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Day #130: Schizoid Personality Disorder

Today we will continue our current theme of cluster A personality disorders as we discuss schizoid personality disorder.

Introduction 1

  • Individuals with schizoid personality disorder have a lifelong pattern of social withdrawal and are often perceived as eccentric and reclusive.

  • The adjective "schizoid" was originally coined to describe the prodromal seclusiveness and isolation observed in schizophrenia, however the schizoid personality type was made official in DSM-3 in 1980.

  • They tend to be uncomfortable with human interaction and often display a bland and constricted emotional affect. They have no desire for close relationships and prefer to be alone.

  • Common traits/symptoms may include being -> quiet, reclusive, unsociable, isolated, eccentric, aloof, blunted, disengaged, and distant.

Diagnostic Criteria 2

  • The diagnosis of schizoid PD requires a pervasive pattern of voluntary social detachment and a restricted range of emotional expression in interpersonal settings, beginning by early adulthood, and present in a variety of contexts.

  • ≥ 4 of the following must also be present: Mnemonic "DISTANT"

  • Detached - emotional coldness or flattened affect.

  • Indifference to praise or criticism.

  • Sexuality - little (if any) interest in sexual activity with another person.

  • Tasks / activities - generally chooses solitary activities.

  • Absence of friends or a few close friends or confidants.

  • NOT enjoying or desiring close relationships (including family).

  • Taking pleasure in few activities (if any).

  • Symptoms do not occur exclusively during the course of another mental illness such as schizophrenia, bipolar disorder, depressive disorder with psychotic features, or the effects of another medical condition. If criteria are met prior to the onset of schizophrenia, add "premorbid" as a specifier to the diagnosis.

Epidemiology/Pathogenesis 3, 4

  • Prevalence is estimated to be 3-5% of the general population, however this is difficult to study since those with the disorder rarely seek treatment and it is uncommon in clinical settings.

  • More commonly diagnosed in men than in women, however some sources observe no differences.

  • Relatives of patients with schizophrenia and schizotypal personality disorder show a higher incidence of schizoid personality disorder than control participants.

  • Data regarding etiology of schizoid PD is limited, however it is assumed that genetic heritability significantly contributes (twin studies estimate heritability to be about ~30%), however specific genetic, biochemical, or neurotransmitter-associated causes are speculative. It is unknown which environmental factors, if any, contribute to this disorder.

Clinical Pearls 5

  • Those with schizoid personality disorder rarely seek treatment themselves, however they may be referred to treatment by a family member or an employer.

  • Mental status exam: during a psychiatric examination they may act in a way that is perceived as uncomfortable (rarely tolerate eye contact and often eager for the interview to end), cold, or distant. Their affect may be constricted, aloof, or serious and it can be quite difficult to develop rapport. They may find it challenging to be lighthearted and their efforts at humor may seem "off the mark". Their speech is goal directed, but they are likely to give short answers to questions and to avoid spontaneous conversation. They may appear to be self-absorbed, lost in daydreams, use an odd metaphor, or be fascinated with inanimate objects or metaphysical constructs, however they have a normal capacity to recognize reality and thoughts do not reach the level of delusional thinking.

  • Life history: individuals often choose solitary activities, interests, and careers that allow for little/no social contact (night shift security, laboratory, etc.). They may show no interest in the news, everyday events, or popular culture/fashion. Persons often show little concern for others or interest in intimacy. They may invest a significant amount of emotional energy in nonsocial interests such as mathematics, astronomy, animals, philosophy, etc.

  • Optional personality questionnaires: Personality Assessment Inventory (PAI) and Minnesota Multiphasic Personality Inventory (MMPI).

  • Differential diagnosis: consider and rule out schizophrenia or other psychotic disorders (patients with schizoid PD do not have any fixed delusions or hallucinations). Differentiating schizoid PD and milder forms of autism spectrum disorder (ASD) can be challenging in some cases. ASD may be differentiated by stereotyped behaviors and interests and more severely impaired social interactions. Also consider other personality disorders in the differential diagnosis, particularly other cluster A disorders (paranoid, schizotypal). The cluster A disorders have certain shared features, however paranoid PD exhibit more social engagement and greater tendency to project their feelings onto others and schizotypal PD have more eccentric behavior and magical thinking. The social isolation of schizoid PD can be distinguished from that of avoidant PD, which is attributable to fear of being embarrassed and excessive anticipation of rejection. Unlike with avoidant PD, patients with schizoid PD prefer to be alone. Individuals with obsessive-compulsive PD may also show an apparent social detachment, however this stems from devotion to work and discomfort with emotions rather than a lack of desire and capacity for intimacy.

Treatment 6, 7

  • General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

  • Psychotherapy: Psychotherapy is the treatment of choice for schizoid personality disorder, however little is known about effective psychotherapeutic approaches for this condition. Schizoid PD has been virtually ignored in comparison to other personality disorders, and thus treatments options are limited and insufficiently studied. Cognitive behavioral therapy (CBT) has been advocated for and case studies support its potential effectiveness, however systematic data is lacking. Other approaches that have been used include psychodynamic therapy and social skills training. It may take considerable time to slowly develop trust and rapport with these patients. They will likely find group psychotherapy intimidating, however there are case reports of individuals opening up over time. The group may provide the only meaningful social contact in their lives.

  • Pharmacotherapy: There are no FDA approved medications for schizoid personality disorder. There have been no clinical trials specific to schizoid PD and the evidence for adjunctive pharmacotherapy is limited. Clinical practice is largely guided by expert opinion and experience and some patients have benefited from small dosages of antipsychotics (for quasi-delusional thinking or transient psychosis during stress), serotonergic antidepressants (for decreasing rejection sensitivity), benzodiazepines (for reducing interpersonal anxiety), or psychostimulants, however these treatments are not well-studied in schizoid PD. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment. Comorbid anxiety and depressive disorders should be treated accordingly (see treatment of depression; treatment of anxiety).


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