Because schizoid patients are generally uncomfortable with emotional closeness, dynamic therapy is best carried out on a once- or twice-weekly schedule, rather than on the more frequent basis that is customary in classical psychoanalysis. This stricture might not apply to archetypical schizotypal patients, although, as noted above, admixture with paranoid traits is very common in this group.
The overarching goal of helping the patient achieve stability in a close personal relationship will more often be feasible with schizotypal than with schizoid patients. For many schizoid patients, the more reasonable goal is to help make their solitary life more endurable and rewarding.
Several analysts have reported good outcomes using dynamic therapy with schizoid patients. The focus in these studies was on the patients’ compensatory, omnipotent fantasies (as defenses against futility and feelings of ineffectiveness or low self-esteem [Nachmani 1984]) and on their use of splitting and projective identification. Liberman recommended interpretations that linked together various feelings isolated at different moments of the session.
Both schizoid and schizotypal patients are especially prone to channel embarrassing thoughts into symbolic equivalents whose meaning is now quite remote to them. Dream analysis may be helpful in establishing the proper connections. A schizoid patient dreamed, for example, of walking nervously through the halls of his old high school, the walls of which were plastered with posters warning against the dangers of syphilis. The dream brought to light his hitherto repressed fearfulness about intimacy and sex. Another schizoid patient, struggling against sexual impulses toward his very seductive mother, dreamed of world-destroying conflagrations that consumed him along with everybody else. This material helped him recognize the intensity of his own incestuous impulses, as well as the hatred toward his mother for enkindling this forbidden love.
Dynamic therapy with schizotypal patients is often focused on the marked transference distortions regarding the image of the therapist. One schizotypal patient for years saw her therapist as a kind of palimpsest, the picture of her mother superimposed atop the actual face of the therapist, whom she might greet with the comment, meant quite literally for some minutes at a time: “You’re my mother!” The gradual stripping away of the “overlay” allowed her eventually to form a more realistic image of the therapist and, by extension, of other persons who figured in her day-to-day interactions.
It is advantageous, in any event, to conduct the sessions with schizotypal and schizoid patients face-to-face, rather than to use the analytic couch. The reason for this is that schizotypal and, to a lesser extent, schizoid patients are customarily both rigid in their character structure and more than ordinarily vulnerable to interpersonal stresses. These stresses would also include being unable to see the therapist and having to make do with the lesser degree of feedback characteristic of the psychoanalytic setting.
Dynamic psychotherapy is indicated, and best limited, to those schizoid and schizotypal patients who, in relation to their shyness, show themselves to be predominantly “avoidant”, rather than innately indifferent to the possibility of human contact. Other prerequisites include high motivation for therapy and a good degree of psychological mindedness (e.g., an openness to self-awareness and to working with symbolism, dream material, double entendres, and the like).
As to the risk of suicide in schizotypal patients, this was found to be negligible in the Psychiatrie Institute-500 long-term follow-up study, but more recently, Fenton and colleagues drew attention to a differential effect of “positive” versus “negative” symptoms in patients with schizophrenia spectrum disorders (which include schizoid and schizotypal PDs, besides schizophrenia itself). Patients with prominent negative (or “deficit-type”) symptoms had a low suicide risk, on the order of 1.5%, whereas those with severe suspiciousness or delusions (i.e., marked paranoid features) had a high risk (12%) for completed suicide.
Supportive interventions will be useful in work with most schizoid and schizotypal patients; for many, these interventions will constitute the mainstay of treatment. Supportive therapy relies on measures such as sympathetic listening, education about the world, advice giving, problem solving, exhortation, and also the quiet establishment of relatedness enhanced by the regularity of visits and nonjudgmental acceptance of the therapist. Problem-solving techniques may include role-playing, in which the therapist might, for example, simulate an interviewer screening an applicant for a job. Some therapists go a step further and accompany a schizotypal patient who is out of touch with societal conventions to a clothing store, helping the patient select the apparel most appropriate to an upcoming interview. Interventions of this sort were utilized by Albert in working with both schizotypal and schizophrenic patients.
The patience required of the therapist may be prodigious. Those schizotypal patients exhibiting odd communication or severe impairment in their ability to resonate empathically with others may need the therapist as a “reality organ” (auxiliary ego) for many years or even for life. Certain schizoid patients may remain uncommunicative for long stretches, as in a case described by Mogstad: his patient, a sculptress, was electively mute for 2 years. During this time, she brought many small sculptures to Mogstad’s office. Each portrayed some aspect of the hostile symbiosis between her and her mother. Mogstad said very little during all this time, simply looking admiringly at the sculptures, which eventually filled all the shelves of his office. Perhaps sensing how important she had become to him, given his willingness to convert his office into her personal museum, she eventually felt emboldened to talk, at first about her combined longing and hatred for her emotionally arid mother and later about the transference and about her current life. Her adjustment, socially and professionally, improved dramatically after this point, the whole process requiring some 8 to 10 years.
Psychotherapy, of whatever sort, with schizoid to schizotypal patients should usually proceed at a slow pace. Bonime once advocated a more confrontational technique, but this would seem applicable only to a few patients. With most schizoid and schizotypal patients, a more effective path to pursue is one in which the therapist, while remaining active and involved, avoids becoming overly ambitious or impatient. Expectations need to be tailored so as to be in harmony with the patient’s capabilities, which may fall well short of some hypothetical “ideal life.”
One must respect the emotional distance customarily required by patients with these disorders. Many embarrassing topics may have to remain under wraps for a long time or even permanently, especially when grotesque sexual or aggressive fantasies or memories dominate the patient’s inner life. An overeager therapist may succeed only in frightening or altogether alienating patients of this sort, who may be exquisitely sensitive and prone to feelings of shame if such fantasies were forced out into the open prematurely.
An example concerns a schizoid man with pronounced paranoid features who had been abused physically by an older brother throughout his early years and sodomized by his father at age 9. A therapist whom he consulted in his 20s at once zeroed in on the man’s homosexual experience and fears. Unable to tolerate the rapid exposure of this material, he became panicky and unable to work. A second therapist, sensing the man’s fragility, focused on restoring his work potential and purposely sidestepped the allusions to homosexuality in the dream material until such time, 6 years later, when the patient himself was able to broach such material without undue anxiety.
Beck and Freeman offered an overview of the cognitive-behavioral approach to the whole roster of disorders in DSM Axis II, including schizoid and schizotypal PDs. Their orientation emphasizes, first, the isolation of the important set of basic assumptions maintained by persons with these character types, and then the palette of clinical strategies and techniques that therapists can bring to bear in ameliorating these (uncomfortable and self-defeating) assumptions. The ultimate goal is, via substitution of these old assumptions with more life-positive ones, to enable the patient, by becoming more at ease and socially better adapted, to lead a more fulfilling life.
Among the negative attitudes and assumptions characteristic of the schizoid person are the following :
“Life is less complicated without other people.”
“I’m a social misfit.”
“It is better for me to keep my distance and keep a low profile.”
Those characteristic of the schizotypal person include the following:
“I feel like an alien in a frightening environment.”
“Things don’t happen by chance.”
“Relationships are threatening.”
In working with the schizoid patient, the therapist will, at a suitable point, encourage the patient to develop a social network within which other persons can be found who will be reassuring and supportive. Even the discovery of one such person helps to overturn the assumption that people do not care about the patient. Beck and Freeman recommend the use of the dysfunctional thought record, in which, as a homework device, the patient is asked to list major assumptions and typical negative thoughts. These then become grist for the mill in subsequent sessions. One aspect of cognitive-behavioral therapy is social skills training, the importance of which, vis-a-vis schizotypal patients, has been emphasized by McKay and Neziroglu. These authors also mention the similarity between the clinical presentation in some patients with schizotypal PD and that in obsessive-compulsive disorder (OCD). Cases of schizotypal PD with comorbid OCD have been reported elsewhere as well.
Recommendations for the cognitive-behavioral treatment of schizotypal patients begin with the need to establish a solid therapeutic relationship, which often serves as the first bridge by which the patient crosses into the world of ordinary folk. Because many schizotypal patients inadvertently alienate others via their eccentric habits, odd speech intonation, and other traits, social skills training comes into play. Here the therapist strives to enhance the social appropriateness of the patient’s gestures, dress, and ways of communicating. A useful behavioral device in this connection is the use of videotapes of the patient’s conversation with the therapist. This material can be played back and minutely examined, allowing the patient to learn in which areas he or she is appropriate and in which gauche or socially offensive.
Small talk is often inordinately difficult for schizoid or schizotypal patients, who find it next to impossible to banter with co-workers or exchange pleasantries with store attendants. This contributes to the impression of oddness that they create. Improvements may come about in this realm through the therapist’s efforts to make the patient less anxious in social situations (via exploration of the negative assumptions) and to educate the patient about the kinds of comments people ordinarily make and expect in these casual encounters.
Schizoid and schizotypal patients both have a tendency to concretize negative feelings about their psychological self and their personalities via assumptions about their bodies. Symbolization is used and may become deeply entrenched in the manner of a somatic delusion. Thus one schizotypal man, extremely un-self-confident in approaching women (partly as an aftereffect of intense parental humiliation), would deflect attempts a woman might make to kiss him on the lips, on the grounds that “probably I smell bad, so I’d best not let her get that close to me.” At other times, he would worry that his lower lip was protruding a millimeter too far, so as to give him an unattractive appearance. By leading the patient back toward the origins of these concretizations - the incorrect but dynamically determined assumptions that underlay the bodily concerns - the therapist could in time help the patient to supplant the earlier, destructive convictions with more realistic and self-sustaining ones. This approach could also form part of a supportive technique; dynamic therapy with such patients can also be made to include cognitive interventions of this sort. Certain interventions with schizoid and schizotypal patients cannot, in other words, be considered the exclusive preserve of one or another competing school of thought.
Revision date: June 14, 2011
Last revised: by Sebastian Scheller, MD, ScD