Psychiatry and Behavioral Health Rotation

Patient will present as → a 30-year-old male presents to his new primary care provider for an annual physical, accompanied by his sister who reports concern about his “social withdrawal.” The patient has no current complaints and only agreed to come after significant urging. He is quiet, reserved, and provides minimal eye contact. When asked about his mood, relationships, or interests, he responds flatly that he prefers to be alone and has never had close friends or romantic relationships. He denies depressed mood, suicidal ideation, hallucinations, or paranoia. His affect is constricted, and his speech is brief but coherent. He describes no desire for emotional or physical closeness and spends most of his time reading and walking alone. This presentation is consistent with schizoid personality disorder, characterized by detachment from social relationships, restricted emotional expression, and a preference for solitary activities. Unlike avoidant personality disorder, patients with schizoid traits do not desire close relationships or fear rejection. He does not meet the criteria for schizophrenia, as there are no psychotic symptoms such as hallucinations or delusions. Management is primarily psychotherapeutic, though patients are often reluctant to engage in therapy. If willing, cognitive-behavioral therapy may be beneficial to develop social skills and improve functioning. Pharmacologic treatment is not indicated unless comorbid depression or anxiety is present. The patient is offered supportive therapy and a follow-up appointment to further explore his goals and needs.

Key Points:

Patients tend to have emotional aloofness, indifferent to praise or criticism, without bizarre or idiosyncratic thinking

• Exhibit voluntary social withdrawal 
• Content with social isolation (vs avoidant)
• Limited emotional expression
• No association with schizophrenia

DSM-5 Diagnostic Criteria

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, if any, activities.
• Lacks close friends or confidants other than first-degree relatives.
• Appears indifferent to the praise or criticism of others.
• Shows emotional coldness, detachment, or flattened affectivity.

Is not attributable to another medical condition; does not occur in the setting of schizophrenia, manic depression, autism spectrum disorder, or another affective disorder with psychotic features.

Treatment is often challenging, as patients rarely seek help; psychotherapy (particularly supportive therapy) may help improve social functioning if the patient is open to it

• Pharmacologic treatment is not routinely indicated, but may be used if comorbid depression or anxiety is present