SPECIAL REPORT: CLINICAL COMPLICATIONS OF COORBIDITIES
FAQs
How can hospital staff provide the most effective care to patients with comorbid conditions and serious mental illness? Here is a discussion about it comorbiditiesthe 7 personality types and best practices hospital staff should follow when treating patients with each personality type.
What makes comorbidities important?
Psychiatrists see many patients with comorbid psychiatric disorders such as substance use disorder and mood disorder, or epilepsy and nonepileptic psychogenic seizures. The most common comorbidities are medical conditions and personality traits and/or disorders.
Psychiatrists from all walks of life encounter these individuals; however, comorbidity is more common in the consultation-liaison experience. Here, personality traits or disorders can create problems in the treatment of patients with complex illnesses.
Why does this happen?
Serious illness is a regressive experience. The person hospitalized with a serious illness is placed in a position of dependence on others, similar to the experience of a child. Regression can be thought of as the use of coping skills learned at an earlier stage of life or the use of less mature defenses. Regression can be very adaptive (e.g., allowing other individuals to care for them without feeling like they have lost control).
Patients are usually dressed in hospital gowns; they may have to give up control over cleanliness or diet. Patients may have to give up the accessories of working life, such as cell phones and computers, and in some cases, they must let a machine breathe for them. The individual can cope adaptively or maladaptively, influenced by their personality style. For critically ill patients, the severity of the illness can be as disruptive as possible to their usual coping mechanisms.
What are the 7 personality types and how do they differ in their ability to cope with serious medical illness?
Kahana and Bibring defined 7 personality types in 1964.1 Geringer and Stern2 modernized these descriptions in a later article. The 7 types are dependent, obsessive, histrionic, masochistic, paranoid, narcissistic and schizoid (Figure1.2).
Figure. The 7 personality types1.2
These don’t exactly correspond to the DSM-5-TR personality disorders, but they are useful concepts for understanding how different types of individuals cope with illness. For each type, there are differences in the meaning of being ill, how the individual interacts with medical staff (transferences), and how staff respond to the individual (countertransference). . Managing countertransference and providing care unique to each type of individual can reduce stress for patients and hospital staff.3.4
Can you review each of these personality types?
The dependent personality type tends to be needy, demanding, and clingy. They may be unable to reassure themselves and therefore repeatedly seek reassurance from medical personnel. Illness is experienced as a threat of abandonment.
At first, hospital staff may feel important and needed, but the constant need for reassurance leads staff to feel annoyed or overwhelmed. This may cause them to avoid the patient, increasing the individual’s fear of abandonment. Scheduling time-limited visits, providing realistic assurance, and using other resources to support the patient help alleviate negative feelings and create a successful hospital stay.
The obsessive personality type likes to feel in control and can be meticulous about details. They can focus on what is “right” or “wrong” about the care they receive. The illness arouses the fear of losing control of one’s body, one’s emotions or one’s impulses.
At first, we may admire their attention to detail, but repeated questions, especially when the questions have been answered thoroughly, can seem exhausting for staff. The patient may research the disease and therapies, making the doctor feel that the patient does not trust him. Respecting the patient’s need for detail, giving the patient “homework” between visits, and creating collaboration with the patient will counter a battle of wills between the patient and staff.
Histrionic patients may be entertaining at first, although they may be melodramatic. They may appear attractive and seductive in their interactions with staff. The illness stimulates the fear of not being loved or losing one’s attractiveness.
Initially, the patient may appear attractive, but when he is attractive, this generates discomfort among the staff who may then confront the patient. Seduction can take the form of gifts or offers of tickets to special events. Maintaining clear boundaries between what is allowed and what is not, offering warmth in a formal setting, and encouraging the patient to discuss their fears creates an environment in which the patient and staff all feel safe .
The masochistic patient appears to be a perpetual and long-suffering victim. They may experience illness as a punishment, although this is often not conscious. These patients can irritate staff who think the person “wants to be sick” or does not want to get well. Staff may feel helpless in the face of the patient’s apparent need to suffer.
Avoid being too positive, as this may increase the individual’s unconscious need to suffer. Acceptance of the individual’s experience of suffering, while encouraging recovery as a “responsibility” to family and friends, can guide the patient through their hospital stay.
Paranoid personalities view the world with suspicion. They fear being exploited by hospital staff. Illness can be felt when the world is against it. Medical procedures can be considered exploitative. When waiting for a procedure longer than expected, the patient may then refuse the procedure, not accepting that the delay was not intended for them.
It is not surprising that staff feel attacked, feel defensive and feel anger towards the patient. Acknowledging how the patient feels, while presenting the reality of what is happening in hospitals, avoids unproductive confrontation.
Narcissistic personality types may appear arrogant, self-important, and demeaning. They may wonder why a student or resident is involved in their care because they expect the department head to be their doctor. Illness threatens their fear of being vulnerable and unimportant. They may not hold high positions in everyday life, but they present themselves as VIPs with the expectation of special treatment.
Patients may delay tests or procedures, claiming they have more important things to worry about, like talking on their cell phones. Staff may be treated as if they are less than the person or as having the privilege of caring for such an important person. When devalued by the patient, staff may wish to counterattack by saying, “Who do you think you are?” types of comments. However, these comments only make the situation worse.
Encouraging the patient to collaborate by reframing their entitlement as someone who can understand that not everyone is as perfect as they are helps them to be magnanimous and tolerant.
Schizoid personalities may appear distant, distant, or strange. Illness is experienced as a potential and frightening intrusion. Staff may find it difficult to interact with the person and thus avoid interactions. Maintaining active participation, while respecting the individual’s need for privacy, facilitates the patient’s treatment; however, not allowing the patient to completely withdraw is also important for a successful hospitalization. These patients benefit from knowing the routine of procedures, meals, and medication administration.
Thinking about how each personality type copes with the stress of a serious illness prepares us to better understand their experience. Patients with personality disorders are particularly vulnerable when hospitalized for medical reasons. Nevertheless, every patient deserves the best care, which we can help our colleagues to provide within the framework of consultation-liaison psychiatry interaction both with patients directly and with hospital staff.
Dr. Muskin is a professor of psychiatry and senior consultant in consultation-liaison psychiatry at Columbia University Irving Medical Center in New York, New York. He is also a member of the Psychiatric Time® Editorial committee.
The references
1. Kahana RJ, Bibring G. Personality Types in Medical Management. In: Zinberg NE, ed. Psychiatry and medical practice in a general hospital. International University Press Inc.; 1964.
2. Geringer ES, Stern TA. Coping with a Medical Illness: The Impact of Personality Types. Psychosomatic. 1986;27(4):251-261.
3. Gazzola L, Muskin PR. The impact of stress and the objectives of psychosocial interventions. In: Schein LA, Bernard HS, Spitz HI, Muskin PR, eds. Psychosocial treatment of medical conditions: principles and techniques. Routledge; 2003.
4. Muskin PR, Haase EK. Difficult patients and patients with personality disorders. In: Noble J, ed. Textbook of Primary Care Medicine, 3rd Edition. Mosby; 2001.
