1. Personality and Personality Disorders Behavioral response to Illness TMC Psychiatry Rotation By: Cristal Laquindanum, Russell Rivera, Justine Alessandra Uy ASMPH 2012

2. “Behavioral Responses to Illness, Personality and Personality Disorders” Robert J. Ursano, MD Richard S. Epstein, MD Susan G. Lazar, MD Reference

3. 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)

4. Past experiences  form the lenses through which the patient looks at the present world  directs the pattern of future behaviors Biological 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 behavior personality

5. Patient’s personality interacts with and is reactive to the individuals on the treatment team Transference and counter-transference CL psychiatrist’s goals is to understand how the patient’s personality contributes to the patient’s illness, treatment, and adaptation.

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

7. Patient’s response to illness

8. Common responses to illness High adaptive level: maximize gratification and promote optimum balance between conflicting motives Affiliation Altruism Anticipation Humor Self-assertion Self-observation Sublimation Suppression

9. Common responses to illness Mental inhibitions (compromise formation) level: keep threats out of awareness Displacement Dissociation Intellectualization Isolation of affect Reaction formation Repression Undoing

10. Common responses to illness Minor image-distorting level: distortions used to regulate self-esteem Devaluation Idealization Omnipotence

11. Common responses to illness Disavowal level: removal from awareness or misattribution to external causes Denial Projection Rationalization

12. Common responses to illness Major image-distorting level: gross distortion or misattribution of the image of self or others Autistic fantasy Projective identification Splitting of self-image or image of others

13. Common responses to illness Action Level: action or withdrawal Acting out Apathetic withdrawal Complaining Help-rejecting Passive aggression

14. Common responses to illness Level of defensive dysregulation: pronounced break with objective reality Delusional projection Psychotic denial Psychotic distortion Exaggerated character defense mechanisms

15. Dependent clingers Entitled demanders Manipulative help rejecters Self-destructive deniers Four Types of patients who stir dislike and hate in physicians, Groves (1978)

16. Patients… Demanding and prone to rejection Shows extreme gratitude with flattery “sticky”, unable to be left alone Associated personality traits/disorder: codependent Clinicians… Make time limits clear in advance and schedule appointments so that patients know when their next contacts will be Ensure consistency in staff-patient interactions may decrease the aversion Dependent clinger

17. Patient… Also profoundly needy Overtly hostile and belittling in an unconscious attempt to avoid feelings of helplessness and overwhelming fear of the illness Associated personality traits/ disorders: Narcissistic, borderline personality disorder Clinician… 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 attention Must not challenge the entitlement; recognize and decrease the terror of abandonment and mistreatment that often fuels this type of patient’s angry demands Entitled demander

18. Patient… Pessimistic, undermine treatment, negative about their care Very dependent and seemingly inexhaustible in their demands Typically defeat all attempts to satisfy their needs Wants to be close to their doctors and nurses while keeping them at a safe distance Clinician… Manipulative help rejecters Might feel anxious, irritated, frustrated and depressed, eventually doubt their own skills Help 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

19. Patient… Most difficult of the four types of patients Believe that there is no hope Denial helps them survive Uncooperative and dependent Appear 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 behaviors Clinician… Attitude of diligence and compassion Treat the underlying depression Physician must lower his or her expectations and accept the limits the patient places on the treatment and on the physician Often feels angry and must grapple with his or her ongoing feeling of loss of power and competence Self-destructive denier

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

21. 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 hospital Helplessness and control

22. Altering psychological risk factors with cognitive behavioral treatment reduced mortality Geyer (1997), those with strong sense of coherence see the world as comprehensible, manageable, and meaningful = better health Controllable conditions, monitoring information is adaptive Uncontrollable conditions (terminal illness), avoiding distressing information and blunting may be more adaptive Helplessness and control

23. Physicians… Shame Non-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 relationship Patients… Often react with shame and guilt if their lifestyles have contributed to their illnesses. Smoking, substance abuse, risky sexual behaviors Guilt

24. 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

25. 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 team Address the patient’s transference and/or the countertransference of the staff Empathize 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

26. Cardiac Disease AIDS Gastrointestinal Disease Somatization and Somatization Disorder Specific illnesses, personality, and behavior

27. Personality Collection of behavioral response probabilities High likelihood of certain affective, cognitive or behavioral responses to life events

28. Disease-personality interaction

31. Deny physical or emotional vulnerability

32. Self-esteem dependent on constant achievement

33. Mistrustful

34. Need to be in control

37. Cl psychiatrist approach

39. Cl psychiatrist approach

41. Somatization and somatization disorder Fogel and Sadavoy (1996) – neuroticism is a stronger predictor of somatic complaints than age Hypochondriacal behavior is not a normal part of aging Factitious 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

42. Cl psychiatrist approach

43. 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

44. DSV-IV-TR Axis II disorders

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

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

48. Classification and Assessment AXIS 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.

49. Diagnosis OBTAINING 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.

50. Diagnosis Some patient’s chronic physical disorders or Axis I conditions are sometimes misdiagnosed as personality disorders because the clinician incorrectly assesses the onset and chronicity of the symptoms. The high comorbidity of Axis I and Axis II disorders also creates diagnostic difficulties.

51. Epidemiology The epidemiology of personality disorders in medical-surgical patients has been limited by the nosological fuzziness of the personality disorders, the comorbidity of Axis II and Axis I disorders, the difficulty in making cross-sectional assessment at times of great duress, and the fact that epidemiological assessments of Axis II disorders are time-consuming and expensive.

52. Epidemiology Personality disorder diagnoses are almost never included in hospitalization discharge summaries. Mounting evidence suggests that somatization is associated with Axis II disorders.

53. Interaction of Personality Disorders and Somatic Illness The relative fixed behavioral response patterns found in patients with personality disorders can affect illness in many ways. The patient’s personality greatly influences his or her likelihood of seeking out rather than delaying obtaining appropriate treatment or complying with rather than interfering with needed treatment. Personality disorders per se can be major etiological factors in somatic symptomatology.

54. Interaction of Personality Disorders and Somatic Illness Poor health care habits and improper attention to early symptoms of an impending medical condition can lead to exacerbation or early onset of a disease. A somatic presentation is also very common in dissociative identity disorder (DID) and may be more frequent than in other psychiatric conditions. 35% of patients with DID also met criteria for somatization disorder.

55. Interaction of Personality Disorders and Somatic Illness Self-defeating behaviorhas been implicated frequently in treatment compliance problems. It is described as: An unconscious need to suffer and to be punished A way to punish the physician A wish for attention and caring A way to provoke rejection An exhibitionistic attempt to parade suffering to ensure lovability and respect A way to maintain worthiness to be taken care of

56. Interaction of Personality Disorders and Somatic Illness Patients with personality disorders probably constitute the group with the highest likelihood of stimulating countertransference reactions that lead to nontherapeutic staff and physician behavior. Personality disorders also influence the presentation of somatic illness. Consultation-liaison psychiatrists are sometimes consulted for assessment of an unusual presentation of pain by a patient.

57. Conclusion

60. Personality and Personality Disorders Behavioral response to Illness TMC Psychiatry Rotation By: Cristal Laquindanum, Russell Rivera, Justine Alessandra Uy ASMPH 2012