Journal of Personality Disorders, 26(6), 919–926, 2012

© 2012 The Guilford Press

SCHIZOID PERSONALITY DISORDER

Joseph Triebwasser, MD, Eran Chemerinski, MD,
Panos Roussos, MD, PhD, and Larry J. Siever, MD

Schizoid personality disorder (ScPD) is one of the “odd cluster” or “clus-

ter A” personality disorders in DSM-IV. In the present article, the au-
thors review information pertaining to the psychometric characteristics
of ScPD as gleaned from a search of relevant publications as well as
from databases of personality disorder study groups. Comparatively
little evidence exists for the validity and reliability of ScPD as a sepa-
rate, multifaceted personality disorder. Some authors, moreover, have
contended that the group of patients termed “schizoid” actually fall into
two distinct groups—an “affect constricted” group, who might better be
subsumed within schizotypal personality disorder, and a “seclusive”
group, who might better be subsumed within avoidant personality dis-
order. The research-based justification for retaining ScPD as an inde-
pendent diagnosis is sufficiently sparse for it to seem reasonable to re-
move ScPD from the list of personality disorders in DSM-V, and instead
to invite clinicians to code for schizoid traits using a dimensional model.

CLINICAL DESCRIPTION/SYMPTOM PICTURE

Individuals with schizoid personality disorder (ScPD) are characterized by
“a pervasive pattern of detachment from social relationships and a re-
stricted range of expression of emotions in interpersonal settings” (Ameri-
can Psychiatric Association [APA], 1994, p. 638). The term schizoid ap-
pears to have originated with Bleuler (1908/1987). Since then, it has been
elaborated on by numerous authors, including those in the psychodynam-
ic and descriptive traditions, and ScPD has been present in all four edi-
tions of DSM. Until the introduction of schizotypal personality disorder
(SPD) into DSM in 1980, ScPD was the predominant nonpsychotic diagno-
sis within the schizophrenia spectrum, although “schizoid” was also used
as an adjective to describe a “position” or “stance” in which the individual
withdraws into the self (e.g., Fairbairn, 1994; Klein, 1975). Although this
use of “schizoid” to denote a defense style has continued in the psychoana-
lytic community, among descriptive and biological clinicians and writers
SPD has in large part subsumed ScPD in research and clinical practice.

This article was accepted under the editorship of Paul S. Links.

From James J. Peters VA Medical Center (J. T., E. C., P. R., L. J. S.).
Address correspondence to Larry J. Siever, Bronx VA Medical Center (OOMH), 130 W. Kings-
bridge Rd., Bronx, NY 10468; E-mail:larry.siever@mssm.edu

919
920 TRIEBWASSER ET AL.

Since the publication of DSM-III (APA, 1980), in fact, ScPD has been
among the least studied of the personality disorders, with virtually no em-
pirical investigations specifically devoted to it in the published literature.
Descriptive information about ScPD is derived almost entirely from broad-
based epidemiological studies of personality disorders as a whole (e.g.,
Coid, Yang, Tyrer, Roberts, & Ullrich, 2006), plus a few examinations of
the cluster A personality disorders and their relationship to schizophrenia
(e.g., Kendler, Myers, Torgersen, Neale, & Reichborn-Kjennerud, 2007),
although this latter group of studies tends to focus on SPD rather than
ScPD (e.g., Hazlett et al., 2008; Torgersen et al., 2002). There are virtually
no published neurobiological studies devoted exclusively—or even primar-
ily—to ScPD, and there is no published quantitative somatic or psycho-
therapeutic treatment research. This academic neglect has persisted de-
spite evidence that ScPD has been found by Ullrich and colleagues (2007)
to imply the lowest functioning among the personality disorders with re-
spect to achievement and interpersonal relations and has been associated
with considerable reduction in quality of life (Cramer, Torgersen, & Kring-
len, 2006; Grant et al., 2004). Also, although probably the least common
of the cluster A disorders and one of the less prevalent (0.9%) of the DSM-
IV personality disorders (Torgersen, 2009), ScPD nevertheless occurs fair-
ly frequently in both clinical (Herpertz, Steinmeyer, & Sass, 1994) and
general (Torgersen, Kringlen, & Cramer, 2001) populations.
There are several possible reasons for the relative paucity of published
research on ScPD. In clinical populations, it is consistently one of the
least commonly encountered personality disorders (2.2%) (Stuart et al.,
1998; Zimmerman, Rothschild, & Chelminski, 2005): Although, as noted
above, ScPD patients sometimes find their way into treatment, because of
their isolativeness they are probably less likely to do so than almost all
other personality-disordered individuals (Tyrer, Mitchard, Methuen, &
Ranger, 2003); presumably this influences their willingness to be recruit-
ed or retained in research studies as well. Investigators interested in clus-
ter A disorders have tended to devote more attention to SPD, with its more
clear-cut familial association to schizophrenia and more easily identified
and quantifiable “positive” thought disorder symptoms, than to ScPD.
Sometimes this preferential recruiting of SPD subjects occurs by choice
(e.g., McClure, Barch, Flory, Harvey, & Siever, 2008), and sometimes it oc-
curs when families of schizophrenia probands are culled and SPD turns
out to be the predominant Axis II diagnosis (e.g., Filbey, Holcomb, Nair,
Christensen, & Garver, 1999).
The current conceptualization of ScPD has been challenged as repre-
senting the uneasy union of two separate disorders, an SPD-like “affect-
constricted disorder,” and a “seclusive disorder” similar to avoidant per-
sonality disorder (APD) (Kalus, Bernstein, & Siever, 1995). On the other
hand, it might be argued that ScPD and APD are fundamentally different
in that APD patients crave social interaction but are too anxious—because
of low self-esteem or rejection sensitivity—to pursue or enjoy it, whereas
ScPD patients are genuinely indifferent to the company of others. Howev-
SCHIZOID PERSONALITY DISORDER921

er, in practice it can be difficult to make this distinction, and family re-
search has suggested that APD is in fact part of the schizophrenia spec-
trum (Fogelson et al., 2007; Silberschmidt & Sponheim, 2008). It may be,
then, that the habitual reclusiveness central to ScPD can often better be
attributed to other disorders, for example, APD, mood disorders, anxiety
disorders, and disorders with a prominent paranoia or irritability compo-
nent, that cause affected individuals to isolate themselves.
As stated above, there are few published psychometric studies known to
us that comment on clinical validators for ScPD. Recently, the Interper-
sonal Measure of Schizoid Personality Disorder (IM-SZ), a means of diag-
nosing ScPD based on nonverbal and interpersonal behaviors, was tested
in two large forensic samples, one in the United States and one in the
United Kingdom. The IM-SZ demonstrated adequate reliability and validi-
ty (Kosson et al., 2008).
A large population-based study found that ScPD and paranoid person-
ality disorder (PPD) were strongly associated with dysthymia, mania, pan-
ic disorder with agoraphobia, social phobia, and generalized anxiety disor-
der (Grant et al., 2005). ScPD has also been found to be correlated with
violent behavior (Pulay et al., 2008) as well as with arthritis (McWilliams,
Clara, Murphy, Cox, & Sareen, 2008), obesity (Petry, Barry, Pietrzak, &
Wagner, 2008) and, in two separate cohorts, coronary artery disease (Mo-
ran et al., 2007; Pietrzak, Wagner, & Petry, 2007). A subset of individuals
self-described as “asexuals” appear to meet criteria for ScPD (Brotto,
Knudson, Inskip, Rhodes, & Erskine, 2010), as does a subset of individu-
als found guilty of multiple sexual murders (Hill, Habermann, Berner, &
Briken, 2007). It has been suggested on theoretical grounds that ScPD
may be a precursor of violence toward self and/or others (Loza & Hanna,
2006), and ScPD symptoms have been found to be prospective risk factors
for recidivism in criminals (Hiscoke, Långström, Ottosson, & Grann,
2003). In a sample of individuals with kleptomania, ScPD was the second
most common personality disorder (after PPD) (Grant et al., 2004).
Individuals with ScPD thus appear to be at high risk for marked func-
tional and/or behavioral disturbance.

PREMORBID BACKGROUND
Childhood and adolescent major depressive disorder was found to be more
strongly predictive of adult ScPD than of any other adult personality dis-
order (Ramklint, von Knorring, von Knorring, & Ekselius, 2003). In adult
prisoners, a history of childhood institutionalization has been found to be
associated with ScPD traits (Yang, Ullrich, Roberts, & Coid, 2007).

LABORATORY STUDIES
As stated above, there are no psychological test data, genetic studies, or
neurobiological studies on ScPD itself. Such studies have been done with
samples that include patients with schizophrenia-spectrum disorders
922 TRIEBWASSER ET AL.

and/or cluster A personality disorders in general, but generally these

studies have focused on SPD as the prototypical schizophrenia-spectrum
disorder (SSD; e.g., Filbey et al., 1999; Hazlett et al., 2008; Koenigsberg et
al., 2005; Koo et al., 2006).

EPIDEMIOLOGICAL/FAMILY STUDIES
According to DSM-IV, ScPD “is uncommon in clinical settings” (APA, 1994,
p. 639). Since DSM-IV’s publication, the prevalence of ScPD in clinical
populations has been estimated as ranging from 0.0% (Molinari, Ames, &
Essa, 1994) to 11.5% (Herpertz et al., 1994), depending on the diagnostic
methods used and the nature of the sample studied. In general, struc-
tured diagnostic methods yield higher prevalence rates than unstructured
clinical assessments. The most convincing estimate of the prevalence
among psychiatric outpatients is probably that of Zimmerman and col-
leagues (2005), who found 1.4% of patients meeting criteria for ScPD and
0.3% for whom ScPD was the only personality disorder. In nonclinical
samples, prevalence estimates have ranged from 0.0%, in studies of
healthy and obsessive-compulsive controls and their relatives (Black, Noy-
es, Pfohl, Goldstein, & Blum, 1993; Moldin, Rice, Erlenmeyer-Kimling, &
Squires-Wheeler, 1994), to 3.13%, in the National Epidemiologic Survey
on Alcohol and Related Conditions, a population-based U.S. study using
lay interviewers (Grant et al., 2004). The most convincing population-
based estimates are probably those obtained by Torgersen and colleagues
(2001), who found a weighted prevalence of 1.7% in Oslo, Norway; and
Coid and colleagues (2006), who found a weighted prevalence of 0.8% in
the United Kingdom.
The heritability of ScPD itself has been estimated as .29 in a twin study
using a Norwegian clinical sample (Torgersen et al., 2000), and .28 in a
twin study of dimensional representations of the cluster A personality dis-
orders using a Norwegian population-based sample (Kendler et al., 2006).
The SSDs as a group tend to show strong familial aggregation in some
(Filbey et al., 1999; Parnas et al., 1993; Siever et al., 1990) although not
all (Kendler, Gruenberg, & Kinney, 1994) evaluations. This familial aggre-
gation, if it exists, appears not to be caused by shared environmental ef-
fects (Reichborn-Kjennerud, 2008), but may in part be secondary to a
gene–environment interaction (Tienari et al., 2004). In ScPD, the best-fit
hereditary model includes both genetic and environmental factors (Kend-
ler et al., 2007).

FOLLOW-UP STUDIES
In a 2-year follow-up study of personality disorder symptoms in older ado-
lescent psychiatric outpatients, ScPD dimensions, along with antisocial
personality disorder dimensions, showed the highest degree of stability
over time (Chanen et al., 2004). Within a stratified random community
SCHIZOID PERSONALITY DISORDER923

sample assessed for DSM-III personality disorders and then for psychoso-
cial functioning 13–18 years later, ScPD traits were inversely associated
with later Global Assessment of Functioning Scale scores, even when con-
trolling for Axis I co-morbidity (Hong et al., 2005).

TREATMENT-RELATED STUDIES
There is a marked paucity of treatment-response studies of ScPD as such
in the published literature. A low number of schizoid personality disorder
symptoms have been found to be predictive of good outcome in the phar-
macological treatment of depression (Mulder, Joyce, Frampton, Luty, &
Sullivan, 2006).
In a large epidemiological survey, ScPD has been shown to be associat-
ed with emotional disability (Grant et al., 2004). Cramer and colleagues
(2006) found an association between ScPD and poorer quality of life that
was stronger than the effect of sociodemographic variables, physical
health, or Axis I pathology. More recently, ScPD was the second most fre-
quently diagnosed personality disorder (after PPD) in a sample of clients at
an urban homeless shelter (Connolly, Cobb-Richardson, & Ball, 2008).

IMPLICATIONS FOR DSM-5

The paucity of studies of ScPD at this point cannot provide external vali-
dation for this disorder, which appears to represent a milder version of
schizotypal personality disorder without psychotic-like symptoms. Wheth-
er it will be acknowledged as a type in DSM-5 for clinical reference is un-
clear, but it does not have the empirical support that SPD has. In the
proposed DSM-5 system currently under review, ScPD traits such as so-
cial withdrawal and detachment, intimacy avoidance, anhedonia, and re-
stricted affectivity, if sufficiently severe to warrant a personality disorder
diagnosis, would be subsumed under the new “Personality Disorder Trait
Specified” category.

CONCLUSIONS
Unlike SPD, which has received substantial validation as a distinct disor-
der, ScPD suffers from a paucity of such validating data. Although ScPD
occurs frequently in clinical and nonclinical samples reported in the pub-
lished literature, it may be that ScPD’s core features often can best be
explained by other disorders that provide a more comprehensive formula-
tion of the individual’s psychological issues. There is some evidence for
ScPD belonging among the SSDs, although the empirical support for this
inclusion is not nearly as compelling as for SPD. Meanwhile, the research
community largely has avoided conducting descriptive, neurobiological, or
treatment studies in ScPD. Given these conceptual, psychometric, and
practical problems with the DSM-IV-TR ScPD construct, it seems reason-
924TRIEBWASSER ET AL.
able for DSM-5 to move away from ScPD as a categorical diagnosis and
instead to include Detachment traits as a codable dimension that can
have a substantial impact on an individual’s functioning and quality of
life, and that can moreover be a focus of treatment.
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