schizoid personality disorder schizoid personality disorder schizoid personality disorder (/ˈskɪtsɔɪd, ˈskɪdzɔɪd, ˈskɪzɔɪd/, often abbreviated as szpd or scpd) is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered life style, secretiveness, emotional coldness, detachment, and apathy. affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world. other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, a degree of asexuality, and idiosyncratic moral or political beliefs. schizoid personality disorderpeople with schizoid personality disorder often prefer solitary activities.pronunciation/ˈskɪtsɔɪd, ˈskɪdzɔɪd, ˈskɪzɔɪd/ specialtypsychiatry, clinical psychologysymptomspervasive emotional detachment, reduced affect, lack of close friends, apathy, anhedonia, unintentional insensitivity to social norms, sexual abstinence, preoccupation with fantasy, autistic thinking without loss of skill to recognize realityusual onsetlate childhood or adolescencedurationlife longtypeslanguid schizoid, remote schizoid, depersonalized schizoid, affectless schizoid (millon's subtypes)causesfamily history; cold, indifferent, or intrusive parenting; traumatic brain injury; low birth weight; prenatal malnutritionrisk factorsfamily historydiagnostic methodbased on symptomsdifferential diagnosisother mental disorders with psychotic symptoms (schizophrenia, delusional disorder, and a bipolar or depressive disorder with psychotic features), personality change due to another medical condition, substance use disorders, autism spectrum disorder, other personality disorders and personality traitstreatmentpsychodynamic psychotherapy; cognitive behavioral therapymedicationnot general practice but may include low dose benzodiazepines, β-blockers, nefazodone, bupropionprognosistypically poorfrequency0.8% personality disorders cluster a (odd) paranoid schizoid schizotypal cluster b (dramatic) antisocial borderline histrionic narcissistic cluster c (anxious) avoidant dependent obsessive–compulsive not otherwise specified depressive depressive cyclothymic others passive–aggressive masochistic sadistic psychopathy haltlose immature post-traumatic organic symptoms typically start in late childhood or adolescence. the cause of szpd is uncertain, but there is some evidence of links and shared genetic risk between szpd, other cluster a personality disorders, and schizophrenia. thus, szpd is considered to be a "schizophrenia-like personality disorder". it is diagnosed by clinical observation, and it can be very difficult to distinguish szpd from other mental disorders or conditions (such as autism spectrum disorder, with which it may sometimes overlap). the effectiveness of psychotherapeutic and pharmacological treatments for the disorder has yet to be empirically and systematically investigated. this is largely because people with szpd rarely seek treatment for their condition. originally, low doses of atypical antipsychotics were also used to treat some symptoms of szpd, but their use is no longer recommended. the substituted amphetamine bupropion may be used to treat associated anhedonia. however, it is not general practice to treat szpd with medications, other than for the short-term treatment of acute co-occurring disorders (e.g. depression). talk therapies such as cognitive behavioral therapy (cbt) may not be effective, because people with szpd may have a hard time forming a good working relationship with a therapist. szpd is a poorly studied disorder, and there is little clinical data on szpd because it is rarely encountered in clinical settings. studies have generally reported a prevalence of less than 1%. it is more commonly diagnosed in males than in females. szpd is linked to negative outcomes, including a significantly compromised quality of life, reduced overall functioning even after 15 years, and one of the lowest levels of "life success" of all personality disorders (measured as "status, wealth and successful relationships"). bullying is particularly common towards schizoid individuals. suicide may be a running mental theme for schizoid individuals, though they are not likely to attempt it. some symptoms of szpd (e.g. solitary lifestyle, emotional detachment, loneliness, and impaired communication), however, have been stated as general risk factors for serious suicidal behavior. history the term schizoid was 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. bleuler labeled the exaggeration of this tendency the "schizoid personality". he described these personalities as "comfortably dull and at the same time sensitive, people who in a narrow manner pursue vague purposes". in 1910, august hoch 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. the descriptive tradition began in 1925 with the description of observable schizoid behaviors by ernst kretschmer. he organized those into three groups of characteristics: unsociability, quietness, reservedness, seriousness and eccentricity. timidity, shyness with feelings, sensitivity, nervousness, excitability, fondness of nature and books. 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. the second path, that of dynamic psychiatry, began in 1924 with observations by eugen bleuler, who observed that the schizoid person and schizoid pathology were not things to be set apart. 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:, who observed that the schizoid person and schizoid pathology were not things to be set apart. the need to regulate interpersonal distance as a central focus of concern. the ability to mobilize self-preservative defenses and self-reliance. a pervasive tension between the anxiety-laden need for attachment and the defensive need for distance that manifests in observable behavior as indifference. an overvaluation of the inner world at the expense of the outer world. following fairbairn, 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. 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. epidemiology it remains unclear how prevalent the disorder is. it may be present in anywhere from 0.5% to 7% of the population and possibly 14% of the homeless 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 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. a university of colorado colorado springs study comparing personality disorders and myers–briggs type indicator types found that the disorder had a significant correlation with the introverted (i) and thinking (t) preferences. etiology 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%. other research has 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. 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 understudied 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 schizoids 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. signs and symptoms social isolation people with szpd are often socially isolated. szpd is associated with a dismissive-avoidant attachment style. people with this disorder will