Behavioral response to illness

Personality and Personality DisordersBehavioral response to IllnessTMC Psychiatry RotationBy: Cristal Laquindanum, Russell Rivera, Justine Alessandra UyASMPH 2012

“Behavioral Responses to Illness, Personality and Personality Disorders” Robert J. Ursano, MDRichard S. Epstein, MDSusan G. Lazar, MDReference

Cluster of characteristic behavioral responses that depend on a person’s past experiences, biological propensities, social context, and view of the future. Not static. Changes throughout the life cycle (childhood  adulthood  old age)

Past experiences  form the lenses through which the patient looks at the present world  directs the pattern of future behaviorsBiological propensities  underpinning of basic human feelings such as anxiety and excitement; directs individuals’ needs for security, novelty, and avoidance. Social context  complex web of interpersonal relationships that make up our world and influence our behaviorpersonality

Patient’s personality interacts with and is reactive to the individuals on the treatment teamTransference and counter-transferenceCL psychiatrist’s goals is to understand how the patient’s personality contributes to the patient’s illness, treatment, and adaptation.

Identify patient’s behavioral tendencies both during times of acute stress and throughout the life cycleIdentified from the present and past history of the patient, MSE, observations of how the patient relates to othersDefense Functioning ScaleHigh adaptive level, mental inhibitions level, minor image-distorting level, disavowal level, major image-distorting level, action level, level of defensive dysregulation.Defense mechanisms

Patient’s response to illness

Common responses to illnessHigh adaptive level: maximize gratification and promote optimum balance between conflicting motivesAffiliationAltruismAnticipationHumorSelf-assertionSelf-observationSublimationSuppression

Common responses to illnessMental inhibitions (compromise formation) level: keep threats out of awarenessDisplacementDissociationIntellectualizationIsolation of affectReaction formationRepression Undoing

Common responses to illnessMinor image-distorting level: distortions used to regulate self-esteemDevaluationIdealizationOmnipotence

Common responses to illnessDisavowal level: removal from awareness or misattribution to external causesDenialProjectionRationalization

Common responses to illnessMajor image-distorting level: gross distortion or misattribution of the image of self or othersAutistic fantasyProjective identificationSplitting of self-image or image of others

Common responses to illnessAction Level: action or withdrawalActing outApathetic withdrawalComplainingHelp-rejectingPassive aggression

Common responses to illnessLevel of defensive dysregulation: pronounced break with objective realityDelusional projectionPsychotic denialPsychotic distortionExaggerated character defense mechanisms

Dependent clingersEntitled demandersManipulative help rejectersSelf-destructive deniersFour Types of patients who stir dislike and hate in physicians, Groves (1978)

Patients…Demanding and prone to rejectionShows extreme gratitude with flattery“sticky”, unable to be left aloneAssociated personality traits/disorder: codependentClinicians…Make time limits clear in advance and schedule appointments so that patients know when their next contacts will beEnsure consistency in staff-patient interactions may decrease the aversionDependent clinger

Patient…Also profoundly needyOvertly hostile and belittling in an unconscious attempt to avoid feelings of helplessness and overwhelming fear of the illnessAssociated personality traits/ disorders: Narcissistic, borderline personality disorderClinician…Often wants to counterattack (can easily become vindictive and punitive rather than to help)Encourage to accept the patient’s angry sense of entitlement & redirect the entitlement to an expectation of appropriate medical attentionMust not challenge the entitlement; recognize and decrease the terror of abandonment and mistreatment that often fuels this type of patient’s angry demandsEntitled demander

Patient…Pessimistic, undermine treatment, negative about their careVery dependent and seemingly inexhaustible in their demandsTypically defeat all attempts to satisfy their needsWants to be close to their doctors and nurses while keeping them at a safe distance Clinician…Manipulative help rejectersMight feel anxious, irritated, frustrated and depressed, eventually doubt their own skillsHelp the patient limit demands and hostility by reassuring him or her that good care will be provided, while encouraging the treatment team to help the patient maintain a sense of separateness and autonomy

Patient…Most difficult of the four types of patientsBelieve that there is no hopeDenial helps them surviveUncooperative and dependentAppear to desire self-destruction by continuing to engage in self-injurious behaviors, such as drinking or smoking, after developing repeated serious medical complications caused by these behaviorsClinician…Attitude of diligence and compassionTreat the underlying depression Physician must lower his or her expectations and accept the limits the patient places on the treatment and on the physicianOften feels angry and must grapple with his or her ongoing feeling of loss of power and competenceSelf-destructive denier

Patients feel…Physicians should… Help medically ill patients accept inevitable demands of the hospital, their loss of autonomy, and their dependency on the treatment teamSense of control over their illness can greatly enhance the doctor-patient relationshipHelplessness and controlFrequently experience fear and feelings of helplessness. Not knowing enough facts about their illness and treatment increases sense of helplessness.

Correlation between self-regulation and health, independent of physical risk factors. High degrees of self-regulation actively regulate their own lives, without a degree of emotional dependence on others Low degrees of self-regulation have higher blood pressure, are more likely to have diabetes, exercise less, are more overweight, smoke and drink more, have more accidents, have poorer diets, and are more frequently ill and spend more time in the hospitalHelplessness and control

Altering psychological risk factors with cognitive behavioral treatment reduced mortalityGeyer (1997), those with strong sense of coherence see the world as comprehensible, manageable, and meaningful = better healthControllable conditions, monitoring information is adaptiveUncontrollable conditions (terminal illness), avoiding distressing information and blunting may be more adaptiveHelplessness and control

Physicians…ShameNon-judgmental, emphatic, and supportive stance Encouraging ventilation of self-criticism and guilty ruminations can increase cooperativeness, improve the patient’s mood, and strengthen the doctor-patient relationshipPatients…Often react with shame and guilt if their lifestyles have contributed to their illnesses. Smoking, substance abuse, risky sexual behaviorsGuilt

Countertransference Response to the patient or an identification with the patient’s feelings and beliefs. Physician should perform a thorough evaluation and obtain information from the treatment team. Using one’s reactions to a patient as information to help understand what the treatment team experiences can help the physician recommend effective interventions. Transference and countertransference

Task for CL psychiatrist is to forge a therapeutic alliance with the patient and to help the patient form an alliance with the medical and surgical treatment teamAddress the patient’s transference and/or the countertransference of the staffEmpathize with the patient’s specific fears and foster a sense of mastery and control; this may alleviate anxiety and regression and reinforce more mature cooperation. Must help other physicians and staff to avoid defensive postures that are stimulated by countertransference responses such as being too competitive, solicitous, or detached. Modeling and explaining how best to react supportively in the patient’s regressive behavior and defenses. Transference and countertransference

Cardiac DiseaseAIDSGastrointestinal DiseaseSomatization and Somatization DisorderSpecific illnesses, personality, and behavior

PersonalityCollection of behavioral response probabilitiesHigh likelihood of certain affective, cognitive or behavioral responses to life events

Disease-personality interaction

Deny physical or emotional vulnerability

Self-esteem dependent on constant achievement

May be anxious, hostile towards psychiatrist consultationCl psychiatrist approach

Somatization and somatization disorderFogel and Sadavoy (1996) – neuroticism is a stronger predictor of somatic complaints than ageHypochondriacal behavior is not a normal part of agingFactitious Disorder or Munchausen syndrome Patients with somatic symptoms that are dramatic, self-induced, have history of emotional deprivation and severe personality disorder, fragile sense of identity, profound sense of helplessness

PERSONALITY TRAITS – characteristic behavioral response patterns – are the typical ways that an individual thinks, feels and relates to others. When FIXED, INFLEXIBLE, UNRESPONSIVE TO CHANGES IN THE ENVIRONMENT and MALADAPTIVE, they can result in psychological and social dysfunction and may constitute a personality disorder.Personality disorders and somatic illness

Five-factor System of Personality TraitsThis model has been used to study the relationship between individual traits and somatic disease

Cloniger’s Neurotransmitter-Personality Trait Classification SystemA classification system that attempts to integrate knowledge of the major neurotransmitter systems (dopaminergic, serotonergic, and noradrenergic) with a tri-dimensional description of personaility traits

Classification and AssessmentAXIS II DIAGNOSES are defined by symptom “menus” that range from 7-10 items.Depending on the disorder, at least 4 or 5 symptoms are necessary before a specific Axis II diagnosis can be made.

DiagnosisOBTAINING THE COMPREHENSIVE HISTORY necessary for diagnosing a personality disorder is time-consuming and difficult.Consultation-liaison psychiatrists initially tend to focus on the most prominent and remediable psychiatric symptomatology and defer Axis II assessment until the patient is discharged to his or her usual environment.

Behavioral response to illness

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