Personality Types in Medical Management

Grete

Ralph J. Kahana and Grete L. Bibring
in: N.E. Zinberg (Ed.) Psychiatry and Medical Practice in a General Hospital. International Universities Press, New York; 1965: 108–123.

Grete Bibring (in the picture) was a prominent psychoanalyst of her era (1899-1977), who applied analytic concepts to the everyday practice of medicine, emphasizing the importance of understanding patient’s personality and psychological needs for optimal delivery of medical care. In 1956, she published this paper with her colleague Kahana, describing seven personality types with the underlying psychological needs and conflicts. This is an important paper for the psychiatric consultation-liaison reading list.

The authors described the personality types based on the characteristic ways of coping with stressful, anxiety-provoking situation in possibly otherwise psychologically normal, well-functioning individuals. The distinction can inform psychiatrists of possible meaning of illness to the particular kind of person, the perceived threat that they need to cope with, the kind of defensive and adaptive behaviour that has become intensified under stress, and some suggestions for management in regards to medical psychotherapy.

1. The dependent, overdemanding patient
Characteristics – Urgent quality to all requests; needs special attention or unusual amount of advice; quick to put themselves in the hands of doctor with expectations of limitless care; may appear generous and concerned about others, but they expect manifold repayment and feel resentful when disappointed; dependent on others to protect them and to help feel secure and accepted; low frustration tolerance and may lead to intense feelings of anger, depression, apathy, or helplessness; if disappointments in childhood then may be revengeful, nagging, demanding, and expectation of being disappointed by the doctor; craving for satisfaction or stimulation through oral addictions.
Developmental imprints – earliest childhood experiences of infant’s basic needs linked with outside stimulation.
Meaning of illness – food or medicine or special considerations equates to being loved; anxiety of illness transforms into wish for boundless interest and abundant care; but also deep fear of being abandoned, helpless, and starving; the struggle between wishes and fear may represent itself in persistent demands, over dependency on doctor’s prescriptions, or fights any need for care; feelings as small children that their suffering is because nobody loves them, and may blame others for any discomfort.
Strategies – need for special attention could be satisfied to reasonable extent, and after that some limit setting can be presented to the patient through thoughtful explanation; great care to not come across as impatient or punitive, or using withdrawal of interest and consideration as forms of limit setting; directly or implicitly convey readiness to care; temporary active and undemanding nursing care directed for physical comfort; some minor concessions in exchange for limit setting as friendly interest of the doctor, change of diet, or offer to provide hospital transport for their family member’s visit.

2. The orderly, controlled, compulsive patient
Characteristics – excellent self-discipline; gather extensive information about their condition; ritualistic tendencies; rigid righteous sense and conscientious; frugal wit finances
Developmental imprints – formation between ages 2-4; precocious development of motor and intellectual abilities; early insistence by parents on cleanliness, or control of body functions and behaviours, and disregard for child’s need for balance between the struggle to comply and rebel; intellect is used to curb impulses, thinking becomes substitute to action, and impulses are warded off by rigid opposite overcompensating behaviours.
Meaning of illness – sickness threatens loss of control over impulses; redoubled efforts to be responsible and orderly and to supress uncontrolled emotions; may seem inflexible and opinionated; increased striving for intellectual control; may hesitate, doubt, and be indecisive due to lack of all possible information.
Strategies – use scientific medical approach by careful and systematic method of assessment and treatment; sympathetic efficiency and cleanliness in nursing care; inform methodically and in detail about his illness and steps in diagnosis and therapy to help him establish intellectual control over his anxiety; encourage active participation in decision making and where possible, control over some aspects of their own treatment; acknowledge patient’s discernment, comprehension, sound reasoning, and high standards.

3. The dramatizing, emotionally involved, captivating, hysterical patient
Characteristics – interesting, charming, but also mystifying; acts in a very warm and personal manner and expects the doctor to do the same in return; strives for an intense, idealizing relationship with the doctor; readily develops anxiety for even minor medical procedures; would avoid frightening situations, but at times run towards danger in an attempt to overcome fear; tendency towards denial or amnesia for previous upsetting events;
Developmental imprints – period of development between 3-6 years of age in which child forms a strong attachment to the parent of the opposite sex; the warm, personal responses are emotional expression to impulses stemming from this early affection, while the guilt over hostile urges towards the same sex parent and in turn fear of punishment and retaliation forms the basis of characteristic anxieties.
Meaning of illness – sickness may feel like a personal defect; fears of being weak or unattractive; men may display physical strength, competitiveness or quick to fight, or may engage in fantacies involving nurses or other female attendants, as means to overcome those anxieties; women may become flirtatious or dress up; at times anxieties may lead to paradoxical reactions, where the patient may be too ready for an inappropriate procedure to deny their anxieties.
Strategies – doctor should not be too reserve as the patient seeks appreciation of their attractiveness or courage; proceed with calmness and firmness to avoid stirring emotional fantacies or anxieties; reassure about the illness and medical procedures, and may have to give chance for the patient to discuss their fears often to help them discharge their fears.

4. The long-suffering, self-sacrificing, masochistic patient
Characteristics – inclined to disregard their own comfort and be of service to others; tendency to display suffering in an exhibitionistic way; tendency for involuntary self-victimization; doesn’t accept encouragement or reassurance, and deny any improvement; complaints increase when given any comforting reassurance; disregards evidence of recovery and accentuates what is still not recovered
Developmental imprints – severely repressive upbringing in which child was made to feel excessively guilty, was not allowed to show anger even in harmless manner, and was given corporal punishment, which provoked excitement tinged with pleasure; an attachment with the aggressive parent may shape later relationships, or the child may have unconsciously modelled self on the suffering parent.
Meaning of illness – basic striving is to gain love, care and acceptance, although feels too guilty or anxious to expect this without self-sacrificing and suffering; love me because I am suffering;
Strategies – when this patient expresses their suffering, they are not looking for reassurance, but for acknowledgement of their pain and sacrifices; express appreciation of the difficulties of illness as is experienced by the patient; may co-operate with the medical regimen if it is an added burden rather than for personal relief; present recovery as a special additional task for benefit of others.

5. The guraded, querulous, paranoid patient
Characteristics – openly or covertly watchful of others; suspicious of other’s intentions, querulous, or blameful of their motives; deep, long held grudges; oversensitive to slights and to hints of negative feelings in others; easily feel persecuted or oppressed, and react with out of proportion self-righteous counter-attack;
Reactions against developmental imprints – excessive sensitivity to criticism and underlying fear of persecution reflects deep concerns with own faults and weaknesses; self-reproach is disclaimed and read into other people’s attitudes, with indignant disapproval; a way of elevating their self-regard and reinforcing beliefs about others as bad.
Meaning of illness – during sickness his fears of persecution may be intensified and he may become more guarded, suspicious, quarrelsome, controlling of others;
Strategies – tell the patient as far as foreseeable the strategy of diagnosis and treatment; respect the fact of their hypersensitivity to slights; friendly and courteous attitude that is not too close, nor too far; they may fear being forced or manipulated if doctor makes attempts to come too close; do not argue or ignore his suspicious attitudes or reassure him, he is unable to believe it and might lead to further distrust.

6. The narcissistic patient with feeling of superiority
Characteristics – appears vain or grandiose, or hidden beneath shallow humility; arrogant and an aura of mysterious knowledge; chooses only the best of the doctors or care; benevolent or begrudging tolerance of junior staff; constantly searches for the weakness in the doctor and inclined to lose confidence in him
Reactions against developmental imprints – underlying doubts about self;
Meaning of illness – sickness as a threat to his self-image of perfection and invulnerability; reacts with defensive grandiosity
Strategies – implicit acknowledgement as a person of achievement in his own right; calm confident approach, as he may be deeply afraid of an incompetent doctor, despite constantly searching for faults.

7. The uninvolved, aloof, schizoid patient
Characteristics – quiet, distant, reclusive, little need for emotional ties, independent, and hard to impress;
Reactions against developmental imprints – underlying oversensitivity, fragility, and lack of resilience; aloofness as a protective denial of painful experiences; earliest efforts to form a loving attachment with others led to repeated disappointments; also genetic influences
Meaning of illness – sickness is a threat to this equilibrium, so the denial is intensified in proportion to the increase in underlying anxiety;
Strategies – unsocialibility needs to be understood and accepted; as few demands as possible to involve personally with others, but also not let completely withdraw; maintain a quiet and considerate interest, without asking for reciprocity.

At the end of the paper an approach to working with difficult patients in medical settings is illustrated through a case. Understanding of personality structure helps to provide meaning to patient’s recovery-interfering behaviours. This paper provides a useful framework for common behavioural problems encountered on a medical ward, in a GP practice, or in a non-acute psychiatric setting.

5 Key Points:
– Illness activates dependency needs – need to be cared, to depend on others, to trust others for the care and protection.
– During illness, early experiences of caregivers and the care patterns are activated. Some adults repeat the same care-eliciting behaviours that proved successful in the childhood; what was adaptive then, but now appears to be maladaptive – overdependent, overly controlled, dramatic, masochistic. Whilst for others, illness presents a threat of becoming vulnerable again and at risk of being abused, thus they tend to strengthen their defensive manoeuvres to protect themselves – paranoid, narcissistic, aloofness.
– Recovery-interfering behaviours can be considered as either care-eliciting behaviours or care-rejecting (but self-protective) behaviours.
– Developmental imprints of care experiences lend personal meaning of illness, and related anxiety is due to fear of either not receiving the needed care or care would be provided in an abusive way. Defences are to protect oneself against the activated anxiety.
– Defences are to be respected and acknowledged, implicitly or explicitly, and use strategies that do not challenge the patient, thus not reinforcing the underlying fears.

See also, Care-Eliciting Behaviour in Man, by Scott Henderson (1974).
See also, The Beginning of Wisdom is Never Calling a Patient a Borderline; or, The Clinical Management of Immature Defences in the Treatment of Individuals with Personality Disorders, by George Vaillant (1992).