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Behavioral response to illness

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  • Intimidates, devalues, induces guilt,
  • Resists treatmentManagement: schedule regular follow up visits, tell them the treatment may not cure the illness, dii
  • Monitoring – tendency to focus attention on a stressor and one’s responses to it; includes gathering and applying relevant informationBlunting – focus attention away from the stressors and one’s own reactions and thus avoiding, rejecting, and denying the existence of relevant information.

Behavioral response to illness Behavioral response to illness Presentation Transcript

  • Personality and Personality Disorders
    Behavioral response to Illness
    TMC Psychiatry Rotation
    By: Cristal Laquindanum, Russell Rivera, Justine Alessandra Uy
    ASMPH 2012
  • “Behavioral Responses to Illness, Personality and Personality Disorders”
    Robert J. Ursano, MD
    Richard S. Epstein, MD
    Susan G. Lazar, MD
    Reference
  • 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 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
  • 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.
  • 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
  • Patient’s response to illness
  • 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
  • Common responses to illness
    Mental inhibitions (compromise formation) level: keep threats out of awareness
    Displacement
    Dissociation
    Intellectualization
    Isolation of affect
    Reaction formation
    Repression
    Undoing
  • Common responses to illness
    Minor image-distorting level: distortions used to regulate self-esteem
    Devaluation
    Idealization
    Omnipotence
  • Common responses to illness
    Disavowal level: removal from awareness or misattribution to external causes
    Denial
    Projection
    Rationalization
  • 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
  • Common responses to illness
    Action Level: action or withdrawal
    Acting out
    Apathetic withdrawal
    Complaining
    Help-rejecting
    Passive aggression
  • Common responses to illness
    Level of defensive dysregulation: pronounced break with objective reality
    Delusional projection
    Psychotic denial
    Psychotic distortion
    Exaggerated character defense mechanisms
  • Dependent clingers
    Entitled demanders
    Manipulative help rejecters
    Self-destructive deniers
    Four Types of patients who stir dislike and hate in physicians, Groves (1978)
  • 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
  • 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
  • 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
  • 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
  • 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.
  • 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
  • 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
  • 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
  • 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 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
  • Cardiac Disease
    AIDS
    Gastrointestinal Disease
    Somatization and Somatization Disorder
    Specific illnesses, personality, and behavior
  • Personality
    Collection of behavioral response probabilities
    High likelihood of certain affective, cognitive or behavioral responses to life events
  • Disease-personality interaction
  • Type a personality
    • Workaholic
    • Deny physical or emotional vulnerability
    • Self-esteem dependent on constant achievement
    • Mistrustful
    • Need to be in control
    • May be anxious, hostile towards psychiatrist consultation
  • Cl psychiatrist approach
  • Cl psychiatrist approach
  • Cl psychiatrist approach
  • 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
  • Cl psychiatrist approach
  • 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
  • DSV-IV-TR Axis II disorders
  • Five-factor System of Personality Traits
    This model has been used to study the relationship between individual traits and somatic disease
  • 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
  • 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.
  • 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.
  • 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.
  • 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.
  • Epidemiology
    Personality disorder diagnoses are almost never included in hospitalization discharge summaries.
    Mounting evidence suggests that somatization is associated with Axis II disorders.
  • 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.
  • 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.
  • 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
  • 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.
  • Conclusion
  • Personality and Personality Disorders
    Behavioral response to Illness
    TMC Psychiatry Rotation
    By: Cristal Laquindanum, Russell Rivera, Justine Alessandra Uy
    ASMPH 2012