Mister D. had a normal childhood with normal attachments to his parents.

He had friends up to
the tenth grade. Going into his senior year in high school in the late 60s, Mister B. was happy
and looked forward to University College. He was an excellent student. However, he was small,
shy, nerdy and sometimes teased by other students. In this senior year, he developed a kind
of depression which lasted the entire year. The cause of this depression is unclear. He spent
most of his spare time in my room and he sometimes wept. After graduation, his depression
was gone and he left home to study mathematics and electric engineering (he finished both
studies successfully) with basically the same temperament he has today. Since then he did not
weep again. He did have a quick temper that developed in his twenties. He did curse loudly
and sometimes at himself if he made a stupid mistake. His temper improved when he became
older because he got more insight into human nature. For example, small talk was particularly
difficult for him to understand in terms of why people did it. When he was in his early forties,
he finally became aware that people might actually enjoy small talk. He realized that small talk
is only satisfying if we think that the other person is paying attention to and responding to
what we are saying and he discovered that attention is a basic human need. Nowadays, he still
does not have any need for attention, but at least he makes an effort to reciprocate the
greetings or gestures of others although he still try to avoid small talk of more than a few
minutes. When he is engaged in conversation, people aren't likely to see from him much
humor, enthusiasm, passion, affection, or sympathy. He is unable to convey a genuine sense
of joy in seeing a person again and in wanting to talk about what's new.

He is not able to enjoy life as much as other people do. Even his most intense feelings of
"ecstasy" are not very intense and they don't last very long. He has these levels of subdued
emotions for almost 40 years now (since he was 18). There is an emptiness, a lack of interest,
and a lack of caring. He reported that it's like being dead inside. He demonstrates a lack of
enthusiasm that manifests itself not only in a lack of effusiveness, but also in a lack of action.
His inability to be passionate about anything has affected his views about what's important in
life. He never had a meaning-of-life pursuit and he never been very passionate about any
particular activity or belief.

Not being able to enjoy life was linked to limitation of his basic needs over the years. He had
only worked about half of his adult life and only fifty percent of the time. This was easy since
he had never had that much enjoyment in spending money. So when he was working, he
accumulated tons of money that are now in bank accounts. All that he presently owned is
stored either in his 5 by 5 foot storage locker, his car, or his workplace cubicle. He owns a
seven-inch black-and-white TV and no audio CDs or DVD movies. Sometimes he watches DVDs
at the library. The closest thing he has to a hobby is tinkering with electronics that he buys at
the flea market. He never had any desire to participate in any sports or outdoor recreational
activities or to travel and see the world. He never had any desire to own real estate. After his
landlady passed away 7 years ago, he decided to live in his car temporarily until he found a
new place to rent. But he concluded that living in his car was just as comfortable as living in
his previous, so he lives in his car ever since.

His sexual needs seemed to be stuck in that pre-adolescent stage. He has some feelings for
members of the opposite sex, but the feelings are not strong enough to do all the work
necessary to court the other person, or to make himself physically more attractive. Over the
years, he did not care that much about the appearance or health. He hardly visited a dentist
(he lost most of his tees) or a doctor over the years.

His father and brother passed away in recent years but he did not attend their funerals (fear of
flying had something to do with this also). But he did not feel much grief in losing a father and
brother, and he did not feel much guilt for not going to the funerals. He reported, he had never
had a generally hostile attitude towards others. He could not remember the last time he loved
or hated anyone or that he felt seriously guilty or shameful about something.

With no emotional attachments to others for the last 40 years and no rewards in social
interactions, he experienced no motivation to learn how to recognize and respond to the
feelings of others. His disorder might be triggered by lasting depression during his
adolescence.

References

1. Martens WHJ. Schizoid Personality Disorder - The multiple Determinants of Unbearable and
Inescapable Loneliness and Associated Character Disturbance. Eur J Psychiatry 2010; 24(1):
38-45.

“Mr. J” is a 65-year-old Caucasian man with no prior psychiatric history, history of

chronic obstructive pulmonary disease, and a benign vocal cord lesion. He was
brought to the emergency department by police for concerns of psychosis and
delusions. Records stated that the “patient is delusional, in a state of acute
psychosis, easily agitated.”

Upon initial contact with the emergency department psychiatrist, the patient
reported feeling that the staff at the hospital were against him. He reported never
having seen a psychiatrist before, although he reported having been on a selective
serotonin reuptake inhibitor in the past to help equilibrate his “serotonin levels.” He
did not fully cooperate with the interview, was guarded and evasive, and often said,
“You don’t need to know.” His mental status examination was notable for
disorganized process and paranoid content. During the latter part of the
assessment, the patient became loud, intrusive, and agitated. He pounded his cane
on the ground and threw it to the floor in a threatening manner.

He requested discharge but would not elaborate on a safe discharge plan nor allow
his family to be contacted. He declined voluntary inpatient hospitalization and
threatened to sue the emergency department psychiatrist if he were to be
involuntarily committed.

The patient was involuntarily admitted to the inpatient unit due to aggressive
behavior and risk of harm to others. He remained at the hospital for 15 days. During
the initial part of his stay, he was easily agitated, displayed verbal aggression,
exhibited paranoia, and refused treatment. He would not engage in conversation
with most team members, with the exception of a medical student on the team to
whom he reported paranoid ideations about various family members and friends.
He was suspicious and mistrustful of the treatment providers and mostly focused
his conversations on legal issues. He claimed that he was being held in the hospital
illegally and threatened to sue the providers for holding him against his will.

He reported being estranged from most of his family since his wife’s death. He
stated that his daughters “did not understand him.” Very reluctantly, he gave
permission for one of his daughters to be contacted. His daughter described him as
always being an “eccentric and distrustful person.” She described incidents in the
past in which he had held beliefs about others “being against” him, resulting in
isolation from friends and family. She described him as someone who “often held
grudges and for a long time.” She reported a chronic pattern of behavioral
problems, aggression, strained relationships, and suspicious thinking. She also
described his behavior as worsening recently. Additionally, the patient reported
increasing use of cannabis and synthetic cannabinoids over the past few years;
indeed, the frankly disorganized thought process he displayed during his emergency
department assessment and the initial part of his hospital stay was most consistent
with intoxication in that it resolved early on without medication, but his paranoia
lingered.

Mr. J continued to refuse treatment, and thus a medication commitment was

pursued. Following court approval, he was started on olanzapine (10 mg q.h.s.) and
gradually uptitrated (to 20 mg q.h.s.). He subsequently remained medication
compliant and tolerated the medication well while showing gradual improvement in
his disorganized thought process. Initially, he displayed angry outbursts that
precluded meaningful discussions about discharge planning. However, he
eventually became calm enough to develop a safe discharge plan. At the time of
discharge, he was calm and cooperative and denied all psychiatric symptoms.
Nevertheless, he continued to be mistrustful of providers and continued to report
paranoid ideations about family members. The patient’s final diagnosis was
cannabis-induced psychosis with intoxication, with underlying paranoid personality
disorder.