Psychology of personality. Modern theories of

personality. Personality and illness. Internal picture of illness, types of patients. 

PersonalityPersonality

Freud had said that a healthy Freud had said that a healthy personality was d emonstrated by the personality was d emonstrated by the

ability to “love and work”.ability to “love and work”. To be a able to love means to be To be a able to love means to be able to be warm, supportive, able to be warm, supportive, encouraging, intimate, forgiving encouraging, intimate, forgiving and respectful of others; and respectful of others;

to be able to work means to be to be able to work means to be able to accept responsibility for able to accept responsibility for one’s actions, take directions, one’s actions, take directions, expend effort in spite of lacking expend effort in spite of lacking energy and to delay gratificationenergy and to delay gratification

Personality disorderPersonality disorder

is an enduring pattern of inner is an enduring pattern of inner experience and behaviour that experience and behaviour that deviates markedly from the deviates markedly from the expectations of the individual’s expectations of the individual’s culture, is pervasive and inflexible, culture, is pervasive and inflexible, has an onset in adolescence or early has an onset in adolescence or early adulthood, is stable over time and adulthood, is stable over time and leads to distress and impairment” leads to distress and impairment” (DSM-IV-TR).(DSM-IV-TR).

Characteristics of PD’s:Characteristics of PD’s:

EgoEgo--syntonicsyntonic Maladaptive behaviorMaladaptive behavior Inflexible traitsInflexible traits Long-standingLong-standing PervasivePervasive Difficult to treatDifficult to treat

EgoEgo--syntonicsyntonic

People with “neurotic disorders” (an example is People with “neurotic disorders” (an example is anxiety disorder) have “autoplastic defences” meaning anxiety disorder) have “autoplastic defences” meaning they react to stress by changing their internal they react to stress by changing their internal psychological process, and perceive their disorder as psychological process, and perceive their disorder as “ego-dystonic” meaning they find their symptoms “ego-dystonic” meaning they find their symptoms unacceptable, objectionable and needing to be unacceptable, objectionable and needing to be changed.changed.

People with personality disorders, in contrast, have People with personality disorders, in contrast, have “alloplastic defences” meaning they react to stress by “alloplastic defences” meaning they react to stress by attempting to change the external environment (rather attempting to change the external environment (rather than themselves), and perceive their symptoms than themselves), and perceive their symptoms (personality deficits) as “ego -syntonic” meaning they (personality deficits) as “ego -syntonic” meaning they find these aspect of themselves to be acceptable, find these aspect of themselves to be acceptable, unobjectionable and not in need of change.unobjectionable and not in need of change.

Maladaptive behaviorMaladaptive behavior

As people with personality believe the world should change As people with personality believe the world should change to accommodate them (rather than they adjust to the world) to accommodate them (rather than they adjust to the world) and view their own features as being acceptableand not in and view their own features as being acceptableand not in need of change, they experience less distress as a direct need of change, they experience less distress as a direct result of their personality disorder than might be expected.result of their personality disorder than might be expected.

However , the world does not change to suit them, and they However , the world does not change to suit them, and they experience much indirect distress as a result of their experience much indirect distress as a result of their personality disorder; that is, their maladaptive responses personality disorder; that is, their maladaptive responses lead to failed relationships (with lovers, family and lead to failed relationships (with lovers, family and employers), losses and disappointments. employers), losses and disappointments.

Maladaptive behaviorMaladaptive behavior

The individual with personality disorder The individual with personality disorder (particularly, antisocial personality (particularly, antisocial personality disorder) generate distress in others, disorder) generate distress in others, irrespective of whether they experience irrespective of whether they experience distress themselves . distress themselves .

The failure of the relationships and The failure of the relationships and conflicts experienced by people with conflicts experienced by people with personality disorder inevitably involve personality disorder inevitably involve others, and naturally generate distress others, and naturally generate distress in others.in others.

InflexibleInflexible The individual with a personality has a limited repertoire, The individual with a personality has a limited repertoire,

or number of ways of responding. Faced with opposition or number of ways of responding. Faced with opposition the normal/average individual has a range of responses: to the normal/average individual has a range of responses: to think of a new approach, work harder and try again when think of a new approach, work harder and try again when better prepared, to use humour, to be more assertive, etc. better prepared, to use humour, to be more assertive, etc.

The person with a personality disorder has a limited The person with a personality disorder has a limited number of ways of responding (and, for example may be number of ways of responding (and, for example may be largely limited to seduction or aggression). These are largely limited to seduction or aggression). These are applied in all situations, and because of the inflexibility of applied in all situations, and because of the inflexibility of the individual, they are applied repeatedly, even when the individual, they are applied repeatedly, even when they have already proved unsuccessful. In these they have already proved unsuccessful. In these circumstances loss and disappointment, and direct and circumstances loss and disappointment, and direct and indirect distress are inevitable.indirect distress are inevitable.

Clusters of personality disorderClusters of personality disorderClusterCluster SubtySubtyррee Discriminating Discriminating featuresfeatures

A Odd/eccentricA Odd/eccentric ParanoidParanoidSchizoidSchizoidSchizotypalSchizotypal

SuspiciousSuspiciousSocially Socially indifferent indifferent EccentricEccentric

В В Erratic/impulsiveErratic/impulsive

AntisocialAntisocialBorderlineBorderlineHistrionicHistrionicNarcissisticNarcissistic

DisagreeableDisagreeableUnstableUnstableAttention Attention seekingseekingSelf-canteredSelf-cantered

С С Anxious/fearfulAnxious/fearful

AvoidantAvoidantDependentDependentObsessiveObsessive

InhibitedInhibitedSubmissive Submissive PerfectionisticPerfectionistic

Dissociative (Conversion) Dissociative (Conversion) DisordersDisorders

The common theme shared by dissociative disorders The common theme shared by dissociative disorders is a partial or complete loss of the normal is a partial or complete loss of the normal integration between memories of the past, integration between memories of the past, awareness of identity and immediate sensations, awareness of identity and immediate sensations, and control of bodily movements. There is normally and control of bodily movements. There is normally a considerable degree of conscious control over the a considerable degree of conscious control over the memories and sensations that can be selected for memories and sensations that can be selected for immediate attention, and the movements that are to immediate attention, and the movements that are to be carried out.be carried out.

The term “conversion hysteria” should be avoided, The term “conversion hysteria” should be avoided, because it is confusing and stigmatizing.because it is confusing and stigmatizing.

The prevalence is not exactly known (up to 10%) The prevalence is not exactly known (up to 10%) .. Sudden onset and termination of dissociative statesSudden onset and termination of dissociative states..

Dissociative Disorders of Dissociative Disorders of Movement and SensationMovement and Sensation

There is a loss of or interference with movements or loss of There is a loss of or interference with movements or loss of sensations (usually cutaneous). Mild and transient varieties of sensations (usually cutaneous). Mild and transient varieties of these disorders are often seen in adolescence, particularly in these disorders are often seen in adolescence, particularly in girls, but the chronic varieties are usually found in young adults.girls, but the chronic varieties are usually found in young adults.

Dissociative motor disordersDissociative motor disorders Dissociative convulsionsDissociative convulsions Dissociative anaesthesiaDissociative anaesthesia Ganser’s syndromeGanser’s syndrome – „– „approximate” or grossly incorrect answersapproximate” or grossly incorrect answers MMultiple personality disorderultiple personality disorder means the apparent existence of means the apparent existence of

two or more distinct personalities within an individual, with only two or more distinct personalities within an individual, with only one of them being evident at a time.one of them being evident at a time.

Each personality is complete, with its own memories, Each personality is complete, with its own memories, behaviours, and preferences, but neither has access to the behaviours, and preferences, but neither has access to the memories of the other and the two are almost always unaware of memories of the other and the two are almost always unaware of each other’s existence. Change from one personality to another each other’s existence. Change from one personality to another is in the first instance usually sudden and closely associated with is in the first instance usually sudden and closely associated with traumatic events. traumatic events.

Clinical ManagementClinical Management

PsychotherapyPsychotherapy is a method of choice of is a method of choice of treatment of dissociative disorders treatment of dissociative disorders ((e.g. e.g. psychodynamic programspsychodynamic programs,, hypnosis hypnosis))..

Medications have no proven value with Medications have no proven value with exception of sodium amobarbital exception of sodium amobarbital interview.interview.

F43 Reaction to Severe Stress, F43 Reaction to Severe Stress, and Adjustment Disordersand Adjustment Disorders

F43.0F43.0 Acute stress reaction Acute stress reaction

F43.1F43.1 Post-traumatic stress disorder Post-traumatic stress disorder

F43.2F43.2 Adjustment disorders Adjustment disorders

F43.8F43.8 Other reactions to severe stress Other reactions to severe stress

F43.9F43.9 Reaction to severe stress, Reaction to severe stress, unspecified unspecified

F45 Somatoform DisordersF45 Somatoform Disorders

F45.0F45.0 Somatization disorder Somatization disorder

F45.1F45.1 Undifferentiated somatoform disorder Undifferentiated somatoform disorder

F45.2F45.2 Hypochondriacal disorder Hypochondriacal disorder

F45.3F45.3 Somatoform autonomic dysfunction Somatoform autonomic dysfunction

F45.4F45.4 Persistent somatoform pain disorder Persistent somatoform pain disorder

F45.8F45.8 Other somatoform disorders Other somatoform disorders

F45.9F45.9 Somatoform disorder, unspecified Somatoform disorder, unspecified

Somatoform disorders Somatoform disorders -- multiple, recurrent and multiple, recurrent and frequent somatic complaints requiring medical frequent somatic complaints requiring medical attention without association with any physical attention without association with any physical disorder are prominent. disorder are prominent.

The medical history of multiple contacts with The medical history of multiple contacts with primary care and specialized health services is primary care and specialized health services is typical before the patient is referred to typical before the patient is referred to psychiatric care.psychiatric care.

Characteristics of somatoform disorders:

• somatic complains of many medical maladies without association with serious demonstrable peripheral organ disorder

• psychological problems and conflicts that are important in initiating, exacerbating and maintaining the disturbance

Somatization DisorderSomatization Disorder

A definite diagnosis requires the presence of all of A definite diagnosis requires the presence of all of the following:the following:

a)a) at least 2 years of multiple and variable at least 2 years of multiple and variable physical symptoms for which no adequate physical symptoms for which no adequate physical explanation has been found,physical explanation has been found,

b)b) persistent refusal to accept the advice or persistent refusal to accept the advice or reassurance of several doctors that there is no reassurance of several doctors that there is no physical explanation for the symptoms,physical explanation for the symptoms,

c)c) some degree of impairment of social and family some degree of impairment of social and family functioning attributable to the nature of functioning attributable to the nature of symptoms and resulting behavior.symptoms and resulting behavior.

Somatization DisorderSomatization DisorderDifferential DiagnosisDifferential Diagnosis

Medical conditions may be confused with Medical conditions may be confused with somatoform disorder especially early in their course somatoform disorder especially early in their course (multiple sclerosis, brain tumor, (multiple sclerosis, brain tumor, hyperparathyroidism, hyperthyroidism, lupus hyperparathyroidism, hyperthyroidism, lupus erythematosus). erythematosus).

Further investigation or consultation should be Further investigation or consultation should be considered in long-term somatization disorder if considered in long-term somatization disorder if there is a shift in the emphasis or stability of the there is a shift in the emphasis or stability of the physical complaints. This change in symptoms physical complaints. This change in symptoms suggests possible development of physical disease.suggests possible development of physical disease.

Affective (depressive) and anxiety disordersAffective (depressive) and anxiety disorders accompany somatization disorders but need not be accompany somatization disorders but need not be specified separately unless they are sufficiently specified separately unless they are sufficiently marked and persistent. marked and persistent.

Somatization DisorderSomatization DisorderTherapy and PrognosisTherapy and Prognosis

Chronic relapsing condition starting in adolescence or even as Chronic relapsing condition starting in adolescence or even as late as the third decade of life.late as the third decade of life.

New symptoms during the emotional distress.New symptoms during the emotional distress. Typical episodes last 6 to 9 months.Typical episodes last 6 to 9 months. Management strategies:Management strategies:

1.1. the trusting relationship between the patient and one (if possible) the trusting relationship between the patient and one (if possible) primary care physician primary care physician

2.2. set up regularly scheduled visits every 4 or 6 weeksset up regularly scheduled visits every 4 or 6 weeks3.3. keep outpatient visits brief-perform at least a partial physical keep outpatient visits brief-perform at least a partial physical

examination during each visit directed at the organ system of examination during each visit directed at the organ system of complaintcomplaint

4.4. understand symptoms as emotional message rather than a sing of understand symptoms as emotional message rather than a sing of new disease, look for signs of disease rather than focus on new disease, look for signs of disease rather than focus on symptomsymptom

5.5. avoid diagnostic tests, laboratory evaluations and operative avoid diagnostic tests, laboratory evaluations and operative procedures unless clearly indicated procedures unless clearly indicated

6.6. set a goal to get selected somatization patients referral- ready for set a goal to get selected somatization patients referral- ready for mental health caremental health care

Group therapy (time limited, behavior oriented and structured Group therapy (time limited, behavior oriented and structured group). group).

Hypochondriacal DisorderHypochondriacal Disorder

The disorder is characterized by a persistent The disorder is characterized by a persistent preoccupation and a fear of developing or having preoccupation and a fear of developing or having one or more serious and progressive physical one or more serious and progressive physical disorders.disorders.

Patients persistently complain of physical problems Patients persistently complain of physical problems or are persistently preoccupied with their physical or are persistently preoccupied with their physical appearance. appearance.

The fear is based on the misinterpretation of The fear is based on the misinterpretation of physical signs and sensations.physical signs and sensations.

Physician physical examination does not reveal any Physician physical examination does not reveal any physical disorder, but the fear and convictions physical disorder, but the fear and convictions persist despite the reassurance.persist despite the reassurance.

Hypochondriacal DisorderHypochondriacal Disorder

Presence of both of the following criteria:Presence of both of the following criteria:1.1.persistent belief in the presence of at least one serious persistent belief in the presence of at least one serious

physical illness underlying the presenting symptom or physical illness underlying the presenting symptom or symptoms, even thought repeated investigations and symptoms, even thought repeated investigations and examinations have not identified any adequate physical examinations have not identified any adequate physical explanation, or a persistent preoccupation with presumed explanation, or a persistent preoccupation with presumed deformity or disfigurementdeformity or disfigurement

2.2.persistent refusal to accept the advice and reassurance of persistent refusal to accept the advice and reassurance of several different doctors that there is no physical illness or several different doctors that there is no physical illness or abnormity underlying the symptomsabnormity underlying the symptoms

Includes: Body dysmorphic disorder, Includes: Body dysmorphic disorder, Dysmorphophobia (non delusional), Dysmorphophobia (non delusional), Hypochondriacal neurosis, Hypochondriasis, Hypochondriacal neurosis, Hypochondriasis, NosophobiaNosophobia

Hypochondriacal DisorderHypochondriacal Disorder Differential DiagnosisDifferential Diagnosis

Basic - ruling out underlying Basic - ruling out underlying organic disease.organic disease.

The main somatoform disorder The main somatoform disorder that need to be differentiated that need to be differentiated from hypochondriasis is from hypochondriasis is somatization disorder.somatization disorder.

Hypochondriasis needs to be Hypochondriasis needs to be distinguished from factitious distinguished from factitious disorder with predominantly disorder with predominantly physical signs and from physical signs and from malingering.malingering.

Hypochondriacal DisorderHypochondriacal Disorder Therapy and PrognosisTherapy and Prognosis

The illness is usually long-standing, with episodes The illness is usually long-standing, with episodes lasting months or years. Recurrences occur lasting months or years. Recurrences occur frequently after psychosocial distress.frequently after psychosocial distress.

Higher socio-economic status, presence of other Higher socio-economic status, presence of other treatable condition, anxiety and depression, an treatable condition, anxiety and depression, an acute onset, absence of personality disorder or acute onset, absence of personality disorder or comorbid organic disease predict better outcome.comorbid organic disease predict better outcome.

NNo evidence-based treatment has been described. o evidence-based treatment has been described. Patients strongly refuse the mental health care Patients strongly refuse the mental health care

professionals and remain in primary health care.professionals and remain in primary health care. Similar management and group therapy strategy as Similar management and group therapy strategy as

in somatization disorder may be useful.in somatization disorder may be useful.

Somatoform Autonomic Somatoform Autonomic DysfunctionDysfunction

The symptoms are presented as physical disorder of The symptoms are presented as physical disorder of system or organ largely or completely under system or organ largely or completely under controlled by autonomic innervation, i.e. the controlled by autonomic innervation, i.e. the cardiovascular, gastrointestinal, or respiratory cardiovascular, gastrointestinal, or respiratory system and some aspects of genitourinary system. system and some aspects of genitourinary system.

The symptoms are usually of two typesThe symptoms are usually of two types::1.1. complaints based on objective signs of autonomic arousal complaints based on objective signs of autonomic arousal

(palpitation, sweating, flushing, tremor)(palpitation, sweating, flushing, tremor)

2.2. idiosyncratic, subjective, non-specific (fleeting aches and idiosyncratic, subjective, non-specific (fleeting aches and pains, burning, heaviness, tightness, sensation of being pains, burning, heaviness, tightness, sensation of being bloated or distended)bloated or distended)

These symptoms patients refer to a specific organ These symptoms patients refer to a specific organ or system. or system.

In many cases there is evidence of psychological In many cases there is evidence of psychological stress or current problems related to the disorder.stress or current problems related to the disorder.

Somatoform Autonomic DysfunctionSomatoform Autonomic Dysfunction

a)a) Symptoms of autonomic arousal such as Symptoms of autonomic arousal such as palpitations, sweating, tremor, flushing which are palpitations, sweating, tremor, flushing which are troublesome and persistenttroublesome and persistent

b)b) Additional subjective symptoms referred to Additional subjective symptoms referred to specific organ or systemspecific organ or system

c)c) Preoccupation with the symptoms and possibility Preoccupation with the symptoms and possibility of serious (often non specified disorder). It does of serious (often non specified disorder). It does not respond to repeated explanations and not respond to repeated explanations and reassurance of physiciansreassurance of physicians

d)d) No evidence of a significant disturbance of No evidence of a significant disturbance of structure or function of the system or organstructure or function of the system or organ

Somatoform Autonomic DysfunctionSomatoform Autonomic Dysfunction Differential DiagnosisDifferential Diagnosis

In comparison with generalized anxiety there is In comparison with generalized anxiety there is predominance of psychological component of predominance of psychological component of autonomic arousal. In somatization disorders autonomic arousal. In somatization disorders autonomic symptoms when they are present they autonomic symptoms when they are present they are nor prominent nor persistent and symptoms are nor prominent nor persistent and symptoms are not so persistently attributed to one organ or are not so persistently attributed to one organ or system.system.

Somatoform Autonomic DysfunctionSomatoform Autonomic Dysfunction Therapy and PrognosisTherapy and Prognosis

Similar chronic relapsing condition as the Similar chronic relapsing condition as the somatization disorder. somatization disorder.

Patients report worse health than do those with Patients report worse health than do those with chronic medical condition and their report of chronic medical condition and their report of specific symptoms if they meet the severity specific symptoms if they meet the severity criteria is sufficient and need not to be criteria is sufficient and need not to be considered legitimate by the clinician.considered legitimate by the clinician.

Treatment strategies will be similar stressing the Treatment strategies will be similar stressing the importance of the interdisciplinary collaboration.importance of the interdisciplinary collaboration.

Persistent Somatoform Pain Persistent Somatoform Pain DisorderDisorder

The predominant symptom is a persistent severe The predominant symptom is a persistent severe and distressing pain that cannot be explained and distressing pain that cannot be explained fully by a physiological process of physical illness.fully by a physiological process of physical illness.

Pain occurs in association with emotional conflicts Pain occurs in association with emotional conflicts or psychosocial problems. or psychosocial problems.

The expression of chronic pain may vary with The expression of chronic pain may vary with different personalities and cultures.different personalities and cultures.

TThe patient is not malingering and the complaints he patient is not malingering and the complaints about the intensity of the pain are to be believed.about the intensity of the pain are to be believed.

F45.4 Persistent Somatoform PainF45.4 Persistent Somatoform Pain Diagnostic GuidelinesDiagnostic Guidelines

The clinical examination should focus onThe clinical examination should focus ona)a) the extend the patient is disabled by the painthe extend the patient is disabled by the pain

b)b) the degree of complicating emotional factors and the degree of complicating emotional factors and comorbid psychiatric conditionscomorbid psychiatric conditions

Includes: psychalgia, psychogenic backache or Includes: psychalgia, psychogenic backache or headache, somatoform pain disorder.headache, somatoform pain disorder.

F45.4 Persistent Somatoform PainF45.4 Persistent Somatoform PainDifferential DiagnosisDifferential Diagnosis

Not included:Not included:• pain presumed to be of psychological origin occurring pain presumed to be of psychological origin occurring

during the course of depression or schizophreniaduring the course of depression or schizophrenia• pain due to known or inferred physiological mechanism pain due to known or inferred physiological mechanism

such as muscle tension pain or migraine but still such as muscle tension pain or migraine but still believed to have psychological cause are coded as P54believed to have psychological cause are coded as P54

• the somatoform pain disorder has to be differentiated the somatoform pain disorder has to be differentiated from histrionic behaviour in reaction to organic painfrom histrionic behaviour in reaction to organic pain

Excluded backache NOS (M54.9), pain NOS Excluded backache NOS (M54.9), pain NOS (acute, chronic) (R52.-), tension type headache (acute, chronic) (R52.-), tension type headache (G44.2).(G44.2).

F45.4 Persistent Somatoform PainF45.4 Persistent Somatoform PainTherapy and prognosisTherapy and prognosis

Once diagnosis is completed the outpatient Once diagnosis is completed the outpatient treatment on regular basis by one interested treatment on regular basis by one interested physician has to be carried out. physician has to be carried out.

Patients have to be reassured that the treatment Patients have to be reassured that the treatment continues if there is some improvement.continues if there is some improvement.

Those with painThose with pain--prone reaction to distress are prone reaction to distress are described to have poor or transient improvement. described to have poor or transient improvement.

Patients with comorbid depression may improve Patients with comorbid depression may improve with antidepressant medication. with antidepressant medication.

Treatment with any type of the pain disorder Treatment with any type of the pain disorder subtypes needs to be multidisciplinary and subtypes needs to be multidisciplinary and multidimensional from the onset.multidimensional from the onset.

Thank You for the Thank You for the attentionattention