The Case of Dom Schizoid Personality Disorder

Dom D. came to the United States as a young boy, together with his parents and two older brothers. They settled in a large metropolitan area where his father worked as a skilled laborer in a factory and his mother as a homemaker. Dom was an easy child for his overwhelmed mother to raise. While she counted on her older sons to ease her way in this new country, she relied on Dom to help her with domestic chores, which he did dutifully, if not willingly. He did not appear to anticipate or even to react to his mother's expressions of sadness or explosions of anger—but he did do what he was told and never appeared especially concerned or moved to exhibit emotional responses, whether of happiness, sadness, irritability, or anger.

He attended school regularly but was an indifferent student. He did not relate to his teachers or to the other students. His work was most often minimally executed, without any reflection of what he thought or felt inside. On the playground, he typically stood off to the side, not showing much interest in what the other children were doing. It was as if the whole concept of play was extraneous and foreign to him. On those occasions when participation in team sports was required, he was often the last one chosen to be on a team. This was less because others viewed him uncoordinated (which he was not), but more because he was unknown, making the other children feel uncomfortable in his presence.

When he became a student in a large city high school, Dom became even more invisible. When he dropped out of school shortly after his 16th birthday, few noticed or cared. It was as if the enthusiasm, passion, and self-presence lacking in him was reflected in his lack of connection to and effect on others.

His mother was aware that he was very different from her two older boys. They were good students and had been energetic, ambitious, and occasionally volatile adolescents. Each had moved on to a community college, and the eldest was completing a bachelor's degree at a university. After Dom dropped out of school, his mother could no longer provide him with enough chores to keep him from appearing idle to her. To complicate matters, he was not willing to do things that required socializing, or even more than the briefest communication with others. In time, she appealed to her husband to use his connections through his job to provide Dom with a position and a future.

The father knew very little about his sons. He had never been involved with the children, leaving that to their mother. He worked very hard, often doing double shifts at the factory, to support the family. He considered his hard work to be good enough parenting. When he allowed himself time for his own pleasure, it was with one or two coworkers from the plant. He was neither abusive nor demanding of his wife or sons, nor did he offer them much beyond financial support. He was both proud and resentful of his "college boy" sons, but had never given thought to any alternatives. When he was made aware that this same scenario would not apply to his third child, he was perplexed. What did he know about this boy, this young man?

One thing he did know was that Dom was "good with his hands" and naturally adept at electrical work. He seemed to have great patience doing minor electrical repairs around the apartment. The few books he borrowed from the library were manuals of circuitry and wiring that he would take off to his bedroom and read over and over. His father spoke to someone he knew in the office at work, and the company was able to hire Dom as an electrician apprentice. Dom learned quickly. His work ethic was excellent. He made no friends on the job, but just attended to his work. Fortunately, the man assigned to train him made no demands on Dom to be sociable; therefore, Dom's lack of social skills did not have negative occupational consequences. For his boss's part, he was happy to train an extra pair of hands and relished the shared solitude.

Dom engaged in few activities outside of work. He rented his own small apartment a short distance from where he had been raised and lived there all his adult life. He saved his money, not because he had any plans or goals that it might support, but because he did not especially want anything. His major personal expense was on magazines related to his interest in gadgetry and electronics. His living room was piled high with back issues of Popular Mechanics. Dom's hygiene and appearance were marginal. He looked "okay" for the machine shop at work (just barely), but was always a bit disheveled in public. Dom did not appear to be someone a passerby or fellow shopper would want to smile at or exchange pleasantries with, and this suited him well.

His daily routine changed little over the years. During the work week, he worked. On Sundays, he had dinner with his parents. After they died, he took Sunday dinner with one or the other of his brothers and their families. Dom never evidenced any sexual interest or desire to create a family of his own. His nieces and nephews came to understand Uncle Dom as a loner. He was not lonesome and not especially weird, but he was remarkably detached—a solitary man living out his life.

Dom developed no bad health habits, as he pursued no pleasures. He did not take up smoking or drinking, and his diet was plain and simple. He walked to and from his work each day, and he avoided doctors, beyond the cursory health checkups required by the company. He remained at his job well into his 60s. One winter morning as he left his apartment to head to work, he noticed a tin can at the bottom of the building's steps. As he went to pick it up, he missed a step and tumbled in such a way as to incur severe compound fractures of his pelvis and thigh. He was transported to the hospital where he endured several surgical procedures to stabilize the fractures. He was bedridden for a time, then wheelchair bound; and ultimately he was transferred to a rehabilitation facility for intensive physical therapy as well as the tincture of time. It was there that his personality disorder became evident.

He was assigned a bed in a three-bed room, sharing the room and the lavatory with two other men. He took the third bed, as the other two men had already been at the facility for several weeks. They had already struck up a nice friendship, offering one another encouragement and considerable good-natured bantering. They were eager to show the ropes to their new roommate and to welcome him as a friend and fellow traveler though the rehabilitation process.

Dom had been sent to an excellent rehabilitation facility. The physical therapists on staff were all dedicated and knowledgeable professionals, offering good therapy and much encouragement. They had many tricks and techniques to cajole the patients, frequently older adults, past discomfort and fatigue to do the necessary exercises and maintain a positive outlook. They welcomed Dom and introduced him to the professional staff and their assistants, all of whom warmly greeted and welcomed him.

By Day 2, the social worker and the head dietician had visited with Dom. The social worker tried to learn about what he enjoyed and who was in his friendship and kinship network and might be involved during his stay at the facility. The dietician also visited, wanting to know his food preferences and what might make his experience in the dining room most agreeable.

By Day 3, a pleasant volunteer came to visit, introducing herself as "a friendly visitor." The social worker had noted that Dom had indicated no friends and a small family, and had notified the volunteer office. By Day 4, Dom refused to participate in his therapy, or to go to the dining room for meals. By Day 5, he refused to get out of bed, and screamed at the morning aide "Get the hell away from me!" A mental health consultation was then ordered.

The consulting clinician read the record and interviewed a number of staff before meeting with Dom. It became apparent that the demands of the system were what had pushed Dom to the edge, not the requirements and challenges of the physical therapies. Dom was an absolute loner and did not have the skills nor the desire to get close to others. He had been used to living alone, and his personal space was violated by the accommodations in the facility. The warmth and friendliness of the system functioned well, and the employees were respected and satisfied. This is admirable and generally bodes well for patients, but it does not suit everyone. Dom was an example of a poor fit with the environment.

The consultation plan was developed with three main goals:

1. The staff would deviate from the system's culture and their own need to offer patients warmth and support in addition to direct care and physical therapy. They would understand that their feelings of being ignored, dismissed, or not valued did not reflect their deficiencies, but rather the personality structure of this particular patient. Their good and compassionate care was directly serving to exacerbate expressions of Dom's psychopathology. The consultant "introduced" them to the person who was Dom, reviewed his history, and identified his dominant personality traits. These traits included being purpose driven and industrious, with marked preferences for routine and minimal interpersonal involvement. What had been toxic to Dom was staff attempts to connect, express, or demand affect, touch, sustained prox imity, and intimations of intimacy. He did not require praise or encouragement and would prefer to keep this to a minimum. His goal was the most expedient, least intrusive return to his former life. The staff discussed how this made them feel, touching on how the richness of their work was in large part derived from the interpersonal context. They agreed that while they would try to understand Dom's character, they were glad that most patients were not like him, but rather thrived in their loving care.

2. The staff was asked to identify the specific goals that Dom would ideally need to meet to be discharged to home. They were also asked to design an ideal aftercare plan.

At the next meeting with the consultant and staff, each goal was discussed and appraised as either being ideal/optimal or absolutely necessary for his discharge. The "absolutely necessary" goals were then each discussed in terms of what minimal amount of interpersonal contact would be required. The staff were creative in generating ideas. For example, Dom would be set up with a piece of equipment to do 30 repetitions. Typically, the therapist watches and cheers the patient on, especially toward the end of the cycle when weakened muscles become fatigued. Instead, Dom would have a bell to ring when he had completed the repetitions, and then the therapist would transfer him to the next therapy activity. No coaching, cheering, praise, or even conversation would be necessary.

The aftercare plan was discussed and reduced to a weekly home visit rather than two per week, if Dom would contract to document executing the assigned routine. The therapist who paid home visits would be encouraged not to chat, but only to go over the physical program, make the necessary adjustments, review the documentation, and respond to any questions Dom might have. No friendly visitors allowed!

3. Dom would agree to meet with the consultant to determine how he and the facility could speed up his rehabilitation and discharge to home. Dom would shower and dress and they would meet in a private room where it would be quiet and free of interruptions. They would sit at a table a reasonable distance apart. The consultant would sit to the side to avoid direct eye contact with Dom when he looked up from his notes from his sessions with the staff.

It was explained to Dom that the staff knew that he was a man who was used to being on his own, by himself, and that this experience in the rehabilitation facility was a difficult one. There were a lot of things that understandably bothered him. The staff was responsible for patient care and for getting patients back on their feet as well and as quickly as possible. The consultant explained that he had met with the staff to learn what exactly Dom needed to be able to do before he could safely return home. They went over each of the rehabilitation goals. It was then explained how each would be addressed so as to not bother Dom any more than was necessary. Dom was asked if he had any suggestions and if he would agree to this contract. This procedure was carried out again with each of the aftercare goals. Dom wanted to know how many weeks someone would have to come to his house for therapy visits after he went home. The consultant said that he would ask the staff and get back to Dom with this information.

The final product was a brief, written contract signed by the Director of Nursing and Dom and witnessed by the consultant. Each side kept up its half of the bargain, and Dom was discharged to his home in a few weeks. The contract was able to serve the functions of binding Dom's acting out (in this case, an exacerbation of his tendency to withdraw, isolate, and disallow interpersonal cooperation), and unlinking the kindness culture of the facility from the necessary, technical aspects of care.

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