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Question

Difficulty: EasyPersonality Disorders

A 45-year-old night-shift security guard is evaluated at a primary care clinic for a routine employment physical. The patient reports that he lives entirely alone and spends his off-hours building intricate model ships. When the physician asks about his social support system, the patient states that he has no close friends and prefers it that way, noting that interacting with others is exhausting and uninteresting to him. He expresses no desire for romantic or sexual relationships. During the interview, he appears indifferent to the physician's attempts to build rapport and displays a flattened, detached affect. He denies experiencing any hallucinations, paranoia, or periods of depressed mood. Which of the following is the most likely diagnosis?

  1. Schizoid personality disorderAnswer
  2. B
    Avoidant personality disorder
  3. C
    Schizotypal personality disorder
  4. D
    Schizophrenia
  5. E
    Social anxiety disorder

Answer

The most likely diagnosis is schizoid personality disorder.
The correct diagnosis is schizoid personality disorder. This condition is distinguished by a pervasive, lifelong pattern of voluntary social detachment and a severely restricted range of emotional expression in interpersonal settings. Patients typically choose solitary jobs (like night-shift security), engage in solitary hobbies, show little to no interest in sexual or romantic relationships, and appear indifferent to the approval or criticism of others. Crucially, their isolation is ego-syntonic; they do not secretly wish for friends but genuinely prefer being alone.

Step-by-Step Solution

1
Analyze the patient's interpersonal preferences and social history.
The patient actively chooses to be alone, has no close friends, lacks interest in romantic relationships, and is completely content with his isolation.
Determining whether social isolation is voluntary (ego-syntonic) or driven by fear/anxiety (ego-dystonic) is the first step in differentiating personality disorders.
2
Evaluate the patient's affect and behavior during the clinical encounter.
The patient exhibits emotional coldness, a flattened affect, and indifference to praise or rapport-building.
Restricted emotional expression is a hallmark of Cluster A personality disorders, specifically schizoid.
3
Rule out psychotic disorders and other closely related personality disorders.
The absence of hallucinations, delusions, odd beliefs, and magical thinking rules out schizophrenia and schizotypal personality disorder.
Diagnostic criteria require distinguishing pervasive personality traits from acute psychotic illnesses or more eccentric Cluster A disorders.

Key Concept

Schizoid personality disorder is a Cluster A personality disorder characterized by a lifelong pattern of voluntary social withdrawal, restricted emotional expression, and a profound lack of desire for intimacy.
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Topics

Personality Disorders

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