Cluster A: Schizoid Personality Disorder

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29 March, 2000

Cluster A: SCHIZOID PERSONALITY DISORDER (SPD)

Mental Health Issues Treatment Issues SPD & Addiction:
Dual Diagnosis Treatment Issues

Essential Feature: A pattern of detachment from social relationships and a restricted range of emotional expression (DSM-IV™, 1994).
Self Image: SPDs view themselves as loners who prize independence, solitude, and mobility (Beck). In treatment, SPDs describe feeling that life is passing them by; they feel like they are observing life at a distance (Siever).
View of Others: SPDs fear engulfment and preserve a sense of safety by maintaining distance from others. Abandonment is a lesser evil than engulfment (McWilliams). SPDs view others as intrusive (Beck).
Relationships: The hallmark of SPD is social isolation (Siever). SPDs are not responsive to the feelings of others; their social detachment is preferred and comfortable (Millon).
Authority Issues: SPDs will avoid contact with authority; they are indifferent to either praise or criticism (DSM IV™, 1994).
Behavior: SPDs appear colorless, shy, and indifferent to others (Millon); they seem quiet, serious, and eccentric (Siever). Others view SPDs as dull, uninteresting, and humorless; they are often ignored (Beck).
Affective Issues: Impoverished affect; the inner world of SPDs lacks intensity (Millon). SPDs do not particularly struggle with shame or guilt but they are quite anxious about basic safety (McWilliams).
Defensive Structure: The external world seems full of threats against security and individuality; SPDs tend to withdraw and seek satisfaction in fantasy. It is common for SPDs to wonder how other people can lie to themselves so effortlessly when the harsh facts of life are so clearly evident. Other people do not see what they see (McWilliams).
The SPD Coming Into Treatment: No Cluster A personality disorder is particularly inclined to seek treatment. They are often forced into therapy by family or the legal system. These individuals are not psychologically resilient and will have severe difficulty in jail. SPDs are often the society's quiet misfits. Odd, distant, and unsocialized, they can spend a lifetime in single rooms in interpersonal isolation.
Medication Issues: SPD appears to characterize the negative symptoms of schizophrenia, e.g. anhedonia, little affect, low energy. These symptoms are potentially responsive to the new antipsychotic medications such as risperdal. Use of antidepressants are suggested for anhedonia and social discomfort (Joseph). Use of medication should be considered with caution. Clients with SPD are not necessarily distressed by their symptoms.
Treatment Provider Guidelines: The clinician must respect the SPDs need for a safe distance and his/her fear of engulfment. Early in treatment, the SPD may feel lost and tongue-tied. The treatment provider must neither intrude nor fall into counter-detachment. Also, the treatment provider must convey understanding of the internal experience of the SPD; their limited communication must be sufficient for a therapeutic connection. Even high functioning SPDs worry that they are aberrant and incomprehensible. Be alert for possible psychotic processes; assess for hallucinations, delusions, and a thought disorder (McWilliams).
Countertransference Issues: SPDs are unable to make interaction rewarding to the service provider, i.e., there is a general lack of responsivity, a frustrating incapacity to relate, and a general and pervasive lack of empathy. It may become increasing easy to overlook or ignore these individuals. Most treatment providers are slightly depressive and their fear of abandonment is greater than their fear of engulfment; they naturally try to move close to the people they wish to help (McWilliams).
Treatment Techniques: Rule out a psychotic disorder. Treatment is often educational in design and aimed at teaching social appropriateness, social customs and manners, and social comfort (Stone). Interventions may include exploring self-concept and a sense of where these individuals belong in the world (Dorr).
Treatment Goals: Treatment should address, realistically, SPDs capacity for becoming more at ease with others. Treatment can provide psychoeducation about what is socially appropriate (Stone) and should promote effective social adjustment (Livesley).
Incidence of Co-Occurring SA Disorders: Cluster A represents the lowest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, 1990).
SPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders. SPDs may have trouble accessing drugs.
Overall, marijuana may be the most ego syntonic drug for SPDs. It allows a detached state of fantasy and distance from others, provides a richer internal experience than the SPD can normally create, and reduces the feeling of failing to participate in life.
Alcohol, readily available and safe to obtain, is another obvious drug of choice for these individuals. Some will use both alcohol and marijuana and see little point in giving up either. They are not likely to use marijuana or alcohol for social disinhibition; 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.
Dual Diagnosis Treatment: If drug use is ego-syntonic and augments the defenses already in place, treatment will not be welcome. If a relationship with a drug has been established, these individuals will have an ongoing inclination to value attachment to things (drugs) over people. The development of constructive, positive relationships to counteract addiction will be extraordinarily difficult to achieve.
SPDs will not prosper with direct confrontation. Abstinence must be a goal of treatment. Use should not result in termination from services.

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Cluster A: SCHIZOID PERSONALITY DISORDER (SPD)
Mental Health Issues	Treatment Issues	SPD & Addiction: Dual Diagnosis Treatment Issues
Essential Feature: A pattern of detachment from social relationships and a restricted range of emotional expression (DSM-IV™, 1994). Self Image: SPDs view themselves as loners who prize independence, solitude, and mobility (Beck). In treatment, SPDs describe feeling that life is passing them by; they feel like they are observing life at a distance (Siever). View of Others: SPDs fear engulfment and preserve a sense of safety by maintaining distance from others. Abandonment is a lesser evil than engulfment (McWilliams). SPDs view others as intrusive (Beck). Relationships: The hallmark of SPD is social isolation (Siever). SPDs are not responsive to the feelings of others; their social detachment is preferred and comfortable (Millon). Authority Issues: SPDs will avoid contact with authority; they are indifferent to either praise or criticism (DSM IV™, 1994). Behavior: SPDs appear colorless, shy, and indifferent to others (Millon); they seem quiet, serious, and eccentric (Siever). Others view SPDs as dull, uninteresting, and humorless; they are often ignored (Beck). Affective Issues: Impoverished affect; the inner world of SPDs lacks intensity (Millon). SPDs do not particularly struggle with shame or guilt but they are quite anxious about basic safety (McWilliams). Defensive Structure: The external world seems full of threats against security and individuality; SPDs tend to withdraw and seek satisfaction in fantasy. It is common for SPDs to wonder how other people can lie to themselves so effortlessly when the harsh facts of life are so clearly evident. Other people do not see what they see (McWilliams).	The SPD Coming Into Treatment: No Cluster A personality disorder is particularly inclined to seek treatment. They are often forced into therapy by family or the legal system. These individuals are not psychologically resilient and will have severe difficulty in jail. SPDs are often the society's quiet misfits. Odd, distant, and unsocialized, they can spend a lifetime in single rooms in interpersonal isolation. Medication Issues: SPD appears to characterize the negative symptoms of schizophrenia, e.g. anhedonia, little affect, low energy. These symptoms are potentially responsive to the new antipsychotic medications such as risperdal. Use of antidepressants are suggested for anhedonia and social discomfort (Joseph). Use of medication should be considered with caution. Clients with SPD are not necessarily distressed by their symptoms. Treatment Provider Guidelines: The clinician must respect the SPDs need for a safe distance and his/her fear of engulfment. Early in treatment, the SPD may feel lost and tongue-tied. The treatment provider must neither intrude nor fall into counter-detachment. Also, the treatment provider must convey understanding of the internal experience of the SPD; their limited communication must be sufficient for a therapeutic connection. Even high functioning SPDs worry that they are aberrant and incomprehensible. Be alert for possible psychotic processes; assess for hallucinations, delusions, and a thought disorder (McWilliams). Countertransference Issues: SPDs are unable to make interaction rewarding to the service provider, i.e., there is a general lack of responsivity, a frustrating incapacity to relate, and a general and pervasive lack of empathy. It may become increasing easy to overlook or ignore these individuals. Most treatment providers are slightly depressive and their fear of abandonment is greater than their fear of engulfment; they naturally try to move close to the people they wish to help (McWilliams). Treatment Techniques: Rule out a psychotic disorder. Treatment is often educational in design and aimed at teaching social appropriateness, social customs and manners, and social comfort (Stone). Interventions may include exploring self-concept and a sense of where these individuals belong in the world (Dorr). Treatment Goals: Treatment should address, realistically, SPDs capacity for becoming more at ease with others. Treatment can provide psychoeducation about what is socially appropriate (Stone) and should promote effective social adjustment (Livesley).	Incidence of Co-Occurring SA Disorders: Cluster A represents the lowest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, 1990). SPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders. SPDs may have trouble accessing drugs. Overall, marijuana may be the most ego syntonic drug for SPDs. It allows a detached state of fantasy and distance from others, provides a richer internal experience than the SPD can normally create, and reduces the feeling of failing to participate in life. Alcohol, readily available and safe to obtain, is another obvious drug of choice for these individuals. Some will use both alcohol and marijuana and see little point in giving up either. They are not likely to use marijuana or alcohol for social disinhibition; 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. Dual Diagnosis Treatment: If drug use is ego-syntonic and augments the defenses already in place, treatment will not be welcome. If a relationship with a drug has been established, these individuals will have an ongoing inclination to value attachment to things (drugs) over people. The development of constructive, positive relationships to counteract addiction will be extraordinarily difficult to achieve. SPDs will not prosper with direct confrontation. Abstinence must be a goal of treatment. Use should not result in termination from services.