Michael H. Stone, M.D.

Schizoid and schizotypal personality disorders (PDs) have enjoyed separate status in DSM-III and DSM-IV (American Psychiatric Association 1980, 1994) as distinct categories, their chief attributes being “aloofness” (in schizoid) and “eccentricity” (in schizotypal). Before DSM-III, as Gabbard mentions, the concepts embodied in these two categories were conflated in the notions of “schizoid” abnormalities that were understood as attenuated manifestations of schizophrenia.

Both psychoanalysts and psychogeneticists maintained this view. Fairbairn spoke of the “schizoid character” as a dilute form of major psychosis and depicted persons of this type in terms similar to those used by either Jung, in describing the “introvert,” or Rado, in speaking of the presumably inherited “schizotype.”

Another important issue concerns the schizoid person’s shyness. Some have argued for a fundamental difference between the schizoid and the avoidant patient, in that the former has little or no interest in getting close to others, whereas the avoidant person longs for closeness but is too afraid of social encounters. Others, including Gabbard and Akhtar, see schizoid persons as yearning secretly for closeness but adopting a facade of aloofness or indifference out of an even more extreme fear of closeness. In this view, schizoid adaptation is the more severe abnormality, of which avoidant adaptation is the milder variant. The truth may lie in the middle of these positions: schizoid persons who accept “patienthood” and seek help spontaneously are probably those whose desire for closeness lies nearer the surface and who are more readily disposed to form a good therapeutic alliance. Those who come to treatment begrudgingly and only under pressure from family may be less accessible. Schizoid patients, for example, who are truly comfortable with hermit-like solitariness experience little or no discomfort at being alone and thus do not seek treatment.

Contemporary research has demonstrated a number of abnormalities in the cognitive processing of schizotypal patients that help explain the clinical features of their disorder. These abnormalities have important implications for treatment. Several investigators, for example, point to the difficulties schizotypal patients experienced in inhibiting inappropriate information from crowding their mental screen. Others report findings that underscore difficulties in abstract reasoning and sustained attention. Recognition of emotional expressions is also impaired in many schizotypal patients, who, because of this difficulty, tend to misread the feeling states of others. Deficiencies of these types conspire in the aggregate to hamper schizotypal patients in their efforts to establish lasting and harmonious relationships with others. In general, schizotypal patients (and, to a lesser extent, those with schizoid PD) have the closest link to an Axis I disorder (namely, schizophrenia). The main indicators of the close link between schizotypal PD and schizophrenia, as emphasized by Battaglia and Torgersen (1996), are affect constriction and eccentricity.