Schizoid personality disorder

Schizoid personality disorder
People with schizoid personality disorder often prefer solitary activities.
Specialty Psychiatry and Clinical Psychology
Symptoms Emotional coldness and reduced affect display, few or no close friends, indifference to criticism and praise, anhedonia, unintentional insensitivity to social norms; asexual tendencies, excessive preoccupation with fantasy,[1] autistic thinking without loss of skill to recognize reality[2]
Usual onset Late childhood or adolescence[1]
Duration Long term
Types Languid schizoid, remote schizoid, depersonalized schizoid, affectless schizoid (Millon's subtypes)[3]
Risk factors Relatives with schizophrenia[4]
Diagnostic method Based on symptoms
Differential diagnosis Other mental disorders with psychotic symptoms (schizophrenia, delusional disorder, and a bipolar or depressive disorder with psychotic features), personality change due to another medical condition, substance use disorders, autism spectrum disorder, other personality disorders and personality traits[5]
Medication Low dose benzodiazepines, β-blockers, nefazodone, bupropion, low dose of risperidone or olanzapine[6]
Frequency 3.1%–4.9%[5]

Schizoid personality disorder (/ˈskɪtsɔɪd, ˈskɪdzɔɪd/, often abbreviated as SPD or SzPD) is a personality disorder characterized by a lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously demonstrate a rich, elaborate, and exclusively internal fantasy world.[7][8]

SPD is not the same as schizophrenia or schizotypal personality disorder, but there is some evidence of links and shared genetic risk between SPD, other cluster A personality disorders, and schizophrenia. Thus, SPD is considered to be a "schizophrenia-like personality disorder".[4][9]

Critics argue that the definition of SPD is flawed due to cultural bias and that it does not constitute a mental disorder but simply an avoidant attachment style requiring more distant emotional proximity.[10][11] If that is true, then many of the more problematic reactions these individuals show in social situations may be partly accounted for by the judgments commonly imposed on people with this style. However, it is important to note that impairment is mandatory for any behaviour to be diagnosed as a personality disorder. SPD seems to satisfy this criterion because it is linked to negative outcomes. These include a significantly compromised quality of life, lower GAF scores even after 15 years, and one of the lowest levels of "life success" of all personality disorders (measured as "status, wealth, and successful relationships").[12][13]

Schizoid personality disorder is a poorly studied disorder, and there is little clinical data on SPD because it is rarely encountered in clinical settings. The effectiveness of psychotherapeutic and pharmacological treatments for the disorder have yet to be empirically and systematically investigated.[7]

Signs and symptoms

People with schizoid personality disorder are often aloof, cold, and indifferent, which causes interpersonal difficulty. Most individuals diagnosed with SPD have trouble establishing personal relationships or expressing their feelings meaningfully. They may remain passive in the face of unfavorable situations. Their communication with other people may be indifferent and terse at times. Because of their lack of meaningful communication with other people, those who are diagnosed with SPD are not able to develop accurate impressions of how well they get along with others.[14]

Schizoid personality types are challenged to achieve self-awareness and the ability to assess the impact of their own actions in social situations. Ronald Laing suggests when injections of interpersonal reality fail to enrich an individual, his or her self-image becomes empty and volatilized, making the individual feel unreal.[14] When someone violates the personal space of an individual with SPD, it suffocates them and they must free themselves to be independent. People who have SPD tend to be happiest when in relationships in which their partner places few emotional or intimate demands on them. It is not people they want to avoid, but negative and positive emotions, emotional intimacy, and self-disclosure.[15]

Therefore, it is possible for individuals with SPD to form relationships with others based on intellectual, physical, familial, occupational, or recreational activities as long as there is no need for emotional intimacy. Donald Winnicott explains this is because schizoid individuals "prefer to make relationships on their own terms and not in terms of the impulses of other people." Failing to attain that, they prefer isolation.[16]

Although there is the belief people with schizoid personality disorder are complacent and unaware of their feelings, many recognize their differences from others. Some individuals with SPD who are in treatment say "life passes them by" or they feel like living inside of a shell; they see themselves as "missing the bus" and complain of observing life from a distance.[17][18]

Aaron Beck and his colleagues report that people with SPD seem comfortable with their aloof lifestyle and consider themselves observers, rather than participants, in the world around them. But they also mention that many of their schizoid patients recognize themselves as socially deviant (or even defective) when confronted with the different lives of ordinary people – especially when they read books or see movies focusing on relationships. Even when schizoid individuals may not long for closeness, they can become weary of being "on the outside, looking in." These feelings may lead to depression or depersonalisation. If they do, schizoid people often experience feeling "like a robot" or "going through life in a dream."[19]

It is speculated schizoid personality disorder may have ties to creativity.[20][21][22]

Phenomenology

The 'secret schizoid'

Many schizoid individuals display an engaging, interactive personality contradicting the observable characteristic emphasized by the DSM-5 and ICD-10 definitions of the schizoid personality. Guntrip (using ideas of Klein, Fairbairn, Woods Winnicott) classifies these individuals as "secret schizoids", who behave with socially available, interested, engaged, and involved interaction yet remain emotionally withdrawn and sequestered within the safety of the internal world.[23][24][25]

Frequently, a schizoid individual's social functioning improves, sometimes dramatically, when the individual knows he or she is an anonymous participant in a real-time conversation or correspondence, e.g. in an online chat-room or message-board. Indeed, it is often the case the individual's online correspondent will report nothing amiss in the individual's engagement and affect.

Withdrawal or detachment from the outer world is a characteristic feature of schizoid pathology, but may appear either in "classic" or in "secret" form. When classic, it matches the typical description of the schizoid personality offered in the DSM-5. It is "just as often" a hidden internal state: that which meets the objective eye may not match the subjective, internal world of the patient. Klein cautions one should not miss identifying the schizoid person because one cannot see the person's withdrawal through the patient's defensive, compensatory interaction with external reality. He suggests one ask the person what his or her subjective experience is to detect the presence of the schizoid refusal of emotional intimacy.[23]

Descriptions of the schizoid personality as "hidden" behind an outward appearance of emotional engagement have been recognized since 1940 with Fairbairn's description of "schizoid exhibitionism," in which the schizoid individual is able to express a great deal of feeling and to make what appear to be impressive social contacts yet in reality gives nothing and loses nothing. Because he or she is "playing a part," his or her personality is not involved. According to Fairbairn, the person disowns the part he is playing and the schizoid individual seeks to preserve his personality intact and immune from compromise.[26] Further references to the secret schizoid come from Masud Khan,[27] Jeffrey Seinfeld,[28] and Philip Manfield,[15] who give a description of an SPD individual who "enjoys" public speaking engagements but experiences great difficulty in the breaks when audience members would attempt to engage him emotionally. These references expose the problems in relying on outer observable behavior for assessing the presence of personality disorders in certain individuals.

Schizoid fantasy

A pathological reliance on fantasizing and preoccupation with inner experience is often part of the schizoid withdrawal from the world. Fantasy thus becomes a core component of the self in exile, though fantasizing in schizoid individuals is far more complicated than a means of facilitating withdrawal.[23]:p. 64

Fantasy is also a relationship with the world and with others by proxy. It is a substitute relationship, but a relationship nonetheless, characterized by idealized, defensive and compensatory mechanisms. This is self-contained and free from the dangers and anxieties associated with emotional connection to real persons and situations.[23] Klein explains it as "an expression of the self struggling to connect to objects, albeit internal objects. Fantasy permits schizoid patients to feel connected, and yet still free from the imprisonment in relationships. In short, in fantasy one can be attached (to internal objects) and still be free."[23] This aspect of schizoid pathology has been generously elaborated in works by Laing,[14] Winnicott,[29] and Klein.[23]:p. 64

Schizoid sexuality

People with SPD are sometimes sexually apathetic, though they do not typically suffer from anorgasmia. Their preference to remain alone and detached may cause their need for sex to appear to be less than that of those who do not have SPD. Sex often causes individuals with SPD to feel that their personal space is being violated, and they commonly feel that masturbation or sexual abstinence is preferable to the emotional closeness they must tolerate when having sex.[30] Significantly broadening this picture are notable exceptions of SPD individuals who engage in occasional or even frequent sexual activities with others.[30]

Harry Guntrip[31]:p. 303 describes the "secret sexual affair" entered into by some married schizoid individuals as an attempt to reduce the quantity of emotional intimacy focused within a single relationship, a sentiment echoed by Karen Horney's "resigned personality" who may exclude sex as "too intimate for a permanent relationship, and instead satisfy his sexual needs with a stranger. Conversely, he may more or less restrict a relationship to merely sexual contacts and not share other experiences with the partner."[32] Jeffrey Seinfeld, professor of social work at New York University, has published a volume on SPD[28]:p.104 that details examples of "schizoid hunger" which may manifest as sexual promiscuity. Seinfeld provides an example of a schizoid woman who would covertly attend various bars to meet men for the purpose of gaining impersonal sexual gratification, an act which alleviated her feelings of hunger and emptiness.

Salman Akhtar describes this dynamic interplay of overt versus covert sexuality and motivations of some SPD individuals with greater accuracy. Rather than following the narrow proposition that schizoid individuals are either sexual or asexual, Akhtar suggests that these forces may both be present in an individual despite their rather contradictory aims.[33] A clinically accurate picture of schizoid sexuality must therefore include the overt signs: "asexual, sometimes celibate; free of romantic interests; averse to sexual gossip and innuendo," as well as possible covert manifestations of "secret voyeuristic and pornographic interests; vulnerable to erotomania; and tendency towards perversions,"[33] although none of these necessarily apply to all people with SPD.

Millon's subtypes

Theodore Millon restricted the term "schizoid" to those personalities who lack the capacity to form social relationships. He characterizes their way of thinking as being vague and void of thoughts and as sometimes having a "defective perceptual scanning". Because of this, some people with SPD may be prone to overlook the fine details of life.[19]

For Millon, SPD is distinguished from other personality disorders in that it is "the personality disorder that lacks a personality." He criticizes that this may be due to the current diagnostic criteria: They describe SPD only by an absence of certain traits which results in a "deficit syndrome" or "vacuum". Instead of delineating the presence of something, they mention solely what is lacking. Therefore, it is hard to describe and research such a concept.[3]

He identified four subtypes of SPD. Any individual schizoid may exhibit none or one of the following:[3][34]

Subtype Features
Languid schizoid (including depressive features) Marked inertia; deficient activation level; intrinsically phlegmatic, lethargic, weary, leaden, lackadaisical, exhausted, enfeebled. Unable to act with spontaneity or seeks simplest pleasures, may experience profound angst, yet lack the vitality to express it strongly.
Remote schizoid (including avoidant and schizotypal features) Distant and removed; inaccessible, solitary, isolated, homeless, disconnected, secluded, aimlessly drifting; peripherally occupied. Seen among people who would have been otherwise capable of developing normal emotional life but having been subjected to intense hostility lost their innate capability to form bonds. Some residual anxiety is present. Often seen among the homeless; many are dependent on public support.
Depersonalized schizoid (including schizotypal features) Disengaged from others and self; self is disembodied or distant object; body and mind sundered, cleaved, dissociated, disjoined, eliminated. Often seen as simply staring into the empty space or being occupied with something substantial while actually being occupied with nothing at all.
Affectless schizoid (including compulsive features) Passionless, unresponsive, unaffectionate, chilly, uncaring, unstirred, spiritless, lackluster, unexcitable, unperturbed, cold; all emotions diminished. Combines the preference for rigid schedule (obsessive-compulsive feature) with the coldness of the schizoid.

Akhtar's profile

Salman Akhtar (a psychiatrist) provided a comprehensive phenomenological profile of Schizoid Personality Disorder in which classic and contemporary descriptive views are synthesized with psychoanalytic observations. This profile is summarized in the table reproduced below that lists clinical features that involve six areas of psychosocial functioning and are organized by "overt" and "covert" manifestations. "Overt" and "covert" are not meant as different subtypes but as traits that may be present simultaneously within one single individual. Dr. Akhtar states that "these designations do not imply conscious or unconscious but denote seemingly contradictory aspects that are phenomenologically more or less easily discernible," and that "this manner of organizing symptomology emphasizes the centrality of splitting and identity confusion in schizoid personality."[33]

In 2013, Akhtar provided a clinical case study of a schizoid man as an illustration of his phenomenological profile.[35]

Clinical Features of Schizoid Personality Disorder[33]
Area
Overt Features Covert Features
Self-concept
  • compliant
  • stoic
  • noncompetitive
  • self-sufficient
  • lacking assertiveness
  • feeling inferior and an outsider in life
  • cynical
  • inauthentic
  • depersonalized
  • alternately feeling empty, robot-like, and full of omnipotent, vengeful fantasies
  • hidden grandiosity
Interpersonal relations
  • withdrawn
  • aloof
  • have few close friends
  • impervious to others' emotions
  • afraid of intimacy
  • exquisitely sensitive
  • deeply curious about others
  • hungry for love
  • envious of others' spontaneity
  • intensely needy of involvement with others
  • capable of excitement with carefully selected intimates
Social adaptation
  • prefer solitary occupational and recreational activities
  • marginal or eclectically sociable in groups
  • vulnerable to esoteric movements owing to a strong need to belong
  • tend to be lazy and indolent
  • lack clarity of goals
  • weak ethnic affiliation
  • usually capable of steady work
  • quite creative and may make unique and original contributions
  • capable of passionate endurance in certain spheres of interest
Love and sexuality
  • asexual, sometimes celibate
  • free of romantic interests
  • averse to sexual gossip and innuendo
  • secret voyeuristic interests
  • vulnerable to erotomania
  • tendency towards compulsive perversions
Ethics, standards, and ideals
  • idiosyncratic moral and political beliefs
  • tendency towards spiritual, mystical and para-psychological interests
  • moral unevenness
  • occasionally strikingly amoral and vulnerable to odd crimes, at other times altruistically self-sacrificing
Cognitive style
  • absent-minded
  • engrossed in fantasy
  • vague and stilted speech
  • alternations between eloquence and inarticulateness
  • autistic thinking
  • fluctuations between sharp contact with external reality and hyperreflectiveness about the self
  • autocentric use of language

Causes

Some evidence suggests the Cluster A personality disorders have shared genetic and environmental risk factors and there is an increased prevalence of schizoid personality disorder in relatives of people with schizophrenia and schizotypal personality disorder.[4] Twin studies with schizoid personality disorder traits (e.g. low sociability and low warmth) suggest these are inherited. Besides this indirect evidence, the direct heritability estimates of SPD range from 50–59%.[36][37] To Sula Wolff, who did extensive research and clinical work with children and teenagers with schizoid symptoms, "schizoid personality has a constitutional, probably genetic, basis."[38] The link between SPD and being underweight may also point to the involvement of biological factors.[39][3]

In general, prenatal caloric malnutrition, premature birth and a low birth weight are risk factors for being afflicted by mental disorders and may contribute to the development of schizoid personality disorder as well. Those who have experienced traumatic brain injury may be also at risk of developing features reflective of schizoid personality disorder.[40][41][42]

Other researchers had hypothesized excessively perfectionist,[43] unloving or neglectful parenting could play a role.

Diagnosis

DSM-5 criteria

The Diagnostic and Statistical Manual of Mental Disorders is a widely used manual for diagnosing mental disorders. DSM- 5 still includes schizoid personality disorder with the same criteria as in DSM-IV. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by at least four of the following:[5]

  1. Neither desires nor enjoys close relationships, including being part of a family.
  2. Almost always chooses solitary activities.
  3. Has little, if any, interest in having sexual experiences with another person.
  4. Takes pleasure in few, if any, activities.
  5. Lacks close friends or confidants other than first-degree relatives.
  6. Appears indifferent to the praise or criticism of others.
  7. Shows emotional coldness, detachment, or flattened affectivity

According to the DSM, those with SPD may often be unable to, or will rarely express aggressiveness or hostility, even when provoked directly. These individuals can seem vague or drifting about their goals and their lives may appear directionless. Others view them as indecisive in their actions, self-absorbed, absentminded and detached from their surroundings (''not with it'' or ''in a fog''). Excessive daydreaming is often present. In cases with severe defects in the capacity to form social relationships, dating and marriage may not be possible.[44]

ICD-10 criteria

The Classification of Mental and Behavioural Disorders of ICD-10 lists schizoid personality disorder under (F60.1).[1]

The general criteria of personality disorder (F60) should be met first. In addition, at least four of the following criteria must be present:

  1. Few, if any, activities provide pleasure.
  2. Displays emotional coldness, detachment, or flattened affectivity.
  3. Limited capacity to express warm, tender feelings for others as well as anger.
  4. Appears indifferent to either praise or criticism from others.
  5. Little interest in having sexual experiences with another person (taking into account age).
  6. Almost always chooses solitary activities.
  7. Excessive preoccupation with fantasy and introspection.
  8. Neither desires, nor has, any close friends or confiding relationships (or only one).
  9. Marked insensitivity to prevailing social norms and conventions; if these are not followed this is unintentional.

Guntrip criteria

Ralph Klein, Clinical Director of the Masterson Institute, delineates the following nine characteristics of the schizoid personality as described by Harry Guntrip:[23]:pp. 13–23

Criteria for the schizoid personality

The description of Guntrip's nine characteristics should clarify some differences between the traditional DSM portrait of SPD and the traditional informed object relations view. All nine characteristics are consistent. Most, if not all, must be present to diagnose a schizoid disorder.[23]

More details about each of the characteristics can be found in the Harry Guntrip (Psychologist) article.

Controversy

The original concept of the schizoid character developed by Ernst Kretschmer comprised an amalgamation of avoidant, schizotypal and schizoid traits. It was not until 1980 and the work of Theodore Millon that led splitting the schizoid character into three personality disorders (now schizoid, schizotypal and avoidant). Since then, there has been debate about whether that is accurate or if these traits are different expressions of a single personality disorder.[45]

It has been also suggested two different disorders may better represent SPD: one affect-constricted disorder (belonging to schizotypal PD) and a seclusive disorder (belonging to avoidant PD). Some have called for the removal of the SPD category from future editions of the DSM and the replacement of it by a dimensional model.[13]

Differential diagnosis

While SPD shares several symptoms with other mental disorders, here are some important differentiating features:

psychological condition Features
Depression People who have SPD may also suffer from clinical depression. However, this is not always the case. Unlike depressed people, persons with SPD generally do not consider themselves inferior to others. They may recognize that they are "different."
Avoidant personality disorder (AvPD) While people affected with APD avoid social interactions due to anxiety or feelings of incompetence, those with SPD do so because they are genuinely indifferent to social relationships. A 1989 study,[46] however, found that "schizoid and avoidant personalities were found to display equivalent levels of anxiety, depression, and psychotic tendencies as compared to psychiatric control patients." There also seems to be some shared genetic risk between SPD and AvPD (see schizoid-avoidant behavior). Several sources to date have confirmed the synonymy of SPD and avoidant attachment style.[47] However, the distinction should be made that individuals with SPD characteristically do not seek social interactions merely due to lack of interest, while those with avoidant attachment style can in fact be interested in interacting with others, but without establishing connections of much depth or length due to having little tolerance for any kind of intimacy.
Other personality disorders Schizoid and narcissistic personality disorders can seem similar in some respects (e.g. both show identity confusion, may lack warmth and spontaneity, avoid deep relationships with intimacy). Another commonality observed by Akhtar is intellectual hypertrophy which leads to a lack of rootedness in bodily existence. There are, nonetheless, important differences. The schizoid hides his need for dependency and is rather fatalistic, passive, cynical, overtly bland or vaguely mysterious. The narcissist is, in contrast, ambitious and competitive and exploits others for his dependency needs. There are also parallels between SPD and obsessive-compulsive personality disorder (OCPD), such as detachment, restricted emotional expression and rigidity. However, in OCPD the capacity to develop intimate relationships is usually intact but deep contacts may be avoided because of an unease with emotions and a devotion to work.[33][44]
Asperger syndrome There may be substantial difficulty in distinguishing Asperger syndrome (AS), sometimes called "schizoid disorder of childhood," from SPD. But while AS is an autism-spectrum disorder, SPD is classified as a “schizophrenia-like” personality disorder. There is some overlap as some people with autism also qualify for a diagnosis of schizotypal or schizoid PD.

However, one of the distinguishing features of schizoid PD is a restricted affect and an impaired capacity for emotional experience and expression. Persons with AS are “hypo-mentalizers”, i.e., they fail to recognize social cues such as verbal hints, body language and gesticulation, but those with schizophrenia- like personality disorders tend to be “hyper-mentalizers,” overinterpreting such cues in a generally suspicious way (see imprinted brain theory). Although they may have been socially isolated from childhood onward, most people with schizoid personality disorder displayed well-adapted social behavior as children, along with apparently normal emotional function. SPD does also not involve impairments in nonverbal communication such as a lack of eye contact, unusual prosody or a pattern of restricted interests or repetitive behaviors. Compared to AS, SPD is characterized by prominent conduct disorder, better adult adjustment, less severely impaired social interaction and a slightly increased risk of schizophrenia.[48][49]

Simple-type Schizophrenia Both simple schizophrenia and SPD share many negative symptoms like avolition, impoverished thinking and flat affect. Although they may look almost identical, what distinguishes them is usually the severity. Also, SPD is characterized by a lifelong pattern without change whereas simple schizophrenia represents a deterioration.[50]

Comorbidity

Some people with schizoid personality features may occasionally experience instances of brief reactive psychosis when under stress. The personality disorders that most frequently co-occur with SPD are schizotypal, paranoid and avoidant PD.[18] The relationship between alexithymia (the inability to identify and describe emotions) and SPD seems to be strong but they are not the same condition.[51]

Schizoid individuals frequently act out with substance and alcohol abuse and other addictions which serve as substitutes for human relationships (see dual diagnosis).[28]:101 The substitute of a nonhuman for a human object serves as a schizoid defense. Providing examples of how the schizoid individual creates a personal relation with the drug, Seinfeld tells of an addict who called heroin his "soothing white pet," and of others who referred to crack as their "bad mama" or "boyfriend." He explains that "Not all addicts name their drug, but there often is the trace of a personal feeling about the relationship."[28]:p.101 The object relations view emphasizes that the drug use and alcoholism reinforce the fantasy of union with an internal object, yet enable the addict to be indifferent to the external object world. Addiction is therefore a schizoid and symbiotic defense.

Sharon Ekleberry suggests that marijuana "may be the single most egosyntonic drug for individuals with SPD because it allows a detached state of fantasy and distance from others, provides a richer internal experience than these individuals can normally create, and reduces an internal sense of emptiness and failure to participate in life. Also, alcohol, readily available and safe to obtain, is another obvious drug of choice for these individuals. Some will use both marijuana and alcohol and see little point in giving up either. They are likely to use in isolation for the effect on internal processes."[18]

Suicide may also be a running theme for schizoid individuals, though they are not likely to actually attempt one. They might be down and depressed when all possible connections have been cut off, but as long as there is some relationship or even hope for one the risk will be low. The idea of suicide is a driving force against the person's schizoid defenses. As Klein says: "For some schizoid patients, its presence is like a faint, barely discernible background noise, and rarely reaches a level that breaks into consciousness. For others, it is an ominous presence, an emotional sword of Damocles. In any case, it is an underlying dread that they all experience."[23]

Treatment

People with schizoid personality disorder rarely seek treatment for their condition. This is an issue found in many personality disorders, which prevents many people who are afflicted with these conditions from coming forward for treatment: They tend to view their condition as not conflicting with their self-image and their abnormal perceptions and behaviors as rational and appropriate. There is little data on the effectiveness of various treatments on this personality disorder because it is seldom seen in clinical settings.[7][52] However, those in treatment have the option of medication and therapy.

Medication

No medications are indicated for directly treating schizoid personality disorder, but certain medications may reduce the symptoms of SPD as well as treat co-occurring mental disorders. The symptoms of SPD mirror the negative symptoms of schizophrenia, such as anhedonia, blunted affect and low energy, and SPD is thought to be part of the "schizophrenic spectrum" of disorders, which also includes the schizotypal and paranoid personality disorders, and may benefit from the medications indicated for schizophrenia.[53] Originally, low doses of atypical antipsychotics like risperidone or olanzapine were used to alleviate social deficits and blunted affect.[6] However, a recent review concluded that atypical antipsychotics were ineffective for treating personality disorders.[54]

In contrast, the substituted amphetamine bupropion may be used to treat anhedonia.[6] Likewise, modafinil may be effective in treating some of the negative symptoms of schizophrenia, which are reflected in the symptomatology of SPD and therefore may help as well.[55] Lamotrigine, SSRIs, TCAs, MAOIs and hydroxyzine may help counter social anxiety in people with SPD if present, though social anxiety may not be a main concern for the people who have SPD. However, it is not general practice to treat SPD with medications, other than for the short term treatment of acute co-occurring Axis I conditions (e.g. depression).[53]

Psychotherapy

Supportive psychotherapy is also used in an inpatient or outpatient setting by a trained professional that focuses on areas such as coping skills, improvement of social skills and social interactions, communication, and self-esteem issues. People with SPD may also have a perceptual tendency to miss subtle differences. That causes an inability to pick up hints from the environment because social cues from others that might normally provoke an emotional response are not perceived. That in turn limits their own emotional experience.[19] The perception of varied events only increases their fear for intimacy and limits them in their interpersonal relationships. Their aloofness may limit their opportunities to refine the social skills and behavior necessary to effectively pursue relationships.

Besides psychodynamic therapy, CBT can be used. But because CBT generally begins with identifying the automatic thoughts one should be aware of the potential hazards that can happen when working with schizoid patients. People with SPD seem to be distinguished from those with other personality disorders in that they often report having few or no automatic thoughts at all. That poverty of thought may have to do with their apathetic lifestyle. But another possible explanation could be the paucity of emotion many schizoids display which would influence their thought patterns as well.[19]

Socialization groups may help people with SPD. Educational strategies in which people who have SPD identify their positive and negative emotions also may be effective. Such identification helps them to learn about their own emotions and the emotions they draw out from others and to feel the common emotions with other people with whom they relate. This can help people with SPD create empathy with the outside world.

Shorter-term treatment

The concept of "closer compromise" means that the schizoid patient may be encouraged to experience intermediate positions between the extremes of emotional closeness and permanent exile.[23] A lack of injections of interpersonal reality causes an impoverishment in which the schizoid individual's self-image becomes increasingly empty and volatilized and leads the individual to feel unreal.[14] To create a more adaptive and self-enriching interaction with others in which one "feels real," the patient is encouraged to take risks through greater connection, communication, and sharing of ideas, feelings, and actions. Closer compromise means that while the patient's vulnerability to anxieties is not overcome, it is modified and managed more adaptively. Here the therapist repeatedly conveys to the patient that anxiety is inevitable but manageable, without any illusion that the vulnerability to such anxiety can be permanently dispensed with. The limiting factor is the point at which the dangers of intimacy become overwhelming and the patient must again retreat.

Klein suggests that patients must take the responsibility to place themselves at risk and to take the initiative for following through with treatment suggestions in their personal lives. It is emphasized that these are the therapist's impressions and that he or she is not reading the patient's mind or imposing an agenda but is simply stating a position that is an extension of the patient's therapeutic wish. Finally, the therapist directs attention to the need to employ these actions outside of the therapeutic setting.[23]

Longer-term therapy

Klein suggests that "working through" is the second longer-term tier of psychotherapeutic work with schizoid patients. Its goals are to change fundamentally the old ways of feeling and thinking, and to rid oneself of the vulnerability to those emotions associated with old feelings and thoughts. A new therapeutic operation of "remembering with feeling" that draws on D. W. Winnicott's concepts of false self and true self is called for.[23] The patient must remember with feeling the emergence of his or her false self through childhood, and remember the conditions and proscriptions that were imposed on the individual’s freedom to experience the self in company with others.[23]

Remembering with feeling ultimately leads the patient to understand that he or she had no opportunity to choose from a selection of possible ways of experiencing the self and of relating with others, and had few, if any, options other than to develop a schizoid stance toward others. The false self was simply the best way in which the patient could experience the repetitive predictable acknowledgment, affirmation, and approval necessary for emotional survival while warding off the effects associated with the abandonment depression.[23]

If the goal of shorter-term therapy is for patients to understand that they are not the way they appear to be and can act differently, then the longer-term goal of working through is for patients to understand who and what they are as human beings, what they truly are like and what they truly contain. The goal of working through is not achieved by the patient’s sudden discovery of a hidden, fully formed talented and creative self living inside, but is a process of slowly freeing oneself from the confinement of abandonment depression in order to uncover a potential. It is a process of experimentation with the spontaneous, nonreactive elements that can be experienced in relationship with others.

Working through abandonment depression is a complicated, lengthy and conflicted process that can be an enormously painful experience in terms of what is remembered and what must be felt. It involves mourning and grieving for the loss of the illusion that the patient had adequate support for the emergence of the real self. There is also a mourning for the loss of an identity, the false self, which the person constructed and with which he or she has negotiated much of his or her life. The dismantling of the false self requires relinquishing the only way that the patient has ever known of how to interact with others. This interaction was better than not to have a stable, organized experience of the self, no matter how false, defensive, or destructive that identity may be.

The dismantling of the false self "leaves the impaired real self with the opportunity to convert its potential and its possibilities into actualities."[23] Working through brings unique rewards, of which the most important element is the growing realization that the individual has a fundamental, internal need for relatedness that may be expressed in a variety of ways. "Only schizoid patients", suggests Klein, "who have worked through the abandonment depression ... ultimately will believe that the capacity for relatedness and the wish for relatedness are woven into the structure of their beings, that they are truly part of who the patients are and what they contain as human beings. It is this sense that finally allows the schizoid patient to feel the most intimate sense of being connected with humanity more generally, and with another person more personally. For the schizoid patient, this degree of certainty is the most gratifying revelation, and a profound new organizer of the self experience."[23]:p. 127

Development and course

SPD can be first apparent in childhood and adolescence with solitariness, poor peer relationships, and underachievement in school. This may mark these children as different and make them subject to teasing.[44][38]

Being a personality disorder, which are usually chronic and long-lasting mental conditions, schizoid personality disorder is not expected to improve with time without treatment; however, much remains unknown because it is rarely encountered in clinical settings.[7]

Epidemiology

SPD is uncommon in clinical settings (about 2.2%) and occurs slightly more commonly in males. It is rare compared with other personality disorders, with a prevalence estimated at less than one percent of the general population.[12][4]

Philip Manfield suggests that the "schizoid condition," which roughly includes the DSM schizoid, avoidant, and schizotypal personality disorders, is represented by "as many as forty percent of all personality disorders." Manfield adds "This huge discrepancy [from the ten percent reported by therapists for the condition] is probably largely because someone with a schizoid disorder is less likely to seek treatment than someone with other axis-II disorders."[56][15]

There is also a very high rate of SPD and other Cluster A personality disorders (up to 92%) among homeless people.[57]

A University of Colorado Colorado Springs study comparing personality disorders and Myers-Briggs Type Indicator types found that the disorder had a significant correlation with the Introverted (I) and Thinking (T) preferences.[58]

History

The term "schizoid" was coined in 1908 by Eugen Bleuler to designate a human tendency to direct attention toward one's inner life and away from the external world, a concept akin to introversion in that it was not viewed in terms of psychopathology. Bleuler labeled the exaggeration of this tendency the “schizoid personality.”[33] He described these personalities as "comfortably dull and at the same time sensitive, people who in a narrow manner pursue vague purposes".[45]

In 1910, August Hoch introduced a very similar concept called the "shut-in" personality. Characteristics of it were reticence, seclusiveness, shyness and a preference for living in fantasy worlds, among others.[45] In 1925 Russian psychiatrist Grunja Sukhareva described a "schizoid psychopathy" in a group of children, resembling today's SPD and Aspergers. About a decade later Pyotr Gannushkin also included Schizoids and Dreamers in his detailed typology of personality types.[59]

Studies on the schizoid personality have developed along two distinct paths. The "descriptive psychiatry" tradition focuses on overtly observable, behavioral and describable symptoms and finds its clearest exposition in the DSM-5. The dynamic psychiatry tradition includes the exploration of covert or unconscious motivations and character structure as elaborated by classic psychoanalysis and object-relations theory.

The descriptive tradition began in 1925 with the description of observable schizoid behaviors by Ernst Kretschmer. He organized those into three groups of characteristics:[60]

  1. Unsociability, quietness, reservedness, seriousness and eccentricity.
  2. Timidity, shyness with feelings, sensitivity, nervousness, excitability, fondness of nature and books.
  3. Pliability, kindliness, honesty, indifference, silence and cold emotional attitudes.

These characteristics were the precursors of the DSM-III division of the schizoid character into three distinct personality disorders: schizotypal, avoidant and schizoid. Kretschmer himself, however, did not conceive of separating these behaviors to the point of radical isolation but considered them to be simultaneously present as varying potentials in schizoid individuals. For Kretschmer, the majority of schizoids are not either oversensitive or cold, but they are oversensitive and cold "at the same time" in quite different relative proportions, with a tendency to move along these dimensions from one behavior to the other.[60]

The second path, that of dynamic psychiatry, began in 1924 with observations by Eugen Bleuler,[61] who observed that the schizoid person and schizoid pathology were not things to be set apart.[23] :p. 5 Ronald Fairbairn's seminal work on the schizoid personality, from which most of what is known today about schizoid phenomena is derived, was presented in 1940. Here Fairbairn delineated four central schizoid themes:

  1. The need to regulate interpersonal distance as a central focus of concern.
  2. The ability to mobilize self-preservative defenses and self-reliance.
  3. A pervasive tension between the anxiety-laden need for attachment and the defensive need for distance that manifests in observable behavior as indifference.
  4. An overvaluation of the inner world at the expense of the outer world.[23]:p. 9

Following Fairbairn, the dynamic psychiatry tradition has continued to produce rich explorations on the schizoid character, most notably from writers Nannarello (1953),[30] Laing (1965),[14] Winnicott (1965),[62] Guntrip (1969),[31] Khan (1974),[27] Akhtar (1987),[33] Seinfeld (1991),[28] Manfield (1992)[15] and Klein (1995).[23]

See also

References

  1. 1 2 3 "F60 Specific personality disorders". The ICD-10 Classification of Mental and Behavioural Disorders – Diagnostic criteria for research (PDF). Geneva: World Health Organization. p. 149.
  2. ↑ American Psychiatric Association (1968). Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition. Washington, D. C. p. 42. doi:10.1176/appi.books.9780890420355.dsm-ii (inactive 2018-02-28). ISBN 978-0-89042-035-5.
  3. 1 2 3 4 The Schizoid Personality (Chapter 11). In: Theodore Millon (2004). Personality Disorders in Modern Life. Wiley, 2nd Edition. ISBN 0-471-23734-5. p. 371-374.
  4. 1 2 3 4 Michelle L. Esterberg (2010). "Cluster A Personality Disorders: Schizotypal, Schizoid and Paranoid Personality Disorders in Childhood and Adolescence". Journal of Psychopathology and Behavioral Assessment. 32 (4): 515–528. doi:10.1007/s10862-010-9183-8. PMC 2992453. PMID 21116455.
  5. 1 2 3 "Schizoid Personality Disorder (pp. 652–655)". Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). ISBN 978-0-89042-555-8.
  6. 1 2 3 Sonny Joseph (1997). "Chapter 3, Schizoid Personality Disorder". Personality Disorders: New Symptom-Focused Drug Therapy. Psychology Press. pp. 45–56. ISBN 9780789001344.
  7. 1 2 3 4 MedlinePlus (2014). "Schizoid Personality Disorder". National Library of Medicine.
  8. ↑ Arthur S. Reber (2009) [1985]. The Penguin Dictionary of Psychology (4th ed.). London; New York: Penguin Books. p. 706. ISBN 9780141030241. OCLC 288985213.
  9. ↑ Dennis S. Charney, Eric J. Nestler (2005): Neurobiology of Mental Illness. Oxford Press. ISBN 978-0-19-518980-3. Schizophrenia-like Personality Disorders. p. 240.
  10. ↑ Nancy McWilliams (2011). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd ed.). New York: Guilford Press. p. 196. ISBN 9781609184940.
  11. ↑ Parpottas Panagiotis (2012). "A critique on the use of standard psychopathological classifications in understanding human distress: The example of 'Schizoid Personality Disorder'". Counselling Psychology Review. 27 (1): 44–52.
  12. 1 2 Paul Emmelkamp (2013): Personality Disorders. p.54. See Cramer (2006) and Hong (2005) for details.
  13. 1 2 Skodol (2011). "Personality Disorder Types Proposed for DSM-5". Journal of Personality Disorders. 25 (2): 150. doi:10.1521/pedi.2011.25.2.136. It [SPD] was found by Ulrich (2007) to have the lowest functioning among the PDs with respect to achievement and interpersonal relations...
  14. 1 2 3 4 5 Ronald D. Laing (1965). "The Inner Self in the Schizoid Condition". The Divided Self: an Existential Study in Sanity and Madness. Harmondsworth, Middlesex; Baltimore: Penguin Books. pp. 82–100. ISBN 9780140207347. OCLC 5212085.
  15. 1 2 3 4 Philip Manfield (1992). Split self/split object: understanding and treating borderline, narcissistic, and schizoid disorders. Jason Aronson. pp. 204–207. ISBN 0-87668-460-6.
  16. ↑ Donald Winnicott (2006). The Family and Individual Development. Routledge. p. 73. ISBN 978-0415402774.
  17. ↑ Jeffrey J. Magnavita (1997). Restructuring Personality Disorders: A Short-Term Dynamic Approach. New York: The Guilford Press. p. 237. ISBN 1-57230-185-6.
  18. 1 2 3 Sharon C. Ekleberry (2008). "Cluster A - Schizoid Personality Disorder and Substance Use Disorders". Integrated Treatment for Co-Occurring Disorders: Personality Disorders and Addiction. Routledge. pp. 31–32. ISBN 978-0789036933.
  19. 1 2 3 4 Aaron T. Beck, Arthur Freeman (1990). "Chapter 7 Schizoid and Schizotypal PD (p.120-146)". Cognitive Therapy of Personality Disorders (1st ed.). The Guilford Press. pp. 125 (Millon), 127–129 (cognitive therapy conceptualization). ISBN 9780898624342. OCLC 906420553.
  20. ↑ David Schuldberg (2001). "Six subclinical spectrum traits in normal creativity". Creativity Research Journal. 13 (1): 5–16. doi:10.1207/s15326934crj1301_2.
  21. ↑ George Domino (2002). "Creativity and Ego Defense Mechanisms: Some Exploratory Empirical Evidence". Creativity Research Journal. 14 (1): 17–25. doi:10.1207/S15326934CRJ1401_2.
  22. ↑ Kinney, Dennis K.; Richards, Ruth (2001). "Creativity in Offspring of Schizophrenic and Control Parents: An Adoption Study" (PDF). Creativity Research Journal. 13 (1): 17–25. doi:10.1207/S15326934CRJ1301_3.
  23. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 James F. Masterson; Ralph Klein (1995). Disorders of the Self – The Masterson Approach. New York: Brunner / Mazel. pp. 25–27, pp. 54–55, pp. 95–143 (therapy). ISBN 9780876307861.
  24. ↑ Guntrip (in James F. Masterson 1995) Disorders of the Self – The Masterson Approach p.17 1995 Accessed September 27th, 2018
  25. ↑ Avner Falk (2008) Islamic Terror: Conscious and Unconscious Motives p.98 ABC-CLIO, 2008 ISBN 0313357641 Accessed September 27th, 2018
  26. ↑ Ronald Fairbairn (1952): Psychoanalytic Studies of the Personality. pp 16–17.
  27. 1 2 Masud Khan (1974). "The Role of phobic and counter-phobic mechanisms and separation anxiety in schizoid character formation". The Privacy of the Self – Papers on Psychoanalytic Theory and Technique. New York: International Universities Press. p. 70. ISBN 0823643107.
  28. 1 2 3 4 5 Jeffrey Seinfeld (1991): The Empty Core: An Object Relations Approach to Psychotherapy of the Schizoid Personality. Jason Aronson, ISBN 0-87668-611-0. Seinfeld writes: "The schizoid may also seem to be sociable and involved in relationships. However, he is frequently playing a role and not ‘fully’ involved, unconsciously disowning this role..."
  29. ↑ Donald Winnicott: Playing and Reality. Routledge Classics, 2012. ISBN 9781135070939 pp. 26–38
  30. 1 2 3 Nannarello, Joseph J. (1953). "Schizoid". The Journal of Nervous and Mental Disease. 118 (3): 237–249. doi:10.1097/00005053-195309000-00004. PMID 13118367.
  31. 1 2 Harry Guntrip (1969). Schizoid Phenomena, Object-Relations, and The Self. New York: International Universities Press. ISBN 978-1-85575-032-6.
  32. ↑ Karen Horney (1999). "Resignation: The Appeal of Freedom". Neurosis and Human Growth: The Struggle Towards Self-Realization. Routledge. pp. 264–265. ISBN 9780415210959.
  33. 1 2 3 4 5 6 7 Salman Akhtar (1987). "Schizoid Personality Disorder: A Synthesis of Developmental, Dynamic, and Descriptive Features". American Journal of Psychotherapy. 41 (4): 499–518. ISBN 9781461627685. PMID 3324773.
  34. ↑ "Theodore Millon – The Retiring or Schizoid Personality". millonpersonality.com.
  35. ↑ Barnhill, John W. (2013-11-08). DSM-5 Clinical Cases – "Oddly isolated" (Case 18.2). American Psychiatric Publishing (2013). p. 303. ISBN 978-1-58562-463-8.
  36. ↑ Kenneth S. Kendler (2006). "Dimensional representations of DSM-IV Cluster A personality disorders in a population-based sample of Norwegian twins: a multivariate study" (PDF). Psychological Medicine. 36 (11): 1583–1591. doi:10.1017/S0033291706008609. PMID 16893481.
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  38. 1 2 Sula Wolff (1995). Loners – The Life Path of Unusual Children. Routledge. p. 35. ISBN 978-0-415-06665-5.
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  40. ↑ Kathryn M. Abel (2010). "Birth weight, schizophrenia, and adult mental disorder: is risk confined to the smallest babies?". Archives of General Psychiatry. 67 (9): 923–930. doi:10.1001/archgenpsychiatry.2010.100. PMID 20819986.
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  42. ↑ Brigham Young University (2014): Head injuries can make children loners. For original study, see Levan, Ashley; Baxter, Leslie; Kirwan, C. Brock; Black, Garrett; Gale, Shawn D (2015). "Right Frontal Pole Cortical Thickness and Social Competence in Children With Chronic Traumatic Brain Injury". Journal of Head Trauma Rehabilitation. 30 (2): E24–E31. doi:10.1097/HTR.0000000000000040.
  43. ↑ R.L. Jenkins; S. Glickman (April 1946). "The Schizoid Child". American Journal of Orthopsychiatry. 16 (2): 255–61. doi:10.1111/j.1939-0025.1946.tb05379.x.
  44. 1 2 3 Descriptions from DSM-III (1980) and DSM-5 (2013):"Schizoid PD, Associated features (p. 310)" and "Schizoid PD (p. 652–655)".
  45. 1 2 3 Livesley, W. J.; West, M. (February 1986). "The DSM-III Distinction between schizoid and avoidant personality disorders". Canadian Journal of Psychiatry. 31 (1): 59–62. doi:10.1177/070674378603100112. PMID 3948107.
  46. ↑ James Overholser (1989) (November 1989). "Differentiation between schizoid and avoidant personalities: an empirical test". Canadian Journal of Psychiatry. 34 (8): 785–90. doi:10.1177/070674378903400808. PMID 2819642.
  47. ↑ Malcolm L. West and A. E. Sheldon-Keller (1994). Patterns of Relating An Adult Attachment Perspective. New York: Guilford Press. pp. 111–113. ISBN 978-0-89862-671-1.
  48. ↑ Fritz-Georg Lehnhardt, Astrid Gawronski, Kathleen Pfeiffer, Hanna Kockler, Leonhard Schilbach, and Kai Vogeley (2013). "The investigation and differential diagnosis of Asperger syndrome in adults" (PDF). Deutsches Ärzteblatt International. 110 (45): 760. doi:10.3238/arztebl.2013.0755. PMC 3849991. PMID 24290364.
  49. ↑ Woodbury-Smith MR, Volkmar FR (2008). "Asperger syndrome". Eur Child Adolesc Psychiatry. 18 (1): 2–11. doi:10.1007/s00787-008-0701-0. PMID 18563474.
  50. ↑ American Psychiatric Association, DSM-IV (1994). Appendix B: Criteria Sets and Axes Provided for Further Study. p. 713. ISBN 9780890420621.
  51. ↑ Coolidge, Frederick L. (2012). "Are alexithymia and schizoid personality disorder synonymous diagnoses?". Comprehensive Psychiatry. 54 (2): 141–148. doi:10.1016/j.comppsych.2012.07.005.
  52. ↑ McVey, D. & Murphy, N. (eds.) (2010) Treating Personality Disorder: Creating Robust Services for People with Complex Mental Health Needs, ISBN 0-203-84115-8.
  53. 1 2 "Schizoid personality disorder". Mayo Foundation for Medical Education and Research (2016).
  54. ↑ Maher, Alicia R.; Theodore, George (2012). "Summary of the Comparative Effectiveness Review on Off-Label Use of Atypical Antipsychotics". Journal of Managed Care Pharmacy. 18 (5 Supp B): 1–20. doi:10.18553/jmcp.2012.18.s5-b.1. ISSN 1083-4087.
  55. ↑ Scoriels, Linda (2013). "Modafinil effects on cognition and emotion in schizophrenia and its neurochemical modulation in the brain" (PDF). Neuropharmacology. 64: 168–184. doi:10.1016/j.neuropharm.2012.07.011. PMID 22820555.
  56. ↑ George Eman Vaillant (1985). "Maturity of Ego Defenses in Relation to DSM-III Axis II Personality Disorder". Archives of General Psychiatry. 42 (6): 597. doi:10.1001/archpsyc.1985.01790290079009. Manfield backs his claim up with this study; it showed that of the seventy-four people inner city males found to have personality disorders, thirty were schizoid or avoidant.
  57. ↑ Connolly, Adrian J. (2008). "Personality disorders in homeless drop-in center clients" (PDF). Journal of Personality Disorders. 22 (6): 573–588. doi:10.1521/pedi.2008.22.6.573. PMID 19072678. Archived from the original (PDF) on 2009-06-17.
  58. ↑ "An Empirical Investigation of Jung's Personality Types and Psychological Disorder Features" (PDF). Journal of Psychological Type/University of Colorado Colorado Springs. 2001. Retrieved August 10, 2013.
  59. ↑ Both types shared a detachment from the world but Schizoids also showed eccentricity and paradoxicality of emotional life and behavior, emotional coldness and dryness, unpredictability combined with lack of intuition and ambivalence (e.g., simultaneous presence of both stubbornness and submissiveness). Characteristic of Dreamers were tenderness and fragility, receptiveness to beauty, weak-willedness and listlessness, luxuriant imagination, dereism and usually an inflated self-concept. (From: Gannushkin, P.B (1933). Manifestations of psychopathies: statics, dynamics, systematic aspects.)
  60. 1 2 Ernst Kretschmer (1931). Physique and Character. London: Routledge (International Library of Psychology,1999). ISBN 0-415-21060-7.
  61. ↑ Eugen Bleuler- Textbook of Psychiatry, New York: Macmillon (1924)
  62. ↑ Donald Winnicott (1965): The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. Karnac Books. ISBN 9780946439843.
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