In the 5th century B.C., Hippocrates first propounded his theory of humorism to describe the different temperaments. This idea postulated that human behavior could be categorized into four distinct temperaments, black bile, sanguine (blood), yellow bile, and phlegm, which in turn correlated with the four elements earth, air, fire, and water, respectively. Hippocrates further elaborated on his theory by describing black bile as melancholic, sanguine as optimistic, yellow bile as irritable and choleric, and phlegm as apathetic. Derivations of this initial theory would be alluded to up until the 20th century, as seen by the descriptive terms, melancholic, sanguine, and choleric used by Emil Kraepelin to describe his "manic-depressive patients." Eventually, formal attempts to list personality types occurred via the production of the Diagnostic and Statistical Manual of Mental Disorders (DSM) I in 1952, which listed seven "personality disturbances." This list was lengthened and then condensed over the subsequent three editions of DSMs, finally settling on a list of ten personality disorders, which is seen in the most recent edition of DSM (DSM V). According to the most recent consensus, personality disorders are explained as chronic maladaptive behavior patterns that are inflexible, pervasive, and lead to social isolation and distress.
These disorders are categorized into three groups or clusters, namely A, B, and C. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Cluster B consists of borderline, narcissistic, histrionic, and antisocial personality disorders. And lastly, cluster C subsists of avoidant, dependent, and obsessive-compulsive personality disorders. Of salience for this article is the evaluation of the schizoid personality disorder. The adjective "schizoid" was originally coined to describe the prodromal seclusiveness and isolation observed in schizophrenia. The schizoid personality type was made official in DSM III in 1980, to describe persons experiencing significant ineptitude in forming meaningful social relationships.
Although not much is definitively known regarding the etiology, it is assumed that heritability significantly contributes to the schizoid personality disorder diathesis. Twin studies using self-report questionnaires have estimated heritability rates for schizoid personality disorder to be about 30%. It is unknown which environmental factors, if any, contribute to this disorder.
Schizoid personality disorder is a chronic life long behavior pattern, stemming from childhood. As stated before, there is a suggested heritability to the disorder, but specific genetic causes have not been identified. Specific anatomic abnormalities (localized brain lobe legions) and biochemical or neurotransmitter associated diseases are suggested in the literature to have a role in the development of this disorder; however, these are purely speculative at this point.
Isolation is a salient feature in the history of a schizoid patient. Rarely do they have close relationships, and often they will choose to participate in occupations that are solitary in nature. They infrequently experience strong emotion, express little to no desire for sexual activity with a partner, and tend to be ambivalent to criticism or praise.
It is unlikely that a person with a schizoid personality disorder will present in the clinical setting of his own volition unless prompted by family, or as a result of a co-occurring disorder, such as depression. As with most personality disorders, the behavior is in synchrony with the ego, and thus the patient does not acknowledge the need to adapt his or her behavior. Individuals afflicted with personality disorders tend to externalize their problems, viewing others as the etiology of any conflict. If, by chance, a person with schizoid personality disorder presents in the clinical setting, DSM V has outlined specific diagnostic criteria for the clinician to use for evaluation. A pronounced blunted affect will immediately be observable on presentation. The patient will be disengaged, aloof, and will most likely diminish symptomatology.
As with most psychiatric disorders, the patient’s history directs the clinician towards the diagnosis. A thorough social and personal history is paramount, as well as the collection of history from collateral sources. Once the clinician deduces the presence of an underlying personality disorder, he or she can use subsequent diagnostic checklists or self-report evaluations to help identify the manifesting disorder.
Diagnostic Criteria for Schizoid Personality Disorder as Outlined in DSM V
It is important that a clinician should not diagnose a personality disorder prematurely. Different disease states can share familiar traits with personality disorders. For example, a patient experiencing a major depressive episode can present as socially anxious and dependent on others; however, this “dependence” is episodic, whereas a person with dependent personality disorder demonstrates a chronic history of such behavior. It may be necessary to evaluate the patient over an extended period of time to confirm the diagnosis. Lastly, the clinician needs to be wary of cultural differences that can present as personality disorder characteristics.
There is no treatment modality approved for the management of schizoid personality disorder. That said, some studies suggest that psychotherapy can help improve the reclusive nature of this disorder. Pharmacotherapy may be an option to treat co-morbid disease states, such as depression. It is the duty of the clinician to tactfully highlight and make salient the patient's maladaptive behavioral patterns, and, in the indelible words of Freud, "make the unconscious conscious." Ideally, the clinician will encourage the patient to implement new behavior to counteract his innate maladaptive impulses. Unfortunately, schizoid personality disorder has been almost virtually ignored in comparison to other personality disorders, and thus treatment options are scant and insufficiently studied.
As with most personality disorders, diagnostic features of schizoid personality disorder overlap with other personality disorders. These include:
Most notably, schizotypal personality disorder shares multiple salient commonalities with schizoid personality disorder. In fact, these two disorders are considered to be on a continuum with schizophrenia spectrum disorders. This continuum consists of schizoid personality disorder and schizophrenia on opposite poles, with schizotypal falling somewhere in between. Schizotypal can be differentiated with its more pronounced “magical” and eccentric thought processes. Paranoid, avoidant, and obsessive-compulsive personality disorders are also often on the clinician's list of differential diagnoses. Unlike the aloofness observed in schizoid, however, patients with paranoid personality disorder are often overly resentful and can demonstrate explosive anger. And although patients with avoidant personality disorder share the trait of social isolation, this isolation precipitates from the fear of rejection, whereas those with schizoid are simply ambivalent towards human contact. Lastly, patients with obsessive-compulsive personality disorder are driven by a necessity to maintain control and will use the ego defense of rationalization to expiate undesirable emotions, appearing similarly ambivalent to those with schizoid personality disorders.
As mentioned in the introduction, personality disorders are chronic and pervasive, and therefore, associated with dire prognoses. Ideally, the patient will acquiesce to long term psychotherapy and sufficiently engage without experiencing significant periods of truancy. Even then, it is unlikely the patient will ever experience significant joy in social engagement.
Although patients with personality disorders, in general, have a higher risk of suicide, substance abuse, and depression, patients with schizoid personality disorder mainly suffer from a lack of social interactions. People with this personality disorder are rarely violent. Mood disturbances, depression, and anxiety disorders, however, can be seen in higher frequency than the general population.
Commonly identified as a heritable disorder, the best practices for obviating this disorder are not well known. Once the disorder is identified, the clinician should educate the family regarding the nature of the disorder, and ask for patience along with unconditional positive regard, for the best possible outcomes.
Schizoid personality disorder can result in serious psychiatric sequelae if left unrecognized and untreated. Thus, it is of paramount importance that the interprofessional care team work cohesively as a unit to identify at-risk patients. Patients with a schizoid personality disorder will diminish affective symptomatology, leading to possible misdiagnosis. Insight from the medical team who are most in contact with the patient can prove invaluable to the clinician in determining the proper treatment plan for the patient.
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