Schizoid personality disorder

Causes

Environmental

Perfectionist and hypercritical parenting or cold, neglectful, and distant parenting contribute to the onset of SzPD. For a person with SzPD, their parents likely were intolerant of their emotional experiences. They may have been forced to repress and compartmentalize their emotions, possibly resulting in the onset of difficulties expressing and processing emotional experiences. These difficulties lead to the child feeling rejected and developing the belief that the only safe environment is one where they are alone and inexpressive. People with SzPD may also have internalized the belief that their emotions are dangerous to themselves and others due to the negative responses received from others. In their status of isolation and emotional bluntness they can be self-sufficient and safe. Childhood trauma can also contribute to feelings of emptiness in adulthood. Alcoholism in parents is associated with a heightened risk of developing SzPD.

Genetic

Sula Wolff, who did extensive research and clinical work with children and teenagers with schizoid symptoms, stated that "schizoid personality has a constitutional, probably genetic, basis." Research on heritability and this disorder is lacking. Twin studies with SzPD traits (e.g., low sociability and low warmth) suggest that these traits are inherited. Besides this indirect evidence, the direct heritability estimates of SzPD range from 50% to 59%. Earlier, less methodologically rigorous research had found the heritability rate to be 29%.

The pathophysiology of SzPD remains unclear. Genetic relationships with people who have schizophrenia spectrum disorders increase the risk of developing schizoid personality disorder. People with SzPD can have a history of schizotypy before developing the disorder. SzPD symptoms can be premorbid to schizophrenia.

Neurological

Prenatal malnutrition, premature birth, and low birth weight are all thought to play a role in the development of SzPD. SzPD is associated with reduced serotonergic and dopaminergic pathways in areas such as the frontal lobe, amygdala, and striatum. Traumatic brain injuries to the frontal lobe may also contribute to the onset of SzPD as that area of the brain controls areas such as emotion and socialization. Deficits in the right hemisphere of the brain may also be associated with SzPD. Lower levels of low-density lipoprotein cholesterol may be correlated with the presence of schizoid traits in women. Excess indices in the left hemisphere may also be related to SzPD.

Diagnosis

Classification

Classification of personality disorders differs significantly between the two most prominent frameworks for classification of mental disorders, namely: the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, the most recent editions of which are the DSM-5-TR and ICD-11, respectively. While personality disorders, including SzPD, are diagnosed as separate entities in the DSM-5; in the ICD-11 classification of personality disorders, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology. There is also a hybrid model, called the Alternative DSM-5 model for personality disorders (AMPD), which defines personality disorder diagnoses through disorder-specific combinations of pathological traits and areas of overall impairment.

The DSM-5-TR defines SzPD as "a pattern of detachment from social relationships and a restricted range of emotional expression" in the section II chapter on personality disorders. The diagnosis is based on the subject exhibiting at least four out of seven specified characteristics of SzPD (criterion A); furthermore, the DSM definition requires that the symptoms are present independently of any psychotic disorder or autism spectrum disorder, and they cannot stem from another medical condition (criterion B). These criteria have been retained from the DSM-IV-TR.

While not listed as its own diagnostic entity in the AMPD, what is conceptualized as SzPD can instead be diagnosed as personality disorder – trait specified, which is a dimensional diagnosis that is constructed from the individual expression of personality disorder, as manifested in both a general impairment in personality functioning along with at least one pathological personality trait.

The ICD-11 classification of personality disorders has replaced the categorical classification of personality disorders in the ICD-10 with a dimensional model containing a unified personality disorder (6D10) with severity specifiers, along with specifiers for prominent personality traits or patterns (6D11). Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder, while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested. Of these, the detachment trait domain has been found to be "substantially consistent" with Schizoid PD as described by the ICD-10, which was a standalone diagnostic category with the code (F60.1).

Differential diagnosis

Depression

People who have SzPD may also have clinical depression. However, this is not always the case. Unlike people with depression, persons with SzPD generally do not consider themselves inferior to others. They may recognize instead that they are "different".

Autism spectrum disorder

Because of overlapping traits, autism spectrum disorder (ASD) may be difficult to differentiate from the schizoid personality type. Shared characteristics include social detachment, limited emotional expression, and a preference for solitary activities.

Several factors discussed in the literature may contribute to this overlap, such as autistic individuals demonstrating increased rates of schizoid personality traits and diagnoses compared with the general population. Researchers have also reported genetic correlations between autism and schizophrenia-spectrum conditions, suggesting partial shared biological risk factors across related psychiatric traits.

The relationship between autism and schizoid traits also has historical roots in early psychiatric terminology. The term autism was originally introduced by Bleuler to describe withdrawal into inner fantasy and detachment from external reality in schizophrenia. During the mid-20th century, socially withdrawn children were often diagnosed with childhood schizophrenia before autism became recognized as a distinct developmental condition following the work of Kanner L (1943). "Autistic disturbances of affective contact". Nervous Child. 2: 217–250..

Later, Wolff S (1995). Loners: The Life Path of Unusual Children. Routledge. used the term schizoid personality in childhood to describe socially detached children with unusual behaviors and interests. Subsequent research suggested that many such cases would likely meet criteria for autism spectrum disorder under modern diagnostic frameworks.

Despite these similarities, autism differs from schizoid personality disorder in several key ways. Autism is classified as a neurodevelopmental condition that emerges in early childhood and is characterized by persistent differences in social communication as well as restricted or repetitive behaviors and sensory sensitivities. By contrast, schizoid personality disorder is defined primarily by a pervasive pattern of social detachment and restricted emotional expression that begins by early adulthood. The motivations underlying similar outward behaviors may therefore differ; individuals with schizoid personality disorder may prefer solitude, whereas autistic individuals may desire relationships but experience difficulty maintaining them.

Personality change due to another medical condition

Traits of SzPD can appear due to damage to the central nervous system.

Substance use disorders

Traits of SzPD can appear due to substance abuse.

Other personality disorders and personality traits

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 preferring ideas over people and displaying "intellectual hypertrophy", with a corresponding lack of rootedness in bodily existence. There are, nonetheless, important differences. A schizoid person hides their need for dependency and is rather fatalistic, passive, cynical, overtly bland or vaguely mysterious. A narcissist is, in contrast, ambitious and competitive and exploits others for their dependency needs.

There are also parallels between SzPD 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.

While people affected with avoidant personality disorder (AvPD) avoid social interactions due to anxiety or feelings of incompetence, those with SzPD do so because they are genuinely indifferent to social relationships. A 1989 study, 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 SzPD and AvPD (see schizoid avoidant behavior). Several sources have confirmed the synonymy of SzPD and avoidant attachment style. However, the distinction should be made that individuals with SzPD 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.

Guntrip criteria

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

• Introversion
• Withdrawnness
• Narcissism
• Self-sufficiency
• A sense of superiority
• Loss of affect
• Loneliness
• Depersonalization
• Regression

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

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 they often do not perceive cues that trigger affective responses, they experience fewer emotional reactions.

For Millon, SzPD 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 SzPD 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.

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

Akhtar's profile

American psychoanalyst Salman Akhtar provided a comprehensive phenomenological profile of SzPD 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 intended to denote seemingly contradictory aspects that may both simultaneously be present in an individual. These designations do not necessarily imply their conscious or unconscious existence. The covert characteristics are by definition difficult to discern and not immediately apparent. Additionally, the lack of data on the frequency of many of the features makes their relative diagnostic weight difficult to distinguish at this time. However, Akhtar states that his profile has several advantages over the DSM in terms of maintaining historical continuity of the use of the word schizoid, valuing depth and complexity over descriptive oversimplification and helping provide a more meaningful differential diagnosis of SzPD from other personality disorders.

Treatment

Medication

There are no medications used specifically for schizoid personality disorder. Certain medications may reduce the symptoms of SzPD and treat co-occurring mental disorders. Since the symptoms of SzPD mirror the negative symptoms of schizophrenia, antipsychotics have been suggested as a potentially effective medication for SzPD. Originally, low doses of atypical antipsychotics like risperidone or olanzapine were used to alleviate social deficits and blunted affect. SSRIs, anxiolytics, bupropion, modafinil, benzodiazepines, and biofeedback may also be effective treatments.

Psychotherapy

Treatment for this disorder uses a combination of cognitive-behavioral therapy and psychodynamic psychotherapy. Recently other integrated treatments have been tested, albeit on very limited samples, such as evolutionary systems therapy. These techniques can be used to help patients identify their defense mechanisms and change them. Therapists attempt to establish healthy relationships with their clients, helping to combat their internalized belief that relationships are harmful and unhelpful. Relationships with a therapist can seem terrifying and intrusive to a person with SzPD. They may feel as if they need to alter or hide their feelings to meet the therapist's demands or expectations. To combat this, therapists try to gradually increase their patient's emotional expression. Expressing too much too early can lead to their ending therapy. Treatment must be person centered, with clients feeling understood and well regarded. This can allow them to connect with and understand their emotions. When people with SzPD do not have their feelings validated, this will confirm their belief that expressing themselves is dangerous. Therapists attempt to avoid intruding on their patients' lives or restricting their freedoms, so as to prevent them from feeling as if therapy is intolerable. Because of this, therapy is usually less structured than treatment programs for other disorders. Patients may benefit from long-term treatment lasting several years. Inpatient care may be effective for treating SzPD and other Cluster A disorders.

Prognosis

Traits of schizoid personality disorder appear in childhood and adolescence. Children with this disorder usually have poor relationships with others, social anxiety, internal fantasies, strange behavior, and hyperactivity. These behaviors can result in teasing and bullying at the hands of others. It is common for people with SzPD to have had major depressive disorder in childhood. SzPD is associated with lower levels of achievement, a compromised quality of life, and a worse outcome of treatment. Treatment for this disorder is under-studied and poorly understood. There is no widely accepted and approved psychotherapy or medication for this disorder. It is one of the most poorly researched psychiatric disorders. Professionals may misunderstand the disorder and the client, potentially reinforcing a feeling of failure and negatively impacting their willingness to continue to commit to treatment. Clinicians tend to worry that they are incapable of properly treating the patient. It is rare for someone with this disorder to voluntarily seek treatment without a comorbid disorder or pressure from family or friends. In treatment, people with SzPD are usually disinterested and often minimize symptoms. Patients with SzPD may fear losing their independence through therapy. Many schizoid individuals will avoid making the efforts required to establish a proper relationship with the therapist. It can be difficult for them to open up or discuss their emotions in therapy. Although people with this disorder can still improve, it is unlikely they will ever experience significant joy through social interaction.

Epidemiology

It remains unclear how prevalent the disorder is. It may be present in anywhere from 0.9% to 1.3% and possibly 3.1% of the population. Gender differences in this disorder are also unclear. Some research has suggested that this disorder may occur more frequently in men than women. SzPD is uncommon in clinical settings (about 2.2%) and occurs more commonly in males. It is rare compared with other personality disorders. 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." A 2008 study assessing personality and mood disorder prevalence among homeless people at New York City drop-in centers reported an SzPD rate of 65% among this sample. The study did not assess homeless people who did not show up at drop-in centers, and the rates of most other personality and mood disorders within the drop-in centers were lower than that of SzPD. The authors noted the limitations of the study, including the higher male-to-female ratio in the sample and the absence of subjects outside the support system or receiving other support (e.g., shelters) as well as the absence of subjects in geographical settings outside New York City, a large city often considered a magnet for disenfranchised people.

Comorbid disorders

• Agoraphobia
• Avoidant personality disorder
• Borderline personality disorder
• Post-traumatic stress disorder
• Major depressive disorder
• Generalized anxiety disorder
• Panic disorder
• Paranoid personality disorder
• Social anxiety disorder
• Schizotypal personality disorder
• Obsessive–compulsive disorder

Autism spectrum disorder

Several studies have reported an overlap or comorbidity with autism spectrum disorder and Asperger syndrome. Asperger syndrome had traditionally been called "schizoid disorder of childhood", and Eugen Bleuler coined both the terms "autism" and "schizoid" to describe withdrawal to an internal fantasy, against which any influence from outside becomes an intolerable disturbance. In a 2012 study of a sample of 54 young adults with Asperger syndrome, it was found that 26% of them also met the criteria for SzPD, the highest comorbidity out of any personality disorder in the sample (the other comorbidities were 19% for obsessive–compulsive personality disorder, 13% for avoidant personality disorder and one female with schizotypal personality disorder). Additionally, twice as many men with Asperger syndrome met the criteria for SzPD than women. While 41% of the whole sample were unemployed with no occupation, this rose to 62% for the Asperger's and SzPD comorbid group. Tantam suggested that Asperger syndrome may confer an increased risk of developing SzPD. A 2019 study found that 54% of a group of males aged 11 to 25 with Asperger syndrome showed significant SzPD traits, with 6% meeting full diagnostic criteria for SzPD, compared to 0% of a control group.

In the 2012 study, it was noted that the DSM may complicate diagnosis by requiring the exclusion of a pervasive developmental disorder (PDD) before establishing a diagnosis of SzPD. The study found that social interaction impairments, stereotyped behaviors, and specific interests were more severe in the individuals with Asperger syndrome also fulfilling SzPD criteria, against the notion that social interaction skills are unimpaired in SzPD. The authors believe that a substantial subgroup of people with autism spectrum disorder or PDD have clear "schizoid traits" and correspond largely to the "loners" in Lorna Wing's classification The autism spectrum (Lancet 1997), described by Sula Wolff. The authors of the 2019 study hypothesized that it is extremely likely that historic cohorts of adults diagnosed with SzPD either also had childhood-onset autistic syndromes or were misdiagnosed. They stressed that further research to clarify overlap and distinctions between these two syndromes was strongly warranted, especially given that high-functioning autism spectrum disorders are now recognized in around 1% of the population.

History

The term schizoid is widely thought to be coined in 1908 by Eugen Bleuler to describe a human tendency to direct attention toward one's inner life and away from the external world. In the fourth edition of his textbook, Bleuler describes these personalities as "comfortably dull and at the same time sensitive, people who in a narrow manner pursue vague purposes". This description echoes Bleuler's 1911 description of a personality pathology functionally related to schizophrenia, as described in his seminal work, Dementia Praecox or the Group of Schizophrenias.

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

It has been argued that descriptive tradition began in 1925 with the description of observable schizoid behaviors by Kretschmer. However, various theorist prior to Kretschmer described observable behaviours characteristic of schizoid personality as conceptualized by the early descriptive tradition, including Karl Kahlbaum in 1890, Emil Kraepelin in 1902 and 1919, Bleuler in 1911 and 1920, and Adolf Meyer in 1906, 1908, and 1912. Nevertheless, Kretschmer's seminal work involving schizoid personality, Physique and Character, was highly influential and constituted the most robust description of observable schizoid behaviours, and was notably descriptive for setting forth classifications based on these observable behaviours. However, it would be in error to claim that Kretschmer was operating solely from the descriptive tradition.

In Physique and Character, and under a specific influence of the Bleuler school, which Kretschmer failed to properly credit, the schizoid is organized into three characteristic groups:

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 are thought to be precursors of the DSM-III subcategorization of the schizoid character into three distinct personality disorders: schizotypal, avoidant and schizoid. However, Kretschmer's divisions were dimensional, and Kretschmer himself 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 schizoid people 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. Though Krestchmer notes that as a schizoid individual ages, she tends to become more anaclitic. Moreover, as per Bleuler's various works on the fundamental features of schizophrenia, this "split" in temperamental characteristics was thought by Kretschmer to be a fundamental, defining feature of schizoid personality.

The second path to schizoid personality, that of dynamic psychiatry, began in 1924 with the influence of observations by descriptive psychiatrist Eugen Bleuler, who observed that the schizoid person and schizoid pathology were not things to be set apart, though Bleuler argued for this earlier, on schizophrenic diseases more generally, in Dementia Praecox or the Group of Schizophrenias. In addition, Bleuler himself was strongly influenced by earlier dynamic theorists, such as Sigmund Freud on the "day-dreamer" in 1908 and on secondary narcissism in 1914, and Carl Jung on introversion in 1917. Later, under the influence of Bleuler and others, Ronald Fairbairn's seminal work on the schizoid condition, which was divided into schizophrenia proper; the schizoid personality type; the schizoid character; and transient schizoid episodes, and from which most of what is known today about psychodynamic 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.

Following Fairbairn's derivation of SzPD from a combination of derealization, depersonalization, splitting, the oral stage of making all subjects into partial objects, and intellectualization; 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).

The DSM-I had the diagnosis of schizoid personality, which was defined by avoidance of close relationships, inability to express aggressive feelings, and autistic thinking (thinking which is preoccupied with one's inner experience). The DSM-II later updated the definition to include daydreaming, detachment from reality, and sensitivity. It was incorporated into the DSM-III as schizoid personality disorder to describe difficulties forming meaningful social relationships and a persistent pattern of disconnection and apathy. The diagnosis of SzPD made it to the DSM-IV and DSM-V.

Controversy

The original concept of the schizoid character developed by Ernst Kretschmer in the 1920s comprised a mix of avoidant, schizotypal, and schizoid traits. It was not until 1980 and the work of Theodore Millon that led to splitting this concept into three personality disorders (now schizoid, schizotypal, and avoidant). This caused debate about whether this was accurate or if these traits were different expressions of a single personality disorder. It has also been argued due to the poor consistency and efficiency of diagnosis due to overlapping traits that SzPD should be removed altogether from the DSM. A 2012 article suggested that two different disorders may better represent SzPD: one affect-constricted disorder (belonging to schizotypal PD) and a seclusive disorder (belonging to avoidant PD). They called for the replacement of the SzPD category from future editions of the DSM with a dimensional model which would allow for the description of schizoid traits on an individual basis.

Some critics such as Nancy McWilliams of Rutgers University and Panagiotis Parpottas of European University Cyprus argue that the definition of SzPD is flawed due to cultural bias and that it does not constitute a mental disorder but simply an avoidant attachment style requiring a 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.

Similarly, John Oldham, using a dimensional approach, thinks that most people with schizoid character features do not have a full-blown personality disorder. Impairment is mandatory for any behavior to be diagnosed as a personality disorder.