so that making such distinctions is not always feasible.

Normal personality traits

Schizotypal features during adolescence may be reflective of transient emotional turmoil, rathe than an enduring personality disorder.

DSM-5

Diagnostic Criteria

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Ideas of reference (excluding delusions of reference).
  2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations).
  3. Unusual perceptual experiences, including bodily illusions.
  4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
  5. Suspiciousness or paranoid ideation.
  6. Inappropriate or constricted affect.
  7. Behavior or appearance that is off, eccentric, or peculiar.
  8. Lack of close friends or confidants other than first-degree relatives.
  9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," e.g., "schizotypal personality disorder (premorbid)."

Alternative Model

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

  1. Identity: Confused boundaries between self and others; distorted self-concept; emotional expression often does not congruent with context or internal experience.
  2. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
  3. Empathy: Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others' motivations and behaviors.
  4. Intimacy: Marked impairments in developing close relationships, associated with mistrust and anxiety.

B. Four or more of the following six pathological personality traits:

  1. 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.
  2. 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.
  3. Eccentricity (an aspect of Psychoticism): Odd, unusual, or bizarre behavior or appearance; saying unusual or inappropriate things.
  4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.
  5. Withdrawal (an aspect of Detachment): Preference for being alone to being with others; reticence in social situations; avoidance of social contracts and activity; lack of initiation of social contact.
  6. 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.

C. The impairments in personality functioning and the individual's personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.

D. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.

E. The impairments in personality functioning and the individual's personality trait expression are not better explained by another mental disorder.

F. The impairments in personality functioning and the individual's personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).

G. The impairments in personality functioning and the individual's personality trait expression are not better understood as normal for an individual's developmental stage or sociocultural environment.

Specifiers

Trait and personality functioning specifiers may be used to record additional personality features that may be present in schizotypal personality disorder but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g., depressivity, anxiousness) are not diagnostic criteria for schizotypal personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of schizotypal personality disorder (Criterion A), the level of personality functioning can also be specified.

Differential Diagnosis

Other mental disorders with psychotic symptoms

Schizotypal personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of schizotypal personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and persist when the psychotic symptoms are in remission. When an individual has a persistent psychotic disorder (e.g., schizophrenia) that was preceded by schizotypal personality disorder, schizotypal personality disorder should also be recorded, followed by "premorbid" in parentheses.

Neurodevelopmental disorders

There may be great difficulty differentiating children with schizotypal personality disorder from the heterogeneous group of solitary, off 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. Milder forms of autism spectrum disorder are differentiated by the even greater lack of social awareness and emotional reciprocity and stereotyped behaviors and interests.

Personality change due to another medical condition

Schizotypal personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.

Substance use disorders

Schizotypal personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

Other personality disorders

Other personality disorders may be confused with schizotypal personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to schizotypal personality disorder, all can be diagnosed.

Paranoid and schizoid personality disorders

Although paranoid and schizoid personality disorders may also be characterized by social detachment and restricted affect, schizotypal personality disorder can be distinguished from these two diagnoses by the presence of cognitive or perceptual distortions and marked eccentricity or oddness.

Avoidant personality disorder

Close relationships are limited in both schizotypal personality disorder and avoidant personality disorder; however, in avoidant personality disorder an active desire for relationships is constrained by a fear of rejection, whereas in schizotypal personality disorder there is a lack of desire for relationships and persistent detachment.

Narcissistic personality disorder

Individuals with narcissistic personality disorder may also display suspiciousness, social withdrawal, or alienation, but in narcissistic personality disorder these qualities derive primarily from fears of having imperfections or flaws revealed.

Borderline personality disorder

Individuals with borderline personality disorder may also have transient, psychotic-like symptoms, but these are usually more closely related to affective shifts in response to stress (e.g., intense anger, anxiety, disappointment) and are usually more dissociative (e.g., derealization, depersonalization). In contrast, individuals with schizotypal personality disorder are more likely to have enduring psychotic-like symptoms that may worsen under stress but are less likely to be invariably associated with pronounced affective symptoms. Although social isolation may occur in borderline personality disorder, it is usually secondary to repeated interpersonal failures due to angry outbursts and frequent mood shifts, rather than a result of a persistent lack of social contacts and desire for intimacy. Furthermore, individuals with schizotypal personality disorder do not usually demonstrate the impulsive or manipulative behaviors of the individual with borderline personality disorder. However, there is a high rate of co-occurence between the two disorders, so that making such distinctions is not always feasible.

Other personality traits

Schizotypal features during adolescence may be reflective of transient emotional turmoil, rather than an enduring personality disorder.