Evidence-Based Reviews

Treating psychiatric reactions to medical illness

Current Psychiatry. 2006 October;5(10):105-119

References

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Encouraging adaptive behavior

Mrs. M is in remission when chemotherapy ends, but she worries that the cancer will come back. “The fear is still there,” she says. “You can’t be called a survivor for 5 years.”

She continues biweekly psychotherapy for the next year, and sertraline, 100 mg/d. She is doing well and has volunteered to help other newly-diagnosed patients at the cancer center.

Personality styles. Kahana and Bibring¹⁷ described 7 personality types that affect how patients cope with illnesses. Based on our experience, we suggest how to observe these styles, identify the emotional pain behind them, and respond in ways that will help each type of patient (Table 2).¹⁷

These personality types are not necessarily personality disorders; rather, they describe pervasive characteristics of coping styles. Some individuals will not match the descriptions of any of these types, and others may fall into more than one. Mrs. M, for example, shows traits of more than one personality style, including avoidant and mild schizoid features.

We helped her by engaging her in psychiatric treatment, helping her better understand her medical situation, and restoring her sense of control in making medical decisions. We discussed psycho-therapy as a two-way street, outlining her responsibilities to practice new CBT skills to use during treatment and in remission.

Table 2

Recommended treatment approaches for 7 patient personalities

Personality	Patients who…	Often feel…	Are helped by…
Dependent	ask many questions, making it hard for you to end conversations or leave the room	afraid you won’t find them worthy, won’t want to care for them	regular, brief sessions (set tactful limits that will reassure patient and not annoy staff)
Obsessive	are insistent, detail-oriented	angry when they can’t control their illness, the staff, and the schedule	detailed explanations (provide choices whenever possible, try to use patient input collaboratively)
Narcissistic	are self-centered, criticize others, believe no one is qualified to care for them	fearful, threatened, and vulnerable	avoiding confrontation but emphasizing that they deserve the best care staff can provide (keep patient informed; be sure all staff provides the same message)
Suffering victim	always have symptoms and request much attention; might not follow recommendations	suffering is their role; views illness and its treatments as punishment, but hopes doctor will keep trying	regular visits, no matter how variable the complaints
Paranoid	do not trust doctors, refuse to participate in treatment plans or sign out	taken advantage of by others or purposefully neglected or harmed	staying calm (don’t argue; offer understanding of patient’s position, provide clear recommendations
Histrionic	are flirtatious, want to call doctors by first names	need to be ‘special’ to the physician; fear illness will invalidate them or make them unattractive	encouraging patient to verbalize concerns (set boundaries for relationship; remain courteous and objective)
Schizoid	are very lonely, tend to avoid medical care	doctors are invading their privacy	engaging patient in making medical decisions
Source: Adapted from reference 17

Supportive therapy. Encourage patients to seek support from family and friends.¹⁸ Some benefit from meeting other patients with the same needs, fears, and questions.¹⁹ The Internet is a good resource to find local support groups.

Becoming sick or disabled and having to change one’s lifestyle can damage a person’s self esteem. Encourage patients to help others by volunteering, participating in research, or engaging in other activities that provide hope, gratification, and a sense of service.²⁰

Some patients regain control and battle their fears by becoming experts on their diseases. This approach will not help those who become anxious learning about prognosis and side effects, however, and prefer to have limited information about their illnesses. Your knowledge of a patient’s personality type can help you determine whether added information might alleviate or worsen that patient’s stress.

Personal transformation can occur when patients face mortality. Their perceptions about what is important and how to achieve their goals can change dramatically.

Related resources

National Cancer Institute. Coping with cancer. www.cancer.gov/cancertopics/coping.
American Psychiatric Association. Patient education site with links to topics such as coping with AIDS/HIV, postpartum depression, alcohol abuse, mental health of the elderly, and common childhood disorders. www.healthyminds.org.
Groves M, Muskin P. Psychological responses to illness. In: Bourgeois JA, Hales RE, Shahrokh N (eds). Textbook of psychosomatic medicine. Washington, DC: American Psychiatric Publishing; 2005:68-88.

Drug brand names

Mirtazapine • Remeron
Sertraline • Zoloft

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.