Synopsis of the Treatment of the Isolative (Schizoid) Substance User

About 5% of dedicated substance users show a “pervasive pattern of detachment from social relationships and a restricted range of expression of emotions.” This is the DSM-V’s narrative for schizoid personality disorder. The DSM-V criteria are as follows:

• 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

Introversion and emotional cutoff are the essence of the condition. The test questions in the PSSU, rather than following the DSM criteria, are intended to be mentalizing. Millon’s “Remote Schizoid” captures the essence of these addicts. He writes that children subjected to intense family dysfunction early in life may protectively withdraw into fantasy, thereby reducing their original potential to feel and relate to the world. Those children genetically burdened with a family history of substance use will then as teens discover the wonders of drugs and will become addicted. Although opioid use is intrinsically isolating, with these users one finds, prior to the onset of drug and alcohol use, a trend toward isolation, loneliness, and fantasy. The experimental literature points out users with such schizoid phenomena tend to leave treatment earlier, relapse sooner, require higher stabilization doses of methadone, and have more problems with alcohol.

Presentations of the schizoid condition

The person with a manifest pure schizoid disorder shows most markedly the features of withdrawnness, self-sufficiency, and loss of affect. Such persons are classic loners. The secret pure schizoid person’s introversion reflects in self-sufficiency, loss of affect, and loneliness. The secret schizoid is less withdrawn, so he or she does not look at first glance like a manifest schizoid. It is secret because introversion is obscured by superficial outgoingness and the apparent lack of withdrawnness. The secret schizoid, however, has marked limits to intimacy, is unable to make a commitment, and becomes anxious when close. The pseudonarcissistic schizoid person has a preponderance of narcissism, self-reliance, and superiority. Pseudoborderline schizoid persons cling, wish to be taken care of, and show seeming borderline chaos. However, scrutiny reveals withdrawal and isolation coupled with self-sufficiency and a history of capability for self-support. They have an underlying self-image of feeling different, alienated, and cast out. Emotional cut-off, rather than the enmeshment of the classic borderline, is seen.

Schizoid phenomena are common among addicts, up to 4.1%. Users with MCMI elevation of schizoid, avoidant, and antisocial scores leave treatment and relapse earlier. Persons on methadone maintenance with MMPI schizoid features have more problems with alcohol. Schizoid patients require higher stabilization doses of Methadone. Schizoid/schizotypal personalities predispose methamphetamine users to psychosis. Emotional neglect particularly predisposes to SPD. Millon writes that children subjected to intense family dysfunction early in life may protectively withdraw.

Introversion, withdrawnness, and loss of affect

Introversion for the schizoid is the tucking away of the essential center of the self for purposes of protection and safety. This action affects every level of mental functioning, is at the heart of the outward behavior of emotional cut-off, and leads to the sense of unreachability one feels with the schizoid user. For example, a heroin addict who repeatedly failed inpatient treatment programs spoke about isolating, stating “It’s safer when I isolate, no one can hurt or touch me. I’ve become expert at it, blocking out people, it makes me comfortable to do it.” When questioned as to how he went about isolating, he replied, “I leave them behind, or lock myself somewhere, where nobody can come in, I set my mind, I don’t think about them, I don’t think about others, I blank them out. I really don’t need them for food or shelter.” This example epitomizes the mental processes of introversion, alludes to its motivation (safety), and closes with the operation necessary to keep it going (denial of the need for others). Inquiry about the “them” in the statement led specifically to his distancing from his alcoholic, abusive parents, as well as from the world in general. He had no ability to assert himself around his family. Paralysis of assertiveness is a common feature of the schizoid user.

Withdrawnness is the visible, or perhaps not so visible, outward behavior stemming from introversion. Many in any lower socioeconomic program are loners or itinerants. Most are unmarried or involved in fleeting relationships. At times withdrawnness may not be obvious. Self-sufficiency is another facet of introversion, and it derives from the denial of need of emotional support from others. Patients may explicitly state, “I don’t need anybody!” The garrulous and seeming self-assurance of other addicts implies the same message. Klein argues that a child’s premature taking on of adult responsibilities is a schizoid phenomena, a defensive attempt at self-sufficiency.

Loss of affect is practically universal among substance abusers. Introverted and self-sufficient persons have distanced themselves from self as well as others. Schizoid persons, usually with significant abuse histories, do not want to, or cannot, feel. Drinking and/or using are commonly cited as ridding oneself of feeling, or, conversely, enabling one to feel. Medical detoxification is often complicated by the emergence of painful affect. When addicted persons do feel, the feelings are invariably unpleasant — anxiety, despair, shame, remorse, and self-loathing. In practice, the taking of a history and performance of a life review often reveals that affect was a casualty of faulty parenting. Such statements as “boys don’t cry,” “if you cry, I’ll give you something to cry about,” “adults are always right (and by inference, kids are always wrong),” and “I’m beating you for your own good” all serve to engineer the repression of affect. Klein points out that schizoid and post-traumatic states can be difficult to distinguish and can co-occur. Chronic repeated trauma, coupled with the inevitable emotional unavailability inherent in abusive families, can lead to a profound introversion spawning all the signs and symptoms of SPD in an addict.

Loneliness is the price paid for the safety of introversion and withdrawal, and further fuels the vicious circles of substance abuse. Loneliness is a sign that the person misses relationships and longs for them. This fundamental human need is always present in the schizoid addict, however much such need is denied. The schizoid is faced with the dilemma of isolating and finding safety, on one hand, or reaching out but running the risk of attack or enslavement, on the other. He or she pays the price of loneliness if isolation is chosen. Klein calls this the “schizoid dilemma.” The classical schizoid resorts to fantasy as a compromise; the substance abuser turns to chemicals. Klein calls this the “schizoid compromise.” Paradoxically, chemicals worsen isolation and increase loneliness.

The self-in-exile

The process of introversion is the central theme of the schizoid, running counter to the natural state of persons to be involved. Although the schizoid person has been driven into exile, he or she comes to embrace introversion as protective. Schizoid patients repeatedly describe childhoods marred by dysfunctional and chemically dependent parents, physical and/or verbal or sexual abuse, or neglect, or having one or more narcissistic parents who were intensely devaluing. A consistent finding is of having been beaten with a belt; this slashed through the child’s defenses and instantaneously drove him or her into exile. The “Adult Child of Alcoholics” Syndrome is common. Neglect was a hidden trauma, contributing to feelings of loneliness, worthlessness, and unlovability. All these traumas established introversion, the self-in-exile. As the person began to embrace introversion as a place of safety, it became ego-syntonic.

Once the child resorted to introversion to feel safe, the next step was to defensively reject the vulnerable impoverished self, the self-in-exile, because that self embodied the basic human trait of need. In other words, the child vowed never to need anybody, that no one would ever be allowed to hurt him/her again. To remain in communion with the self that needs is to be vulnerable. To not need is to become invulnerable. An inner need-fear dilemma is thus created; allowing oneself to need creates vulnerability and hence fear. There is a terrible price to be paid, however, for amputating one’s need; the act cuts off one from one’s self.

The person is also caught in an external bind, in what Klein calls a “schizoid dilemma,” from which he or she tries to escape with a “schizoid compromise.” In a schizoid dilemma, a person can isolate and withdraw and feel safe but must pay the price of loneliness. Or, he or she can engage and interact but face the seeming inevitability of criticism, attack, or, the greatest fear, slavery and the appropriation of the self. Conspicuously absent in this reasoning is the option of self-assertion. The schizoid dilemma is itself a defense, a projection outward, away from the painful, impaired sense of self, to either the safety of introversion, or to the critic, the enslaver, the appropriator. Finding neither loneliness nor anticipated attack acceptable, and totally unable to self-assert, the classic schizoid resorts to fantasy, the “schizoid compromise.” For the substance using schizoid, chemicals take the place of fantasy and become the compromise. Patients consistently report that drugs fuel fantasy. Conventional wisdom has it that patients walk out of treatment programs prematurely because they haven’t hit bottom, or still harbor the desire to use, etc. Could it be that a percentage of such persons are schizoid and fear enslavement in the milieu, but can’t bear to be isolated (in exile), so resort to the compromise of leaving and using?

Case example

A 37 year-old opiate dependent man in a residential treatment center complained of depression, anxiety, suicide attempts, and multiple psychiatric hospitalizations. He had suffered extreme physical abuse as a child. The CDDS also showed elevated scores on the schizoid, narcissistic, and borderline scales. He had successfully detoxed and settled down in the residence, but inquiry about how he was getting along with others revealed that he became irritated if someone wanted him to do something with them. “I’m doing my own thing, in my own space, but someone who is bored wants something from me, and I snap.” Together, we sorted out that his history of physical abuse had engendered introversion, where he could withdraw and feel safe. He had retreated into fantasy as a child, and then found drugs in his early teens. He stated, “When someone wants something, I feel I’m being recruited.” He remarked that he was capable of self-assertion and saying “no;” what really annoyed him was his perception of the other person’s intent. Interpretation of his schizoid dilemma and clarification of how he was mentalizing (and often misconstruing) others’ intentions was a revelation to him.

The schizoid pathway

Figure 1. From abuse and neglect to teenage substance abuse — the schizoid pathway.