|
For references, see the Bibliography page |
Essential Feature
According to the DSM-IV? (1994, p. 638), the essential feature of the schizoid personality disorder "e;is a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings."e; These individuals appear to lack a desire for intimacy. They spend time alone and select activities that do not include interaction with others.
The ICD-10 (1994, p. 225) describes the schizoid personality disorder as "e;characterized by withdrawal from affectional, social and other contacts, with a preference for fantasy, solitary activities and introspection. There is a limited capacity to express feelings and to experience pleasures."e;
Millon & Davis (1996, p. 217) describe the SPD as the "e;asocial"e; pattern characterized by a deficiency in the ability to experience pleasure. Kalus (1995, p. 58) believes that the schizoid personality disorder is distinguished by the predominance of negative symptoms associated with the schizophrenia spectrum disorders, i.e., social, interpersonal, and affective deficits without psychotic-like cognitive/perceptual distortions.
The diagnosis of schizoid personality disorder should not be used if the pattern of behavior occurs only during the course of schizophrenia or other psychotic disorders or is due to neurological or other medical conditions (DSM-IV?, 1994, p. 639).
Individuals with SPD may have particular difficulty expressing anger, even when directly provoked. They often react passively to adverse circumstances and may not respond appropriately to important life events. These individuals may experience brief (minutes to hours) psychotic episodes in response to stress. SPD can be, but is not necessarily, an antecedent disorder to schizophrenia, major depression, or a delusional disorder. The most frequent co-occurring personality disorders with STP are schizotypal, paranoid, and avoidant personality disorders. SPD is diagnosed more frequently in males who seem to be more impaired than females with SPD (DSM-IV?, 1994, p. 639).
SPD is uncommon in clinical treatment settings. It can be very difficult to differentiate from autistic or asperger's disorder. SPD is differentiated from schizotypal personality disorder by the lack of perceptual distortions. It is differentiated from paranoid personality disorder by lack of suspiciousness and paranoid ideation (DSM-IV?, 1994, pp. 639-640).
Self-Image
Beck (1990, pp. 51-52) suggests that individuals with schizoid personality disorder view themselves as loners who prize independence, solitude, and mobility. There is, however, controversy about whether or not schizoid withdrawal from others is preferred or is generated from interpersonal anxiety. Millon & Davis (1996, p. 232) believe that individuals with SPD are complacent with little or no tendency to look into their personal feelings. While there may be minimal anxiety, Magnavita (1997, pp. 237-241) notes that people with SPD recognize their differences from others. He described a client with SPD who was distressed by the thought that there was something wrong with him; he could not enjoy life and seemed to be living inside of a shell. This individual knew that he troubled his wife with his quietness. Seiver (Lion, Editor, 1981, pp. 40-41) described individuals with SPD in treatment who said that life passed them by; they saw themselves as "e;missing the bus"e; and complained of observing life from a distance.
Akhtar (1992, pp. 136-140) states that the DSM-III separated what the analysts understood as the schizoid personality into three separate personality disorders: the schizoid, avoidant, and the schizotypal. The DSM-IIIR then shifted the avoidant personality disorder more toward a phobic disorder and suggested that the indifference and withdrawal in the SPD may be more apparent than real. Akhtar went on to suggest that the individuals with SPD have a self-concept that may be overtly compliant, stoic, noncompetitive, and self-sufficient, but they may covertly see themselves as cynical, inauthentic, and depersonalized.
However, if the apparent lack of overt interpersonal anxiety is covertly experienced, the differentiation between the schizoid personality disorder and the avoidant personality disorder becomes substantially more problematic. The schizoid personality disorder is currently defined by the absence of affect, inability to experience pleasure, and low involvement with others. Individuals with avoidant personality disorder may control affect, withdraw from pleasurable activities and avoid others in the name of anxiety management. Both may seek isolation, but individuals with schizoid personality disorder will tolerate the separation with comfort and individuals with avoidant personality disorder will be distressed and lonely. If Millon's view is accurate, individuals with avoidant personality disorder will evidence greater agitation and subjective discomfort. Individuals with schizoid personality disorder will not indicate dissatisfaction with isolation. It would appear that clinically there is support for this view. Individuals with a schizoid personality disorder rarely seek treatment; individuals with avoidant personality disorders often do.
View of Others: Relationships
It is within relationships that the schizoid personality disorder is most clearly defined. In the movie "e;Barfly,"e; the main character, when asked if he hated people said: "e;No, I don't hate people. I just seem to feel better when they're not around."e; One client assessed in an alcohol and drug program (at the urging of his wife) reported that he had lived in the basement of the home he grew up in and withdrew to the basement of his adult home to be away from his wife and to smoke marijuana daily. He had limited sexual contact with his wife and let her "e;do all the people stuff."e; He was not interested in treatment and did not return after the assessment.
These individuals are characterized by a profound defect in their ability to form personal relationships or to respond to others in an emotionally meaningful way (Frances, 1995, p. 367). They are aloof, introverted, and seclusive; they appear interpersonally indifferent, unengaged, and remote. Social communication is perfunctory and formal (Millon, 1996, pp. 217-231). Magnavita (1997, p. 245) suggests that this distance from others restricts individuals with SPD in their capacity to receive feedback -- the information that could increase their self-awareness and allow them to grow in their capacity to relate.
Individuals with schizoid personality disorder evidence little desire for sexual experiences. They may marry but then be sexually apathetic with their spouse (despite being functional and orgasmic). Sex can mean closeness and enmeshment. For these individuals, abandonment is a lesser evil than engulfment; personal space can become a greater need than maintaining relationships with the people they very much care about (McWilliams, 1994, pp. 193-196).
Gunderson suggests that individuals with SPD "e;feel lost"e; without the people to whom they are attached, but when with them, feel swallowed, smothered, and absorbed. Thus, these individuals seek relationships for security but break out again to gain freedom and independence (Akhtar, 1992, p. 132). Clearly, individuals with schizoid personality disorder are going to be most comfortable with others who demand little intimacy and make few emotional demands. One individual with SPD described his non-demanding marriage as being "e;as good as living alone."e; Marriage for these individuals may look a great deal like a roommate situation. If they do not marry or form significant relationships, they may live out their lives sharing a home with siblings or other relatives in comfortable, but non-intimate, stability. Siever notes that they may live or work in a group setting, e.g. religious or counterculture groups, which allow them to maintain superficial contact without intimacy (Lion, ed., 1981, p. 36).
Kantor believes that true schizoid personality disorder involves reticence and interpersonal withdrawal because of a mild "e;schizophrenic"e; anhedonia, i.e., the compromised capacity for relating due to an inability to anticipate or experience joy in human relationships. This anhedonia appears in bland diffidence about, shyness in, or detachment from relationships. It also appears as a silent simplicity and reserve; a lack of pressure or appearance of a low energy level; and a seeming lack of intelligence (Kantor, 1992, pp. 191-192). Even if individuals with schizoid personality disorder feel it is expedient to fit in with others, they tend to feel awkward; they want to maintain a safe distance from the rest of humanity (McWilliams, 1994, p. 195).
Issues With Authority
Individuals with SPD do not frequently come in contact with society's authority figures. They are inclined to go their own way but will do so without obvious defiance or a need to demonstrate their independence. Thus, they may be non-conforming but will keep a low enough profile to avoid sanctions, whether at work or in society in general. On the other hand, they are quite sensitive to intrusion and will withdraw from external pressure when possible.
Individuals with SPD are essentially free of any particular internal pressure to do as others do or follow the rules made and enforced by others. This elusiveness is a significant barrier to effective treatment. Individuals with SPD feel no particular need to confront service providers when they disagree and will often be treatment compliant. However, they remain quietly committed to their own course of action, e.g. using drugs when they are once again "e;free"e; to do so -- often the day they can leave an AOD or dual diagnosis treatment program.
Schizoid Personality Disorder Behavior
Beck (1990, p. 125) states that others view individuals with schizoid personality disorder as dull, uninteresting, and humorless; they are often ignored. While their speech is laconic and meager, what they say is rarely abnormal (Kantor, 1992, p. 96).
They appear to be indifferent, aloof, and unresponsive to praise, criticism, or feelings expressed by others (Frances, 1995, p. 367). Millon (1996, pp. 217-231) believes that individuals with SPD prefer to be alone and are unaware of the feelings and thoughts of others. While they are not intentionally unkind, they are preoccupied with tangential matters, and seem to have a fundamental incapacity to sense the needs of the people around them. They do not need to communicate and are generally underresponsive to most forms of stimulation or reinforcement. When others attempt to relate to or get to know people with SPD, they are frequently bewildered by the non-response and benign, but very clear, indifference they encounter.
People with relatively normal variants of the schizoid personality disorder appear untroubled and indifferent; they function adequately in their occupations but are rather colorless and shy.
Clients with SPD may live, as adults, with their elderly parents without significant interaction, e.g. they live in the basement and interact with family members in a limited, sporadic fashion. These are individuals who may work as stock clerks during the midnight shift in retail or as a projectionist at a movie theater. If they are detached from a supportive family (particularly if they have become involved with drugs and alcohol) they may become homeless and refuse outreach services designed to engage them in mental health, alcohol and drug, or dual diagnosis services.
Affective Issues
Individuals with SPD are affectively constricted. They are low in emotional arousal and reactivity; they are imperceptive and apathetic. Their inner emotional experience tends to be undifferentiated and unarticulated. Even their language shows a deficit in the range and subtlety of emotionally-related words (Millon, 1996, pp. 232-233).
While these individuals do not particularly struggle with shame or guilt, they can be quite anxious about basic safety (McWilliams, 1994, p. 191). Beck (1990, p.129) suggests that individuals with SPD experience a low level of sadness if separate from people and anxious if they are forced into interaction with others. Once again, most authors will introduce or accept a greater degree of interpersonal ambivalence and discomfort in the schizoid personality disorder than will Theodore Millon who sees these individuals as non-anxious and non-relating.
Defensive Structure
Individuals with SPD utilize defenses to detach and form an emotional barrier; they engage in rumination, rambling speech, intellectualization, cutting off affect, conflict avoidance, and withdrawal (Magnavita, 1997, p. 252). Millon also noted the SPD use of intellectualization. He suggests that these individuals tend to be abstract and matter-of-fact about their emotional and social lives; they engage in few complicated unconscious processes. Their lack of reactivity results in little need for complex intrapsychic defenses (Millon, 1996, p. 232).
McWilliams (1994, pp. 189-191) believes that another defense that defines schizoid personality disorder is withdrawal into fantasy. The external world feels so full of consuming threats against security and individuality that individuals with schizoid personality disorder manifest a tendency to withdraw and seek satisfactions in fantasy.
On the other hand, the most adaptive capacity of individuals with SPD is creativity. Self-esteem is often maintained by creative activity as these individuals seek confirmation of their originality and uniqueness (McWilliams, 1994, pp. 192-196).
The Schizoid Personality Disorder Coming Into Treatment
Few individuals with a Cluster A personality disorder are particularly inclined to seek treatment. Richards (1993, p. 265) notes that individuals with SPD have few complaints and do not seek an interpersonal context for solving their problems. These individuals are society's misfits and can spend a lifetime in single rooms in interpersonal isolation. If they come into treatment, they are often forced to do so by family or the legal system. These individuals are not psychologically resilient and will have severe difficulty in jail. They may not be able to effectively recognize or manage predatory behavior from others; victimization is a serious possibility.
Individuals with SPD who accept treatment voluntarily are those whose need for closeness with others lies closer to the surface and may be more disposed to form a positive therapeutic alliance. Those who are forced into treatment may be less accessible (Gabbard, 1996, p. 953).
In treatment, clients with SPD challenge service providers, not with hostility, distrust, or aggression, but with the absence of response. They do not reciprocate feeling for feeling; they are not responsive to praise, criticism, or other kinds of emotional leverage used between people when one is attempting to influence the other. It is the apparent immunity to influence that can leave service providers feeling frustrated and ineffective. However, the lack of affective bonding or responsiveness does not mean insensitivity or imperviousness. In clinical settings, these individuals, when placed in a social skills group and not pressured to engage at a level they cannot endure or sustain, will become attached in their own
way and are inclined to attend regularly. It would appear that they can value contact if the intensity is controlled and safety ensured.
Medication Issues
Kalus, et. al. (Livesley, Editor, 1995, p. 59) suggest that there is a genetic link between schizophrenia and the schizoid personality disorder. The schizoid personality disorder appears to characterize the negative symptoms of schizophrenia, e.g. anhedonia, little affect, low energy. It is the schizotypal personality disorder, also seen as part of the schizophrenia spectrum disorders, that exemplifies the positive symptoms at a non-psychotic level, e.g. non-delusional odd beliefs, eccentric behavior, agitation, and paranoid thinking.
Until the most recent antipsychotic medications, such as risperdal, became available, no psychotropic medication made much of an impact on the negative symptoms of schizophrenia; thus, by implication, no medication appeared to be effective for the symptoms of schizoid personality disorder. Currently, however, Joseph (1997, pp. 46-47) notes that there are several symptoms in SPD that are potentially responsive to medication. These include the symptoms that resemble the negative or deficit symptoms of schizophrenia: emotional apathy, social withdrawal, blunted or constricted affect, anhedonia, dysphoria, poverty of speech and thought, avolition, and slowed thinking. He suggests low doses of risperidone or olanzapine for the social deficits and blunted affect and Wellbutrin (bupropion) for anhedonia. He believes that clozapine is the most effective medication for the negative symptoms found in SPD but notes that the potential for agranulocytosis makes it unwise to use. He states that clozapine does not have FDA approval for treatment of schizoid personality disorder.
Joseph (1997, pp. 46-47) also suggests the use of SSRIs, TCAs, MAOIs, low dose benzodiazepines, and beta-blockers for social anxiety. While these medications may be effective for the target symptom of social discomfort, there is some controversy as to whether or not this is a concern in SPD. Millon believes that anxiety in social activities are indicative of avoidant personality disorder. It is also a symptom of schizotypal personality disorder. It would appear to be more along the line of analytic thinking that SPD is characterized by overt social detachment and covert social anxiety. While this does not alter consideration of medication for target symptoms, it does highlight one of the diagnostic issues with SPD.
There should be some measure of caution exercised in medicating individuals with SPD. They are often comfortable with their own symptoms and do not voluntarily seek treatment. If they report themselves to be fairly comfortable, consideration should be given to using therapy and skills training alone.
Treatment Provider Guidelines
Individuals with SPD are generally unengaged interpersonally and are likely to relate to service providers in an emotionally bland manner with little interaction. Treatment providers are likely to have to lead discussions and introduce the content of treatment (Craig, Retzlaff, ed., 1995, p. 76).
Most service providers work in mental health, alcohol and drug services, or dual diagnosis treatment because they are motivated to engage and work along with their clients for change. They want to connect and feel that they can make a difference. Clients with SPD are reticent, unconnected, and may not, in fact, allow the service provider to be a significance factor in their lives. This can be frustrating and an invitation to intrusiveness or over-functioning on the part of the service providers. It is important that service providers do not have more ambitious goals for clients with SPD than the clients have for themselves. Also, if affective experience or expression is intolerable to clients with SPD, initial focus on intellectual understanding of interpersonal or addiction issues may be effective and a method of establishing contact with these individuals. Pressure to focus on affective issues is potentially both aversive and confusing to clients with SPD. Service providers must remember that these individuals are adept at "e;leaving the room"e; without having to physically walk out. They can detach and remove themselves from a process they cannot tolerate. Remaining focused on an intellectual level can both be a teaching tool and a means to manage the level of threat clients with SPD feel in the treatment process.
McWilliams (1994, p. 202) believes that individuals with SPD can be cooperative with, and appreciative of, the therapy process when treated with consideration and respect. They may feel empty, lost, and unable to express their thoughts in treatment. Service providers need to communicate that the limited expression of cognitive or affective content from these individuals is intelligible and can form the basis of a connection between them. Even high functioning people with SPD worry that they are aberrant and incomprehensible. Accepting their silence affirms them as individuals of worth.
Countertransference Issues
Clients with SPD have difficulty maintaining a connection to treatment providers between sessions. A possible countertransference issue for service providers, in a corresponding fashion, is to "e;forget"e; about these individuals between sessions as well. These individuals rarely make demands outside of direct treatment contact. Service providers may fail to think about or discuss these clients with colleagues or in supervision because they evoke few feelings or concerns. Within the individual or group session, however, extraordinary patience is required to maintain an empathic stance and to establish a therapeutic bond with these clients (McCann, Retzlaff, ed., 1995, p. 145). Their lack of responsivity, a frustrating incapacity to relate, and a general and pervasive lack of empathy to the treatment process does not make interaction particularly interesting or rewarding for service providers. It is important that service providers not fall into a bored, detached countertransference. Instead, clinicians need to be persistent, patient and tolerant.
Another countertransference issue with clients with SPD is the inclination of service providers to feel helpless in response to the clients' style of passivity and blankness. Treatment providers must structure the treatment sessions, encourage contact and both the experience and expression of feelings, and reward attempts to maintain contact (Hyer, et.al., Retzlaff, ed., 1995, p. 222).
Treatment Techniques
In assessing individuals with SPD, consider possible psychotic processes; determine whether or not there is evidence of hallucinations, delusions, and/or a thought disorder. If symptoms of psychosis are present, treatment must be designed for the seriously mentally ill.
Zimmerman (1994, pp. 90-91) suggests the following questions in assessing for schizoid personality disorder:
Beck & Freeman (1990, p. 125) note that individuals with SPD appear to have defective perceptual scanning which results in missing environmental cues. The defective perceptual scanning is characterized by a tendency to miss differences and to diffuse the varied elements of experience. Perceptions of events are mixed, disorganized, and undifferentiated (Millon, 1996, p. 231). This only serves to increase their fearfulness of intimacy and encourages severely limited interpersonal experiences. The impact of the resulting isolation is insufficient opportunity to learn social skills and failure to correct unusual behavior. Socialization groups offer corrective learning experiences with others; they also involve lower interpersonal intensity than that of individual treatment. Therapy is often educational in design and aimed at teaching social appropriateness, social customs and manners, and social comfort (Stone, 1993, p. 185).
Educational strategies may be effective in working with individuals with SPD to identify their positive and negative emotions. They can use affect identification to learn about: (1) their own emotions; (2) the emotions they elicit in others; and (3) possible feeling states of people with whom they relate . This process can assist in developing the capacity for empathy for these individuals (Will, Retzlaff, ed., 1995, p. 95).
Intervention with individuals with SPD may include exploring their self-concept and sense of where they belong in the world. Confrontation should be minimal. Instead, clarify the relation of emotions to thinking and encourage these clients to be present with reality. Be watchful of an inclination to collude with clients with SPD in their passivity by working harder than they do in the treatment process (Dorr, Retzlaff, ed., 1995, p. 196).
Treatment Goals
Individuals with SPD do not often seek therapy; they are frequently more or less satisfied with what can be regarded by others as an impoverished existence. If family insistence or other circumstances bring individuals with SPD into treatment, Oldham (1990, p. 280) suggests that treatment goals be supportive and practical. The goal should be aimed at achieving reductions in social isolation and in promoting effective adjustment to social circumstance (Livesley, ed., 1995, p. 66).
Treatment goals that address drug and alcohol use must be practical and realistic. These individuals will quietly resist behavioral guidelines they do not like and do not intend to adhere to, e.g. abstinence. They may not directly argue but simply wait for the service providers or the treatment program to be out of their lives so they can resume behavior they never intended to discontinue in the first place. There may be some individuals with SPD that will only consider a treatment goal that reduces the danger or the negative consequences of drug use, e.g. harm reduction techniques. It is important to be direct and open about the realistic possibilities of any treatment goal and to stress that the choice for behavioral, attitudinal, or affective change always remains with the clients.
Cluster A: Incidence of Co-Occurring Substance Abuse Disorders
The Schizoid Personality Disorder is in Cluster A, the "e;odd or eccentric"e; personality disorders (DSM-IV, 1994, p. 629). Cluster A represents the lowest incidence of co-occurring substance abuse disorders of the three DSM-IV personality disorder clusters (Nace, 1990, p. 184). The impoverished social connections experienced by individuals with SPD interfere with their exposure to the drug and alcohol culture. They have marginal skills and limited inclination to learn how to obtain illegal drugs.
On the other hand, these individuals are easy prey for the more aggressive personality disorders such an the antisocial personality disorder. There are many instances in both inpatient and outpatient treatment where individuals with SPD become the mark of more predatory clients and are introduced to and taught how to obtain various drugs.
Drugs of Choice for the Schizoid Personality Disorder
While no single pattern of substance use or abuse can be identified for any of the personality disorders, individuals with SPD may well be attracted to psychedelics. Milkman and Sunderwirth (1987, pp. xiv-xv) suggest that, from a psychological perspective, drug choice depends on a positive "e;fit"e; with individuals' usual style of coping. The drug of choice can function as a pharmacologic defense mechanism. For individuals with SPD, there is the possibility of an addiction to compulsive fantasy and an inclination to seek drug experiences with the psychedelics that provide imaginative transport such as with LSD, psilocybin, and peyote.
Marijuana may be the single most ego syntonic drug for individuals with SPD. 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. A drug that could meet a cluster of needs such as this would be of greater value to these individuals than the interpersonal, and therefore troubling, relationships with a counselor, therapist, or group members. Even so, Walant (1995, pp. 171-175) believes that treatment must address the addicts' inclination to collapse all needs into one object of attachment - drugs. An attempt must be made to shift the object of attachment away from drugs and back into the real world.
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 not as likely to use marijuana or alcohol for social disinhibition as the avoidant personality disordered individuals are; they are likely to use in isolation for the effect on internal processes. As such, they are not particularly vulnerable to negative consequences in early use. They are also inclined to consider their use to be nobody's business but their own. If they are coerced into treatment due to legal difficulty or family pressure, they may well comply with program directives but maintain an internal certainty that they will return to drug use as soon as external sanctions are removed. Essentially, individuals with SPD are highly resistant to influence but are not particularly inclined to engage authority figures with an active struggle against demands for compliance; they will simply wait until they are free of the pressure to return to their preferred behavior.
Dual Diagnosis Treatment for the Schizoid Personality Disorder
Depending upon the severity of the personality disorder, the pattern of drug use and consequent destabilization for individuals with SPD can be similar to the seriously mentally ill/dually diagnosed population, i.e., destabilization may be triggered by use rather than abuse. When there is sufficient psychiatric stability to sustain considerable alcohol or other drug use, these individuals often do not have enough social or interpersonal support to effectively interrupt early drug use or to support an abstinent life style. Treatment therefore must address the development of sufficient social support to foster abstinence without overpowering them with an intolerable level of intimate contact with others. They may well thrive in Twelve Step Meetings if their behavior is socially appropriate enough to be accepted in the self-help community. If not, they may need Dual Recovery Anonymous meetings or AA/NA meetings attached to community mental health centers where there is often greater tolerance for unusual behavior or disquieting personal appearance.
Psychoeducation is vital to treatment, not only because it is an effective tool in substance abuse treatment but also because it can be both received and processed at an intellectual level. Interventions aimed at insight or affective expression may bewilder or threaten clients with SPD. They can most readily understand and accept information presented to them without intensity, pressure, or emotionally laden content. These individuals will withdraw from conflict and contentious interaction but are able to utilize concepts that can then facilitate attitudinal change. Motivational interviewing techniques addressing consequences of alcohol and drug use can be effective in providing these clients with the information they need to consider the possible benefits of abstinence.
Individuals with SPD will not prosper in confrontational treatment. They are effective in withdrawing from uncomfortable situations without needing to physically escape. They will not receive or profit from any approach that assumes greater interpersonal strength than they have. Similarly, abstinence cannot be a prerequisite for treatment. Based upon personality dynamics in the SPD, abstinence must be a goal that comes to make sense to them cognitively if it is to be achieved without coercion.
If individuals with SPD are sent to jail, they will be easy prey and will need protection from the general population. They do not pick up interpersonal cues well enough nor are they interpersonally dominant enough to avoid victimization by more aggressive inmates. In a setting of such serious threat, opportunities for substance abuse or dual diagnosis treatment may be well received -- particularly if they involve separation from dangerous others. Similarly, in either inpatient or outpatient dual diagnosis treatment settings, whether in a substance abuse or mental health facility, individuals with SPD may need some protection from other more predatory and exploitative clients. This is not necessarily easy to achieve as SPDs may not welcome the protective effort of staff. The attempt is worthwhile as it is in these settings that individuals with SPD can discover, experiment with, or learn to obtain drugs with which they had no previous familiarity.
Sharon C. Ekleberry, 2000