by Michael D. Anestis, M.S.
In the early weeks of each semester, as I am teaching Abnormal Psychology to undergraduates, I almost invariably encounter at least one student who raises concerns that our system of classifying mental illnesses simply places labels on people for being different. This is, of course, an important question to consider. After all, if our helping profession is simply placing scarlet letters on people who are different from the norm, we would not be accomplishing anything remotely similar to our purpose. I assure each student, however, that this is not the case for a number of reasons. First of all, mental illnesses are required to not only represent a difference from the norm, but also a source of distress and/or impairment. In other words, due to the symptoms that comprise the diagnosis, the individual is chronically upset and/or unable to function effectively in his or her life. If the individual is not experiencing distress and/or impairment as a result of the symptoms, a diagnosis is not warranted. Additionally, I point out, diagnoses serve an important clinical and scientific function, as they allow us to ensure that we are all discussing the same concept when we study and treat clients. In other words, diagnoses are not labels intended to merely classify people into groups, but rather a method by which we can ensure that everyone has the same understanding of the manner in which symptoms cluster together and through which we can develop databases of information on the course, severity, and effective treatment for particular constellations of symptoms. Much like specifying the type and nature of cancer is intended to inform treatment rather than to simply label an individual a particular type of cancer patient, mental illness diagnoses are used to perform a function that has nothing to do with simply declaring an individual to be different.
All that being said, there is one disorder covered in my course each semester that always leaves both my students and me a bit concerned that the DSM is forgetting its own definition of mental illness: schizoid personality disorder (SZD). SZD is included in the Cluster A personality disorders, which are theorized to be a part of the schizophrenia spectrum, although the relationship between SZD and schizophrenia is supposedly weaker than the relationship between schizotypal personality disorder and schizophrenia. The DSM-IV-TR defines SZD as follows (p.697)
(A) A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
- Neither desires nor enjoys close relationships, including being part of a family
- Almost always chooses solitary activities
- Has little, if any, interest in having sexual experiences with another person
- Takes pleasure in few, in any, activities
- Lacks close friends or confidants other than first-degree relatives
- Appears indifferent to the praise or criticisms of others
- Shows emotional coldness, detachment, or flattened affectivity
(B) Does no occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder and is not due to the direct physiological effects of a general medical condition
So, according to the DSM, individuals with SZD are characterized by a lack of interest in maintaining close relationships with others. They are not anxious about interacting with other people or concerned that they will not be accepted - such symptoms are more closely associated with social anxiety disorder, avoidant personality disorder, and paranoid personality disorder. Additionally, they are not theorized to lack the ability to interpret the non-verbal communications of others and thereby hindered in social interactions, a trait better associated with autism spectrum disorders. They simply do not have any interest in relating to other people. Keep in mind, there is also no evidence that these individuals experience elevated rates of depression as a result of social isolation.
When I think about this disorder, I have a hard time understanding it. After all, who can imagine a life in which we simply do not have any interest in close connections with other people unless we are already depressed or are fearful of others' perceptions of us? An important point to consider, however, is that living in a manner that is difficult to understand or relate to is not grounds for a diagnosis of a mental illness. Personally, I have a similarly difficult time understanding how anyone could live without Pittsburgh sports teams, television, or Kraft macaroni and cheese (forgive me on that last one), but I do not think that individuals who lack interest in these valued resources are mentally ill. Certainly interpersonal relationships are a more pivotal aspect of most individuals' lives and a key component of the evolution and continued existence of our species, but this again does not necessarily speak to the idea of distress and/or impairment.
You may have noticed the complete lack of citations mentioned thus far in this article. This is not due to a lack of interest in the research on my part, but rather a complete dearth of data on this disorder. A quick search for "schizoid personality disorder" or simply "schizoid" will result in a multitude of articles in psychoanalytic journals, none of which include empirical studies. Instead, these are case descriptions of theories based upon psychoanalytic principles rather than an objective evaluation of data accumulated through scientifically sound experiments or epidemiological studies. We know so little about this disorder that the DSM lists its prevalence as "uncommon in clinical settings." That's right...they couldn't even provide a range of numbers because so little is known on the matter. In 2004, Bridget Grant and colleagues published a study in the Journal of Clinical Psychiatry that reported on rates of specific personality disorders in the general population in the United States. That study indicated that 3.13% of Americans meet criteria for SZD, although that number has not been replicated elsewhere.
Considering all of this information, all we know about this disorder is that it appears to be relatively rare, at least in help-seeking populations, and that it is characterized by a lack of interest in a component of life that is typically indispensable to others. Given that no studies have linked SZD to elevated rates of depression, anxiety, suicide, or any other maladaptive outcome, however, it remains unclear why this is considered a personality disorder rather than a personality type. What would the goal of treatment be - to make individuals with SZD be interested in interpersonal relationships? Is therapy to change somebody's interests if those interests do not cause distress and/or impairment even ethical and, if it is, is it feasible? Certainly, SZD is theorized to be associated with schizophrenia, but striving for difficult to attain goals is associated with anorexia nervosa and we do not diagnose "ambitious personality disorder." Only when ambitions cause distress and/or impairment are they seen as problematic.
I'm curious to hear what readers think about this situation. What do you think about this diagnosis? Is it reasonable to keep this in the DSM or does it need to be altered in a particular manner in order to ensure that it truly qualifies as a mental illness?
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