High-Masking Autism or Schizotypal Personality Disorder? Challenges in Differential Diagnosis
K. AkhobadzeIntroduction
Autism Spectrum Disorder (ASD) is often misdiagnosed as a personality disorder in adulthood, particularly Cluster A conditions such as Schizotypal Personality Disorder (StPD). This is especially common in high-masking adults, often women, whose traits can resemble schizotypal eccentricity.
Objectives
This review aims to clarify the shared and distinguishing features of high-masking ASD and StPD, explore factors that might cause misdiagnosis, and suggest ways to improve accurate identification.
Methods
A literature review was conducted using PubMed, focusing on adults aged 18–55 years, both genders, and studies investigating clinical, social interaction, cognitive, and masking characteristics in ASD and StPD.
Results
The literature reveals significant overlap between ASD and StPD, particularly in negative and interpersonal traits like social withdrawal, limited friendships, and idiosyncratic communication (Poletti & Raballo Schizophr Res 2020; 223,53–58). In high-masking ASD, scripted or rigid social behavior may seem eccentric, and intense, niche interests can mimic schizotypal traits (Parvaiz et al. BMC Psychiatry 2023; 23(1)). That is why diagnostic delay is so common: in a study of 161 adults with ASD, the correct diagnosis was often delayed on average by 11 years. Notably, 33.5% had never received any diagnosis, while the rest had been misdiagnosed, with personality disorders among the most frequent (Fusar-Poli et al. Eur Arch Psychiatry Clin Neurosci 2020; 272(2),187–198).
Despite similarities, there are key differences. ASD arises in early childhood with a stable course, has repetitive behaviors and sensory issues. Schizotypal traits emerge later, may progress to psychosis, and are linked to paranoia and self-identity disturbance (Poletti & Raballo Schizophr Res 2020; 223,53–58). In fact, neuroimaging (fMRI) also differentiates them: ASD shows hypoactivation of social brain regions, while StPD shows hyperactivation in the amygdala and related networks, consistent with the “hypo- vs. hyper-mentalizing” model (Stanfield et al. Schizophr Bull 2017; 43(6),1220–1228).
Gender complicates the diagnostic process even more: women with ASD often mask symptoms and are overlooked because of male-normed tools such as ADOS-2, contributing to frequent misdiagnosis as personality disorders. Misdiagnosis is also caused by gaps in developmental history and diagnostic overshadowing (Fusar-Poli et al. Eur Arch Psychiatry Clin Neurosci 2020; 272(2),187–198).
Conclusions
To improve accuracy in diagnosis of ASD and StPD, clinicians need a structured approach that considers developmental history, identifies masking strategies, recognizes diagnostic bias, and distinguishes cognitive from perceptual features (Fusar-Poli et al. Eur Arch Psychiatry Clin Neurosci 2020; 272(2),187–198). Using standardized assessments and providing tailored interventions are key to ensuring accurate diagnosis and appropriate care.
Disclosure of Interest
None Declared