6.65: Schizoid Personality Disorder

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DSM-IV-TR criteria

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 four (or more) of the following:

neither desires nor enjoys close relationships, including being part of a family
almost always chooses solitary activities
has little, if any, interest in having sexual experiences with another person
takes pleasures in few, if any, activities
lacks close friends or confidants other than first-degree relatives
appears indifferent to the praise or criticism of others
shows emotional coldness, detachment, or flattened affectivity

Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition.
NOTE: If criteria are met prior to the onset of Schizophrenia, add “Pre-morbid,” e.g., “Schizoid Personality Disorder (Pre-morbid).”

Associated Features

Individuals with Schizoid Personality Disorder (SPD) have little to no contact with the outside world. They have no desire to have social relationships, and when they do have them they do not enjoy them. This is a reason that they have few to no friends and to others these individuals seem to be cold and distant, often displaying a stoic expression. They are rarely able to express their emotion and often fail to have warm feelings for anyone. They have little to no interest in sexual activity and have very few things in their lives that give them pleasure. They tend to be loners and pursue activities and occupations where they do not have to interact with people.

There is highest Co-morbidity for Schizotypal, Avoidant, and Paranoid Personality Disorders. Thus, is it most likely that another Cluster A disorder will occur with SPD. Anhedonia is often expressed, that is a an inability to experience pleasure and joy in activities and life. People that suffer from SPD tend to show long-standing patterns of behaviors that are abnormal to their environmental norms. They may experience brief psychotic episodes resulting from stress. SPD may appear as a precursor to Delusional Disorder or Schizophrenia, and those with SPD may develop Major Depressive Disorder.

The person may have a stoic look most of the day and not respond to any comments or jokes; they just keep to their self and do what they want to do alone. They are somewhat shy of others, not knowing what is going to happen next.

Child vs. Adult Presentation

Typically, the onset of SPD is in early adulthood or late adolescence were the symptoms can be seen. These would include performing badly in school, self-isolation, and bad relationships with their peers.

The symptoms that are needed for diagnosing SPD need to be shown by early adulthood. The earlier this is found, the better, because it will be more difficult to treat once the person gets older.

One issue that is known is the similarity between SPD, autism and Asperger’s disorder. It is important to know that the personality traits of SPD are inflexible and cause impairment in functioning

Gender and Cultural Differences in Presentation

More males are affected by Schizoid PD than females. The disorder is uncommon in clinical settings because individuals with SPD do not perceive themselves as distressed and, therefore, are not inclined to seek out treatment. They see themselves as normal, but not when they interact with others; they do not know what to expect from other people they have not met because they are socially inclined to be quiet and conserved of mysterious people.

SPD may be more prevalent in individuals with schizophrenic or schizotypal relatives.

Those from a variety of cultural backgrounds may sometimes exhibit defensive behavior and styles which may be mistaken as schizoid.

Immigrants are sometimes mistaken as cold, hostile, or indifferent.

Epidemiology

Schizoid Personality disorder has a prevalence rates in the general population between 1% and 3% and prevalence in an outpatient psychiatric setting around 1%. There is some familial patterns but none that are very significant in general settings.

This is the least diagnosed personality disorder in the general population, and is uncommon in clinical settings.

The diagnosis is based on a clinical interview to assess symptomatic behavior. Other assessment tools that are helpful in diagnosing Schizoid Personality Disorder include:

Minnesota Multiphasic Personality Inventory (MMPI-2)
Millon Clinical Multiaxial Inventory (MCMI-II)
Rorschach Psychodiagnostic Test
Thematic Apperception Test (TAT)

Etiology

SPD shares many commonalities of depression, Avoidant Personality Disorder and Asperger’s syndrome and can be difficult to distinguish from the others because of some of the same symptoms and behaviors that are displayed in the other disorders.

Family life seems to be the underlying cause of Schizoid PD. These families are reserved emotionally, have impersonal communication, and are very formal. The parents often did not give very much attention to the person while they were growing up. This occurring in the first year of their lives, seems to have an impact on their lack of wanting to form close relationships because these children did not learn the necessary skills needed to form and maintain close relationships.

Schizoid Personality Disorder may have increased prevalence in the relatives of those with Schizophrenia and Schizotypal Personality Disorder.

Empirically Supported Treatments

Individuals with Schizoid PD do not usually seek out treatment because they generally do not feel as if they are in need of help, like some of the other disorders; they think they are pretty normal individuals with normal lives but need an intervention by a friend to reveal that the behavior is problematic. When they realize, for the few who do seek treatment, there are medications that treat only the negative symptoms, similar to those persons with schizophrenia.

Psychodynamically oriented therapies:

A psychodynamic approach would typically not be the first choice of treatment due to the patient’s poor ability to explore his or her thoughts, emotions, and behavior. When this treatment is used, it usually centers around building a therapeutic relationship with the patient that can act as a model for use in other relationships.

Cognitive-behavioral therapy:

Attempting to cognitively restructure the patient’s thoughts can enhance self-insight. Constructive ways of accomplishing this would include concrete assignments such as keeping daily records of problematic behaviors or thoughts. Another helpful method can be teaching social skills through role-playing. This might enable individuals to become more conscious of communication cues given by others and sensitize them to others’ needs.

Group therapy:

may provide the patient with a socializing experience that exposes them to feedback from others in a safe, controlled environment. It can also provide a means of learning and practicing social skills in which they are deficient. Since the patient usually avoids social contact, timing of group therapy is of particular importance. It is best to develop first a therapeutic relationship between therapist and patient before starting a group therapy treatment.

Family and marital therapy:

It is unlikely that a person with schizoid personality disorder will seek family therapy or marital therapy. If pursued, it is usually on the initiative of the spouse or other family member. Many people with this disorder do not marry and end up living with and are dependent upon first-degree family members. In this case, therapy may be recommended for family members to educate them on aspects of change or ways to facilitate communication. Marital therapy (also called couples therapy ) may focus on helping the couple to become more involved in each other’s lives or improve communication patterns (minddisorders.com).

Medications

Some patients with this disorder show signs of anxiety and depression which may prompt the use of medication to counteract these symptoms. In general, there is to date no definitive medication that is used to treat schizoid symptoms.

Prognosis

Since a person with schizoid personality disorder seeks to be isolated from others, which includes those who might provide treatment, there is only a slight chance that most patients will seek help on their own initiative. Those who do may stop treatment prematurely because of their difficulty maintaining a relationship with the professional or their lack of motivation for change.

If the degree of social impairment is mild, treatment might succeed if its focus is on maintenance of relationships related to the patient’s employment. The patient’s need to support him- or herself financially can act as a higher incentive for pursuit of treatment outcomes.

Once treatment ends, it is highly likely the patient will relapse into a lifestyle of social isolation similar to that before treatment.

Prevention

Since schizoid personality disorder originates in the patient’s family of origin, the only known preventative measure is a nurturing, emotionally stimulating and expressive care-taking environment

Portrayed in Popular Culture

Mr. Freeze from Batman
- Due to a long-time search for a cure for his wife’s malady, he is an emotionless machine.
Severus Snape from Harry Potter
- He rarely expresses emotions and usually stays in his office or in the Potions chamber away from the company of others

DSM-V Changes

Schizoid Personality Disorder will be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type

(APA, 2010)