Asperger syndrome
Several studies have reported an overlap or comorbidity with autism spectrum disorder and Asperger syndrome.[19][20][87][192][193][194] Asperger syndrome had traditionally been called "schizoid disorder of childhood",[195][196][197] and 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.[198] In a 2012 study of a sample of 54 young adults with Asperger syndrome, it was found that 26% of them also met the 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 the 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.[19] Tantam suggested that Asperger syndrome may confer an increased risk of developing SzPD.[87] A 2019 study 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.[20]
In the 2012 study, it was 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 behaviors, 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.[19] The authors of the 2019 study hypothesized that it is extremely likely that historic cohorts of adults diagnosed with SzPD either also had childhood-onset autistic syndromes or were misdiagnosed. 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 recognized in around 1% of the population.[199]
Treatment
Medication
There are no effective medications for schizoid personality disorder. However, certain medications may reduce the symptoms of SzPD and treat co-occurring mental disorders. Since the symptoms of SzPD mirror the negative symptoms of schizophrenia, antipsychotics have been suggested as a potentially effective medication for SzPD.[22][7][200][201] Originally, low doses of atypical antipsychotics like risperidone or olanzapine were used to alleviate social deficits and blunted affect.[202][203][204][205] However, a 2012 review concluded that atypical antipsychotics were ineffective for treating personality disorders.[21] Antidepressants,[89] SSRIs,[206] anxiolitics,[60] bupropion,[204] modafinil,[207] benzodiazepines,[208][209] and biofeedback[210] may also be effective treatments.
Basic tenets of Cognitive-Behavioral Therapy, a kind of Psychotherapy used to treat SzPD
Psychotherapy
Treatment for this disorder uses a combination of cognitive-behavioral therapy and psychodynamic psychotherapy.[89][211][212] These techniques can be used to help patients identify their defense mechanisms and change them.[47][213][214] Therapists attempt to establish healthy relationships with their clients,[215] helping to combat their internalized belief that relationships are harmful and unhelpful. Relationships with a therapist can seem terrifying and intrusive to a person with SzPD.[216][217] They may feel as if they need to alter or hide their feelings to meet the therapist's demands or expectations. To combat this, therapists try to gradually increase their patient's emotional expression. Expressing too much too early can lead to their ending therapy. Treatment must be person centered, with clients feeling understood and well regarded.[127][218][219] This can allow them to connect with and understand their emotions.[220][221][222] When people with SzPD do not have their feelings validated, this will confirm their belief that expressing themselves is dangerous.[60] Therapists attempt to avoid intruding on their patients' lives or restricting their freedoms,[60] so as to prevent them from feeling as if therapy is intolerable.[6] Because of this, therapy is usually less structured than treatment programs for other disorders.[60] Patients may benefit from long-term treatment lasting several years.[223][21] Inpatient care may be effective for treating SzPD and other Cluster A disorders.[224]
Controversy
The original concept of the schizoid character developed by Ernst Kretschmer in the 1920s comprised a mix of avoidant, schizotypal, and schizoid traits. It was not until 1980 and the work of Theodore Millon that led to splitting this concept into three personality disorders (now schizoid, schizotypal, and avoidant). This caused debate about whether this was accurate or if these traits were different expressions of a single personality disorder.[31] It has also been argued due to the poor consistency and efficiency of diagnosis due to overlapping traits that SzPD should be removed altogether from the DSM.[192] A 2012 article suggested that two different disorders may better represent SzPD: one affect-constricted disorder (belonging to schizotypal PD) and a seclusive disorder (belonging to avoidant PD). They called for the replacement of the SzPD category from future editions of the DSM with a dimensional model which would allow for the description of schizoid traits on an individual basis.[48]
Some critics such as Nancy McWilliams of Rutgers University and Panagiotis Parpottas of European University Cyprus argue that the definition of SzPD is flawed due to cultural bias and that it does not constitute a mental disorder but simply an avoidant attachment style requiring a more distant emotional proximity.[127][225] If that is true, then many of the more problematic reactions these individuals show in social situations may be partly accounted for by the judgments commonly imposed on people with this style.
Similarly, John Oldham, using a dimensional approach, thinks that most people with schizoid character features do not have a full-blown personality disorder.[226] Impairment is mandatory for any behavior to be diagnosed as a personality disorder.