PSYCHIATRY II

PERSONALITY TRAITS AND DEFENSES IN THE MEDICALLY ILL

Gregorio Tan, MD | 24 May 2021
3.01
OBJECTIVES: II. PERSONALITY TRAINTS IN THE MEDICAL
1. UNDERSTAND THE ROLE OF PSYCHIATRY AMONGST SETTING
MEDICAL SURGICAL/PATIENTS
2. APPLY THE BIOPSYCHOSOCIAL APPROACH IN DEALING WITH HISTRIONIC
ALL PATIENTS DESCRIPTION/TRAITS:
3. RECOGNIZE THAHT THERE MAY BE DIFFICULT PATIENTS - Dramatic, vivid, likable, anxious, involved
EVEN AMONG NON-PSYCHIATRIC PATIENTS REACTION TO ILLNESS:
4. BE FAMILIAR WITH THE PSYCHODYNAMICS INVOLVED IN - Were an attack to masculinity or femininity
THE DIFFICULT PATIENT SUGGESTED MANAGEMENT:
5. UTILIZE KNOWLEDGE TO OPTIMIZE THE PROGNOSIS, - Appreciation of attractiveness/courage
IMPROEV QUALITY OF CARE AND OVERALL OUTCOME OF OUR - Ventilation of fears
MEDICAL/SURGICAL PATIENTS. - Supportive but not detained explanations

I. CONSULTATION-LIAISON PSYCHIATRY OBSESSIVE

DESCRIPTION/TRAITS:
CL Psychiatry stand between psychiatry and the rest of - Orderly, dull, likable, anxious, involved
medicine. REACTION TO ILLNESS:
To medicine it interprets what is happening in psychiatry and - As if illness were a punishment for letting things get
behavioral science, and at the same time, to psychiatry it out of control
interprets what is happening to the rest of medicine SUGGESTED MANAGEMENT:
- Detailed “scientific explanations”, and make the
❖ Consultation, with its emphasis on patient partner in the therapeutic process.
• Diagnosis
• Assessment NARCISSISTIC
• Recommendations for management SUGGESTED MANAGEMENT:
• Is the heart of liaison psychiatry - Supporting strength and integrity of the self by
making patient equal independent partner in own
❖ On the other hand, consultation without liaison is care.
• Much more time consuming
• Probably less efficient ORAL
• Because it eliminates the education of DESCRIPTION/TRAITS:
physicians/nurses/staff about the biopsychosocial - Clinging, demanding, attention
factors in illness REACTION TO ILLNESS:
- As if illness posed the threat of abandonment
❖ Consultation-liaison psychiatry proc=vides a SUGGESTED MANAGEMENT:
biopsychosocial approach to patients who are - Warm support but firm limits on undue neediness
treated in hospitals and clinics outside of the and manipulativeness.
psychiatric setting
MASOCHISTIC
❖ Disease can not be explained only by DESCRIPTION/TRAITS:
understanding pathophysiology at the cellular - Long suffering, depressed, help rejecting
and molecular level but by the social, and REACTION TO ILLNESS:
internal psychodynamic factors as well that play - As if illness were deserved, expected punishment of
in the PRECIPITATION, PROLONGATION, and worthlessness
RECOVERY FROM ILLNESS. SUGGESTED MANAGEMENT:
- Appreciation of courage in suffering without undue
FOCUS reassurance or optimism; appeal to altruism
• The health care provider (includes the primary
physician and other doctors, nurses, social worker, SCHIZOID
therapist, etc.) DESCRIPTION/TRAITS:
• The patient - Remote, unsociable, uninvolved
REACTION TO ILLNESS:
• The family and community
- As if illness threatened a dangerous invasion of
• The environment (includes the hospital setting and
privacy
home)
SUGGESTED MANAGEMENT:
- Muted interest in patient but respect need for privacy
PATIENTS IN THE NON-PSYCHIATRIC HOSPITALS MAY
and distance.
BE DIVIDED INTO THE FOLLOWING:
1. Those with physical illness with comorbid psychiatric
PARANOID
illness
DESCRIPTION/TRAITS:
2. Those with behavioral symptoms 2nd to a medical
- Wary, suspicious, aggrieved, querulous, blaming,
condition
hypersensitive
3. Difficult patients
REACTION TO ILLNESS:
4. Normal individuals in very stressful or abnormal
- As if illness were an annihilating assault coming from
situation
everywhere outside of self.
5. Patient with physical disorders for which no cause
SUGGESTED MANAGEMENT:
can be found.
- Honest, simple, full, repeated, explanations;
accusation neither disputed nor confirmed but

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 PSYCHIATRY II
PERSONALITY TRAITS AND DEFENSES IN THE MEDICALLY ILL
explained as coming from illness rather than • Anticipation
someone trying to injure the patient. • Sublimation

III. THEORETICAL HEIRARCHY OF ADAPTIVE EGO Transference and Counter-transference issues

DEFENSES • Patients may hate you for no apparent reason and
vice versa
NARCISSISTIC DEFENSES • Patients may idolize you and vice versa
• Common in healthy individuals before 5 years of age • These are normal phenomena but should be dealt
and in adult dreams and fantasy; such mechanism with in a professional manner
alter reality for the user and appear “crazy” to the • If severe you may refer the patient to another health
beholder, refractory to change by conventional worker.
psychotherapeutic interpretation but are altered y
change in reality (such as antipsychotic meds and Finally,
removal of stressor) - Look at your own personality traits as well
- Sometimes it is the health worker that may have
EXAMPLES OF NARCISSISTIC issues or problems
• Delusional projection - Look at the dynamics of the working group/health
• Psychotic denial team
• Distortion - Address flaws or deficiencies

IMMATURE DEFENSES
• Common in “healthy” individuals between ages 3-16 REFERENCES:
years, in “character” and affective disorders, and in
individuals in psychotherapy, such mechanism 1. PPT
mitigate “dangers” of interpersonal intimacy for the
user but for the beholder they appear socially
undesirable; they may be altered by prolonged
relationship with intuitive, mature individual.

EXAMPLES OF IMMATURE DEFENSES

• Projection
• Schizoid fantasy
• Hypochondriasis
• Passive aggression
• Acting out

NEUROTIC DEFENSES
• Common in “healthy” adults with neurotic disorders
and when mastering acute distress; such mechanism
alters private feelings or instinctual expression
(sexual or aggressive) of the user but to the beholder
appear as quirks or “hang ups”; often they can be
dramatically changed by conventional supportive
therapy and clarification of unconscious wishes or
fears.

EXAMPLES OF IMMATURE DEFENSES

• Intellectualization
• Aggression
• Displacement
• Reaction formation
• Dissociation

MATURE DEFENSES
• Common in healthy adults during optimal function;
they are often regarded as so adaptive and
conscious as to be not defenses but rather “coping
mechanisms”; for the user these mechanisms
integrate conscious reality, interpersonal
relationships, and private feelings; to the beholder
they appear as convenient virtues; under increasing
stress may change to less mature defenses.

EXAMPLES OF IMMATURE DEFENSES

• Altruism
• Humor
• Suppression

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