How can hospital staff provide the most effective care to patients with comorbid medical illness and serious mental illness?
SPECIAL REPORT: CLINICAL COMPLICATIONS OF COMORBIDITIES
How can hospital staff provide the most effective care to patients with comorbid medical illness and serious mental illness? Following is a discussion about these comorbidities, the 7 personality types, and best practices for hospital staff to follow in treating patients with each personality type.
What Makes Comorbidities Important?
Psychiatrists see many patients who have comorbid psychiatric disorders such as a substance use disorder and a mood disorder, or epilepsy and psychogenic nonepileptic seizures. The most common comorbidities are medical disorders and personality traits and/or disorders.
Psychiatrists in every setting encounter these individuals; however, the comorbidity is most common in the consultation-liaison experience. Here personality traits or disorders can create problems in the treatment of patients with complex medical illness.
Why Does This Happen?
Serious medical illness is a regressive experience. The individual who is hospitalized with a serious medical illness is placed in a position of depending on others, akin to the experience of being a child. Regression can be seen as using coping skills from an earlier stage in life or using less mature defenses. The regression can be quite adaptive (eg, allowing other individuals to take care of them without feeling that they have lost control).
Patients are typically dressed in hospital gowns; they may have to relinquish control of toileting or feeding. Patients may have to relinquish the accoutrements of business life such as cell phones and computers, and in some cases, they must allow a machine to breathe for them. The individual may accommodate in an adaptive or a maladaptive way, influenced by their personality style. For critically ill patients, the severity of the illness can be maximally disruptive to their typical coping mechanisms.
What Are the 7 Personality Types and How Do They Differ in the Ability to Cope With Serious Medical Illness?
Kahana and Bibring outlined 7 personality types in 1964.1 Geringer and Stern2 modernized these descriptions in a later paper. The 7 types are dependent, obsessional, histrionic, masochistic, paranoid, narcissistic, and schizoid (Figure1,2).
These do not match exactly to the DSM-5-TR personality disorders, but they are useful concepts to understand 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 the stress on patient 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 thus repeatedly seek reassurance from the medical staff. Illness is experienced as a threat of abandonment.
Initially, hospital staff may feel important and needed, but the constant need for reassurance leads to staff feeling annoyed or overwhelmed. This may result in them avoiding the patient, which increases the individual’s fear of abandonment. Scheduling time-limited visits, providing realistic reassurance, and employing other resources for supporting the patient help mitigate the negative feelings and create a successful hospital stay.
The obsessional personality type likes to feel in control and may be meticulous about details. They may focus on what is “right” or “wrong” in the care they receive. The illness stimulates fears of losing control over their body, emotions, or impulses.
Initially we may admire their attention to detail, but repeated questioning, especially when the questions have been thoroughly answered, can feel draining for the staff. The patient may research the illness and therapies, resulting in the physician feeling that the patient does not trust them. Respecting the patient’s need for detail, giving them “homework” between visits, and creating a collaboration with the patient will work against a battle of wills between the patient and the staff.
Histrionic patients may initially be entertaining, although they can be melodramatic. They can be enticing and seductive in their interactions with staff. Illness stimulates their fears of not being loved or loss of attractiveness.
Initially the patient may seem attractive, but when the patient is seductive, that generates discomfort in the staff who may then confront the patient. Seduction may come in the form of gifts or offering tickets to special events. Maintaining clear boundaries of what is and what is not permissible, providing warmth within a framework of formality, and encouraging the patient to discuss their fears creates an environment in which patient and staff all feel safe.
The masochistic patient seems to be a long-suffering, perpetual victim. They may experience illness as a punishment, although this is often not conscious. Such patients may anger staff who think the individual “wants to be ill” or does not want to recover. Staff may feel helpless in their experience of the patient’s apparent need to suffer.
Avoid being too positive, which may increase the individual’s unconscious need to suffer. The acceptance of the individual’s experience of suffering, while encouraging them to recover as a “responsibility” to family and friends, can guide the patient through the hospital stay.
Paranoid personality types view the world with suspicion. They fear they will be taken advantage of by hospital staff. Illness can be experienced as the world is against them. Medical procedures may be viewed as an exploitation. When kept waiting for a procedure longer than expected, the patient may then refuse the procedure, not accepting that the delay was not targeted at them.
Not surprisingly, staff may feel they are being attacked, feel defensive, and experience anger toward the patient. Acknowledging how the patient feels, while presenting the reality of what happens in hospitals, avoids unproductive confrontation.
Narcissistic personality types can seem arrogant, self-important, and devaluing of staff. They may question why a student or resident is involved in their care, as they expect the head of the department to be their physician. Illness threatens their fears of being vulnerable and unimportant. They may not have lofty positions in everyday life, but they portray themselves as VIPs with expectations of special treatment.
Patients can delay examinations or procedures, claiming they must attend to more important business such as talking on their cellphone. Staff may be treated as though they are inferior to the person, or as being privileged to take care of such an important individual. When devalued by the patient, staff may wish to counterattack with “Who do you think you are?” types of comments. However, these comments only escalate the situation.
Encouraging the patient to be collaborative by reframing their entitlement as someone who can understand that not everyone is as perfect as are they helps them to be magnanimous and accepting.
Schizoid personalities may appear aloof, remote, or odd. Illness is experienced as a potential and frightening intrusion. Staff may find it difficult to engage with the individual and thus avoid interactions. Maintaining an active involvement, while respecting the individual’s need for privacy, aids in the patient’s treatment; however, not allowing the patient to completely withdraw also is important to a successful hospitalization. These patients benefit from knowing the routine of procedures, meals, and medication administration.
Thinking through how each personality type copes with the stress of a serious medical illness prepares us to be the most understanding of their experience. Patients with personality disorders are particularly vulnerable when medically hospitalized. Nevertheless, every patient deserves the best care, which we can help our colleagues provide as part of the 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 Times® Editorial Board.
1. Kahana RJ, Bibring G. Personality types in medical management. In: Zinberg NE, ed. Psychiatry and Medical Practice in a General Hospital. International Universities Press Inc; 1964.
2. Geringer ES, Stern TA. Coping with medical illness: the impact of personality types. Psychosomatics. 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 for 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.