Case Study Schizoid Personality Disorder Cluster A Personality Pathology


Dr. Todd Grande


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welcome to my scientifically informed insider look at mental health topics if you find this video to be interesting or helpful please like it and subscribe to my channel Lois's doctor grande today's question asks if I can analyze a case study involving schizoid personality disorder so a case study is when a clinician documents their experiences in treating a client and they do this with the clients consent sometimes case studies are referred to as clinical vignettes or case reports so essentially it's a report that has the clients presentation what treatments were attempted and how the client responded to the treatment as well as other related information these reports are typically used for educational purposes and sometimes they are used for forensic purposes as well the reports can be transmitted in a number of different ways for example published in a journal published in a book that contains many case studies were presented at a training the case study I'm using for this video today was published in a journal and we also see a response to the original publication was published as well I've included the references for both of those articles in the description for this video so first let's start with the definition of schizoid personality disorder we see that this is a cluster a person I disorder so the odd eccentric cluster it's in the same group as paranoid and schizotypal personality disorders now in terms of the symptom criteria that we see in the DSM we see that there are seven symptom criteria and at least four have to be endorsed for a diagnosis so looking at these criteria we see the individual neither desires nor enjoys close relationships including being part of a family they almost always choose solitary activities they have little if any interest in having sexual experiences with other people they take pleasure and few if any activities they lack close friends or confidants other than first-degree relatives they appear indifferent to praise or criticism and they show emotional coldness so they appear to be detached and have a flat effect the five factor model personality profile associated with this disorder would be a high level of open to experience low conscientiousness low extraversion low agreeableness and low neuroticism so we see this disorder is conceptualized as somebody really being indifferent unresponsive to social stimuli detached being a loner being self-sufficient a tenancy be passive we see a rigid and persistent resistance to exterior influences and an unwillingness to make changes so it's not surprising that many people with this disorder are resistant to psychotherapy they don't like to come into therapy and they don't seem to necessarily benefit from it too often because of this not a lot of clinicians have experienced treating schizoid person is order so what are the risk factors for the development of the disorder well being male having extremely low extraversion a history of schizophrenia or schizophrenia like symptoms and family members a parental lack of affection and parental hostility so before I get into the actual clinical vignette I want to point out something important about this particular case this case was presented as an example of course of schizoid person is order but when looking at the details of them in yet the clinical picture becomes much more murky and I'll expand on this more after I talk about the actual case with all case studies names are changed and some details are changed to protect identities so the client in this clinical vignette is a 41 year old male I'll refer to him as Bruce he was brought in a treatment by his priests and other members of his religious community the first time he was treated for mental health symptoms was 15 years before he came into treatment before he came into the treatment that was documented here in this report so Bruce's primary complaint was that he had feelings of depression that he had been coping with for about six months he also had feelings of frustration obsessive ideas regarding a recent relationship failure limited suicidal ideation and depersonalization in session he manifested anger outbursts and made threats directed to other people he blamed for a situation so we see he's demonstrating a lot of emotionality and already this kind of strikes me as unusual for what we typically see with schizoid person is were now Bruce appeared to have a disregard for his personal hygiene he had poor eating habits he also didn't manage his financial responsibilities well he was having some trouble with being absent work and he had missed a full semester of his college classes now looking a bit at his early history we see Bruce's mother was a single 30 year old art teacher when she had him she was never involved in raising him instead he was brought up by his grandparents Bruce never met his father he described his mother as lacking any affection or care for him he also indicated that she was dreamy which kind of relates to openness to experience introverted passive and lacked emotions he seemed to have a good relationship with this grandmother but she died when he was only 7 years old so his grandfather really played a key role in his upbringing he also had an uncle on his grandmother's side that was influential in his early development both his grandfather and his uncle were army officers and they impressed upon him the importance of respecting Authority and following militaristic rules and norms when Bruce was 24 years old his mother died at the time he was being treated which was around 2009 he had no living relatives when Bruce was considering his educational options he went through a period of time trying to side between the fields of theology engineering and medicine and yet after all that he ended up studying economics he had some difficulty in school but he did graduate I'm guessing that when they say that he graduated that he had a bachelor's degree or something close to that he had a number of difficulties in the workplace and was demoted several times for failing to follow the rules and he also got in trouble for his poor personal hygiene eventually his employer set him up working in an office alone and of course this is highly consistent with schizoid personality disorder Bruce returned to school to study electrical engineering at the time of intake he was in his third year Bruce lives alone has never had a meaningful friendship and was not in a romantic relationship at the time that he came in for intake he also had no children most of his interest were solitary he tended to avoid people with whom he worked as well as neighbors and members of his religious community after work he would walk outdoors occasionally hugging trees and feeling a sense of communion with nature he described unusual experiences that he had during a time when he was highly interested in Oriental philosophies and spirituality later he would consider these beliefs to be sinful now Bruce did have several prior romantic relationships but only one of them lasted for more than just a few months when he reported these relationships to the clinician we see that no emotional content was included and he often presented that he had very high expectations of his romantic partners in terms of their personal hygiene their appearance and their social and cultural values which is interesting considering his poor personal hygiene and his apparent disregard for his appearance I'm not sure exactly what they met when they said high expectations of social and cultural values perhaps it's a reference to morality like he expected them to be highly moral we don't really get a lot of clarity on this part from this case report either way though we see a lack of insight here on his part now the one relationship that lasted a little bit longer and went on for six months he believed he was going to marry that girlfriend and their breakup was a source of frustration for him interestingly it was his decision to break off the relationship and he did so because they had different religious beliefs and he believed there are problems with her health it turns out there were actually no problems with her health by the time Bruce made it into treatment he regretted the decision to break up with his girlfriend and was upset because the woman would not speak to him anymore he obsessed over her and refused to accept that the relationship was actually over now Bruce didn't accept responsibility for his own actions and he even blamed a priest that had given him some advice but it's not clear if there's any advice here directly about this relationship that was given to him now after his intake at this agency he discontinued treatment after 10 days without really seeing any improvement four months later members of his church brought him back to the agency his presentation was even more severe by this point he once again discontinued treatment eventually his symptoms grew worse and he ended up being committed to a psychiatric hospital for an extended period of time so what do I think is going on in this case with Bruce so let's break this down by using the symptom criteria for the disorder the ones I mentioned before so from that we can try to figure out if he really did have schizoid personality disorder so again kind of going through the criteria if we look at the one about not desiring or enjoying relationships he did want a relationship that's one of the main reasons he came in for treatment so he did not meet this symptom criterion we see the always choosing solitary activities he did appear to endorse this one he ended up working in a job where he was always alone in terms of the little interest in sexual behavior he discussed this topic with the clinicians I don't think he met this criterion looking at taking pleasure and few if any activities it did seem like he enjoyed some activities he studied economics and engineering he enjoyed taking walks so I don't think he met this criterion in terms of lacking close friends or confidants this one does appear to be endorsed appearing to be indifferent to the praise of criticism of others I'm not convinced he really meets this criterion we don't see a lot of information specifically about this criterion and the case report and in the last criterion being emotionally cold and detached the case report really alludes to this a little bit so I'll say this one's endorsed but it's not really perfectly clear so he appears to meet three of the seven symptom criteria and again at least four are required I suppose an argument could be made that there's another criterion that's met here but if I had to say one with the other I'd pileinn on the side of no he doesn't seem to have schizoid personality disorder he certainly has schizoid personality features he also did seem to kind of lack a direction when it came to certain goals which is consistent with schizoid person is or it's not one of the symptom criteria but again it seems to be associated with the disorder but even still again not actually convinced he had the disorder some points that really stand out here when we look at this case report we see the genetic influence the mother's behaviors described in a way that is somewhat similar to Bruce's behavior one of the things that really struck me early on here was the idea that he had several romantic partners before having the girlfriend that he was with for six months all this is really inconsistent with schizoid personality even the idea that he had one romantic relationship I think would be somewhat inconsistent with the disorder now as five factor model is fairly consistent with the disorder except for neuroticism Bruce appears to have high neuroticism and of course with schizoid personality disorder we would expect low neuroticism this is an important trait to have misaligned higher neuroticism is something we just don't see very often at all with schizoid personality disorder we see that Bruce reported unusual experiences when studying oriental theology it would have been nice to have more information here in the report what were these unusual experiences like were they similar to the unusual perceptual disturbances that we would see with schizotypal personality disorder again it's not really clear here more information would have really cleared that up and I think would have been important considering that schizoid schizotypal are in the same cluster now the obsession with a romantic partner the refusal to accept responsibility for the end of that relationship this is inconsistent with schizoid personality disorder it's more consistent with borderline personality features now with Bruce we see someone who's stuck in an approach avoidant conflict right so he wants to approach and he wants to avoid at the same time this is referred to as being actively avoidant we would expect to see this with avoidant personality disorder with schizoid personality disorder we would expect to see somebody who's passively avoidant we also see this unusual behavior we had these high expectations of his romantic partners regarding their personal appearance when he really wasn't concerned about his this is more consistent with obsessive compulsive personality disorder or maybe narcissistic personality than is with schizoid person a leader now whenever reviewing a case report it's always important to keep in mind the potential bias that the clinicians making the report may have had so what I mean by that is it's not clear to what extent the clinicians who are making the report saw a few schizoid personality features and that really formed their lens which distorted their interpretations of his behavior from that point on so another way of putting this would be that they may have developed confirmation bias they theorized that they were seeing schizoid personality disorder and they found evidence that supported that I don't know if that's the case here of course it's just something to be on the lookout for whenever looking at a case study now there was some indication that he might have obsessive-compulsive personality in addition to or instead of schizoid personality for example we see the strong influence of the grandfather in the uncle who strictly followed rules and made sure that he followed rules too we see this obsession with perfectionism failing to tolerate the flaws of romantic interest we see breaking up with the girlfriend partially because of a difference in religion now I know this happens fairly often and it doesn't mean somebody has OCPD of course but it could still point to obsessive-compulsive personality features depending on how its framed if he looked at the girlfriend's religious beliefs as violating rules that could not be broken like if he had this idea that her religious beliefs were evil that would point a little bit more toward OCPD as opposed to just looking at the religious beliefs as incompatible Bruce also seemed to be stubborn and rigid in his thinking again refusing to accept that his girlfriend rejected him so that points a little bit toward OCPD so this is a complex case and that's actually indicated in the title of the article the clinicians who wrote this report recognized how complex it was whenever you're dealing with case studies you always really have the same limitations am i seeing a complete record of what happened with all the treatment and everything else of course not that can never happen that would be hundreds of pages to report that am i seeing enough get a clear clinical picture it's hard to tell that the clinicians draw conclusions early and then look to support it like I talked about before that's also hard to tell based on what I see in this report my best guess would be other specified personality disorder so I would list features of schizoid and obsessive-compulsive as well as a few features of avoidant borderline narcissistic and schizotypal personality disorders his presentation really isn't best described categorically to appreciate the complexity of this presentation the dimensional model works better he has features from a number of different personality sorters which is actually really not that unusual so whether Bruce had schizoid personality disorder or not this case really points out the need for careful assessment and the difficulty we sometimes encounter when trying to figure out what's going on in terms of personality pathology so those are my thoughts on this case study I know whenever I talk about topics like this there will be a variety of opinions please put any opinions or thoughts in the comment section they always generate a really interesting dialogue as always I hope you found my analysis of this topic to be interesting thanks for watching