Schizoid personality disorder

People with SzPD tend to be happiest in relationships without the expectation of phatic or social niceties. It is not necessarily people they want to avoid, but negative or positive emotional expectations, emotional intimacy and self-disclosure.[26] Therefore, it is possible for individuals with SzPD to form relationships around intellectual, physical, familial, occupational or recreational activities, as long as there is no need for emotional intimacy. Donald Winnicott explains that this is because 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.[27] In general, friendship among schizoids is usually limited to one person, often also schizoid, forming what has been called a union of two eccentrics; "within it – the ecstatic cult of personality, outside it – everything is sharply rejected and despised".[28]

Ronald Fairbairn notes that schizoids can fear that in a relationship, their needs will weaken and exhaust their partner, so they feel forced to disown them and move to satisfy solely the needs of the partner. The net result of this is a loss of dignity and sense of self within any relationship they enter, eventually leading to intolerable frustration and friction. Appel notes that these fears result in the schizoid's negativism, stubbornness and reluctance to love. Thus, a central conflict of the schizoid is between an immense longing for relationships but a deep anxiety and avoidance of relationships, manifested by choosing to abandon others as the "lesser evil".[29]^: 100 A person with SzPD may feel suffocated when their personal space is violated and take actions to avoid this feeling.

Many schizoid individuals display an engaging, interactive personality, contradicting the observable characteristic emphasized by the DSM-5 and ICD-10 definitions of the schizoid personality. Guntrip (using ideas of Klein, Fairbairn and Winnicott) classifies these individuals as "secret schizoids", who behave with socially available, interested, engaged and involved interaction yet remain emotionally withdrawn and sequestered within the safety of the internal world.[19]^: 17[30] Klein distinguishes between a "classic" SzPD and a "secret" SzPD, which occur "just as often" as each other. Klein cautions one should not misidentify the schizoid person as a result of the patient's defensive, compensatory interaction with the external world. He suggests one ask the person what their subjective experience is, to detect the presence of the schizoid refusal of emotional intimacy and preference for objective fact.[19]

Frequently, a schizoid individual's social functioning improves, sometimes dramatically, when the individual knows they are an anonymous participant in a real-time conversation or correspondence, e.g. in an online chatroom or message board. It is often the case the individual's online correspondent will report nothing amiss in the individual's engagement and affect. A 2013 study looking at personality disorders and Internet use found that being online more hours per day predicted signs of SzPD. Additionally, SzPD correlated with lower phone call use and fewer Facebook friends.[31]

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 they are "playing a part", their personality is not involved. According to Fairbairn, the person disowns the part they are playing, and the schizoid individual seeks to preserve their personality intact and immune from compromise.[32] The schizoid's false persona is based around what those around them define as normal or good behaviour, as a form of compliance.[29]^: 143 Further references to the secret schizoid come from Masud Khan,[33] Jeffrey Seinfeld[34] and Philip Manfield,[26] who give a description of an SzPD individual who "enjoys" public speaking engagements but experiences great difficulty in the breaks when audience members would attempt to engage him emotionally. These references expose the problems in relying on outer observable behavior for assessing the presence of personality disorders in certain individuals.

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.[19]^: 64 The related schizotypal personality disorder and schizophrenia are reported to have ties to creative thinking, and it is speculated that the internal fantasy aspect of SzPD may also be reflective of this thinking.[35][36][37]

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.[19] 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."[19] This aspect of schizoid pathology has been generously elaborated in works by R. D. Laing,[22] Donald Winnicott[38] and Ralph Klein.[19]^: 64

People with SzPD are sometimes sexually apathetic, though they do not typically experience 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 SzPD. The schizoid is often labelled asexual or presents with "a lack of sexual identity". Kernberg states that this apparent lack of a sexuality does not represent a lack of sexual definition but rather a combination of several strong fixations to cope with the same conflicts.[29]^: 125 Significantly broadening this picture are notable exceptions of SzPD individuals who engage in occasional or even frequent sexual activities with others.[39]

Sex often causes individuals with SzPD to feel that their personal space is being violated, and they commonly feel that masturbation or sexual abstinence is preferable to the emotional closeness that they must tolerate when having sex.[39] Individuals with SzPD have long been noted to have an increased rate of unconventional sexual tendencies, though if present, these are rarely acted upon. People with SzPD are often able to pursue any fantasies with content on the Internet while remaining completely unengaged with the outside world.[29]^: 127

Salman Akhtar provided a comprehensive phenomenological profile of SzPD in which classic and contemporary descriptive views are synthesized with psychoanalytic observations. 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 to provide a more meaningful differential diagnosis of SzPD from other personality disorders.[13]

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, intended to denote seemingly contradictory aspects that may simultaneously be present in an individual.[13] These designations do not necessarily imply their conscious or unconscious existence. The covert characteristics are not immediately apparent by definition and difficult to discern. Additionally, the lack of data on the frequency of many of the features makes their relative diagnostic weight difficult to distinguish at this time.

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.[23][40]

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.[3]

He identified four subtypes of SzPD. Any individual schizoid may exhibit none or one of the following:[3][41]

The Diagnostic and Statistical Manual of Mental Disorders is a widely used manual for diagnosing mental disorders. DSM-5 includes SzPD with the same criteria as in DSM-IV. In the DSM-5, SzPD is described as 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 at least four of the following:[5]

1. Neither desires nor enjoys close relationships, including being part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another person.
4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.

According to the DSM, those with SzPD may often be unable to, or will rarely express aggressiveness or hostility, even when provoked directly. These individuals can seem vague or drifting about their goals and their lives may appear directionless. Others view them as indecisive in their actions, self-absorbed, absent-minded and detached from their surroundings. Excessive daydreaming is often present. In cases with severe defects in the capacity to form social relationships, dating and marriage may not be possible.[18]

The Classification of Mental and Behavioural Disorders of ICD-10 lists SzPD under (F60.1).[1]

The general criteria of personality disorder (F60) should be met first. In addition, at least four of the following criteria must be present:

• Few, if any, activities provide pleasure.
• Displays emotional coldness, detachment, or flattened affectivity.
• Limited capacity to express warm, tender feelings for others as well as anger.
• Appears indifferent to either praise or criticism from others.
• Little interest in having sexual experiences with another person (taking into account age).
• Almost always chooses solitary activities.
• Excessive preoccupation with fantasy and introspection.
• Neither desires, nor has, any close friends or confiding relationships (or only one).
• Marked insensitivity to prevailing social norms and conventions; if these are not followed, this is unintentional.

Ralph Klein, Clinical Director of the Masterson Institute, delineates the following nine characteristics of the schizoid personality as described by Harry Guntrip:[19]^: 13–23

• Introversion
• Withdrawnness
• Narcissism
• Self-sufficiency
• 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.[19]

While SzPD shares several symptoms with other mental disorders, there are some important differentiating features.

SzPD is often found to be comorbid with several disorders or pathologies. Persons with SzPD may meet criteria for an additional personality disorder, most often avoidant personality disorder, schizotypal personality disorder or paranoid personality disorder.[24] Alexithymia (the inability to identify and describe emotions) is often present in SzPD.[59] Sharon Ekleberry suggests that some people with schizoid personality features may occasionally experience instances of brief reactive psychosis when under stress.[24]

Very little data exists for rates of substance use disorder among people with SzPD, but existing studies suggest they are less likely to have substance abuse problems than the general population. One study found that significantly fewer boys with SzPD had alcohol problems than a control group of non-schizoids.[60] Another study evaluating personality disorder profiles in substance abusers found that substance abusers who showed schizoid symptoms were more likely to abuse one substance rather than many, in contrast to other personality disorders such as borderline, antisocial or histrionic, which were more likely to abuse many.[61]

American psychotherapist Sharon Ekleberry states that the impoverished social connections experienced by people with SzPD limit their exposure to the drug culture and that they have limited inclination to learn how to do narcotics. Describing them as "highly resistant to influence", she additionally states that even if they could access illegal drugs, they would be disinclined to use them in public or social settings, and because they would be more likely to use alcohol or cannabis alone than for social disinhibition, they would not be particularly susceptible to negative consequences in early use.[24]

Suicide may be a running theme for schizoid individuals, in part due to the knowledge of the large-scale ostracism that would result if their idiosyncratic views were revealed and their experience that most, if not all people, are unrelatable or have polar opposite reactions to them on societally sensitive issues, though they are not likely to actually attempt it. 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. Often among people with SzPD, there is a rationally grounded and reasoned position on why they want to die, and this "suicidal construct" takes a stable position in the mind.

The characteristics of the premorbidities (schizothymia, autism, anhedonia) also affected suicidal behaviour. Suicide attempts were always genuine in nature, well-planned, and it was only by chance that patients survived (usually the fatal outcome was prevented by the sudden appearance of others). They denied the existence of suicidal experiences earlier, but argued that in the current circumstances, suicide seemed to them the most appropriate way out. Important in all these cases was the absence of any significant anti-suicidal factors (most were found in a situation of relative social isolation; there were no professional and personal interests). The high ability to introspect in these cases only increased the isolation from reality, rendering the choice of suicide more reasonable.[62]

A mini-review indicates that SzPD or schizoid traits are a major risk factor for both suicide attempts and suicide,[21] but schizoids tend to hide their suicidal thoughts and intentions. Demonstrative suicides or suicide blackmail, as seen in cluster B personality disorders such as borderline, histrionic or antisocial, are extremely rare among schizoid individuals.[62] As in other clinical mental health settings, among suicidal inpatients, individuals with SzPD are not as well-represented as some other groups. A 2011 study on suicidal inpatients at a Moscow hospital found that schizoids were the least common patients, while those with cluster B personality disorders were the most common.[62]

A study which looked at the body mass index (BMI) of a sample of both male adolescents diagnosed with SzPD and those diagnosed with Asperger syndrome found that the BMI of all patients was significantly below normal. Clinical records indicated abnormal eating behaviour by some patients. Some patients would only eat when alone and refused to eat out. Restrictive diets and fears of disease were also found. It was suggested that the anhedonia of SzPD may also cover eating, leading schizoid individuals to not enjoy it. Alternatively, it was suggested that schizoid individuals may not feel hunger as strongly as others or not respond to it, a certain withdrawal "from themselves".[3]

Another study looked at rates of anti-social conduct in boys with either SzPD or Asperger syndrome compared with a control group of non-schizoid individuals and found the incidence of anti-social conduct to be the same in both groups. However, the schizoid boys stole significantly less. Upon follow-up in adulthood, out of a matched group of 19 boys with SzPD and 19 boys without, four of the schizoid boys reported having exclusively internal violent fantasies (concerned with Zulu wars, abattoirs, fascists and communists and a collection of knives, respectively), which were pursued entirely by themselves, while the only non-schizoid subject to report a violent fantasy life shared his with a group of young men (dressing up and riding motorcycles as a self-styled "panzer" group).[60]

An absent parent or socio-economic disadvantage did not seem to affect the risk of anti-social conduct in schizoid individuals as much as it did in non-schizoid individuals. Absent parents and parental socio-economic disadvantage were also less common in the schizoid group.[60]

Several studies have reported an overlap with Asperger syndrome which had traditionally been called "schizoid disorder of childhood".[63][15][16][64] 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.[65] Tantam suggested that Asperger syndrome may confer an increased risk of developing SzPD.[63]

A study from 2012 found that in a sample of 54 young adults with Asperger syndrome, 26% of them also met 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 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.[15] It 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 behaviours 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.[15]

A study from 2019 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.[16] The authors of the study hypothesised that it is extremely likely that historic cohorts of adults diagnosed with SzPD were either misdiagnosed, or they also had childhood-onset autistic syndromes. 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 recognised in around 1% of the population.[66]

No medications are indicated for directly treating SzPD, but certain medications may reduce the symptoms of SzPD and treat co-occurring mental disorders. However, it is not general practice to treat SzPD with medications, other than for the short-term treatment of acute co-occurring axis I conditions such as depression.[17] The substituted amphetamine bupropion may be used to treat anhedonia.[7] Lamotrigine, SSRIs, TCAs, MAOIs and hydroxyzine may help counter social anxiety if it is a concern for people who have SzPD.

The symptoms of SzPD mirror the negative symptoms of schizophrenia, such as anhedonia, blunted affect and low energy. SzPD is thought to be part of the "schizophrenia spectrum" of disorders, thus it may benefit from the medications that treat those disorders[17] such as modafinil.[68] Originally, low doses of atypical antipsychotics like risperidone or olanzapine were used to alleviate social deficits and blunted affect.[7] However, a 2012 review concluded that atypical antipsychotics were ineffective for treating personality disorders.[69]

Despite the relative emotional comfort, psychoanalytic therapy of schizoid individuals takes a long time and causes many difficulties.[70] Schizoids are generally poorly involved in psychotherapy due to difficulties in establishing empathic relations with a psychotherapist and low motivation for treatment.[71]

Supportive psychotherapy is 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 SzPD may also have a perceptual tendency to miss subtle differences in expression. That causes an inability to pick up hints from the environment because social cues from others that might normally provoke an emotional response are not perceived. That in turn limits their own emotional experience.[23] 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.

Besides psychodynamic therapy, cognitive behavioral therapy (CBT) can be used. But because CBT generally begins with identifying the automatic thoughts, one should be aware of the potential hazards that can happen when working with schizoid patients. People with SzPD seem to be distinguished from those with other personality disorders in that they often report having few or no automatic thoughts at all. That poverty of thought may have to do with their apathetic lifestyle. But another possible explanation could be the paucity of emotion many schizoids display, which would influence their thought patterns as well.[23]

Socialization groups may help people with SzPD. Educational strategies in which people who have SzPD 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 SzPD create empathy with the outside world.

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.[19] 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.[22] 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.[19]

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.[19] 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.[19]

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 acknowledgement, affirmation and approval necessary for emotional survival while warding off the effects associated with the abandonment depression.[19]

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."[19] 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."[19]^: 127

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 descriptive psychiatry tradition began in 1925 with the description of observable schizoid behaviors by Ernst Kretschmer. He organized those into three groups of characteristics:[80]

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 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.[80]

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 dynamic psychiatry tradition began in 1924 with observations by Eugen Bleuler,[81] who observed that the schizoid person and schizoid pathology were not things to be set apart.[19]^{: p. 5} 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.
4. An overvaluation of the inner world at the expense of the outer world.[19]^{: p. 9}

Following Fairbairn, the dynamic psychiatry tradition has continued to produce rich explorations on the schizoid character, most notably from writers Nannarello (1953),[39] Laing (1965),[22] Winnicott (1965),[82] Guntrip (1969),[83] Khan (1974),[33] Akhtar (1987),[13] Seinfeld (1991),[34] Manfield (1992)[26] and Klein (1995).[19]

The original concept of the schizoid character developed by Kretschmer in the 1920s comprised an amalgamation of avoidant, schizotypal and schizoid traits. The work of Millon in the 1980s led to this concept being split into three distinct disorders. This caused debate about whether this was accurate or if these traits were different expressions of a single personality disorder.[78]