Seeing a person rather than a patient

Human reality goes beyond DSM-IV multiaxial diagnosis. Although extremely useful, diagnostic categories do not evaluate disability, capture the patient's experience of suffering, or predict his or her capacity to heal, in part because they are pathologically driven. It is useful to view a patient's personality as his or her attempt to adapt to and remain in equilibrium with the environment rather than solely as a disorder.

Personality styles refer to 'enduring patterns of perceiving, relating to and thinking about the environment and oneself' that manifest in most or all aspects of life. (35) Understanding a patient's personality style helps the clinician to understand the patient with the illness, as well as the illness. Patients' perceptions of their personality traits will often differ from the perceptions of others with whom they live and work. Garnering information about relationships and the perspectives of others adds rich data, whether the source of the information is the patient or family and friends.

With the stress of life circumstances, including illness, personality styles that had been very adaptive can become maladaptive; also, the patient's normal degrees of flexibility may be significantly reduced (Tab.!® 4). For example, a successful accountant with some obsessive-compulsive traits may become dysfunctionally preoccupied with his or her symptoms when confronted with the uncertainties of a chronic illness such as multiple sclerosis. A goal-directed and imaginative executive may become angry about having to wait 15 minutes to see the physician to obtain results of a 'routine' screening laboratory test. Personality styles that are maladaptive under everyday circumstances may become more maladaptive under the stress of illness. Thus, a depressive factory worker will assume that her breast lump is malignant before a biopsy is performed, and a passively dependent graduate student will schedule frequent visits for seemingly minor problems.

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Table 4 Personality styles

Table 4 Personality styles

There are several common pitfalls in the assessment of patients' psychological profiles.

• Some personality traits may appear to be more fixed than they actually are. Defensiveness, mistrust, and anger manifested in situations of emotional distress may be state-dependent rather than traits. Clinicians may underestimate a bereaved patient's ability to cope; the deceased may have been a stabilizing force and the patient is experiencing transient disorientation.

• When there is underlying or overt turmoil in the relationship with the patient, physicians may be prone to prosecute the 'bad' patient with adjectives such as 'manipulator,' 'heartsink', or 'somatizer'.

• Physicians tend to undervalue the intelligence of illiterate, disabled, deaf, or foreign-born patients. (3 3Z) Physicians also tend to underestimate the level of suffering of patients from cultural groups different from their own.(38)

• Physicians are frequently misled by prior diagnoses, particularly if they are associated with legal or ethical transgressions on the part of the patient. Each patient must be given the opportunity to be different and to have a diagnosis different from that found previously.

• Hypochondriacal patients, patients who have problems with the law, and 'manipulators' can be perfect targets for physician mistakes. For these reasons, it is best to apply parsimonious and flexible adjectives when describing patients in medical records.

To overcome simplifications and facile labels (heavy, illiterate, whining, etc.), the clinician needs to maintain interest in the patient's daily life. Part of the interview should be a search for data about a previously undiscovered attribute: What are the patient's professional skills? Is he or she proud of something—a job, the family? Two biographical techniques are particularly useful for gathering such data. Pathobiography is a simple technique in which the clinician draws a time line beginning at the patient's birth and extending to the present. Important life events, including illnesses ( Fig 1), are placed to contextualize the current situation. A genogram, or family tree, can reveal important information about family structure, lifecycle developmental tasks, and family strengths as well as patterns of disharmony. (39> Both can be part of the regular medical record and updated periodically.

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Fig. 1 Sample pathobiography

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