Lack of research and scholarly attention has led important personality dynamics once captured by the schizoid diagnosis to be overlooked. Once an immensely important construct, schizoid personality disorder is at risk of becoming diagnostically irrelevant. Many have argued that this is the result of the emergence of avoidant personality disorder (AVPD), a similar yet theoretically distinct syndrome (see e.g., Ahktar, 1987; Livesley et al., 1985). Schizoid and avoidant personality disorders have been categorized as separate types because different motivations are thought to underlie their social isolation. According to the current DSM (DSM-5, APA, 2013), individuals with schizoid personality disorder reportedly do not desire relationships because of deficits in their capacity to relate meaningfully with others whereas individuals with avoidant personality disorder reportedly desire relationships but fear rejection, shame, and humiliation. This conception leaves two abnormal, maladaptive sub-types of introversion: schizoid withdrawal and avoidant withdrawal:
Isolated, detached, and withdrawn individuals were not always viewed as separable on the basis of sensitivity to evaluation of others or the potential—or lack-thereof—for positive emotional experience in social interaction. In fact, quite the opposite was true. Hypersensitivity and detachment were viewed as going together (in parallel and interval) in abnormal, maladaptive introversion. Historical perspectives on a common schizoid-avoidant syndrome: Outer appearances and internal dynamics
The debate about the validity of the schizoid-avoidant distinction centers on whether the different behavioral manifestations described by Kretschmer above as timid, flat, or hostile coupled with the internal experience of hypersensitivity and tendency to escape into one's thoughts reflect different types of disorders or whether they are subtypes of a common syndrome, such as abnormal, maladaptive introversion.
There has always been an interest within clinical psychology and psychiatry in understanding isolated, detached, and withdrawn individuals (for a review, see Livesley et al., 1985):
The schizoid-avoidant categorical distinction: Evaluating empirical evidence for a controversial differential diagnosis Given the historical importance of schizoid personality disorder for research on schizophrenia-spectrum pathology, psychodynamic theory (e.g., Klein, Guntrip, and McWilliams), and personality disorders, it is surprising how little research there is evaluating the distinction between avoidant personality disorder and schizoid personality disorder. In light of impressively constructed and researched arguments that such a distinction rendered schizoid personality disorder an invalid construct and its proposed removal, it seems responsible to evaluate the validity of its distinction from avoidant personality disorder. The existence of isolated, detached, and withdrawn individuals who lack affiliative motivation, prefer solitude, do not experience pleasure from friendships and family, and are indifferent to external judgments would provide empirical support for the validity of post DSM-III schizoid personality disorder, suggesting it should not be removed. Do such characters like Daniel Day Lewis in There Will Be Blood, who utters the line "There are times when I look at people and I see nothing worth liking. I want to earn enough money that I can get away from everyone," exist without inner sensitivity? Winarick & Bornstein (2015) found that schizoid personality disorder and avoidant personality disorder items show unique patterns of correlations with theoretically relevant traits in many expected ways. Items tapping the need to belong and attachment anxiety were uniquely significantly correlated with avoidant personality disorder items. Items tapping social anhedonia and low empathy were uniquely correlated with schizoid personality disorder. This finding supports the validity of the DSM differential diagnosis. However, both schizoid personality disorder and avoidant personality disorder items were significantly correlated with rejection sensitivity (small r for the schizoid personality disorder link) and internalized shame (large r for schizoid personality disorder and avoidant personality disorder) items. This finding suggests that schizoid personality disorder items are linked with hypersensitivity, inconsistent with post DSM-III definitions but consistent with Meehl's schizotypy (Meehl, 1962), dimensional trait theorists, aspects of psychodynamic theory, and early descriptive psychiatry. Below is a figure representing the correlation clusters for schizoid personality disorder and avoidant personality disorder, respectively - without the rejection sensitivity-schizoid personality disorder correlation included. There is considerable overlap but also clear contrasts (avoidant personality disorder on the right; schizoid personality disorder on the left). Where will all the schizoids go? They will be diagnosed as avoidant or schizotypal. If the dearth of research on schizoid personality disorder continues, then there is a good chance the DSM-5 proposal will get realized, and schizoid personality disorder will be removed. Yet the proposal also calls for re-coupling social anhedonia with anxious/hypersensitivity by moving the schizoid personality disorder symptom over to avoidant personality disorder. The long reign of the label schizoid as a diagnosis will come to an end but the schizoid construct will live on, sort of. A note to readers: Stay tuned for a discussion of the legacy of schizoid personality disorder and discussion of what aspects of the construct will be lost or retained should it be re-named avoidant PD in the DSM-VI. Also much more. This post nor any other I write should be construed as suggesting that a certain behavior or psychological process by itself is diagnostic of a mental disorder. It is irresponsible to make any diagnostic suggestions about a person without meeting them and conducting a thorough interview.
References
Ahktar, S. (1987). Schizoid personality disorder: A synthesis of developmental, dynamic, and descriptive features. American Journal of Psychiatry, 42 (4), 499-518. The relationship between schizoid personality disorder (SPD) and avoidant personality disorder (AvPD) has been a subject of controversy for decades.[1][2] Today it is still unclear and remains to be seen if these two personality disorders are genuinely distinct, but overlapping, personality disorders, or if they are merely two different phenotypic expressions of the same underlying disorder. Both have been associated with a shared genetic risk factor and the same polymorphism within the ANKK1 gene.[3][4] There is also some evidence that AvPD (like SPD) is a personality disorder of the schizophrenia spectrum.[5] Originally, schizoid personality disorder involved social avoidance combined with marked ambivalence regarding the desirability of social contact. It included indifference or even cold disdain oscillating with longing for normal relationships. Through the efforts of Theodore Millon, this complex idea was later divided across two disorders with the emergence of a separate AvPD construct and the idea of ambivalence was lost.[6] According to the differential diagnosis guidelines provided in the text of the DSM-IV the two conditions are distinguished by the extent to which the individual desires social contact versus being indifferent to it. But such distinctions are often difficult to apply in practice, as patients often have unclear, marginal, or shifting status on those elements thought most crucial for differential diagnosis. In the case of the avoidant and schizoid PDs, however, both the problem and its solution may be more academic than real. First, research indicates that all of the avoidant symptoms except social withdrawal correlate negatively with the schizoid symptom list and that differential diagnosis is not difficult.[7] Second, as pointed out by Benjamin (1993), schizoid PD is exceedingly rare and the diagnostic quandary may never occur in practice.[6] However, new research shows that both PDs are linked to hypersensitivity.[8]
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What is the main difference between a person with an avoidant personality disorder and a person with a schizoid personality disorder?
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