P101. Schizoid Personality Disorders
Individuals with schizoid personalities exist on a range from high-functioning to deeply disturbed. They are highly sensitive and reactive to interpersonal stimulation, to which they tend to respond with defensive withdrawal. They easily feel in danger of being engulfed, enmeshed, controlled, intruded upon, and traumatized, dangers that they associate with becoming involved with other people. On the anaclitic-introjective dimension, they are firmly at the pole of introjection and self-definition. They may appear notably detached, or they may behave in a minimally socially appropriate way while privately attending more to their inner world than to the surrounding world of human beings. Some schizoid individuals withdraw physically into hermit-like reclusiveness; others retreat in more psychological ways, to the fantasy life in their minds.
Although seriously schizoid individuals may appear to be indifferent to social acceptance or rejection, to the extent of having quirky characteristics that serve to put others off, this putative indifference may have more to do with establishing a tolerable level of space between themselves and others than with ignorance of social expectations. The DSM distinguishes between schizoid and schizotypal personalities, indicating that the latter is characterized by cognitive or perceptual distortions and marked eccentricity or oddness. Research has not demonstrated that schizoid and schizotypal personalities are qualitatively different; schizotypy, or the combination of quirky qualities with rather magical thinking, seems to be a trait rather than a type of personality, one that can be associated with schizoid personality and also some other personality types (Shedler & Westen, 2004).
Schizoid individuals are often characterized as loners and tend to be more comfortable by themselves than with other people. At the same time, they may feel a deep yearning for closeness and have elaborate fantasies about emotional and sexual intimacy (Doidge, 2001; Guntrip, 1969; Seinfeld, 1991). They can be startlingly aware of features of their inner life that tend to be unconscious in individuals with other kinds of personality, and they consequently may be perplexed when they find that others seem to be unaware of aspects of themselves
that to the schizoid person seem obvious. Contrary to appearances, clinical experience does not support the notion that some schizoid people are completely content in their isolation; in psychotherapy, even extremely withdrawn schizoid individuals have eventually revealed a longing for intimacy, and this observation has been borne out by empirical research (Shedler & Westen, 2004).
Nor does clinical literature support the DSM contention that schizoid individuals rarely experience strong emotions (Shedler & Westen, 2004, p. 638). Rather, they often feel pain at a level so excruciating as to require their defensive detachment in order to endure it. They do well in psychotherapies that both allow emotional intimacy and respect their need for sufficient interpersonal space. They may communicate their concerns most intimately and comfortably via metaphor and emotionally meaningful references to literature, music and the arts.
Contributing constitutional-maturational patterns: Highly sensitive, shy, easily overstimulated
Central tension/preoccupation: Fear of closeness/longing for closeness
Central affects: General emotional pain when overstimulated, affects powerful they feel they must suppress them
Characteristic pathogenic belief about self: Dependency and love are dangerous
Characteristic pathogenic belief about others: The social world is impinging, dangerously engulfing
Central ways of defending: Withdrawal, both physically and into fantasy and idiosyncratic preoccupations
P 102 Paranoid Personality Disorders
Paranoid personality disorders may be considered as among the more severe personality disorders, found at the borderline level of organization, though it is possible that higher-functioning paranoid individuals exist, but are not often seen clinically (given the paranoid person's problem with trust, he or she has to be suffering greatly to seek help). Paranoid psychology is characterized by unbearable affects, impulses, and ideas that are disavowed and attributed to others, and are then viewed with fear and/or outrage. Paranoid psychologies are on the introjective, self-definition end of the continuum from relatedness to self-definition.
Projected feelings may include hostility, as in the common paranoid conviction that one is being persecuted by hostile others; dependency, as in the sense of being deliberately rendered humiliatingly dependent by others; and attraction, as in the belief that others have sexual designs on the self or the people to whom one is attached (for example, in the common phenomenon of paranoid jealousy or the syndrome of erotomania). Other painful affects such as hatred, envy, shame, contempt, disgust, and fear may also be disowned and projected. Although this disorder is described in somewhat one-dimensional ways in the DSM, persons with paranoid personality disorder have complex subjective experiences. Because pathologically paranoid individuals tend to have histories marked by. felt shame and humiliation (Meissner, 1978), they expect to be humiliated by others and may attack first in order to spare themselves the agony of waiting for the "other shoe to drop," the inevitable attack from outside. Their expectation of mistreatment creates the suspiciousness and hypervigilance for which they are noted, attitudes that sadly tend to evoke the humiliating responses that they fear. Their personality is defensively organized around the theme of power, either the persecutory power of others or the megalomanic power of the self.
Paranoid patients tend to have trouble conceiving that thoughts are different from actions, a belief possibly encouraged because in their formative years, they were criticized or humiliated for attitudes rather than behavior. Some clinical reports suggest that they have experienced a parent as seductive or manipulative and are consequently alert to the danger of being exploited in a seductive way by die therapist and others. They exist in an anxious conflict between feeling panicky when alone (afraid that they will be damaged by an unexpected attack and/ or afraid that their destructive fantasies will damage or already have damaged others) and anxious in relationship (afraid that they will be used and destroyed by the agenda of the other).
Therapeutic experience attests to the rigidity of the pathologically paranoid person (Shapiro, 1981). A therapist's countertransference may include strong feelings that mirror those that the paranoid person disowns and projects, such as becoming afraid when a patient expresses only the angry aspects of his or her emotional reaction and shows no sense of personal vulnerability or fear.
The clinical literature emphasizes the importance of maintaining a patient, I matter-of-factly respectful attitude, the communication of a sense of strength (lest paranoid patients worry unconsciously that their negative affects could I destroy the therapist), a willingness to respond with factual information when I the paranoid patient raises questions (lest the patient feel evaded or toyed with), I snd attending to the patient's private conviction that aggression, dependency and sexual desire and the verbal expressions of any of these strivings—are inherently dangerous. It is best not to be too warm and solicitous, as such attitudes may stimulate a terror of regression and consequent elaborate suspicions about why the therapist is "really" being so nice.
Contributing constitutional-maturational patterns: Possibly irritable/ aggressive
Central tension/preoccupation: Attacking/being attacked by humiliating others
Central affects: Fear, rage, shame, contempt
Characteristic pathogenic belief about self: Hatred, aggression and dependency are dangerous
Characteristic pathogenic belief about others: The world is full of poten¬tial attackers and users
Central ways of defending: Projection, projective identification, denial, reaction formation
