For didactic purposes, it is easier to address the issue of treatment in the realm of PDs as though patients manifested “prototypic” or textbook instances of the disorder whose DSM criteria they (predominantly) meet. In actual practice, schizoid and schizotypal are better seen, when present, as central tendencies whose ultimate clinical coloration and response to therapy are both modified by the existence of various coexisting traits that would arbitrarily be assigned to different DSM categories.
Certain combinations are much more common than others: schizoid patients are rarely also histrionic or borderline. Schizoid and schizotypal patients are usually shy and ill at ease socially; nevertheless, some have a good sense of humor and can eventually “warm up” to someone (including a therapist) whom they grow to trust over time. Some may show another mixture of socially positive traits, such as conscientiousness and respectfulness, that augur well for eventual improvement in therapy. Still others may be markedly paranoid or secretly grandiose or negativistic, and any one of these combinations creates much greater challenges to the therapist. Schizoid persons are no more prone, and may be even less prone, to antisocial behavior than are persons in the general community. There is nevertheless a small number of psychopathic patients with schizoid PD who, because of their extreme detachment from ordinary human sentiments, engage in antisocial acts of a bizarre or grotesque quality.
Some persons with schizoid or schizotypal personalities lack the schizotypal item “excessive social anxiety.” This trait is not necessary for the diagnosis of schizotypal PD, because the latter requires only five of nine items. Such patients may never choose to present themselves to a therapist. Those who are contentedly aloof or who are antisocial and hostile to the very notion of treatment take themselves out of the picture relevant to the issues dealt with in this chapter.
The balance in any given schizoid patient between “inherent deficit” (a shyness rooted in innate temperament) and “conflict” (“I want to be close to others, but I fear they will hurt me”) informs the major thrust of therapy. The greater the extent to which intrapsychic conflict dominates the scene, the more the clinical picture will resemble that of the avoidant personality, and the more appropriate will be a “dynamic” (psychoanalytically oriented or “expressive”) approach. The more deficit factors - impoverishment of thought, lack of experience in the realms of social intercourse or intimacy, impediments in the ability to “read” other people’s feelings and intentions (e.g., poor empathy) - appear to be operative, the greater use therapists will find in supportive, particularly educative, interventions.
The earlier psychoanalytic literature on the dynamic therapy of “schizoid” patients bears an uncertain relationship to patients meeting DSM-IV criteria for schizoid and schizotypal disorders. This comes about largely because of the broad and poorly defined way in which Melanie Klein, and those members of the British Object Relations School whom she influenced, used the term schizoid. Fairbairn, Guntrip, and Balint, were less “Kleinian” in their position and belonged to the Independent School. Fairbairn spoke of a “schizoid position” as an early infantile phase of ego development that involved a “splitting” of the maternal image into “good” and “bad” (nourishing and devouring) aspects. Fairbairn and M. Klein speak of this schizoid position as a phase of normal development that forms the basis for adult schizoid and schizophrenic illness.
Similar statements are echoed in the later works of Guntrip and Balint. The latter preferred the term “philobat” (the one who loves to walk away) in distinguishing the schizoid person’s tendency to distance himself or herself from others (in contrast to the “ocnophile’s” coping via clinging to others). Presenting themselves to the analysts of this group apparently were many persons who were reserved, shy, and socially ill at ease. Although not schizoid or schizotypal in the contemporary sense, these patients would have been labeled “schizoid” by therapists of this school and era. Some of the “as-if” patients described by Helene Deutsch, for example, would be “schizoid” in the Kleinian sense, but not by DSM criteria. The patients Fairbairn described more closely resemble the current concept of schizoid than of schizotypal PD and exhibited intrapsychic conflicts regarding object-relatedness.
A number of treatment modalities may be applicable to schizoid and schizotypal patients, depending on their individual characteristics. These include dynamic, supportive, and behavioral-cognitive therapies in individual, group, and family therapies as well as pharmacotherapies. These modalities may be used singly or in combination, in accordance with the nature and special needs of each prospective patient.
Revision date: July 3, 2011
Last revised: by Jorge P. Ribeiro, MD