What is schizoid personality disorder (SPD)?

Introduction

A personality disorder is defined as an inflexible, long-term, and pervasive pattern of perceiving, interpreting, and responding to a variety of personal, social, and historical situations that leads to clinically significant distress or functional impairment. Schizoid personality disorder (SPD) is characterized by emotional coldness, solitariness, and general apathy towards the outside world. Unlike the similar schizotypal personality disorder, schizoid personality disorder is not accompanied by psychotic-like cognitive or perceptual distortions.

Diagnosis

Eugen Bleuler
first introduced the term “schizoid” to describe a tendency of a person to direct inward, away from the outside world, accompanied by an absence of expressivity. Bleuler noted that the individual with a schizoid personality appeared indifferent both to other people and to pleasure. The fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) lists seven criteria: avoidance of close relationships, preference for solitary activities, avoidance of sexual intimacy, anhedonia, lack of close friends, indifference to praise or criticism, and emotional detachment. The individual must have four or more of these criteria to receive the diagnosis of schizoid personality disorder. Schizoid personality disorder is frequently comorbid with other disorders such as major depressive disorder, social phobia, and schizophrenia.

Differential Diagnosis

Many people who are given this diagnosis are also likely to meet the diagnostic criteria for at least one additional personality disorder, typically schizotypal, paranoid, or avoidant personality disorder; this is known as comorbidity. Indeed, some experts question whether schizoid personality disorder is a valid independent diagnosis.

Schizoid personality disorder can be particularly difficult to differentiate from
avoidant personality disorder. The schizoid personality and avoidant personality share the clinical feature of social withdrawal. Although neither may have intimate relationships, the schizoid personality has no interest or desire in having them. Because individuals with schizoid personality are indifferent to interpersonal relationships, they appear less anxious regarding the criticism of others and show little sensitivity to rejection.

Schizoid personality disorder is diagnosed more often in men, whereas avoidant personality disorder is diagnosed more frequently in women. It is unclear whether these sex differences reflect true gender differences in psychopathology or gender differences in the expression of the same disorder.

Prevalence

Schizoid personality disorder is the least frequently diagnosed personality disorder of all the personality disorders. Prevalence rates of schizoid personality disorder in nonclinical populations and community studies have ranged from 0.8 to 4.9 percent. Prevalence rates estimated from clinical settings such as psychiatric hospitals may not be representative, because schizoid patients are unlikely to seek help unless they are in a crisis.

One special population in which there is a high prevalence of individuals with schizoid personality disorder and schizoid personality traits is the homeless mentally ill, a group that typically fails to use mental health and social services. In one recent study of homeless mentally ill persons in Chicago, 14 percent of the sample were diagnosed with schizoid personality disorder. Although this significantly elevated prevalence rate suggests an association between schizoid traits and homelessness, individuals who are both homeless and have schizoid personality disorder may also be more likely to have other serious and persistent mental illnesses, such as schizophrenia and post-traumatic stress disorder; this is known as the third variable problem.

Some studies have also found schizoid personality disorder to be more common in people with relatives who are schizophrenic.

Cause

According to object relations theorists Ronald Fairbairn and Harry Guntrip, the schizoid person has an underlying need for social contact with others and is interested in intimate relationships. Because of an early history of neglect or mistreatment by others, the schizoid person’s needs have gone unmet. To avoid future frustration, the schizoid person avoids interpersonal contact and relationships. In the l990s, both Melanie Klein and L. A. Clark wrote about schizoid personality disorder as a compromise between fear of losing oneself and fear of being completely cut off from all others. For the schizoid individual, interpersonal isolation is the only way to guarantee autonomy.

Data regarding whether schizoid personality disorder is genetically related to schizophrenia is equivocal. An exhaustive review by Joel T. Nigg and H. Hill Goldsmith reveals that several family studies of schizophrenia either fail to include schizoid personality disorder or combine schizoid personality disorder with schizotypal personality disorder, thereby confounding interpretation of the findings. If schizoid personality disorder is truly part of the schizophrenia spectrum, then individuals with the diagnosis have an underlying genetic diathesis, or susceptibility, to schizophrenia.

Michael Rutter has asserted that schizoid personality disorder may be etiologically related to
autism spectrum disorders, which are characterized by severe impairments in social interactions. Some cross-sectional research also suggests a relationship between schizoid personality disorder and autism spectrum disorders. However, schizoid personality disorder is associated with an onset in late adolescence or early adulthood, and little is known regarding the developmental histories of adults with schizoid personality disorders.

Treatment

Comorbid mood disorders are often the reason an individual with schizoid personality disorder seeks treatment. Treatment for schizoid personality disorder typically involves either individual psychotherapy or individual supportive therapy plus group psychotherapy. Intervention for schizoid personality disorder involves educating the person, providing feedback, and fostering social skills and communication, with the goal of increasing the person’s social contact. Therapists employ various techniques such as role-playing, videotaping, and cognitive behavior techniques involving homework assignments of gradual involvement with social activities. Group therapy for people with schizoid personality disorder may be useful in terms of providing an opportunity to observe social interactions and practice social skills.

Psychopharmacological agents are seldom used in the treatment of symptoms associated with schizoid personality disorder. However, medications may be prescribed for comorbid disorders such as depression or anxiety disorders.

Impact

The impact of schizoid personality disorder can vary considerably. The extent of functional impairment that may result from schizoidal traits and symptoms depends in part on the extent to which the person’s job involves interpersonal interactions and how much intimacy is demanded by the person’s partner or family. The schizoid personality may encounter job difficulties or may not benefit from job advancement because of an inability to successfully negotiate social situations. The schizoid personality may continually feel frustrated or misunderstood by others.

Although schizoid personality disorder seems to be stable over time, little is known regarding its course and prognosis. Clearly, the study of schizoid personality disorder is in its infancy.

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