Neha Patil

Schizoid personality disorder

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Specialty  Psychiatry
ICD-9-CM  301.20
MeSH  D012557
ICD-10  F60.1
MedlinePlus  000920

Schizoid personality disorder (SPD) is a personality disorder characterized by a lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously demonstrate a rich, elaborate and exclusively internal fantasy world.

Contents

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 thought to be a "schizophrenia spectrum disorder".

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. 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, smaller GAF scores after 15 years and one of the lowest levels of life success of all PDs (measured as "status, wealth and successful relationships").

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.

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.

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 that when one is not enriched by injections of interpersonal reality, the self-image becomes increasingly empty and volatilized, which leads the individual to feel unreal.

When the individual's personal space is violated, they feel suffocated and feel the need to free themselves and be independent. People who have SPD tend to be happiest when they are in a relationship in which the partner places few emotional or intimate demands on them. It is not people as such that they want to avoid, but emotions both negative and positive, emotional intimacy, and self-disclosure.

This means that it is possible for schizoid individuals to form relationships with others based on intellectual, physical, familial, occupational, or recreational activities as long as these modes of relating do not require or force the need for emotional intimacy, which the affected individual will reject. Donald Winnicott explains this need to modulate emotional interaction by saying that 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.

Although there is the belief that people with SPD are complacent and unaware of their feelings, many recognize their differences from others. Some individuals with SPD who are in treatment say that life passes them by or they feel like living in a shell; they see themselves as "missing the bus" and complain of observing life from a distance. According to Aaron Beck and Freeman, "Patients with schizoid personality disorders consider themselves to be observers, rather than participants, in the world around them."

It is speculated that schizoid personality disorder may have ties to creativity.

The 'secret schizoid'

Many fundamentally schizoid individuals display an engaging, interactive personality that contradicts the observable characteristic emphasized by the DSM-5 and ICD-10 definitions of the schizoid personality. Klein classifies these individuals as "secret schizoids", who present themselves as socially available, interested, engaged and involved in interacting yet remain emotionally withdrawn and sequestered within the safety of the internal world.

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 however "just as often" a hidden internal state: that which meets the objective eye may not match the subjective, internal world of the patient. Klein therefore cautions that one should not miss identifying the schizoid patient because one cannot see the patient's withdrawal through the patient's defensive, compensatory interaction with external reality. He suggests that one need only ask the patient what his or her subjective experience is in order to detect the presence of the schizoid refusal of emotional intimacy.

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/she is only "playing a part," his own personality is not involved. According to Fairbairn, the person disowns the part which he is playing and thus the schizoid individual seeks to preserve his own personality intact and immune from compromise." Further references to the secret schizoid come from Masud Khan, Jeffrey Seinfeld and Philip Manfield, who give a description of an SPD individual who actually "enjoys" regular public speaking engagements but experiences great difficulty in the breaks when audience members would attempt to engage him emotionally. These references expose the problems involved in relying singularly 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.

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. 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." This aspect of schizoid pathology has been generously elaborated in works by Laing, Winnicott, and Klein.

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. Significantly broadening this picture are notable exceptions of SPD individuals who engage in occasional or even frequent sexual activities with others.

Harry Guntrip 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." Jeffrey Seinfeld, professor of social work at New York University, has published a volume on SPD 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. 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," although none of these necessarily apply to all people with SPD.

Causes

Some evidence suggests that 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. Twin studies with schizoid personality disorder traits (e.g. low sociability and low warmth) suggest that these are inherited. Because of this, there is indirect evidence linking the heritability of schizoid personality disorder. 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." The link between SPD and being underweight may also point to the involvement of biological factors.

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.

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

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.

Individuals with SPD may often be unable to express aggressiveness or hostility, even when provoked directly. They can seem vague and drifting about their goals, and often 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.

Criticism

It has been suggested that SPD may be better represented by two different disorders. One affect-constricted disorder (belonging to schizotypal PD) and a seclusive disorder (belonging to avoidant PD). Therefore, 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.

ICD-10 criteria

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

It is characterized by at least four of the following criteria:

  1. Emotional coldness, detachment or reduced affect.
  2. Limited capacity to express either positive or negative emotions towards others.
  3. Consistent preference for solitary activities.
  4. Very few, if any, close friends or personal relationship, and a lack of desire for such.
  5. Indifference to either praise or criticism.
  6. Little interest in having sexual experiences with another person (taking age into account).
  7. Taking pleasure in few, if any, activities.
  8. Indifference to social norms and conventions.
  9. Preoccupation with fantasy and introspection.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Dynamic criteria

Ralph Klein's 1995 description of a schism in the object of relations of the schizoid gave new perspective on commonly held beliefs about the schizoid that focus mainly on the schizoid’s apparent disinterest in relationships.

Of particular significance is the correlation between the narcissistic disorder and the schizoid. The "over-entitlement" of the narcissist in a family can result in the "under-entitlement" of the schizoid sibling. The disavowed shame of the narcissist is often absorbed by or projected onto the schizoid, which causes the experience of psychic invasion and the sense of vulnerability to intrusiveness. A schizoid may also be attracted to exploitative relationships in which they long to experience significance and recognition by serving a need of the other. This same person may yet be highly aware of any forms of corruption or exploitation outside of this relationship. In this approach diagnosis is based on the dynamic of this split and its consequences, as opposed to diagnosis on the basis of a list of external behaviors.

Guntrip criteria

Ralph Klein, Clinical Director of the Masterson Institute, delineates the following nine characteristics of the schizoid personality as described by Harry Guntrip:

The description of the nine characteristics first articulated by Guntrip should bring more clearly into focus some major differences that exist between the traditional descriptive DSM portrait of the schizoid disorder and the traditional psychoanalytically informed object relations view. All nine characteristics are internally consistent. Most, if not all, should be present in order to diagnose a schizoid disorder.

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

Differential diagnosis

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

Comorbid problems

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. The relationship between alexithymia (the inability to identify and describe emotions) and SPD seems to be strong but they are not the same condition.

Schizoid individuals frequently act out with substance and alcohol abuse and other addictions which serve as substitutes for human relationships (see dual diagnosis). 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." 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."

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."

Millon's subtypes

Theodore Millon restricted the term "schizoid" to those personalities with an intrinsic defect in the capacity to form relationships. It was mainly his work which led to the split of the schizoid character into three separate personality disorders (schizoid, schizotypal and avoidant) in DSM III (1980). According to Millon, SPD is distinguished from other personality disorders in that it is "the personality disorder that lacks a personality." He mentions that this could be partly due to the fact that the diagnostic criteria only describe a deficiency and what is not present. Instead of delineating certain traits that may be present, they focus solely on what the schizoid lacks.

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

Akhtar's profile

Salman Akhtar, M.D. 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. 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."

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

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, who tend to view their condition as not conflicting with their self-image and their abnormal perceptions and behaviors as rational and appropriate, from coming forward for treatment. There is little data on the effectiveness of various treatments on this personality disorder due to the infrequency of encountering this personality disorder in clinical settings. 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. Originally, low doses of atypical antipsychotics like risperidone or olanzapine were used to alleviate social deficits and blunted affect. However, a recent review concluded that atypical antipsychotics were ineffective for treating personality disorders. In contrast, the substituted amphetamine Bupropion may be used to treat anhedonia. 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. 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).

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 have a tendency to miss differences that causes an inability to pick up environmental cues and limits their experience. 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. 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. 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. 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.

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. 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.

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.

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." 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."

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.

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.

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 1% of the general population.

Philip Manfield suggests that the "schizoid condition," which roughly includes the DSM schizoid, avoidant, and schizotypal personality disorders, is represented by "as many as 40 percent of all personality disorders." Manfield adds "This huge discrepancy [from the 10 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."

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

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.

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.”

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 Ernst Kretschmer's 1925 description of observable schizoid behaviors, which he organized into three groups of characteristics:

  1. unsociability, quietness, reservedness, seriousness, eccentricity
  2. timidity, shyness with feelings, sensitivity, nervousness, excitability, fondness of nature and books
  3. pliability, kindliness, honesty, indifference, silence, 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.

In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin developed a first detailed typology of personality types. It included Schizoids and Dreamers which seem most similar to today's SPD.

The second path, that of dynamic psychiatry, began in 1924 with observations by Eugen Bleuler, who observed that the schizoid person and schizoid pathology were not things to be set apart. 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, and (4) an overvaluation of the inner world at the expense of the outer world. Following Fairbairn, the dynamic psychiatry tradition has continued to produce rich explorations on the schizoid character, most notably from writers Nannarello (1953), Laing (1965), Winnicott (1965), Guntrip (1969), Khan (1974), Akhtar (1987), Seinfeld (1991), Manfield (1992) and Klein (1995).

References

Schizoid personality disorder Wikipedia


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