What is propose in this chapter is to provide an overview of different modes of psychic functioning which will give rise to different personalities. These will be displayed in the interview, each with characteristic features.
The intention is not to show psychopathology, but to transmit different types of modalities that could be presented in the usual consultation.of the normality of a subject not without conflict, but as with conflicts under the control of the self.
Health is opposed to disease in which it is a conflictive state, where the subject is alienated by it, without possibilities of useful transformation of external reality (1).
If the subject can control them and have dominion over their conflicts, they will be able to operate on reality and develop a life more or less according to their expectations.
Knowing the characteristics of the different modalities that a subject can present in the medical interview will allow not only to register and capture patient characteristics to facilitate their understanding, but also to act as doctors in one way or another to take advantage of the consultation. You could say catch more and better.
The patient does not bring only symptoms to the consultation, but is a whole person. Therefore the doctor cannot pay attention exclusively to the symptom that he brings, but must realize that the patient is treated and in what way he presents his ailments. The possibility of hearing and understanding these differences will allow the doctor to give the necessary indications in a personalized way, since these will not be received in the same way by all patients.
As in all interpersonal relationships, different feelings and feelings are generated in the medical interview. Both in the patient and in the doctor. Being able to perceive what each patient generates, will allow less interference in the development of both the consultation and the treatment.
It is also important to know that in the vast majority of cases, the attitudes of the patients (aggression, seduction, invasion, etc.) are not directed directly at the person of the doctor, but are part of their modality of relationship with the environment of according to your personal characteristics.
The intention is to make the clinical interview operational. For this is included what is agreed to call complementary styles with Dr. David Liberman (3); alluding to the attitude of the health professional during the development of the consultation according to the characteristics of the patient; in a way that favors interrelation and therefore communication. We take as a model for this description the tables as organized by Dr. Lia Ricón, who with some modifications and additions follows the proposal of Dr. Liberman.
As any classification runs the risk of being taken in a rigid way, the idea is that from the general knowledge of certain characterizations each professional can put together their own model, without extreme.
- Describe different types of presentation of patients in the clinical interview.
- That the doctor can grasp the different modalities that can be presented in his office.
- Record the different emotions and sensations that are generated in the doctor during the consultation.
- Develop complementary styles appropriate to each personality.
- Promote a better doctor-patient relationship.
- Demonstrative Personality
- Logical Personality
- Suspicious and Distrustful Personality
- Fearful and Elusive Personality
In each one of them we will develop the general characteristics, the ego functions, the feelings and reactions of the doctor, the complementary styles and the types of psychic and organic pathology that these subjects can develop.
It is important to say that other types of personalities are described but we chose these to consider them the most frequent.
As its name indicates, it is a person who shows, exteriorizes. They express themselves with great verbal and mimic richness. In general they are very attractive and seductive people, with a tendency to dramatization. His way of presenting himself does not go unnoticed. They have great plasticity and theatricality. They seem to live everything with great intensity, which allows them to produce a strong aesthetic impact on the other. (4)
Their language is full of adjectives, they give few concrete data. Its language is rich in metaphors. Example: my heart hurts or he stabbed me to speak of a loving pain. They have great symbolic capacity.
They talk about their emotions and feelings easily. Her particular ease of expression is due to the fact that emotions, language and gesture are perfectly coordinated. They therefore have a very good capacity to express themselves in the three areas of behavior: mind, body and external world.
The body is the area of manifestation par excellence and does not go unnoticed, not only at the level of its ailments but in its mode of presentation: ornaments, clothing, makeup, etc. It is common for sexual allusions to appear during the interview, both in their speech and in the way they insinuate themselves.
They tend to be attentive to the interlocutor. Thanks to their plasticity they can adapt to the characteristics of the interviewer and show themselves differently depending on whether they are men or women. They are people who quickly capture the interest of the other and try to adapt to what they suppose is expected of them.
What have to be described; their need to attract attention and their desire to be noticed is at the service of seducing and being located in the center of the scene. They need to be estimated. They therefore have a secondary benefit, since they often manage to attract the attention of their family and their environment (for example, with some physical ailment).
They may demand frequent inquiries. On the one hand, due to the physical symptoms they can present (they are usually very varied) and, on the other, due to their interest in the relationship with the doctor and the need for individualized attention.
Dispersed attention: They are people who can perceive different stimuli simultaneously.
Example: A patient who had recently undergone cosmetic surgery, while talking to her doctor about the medication she uses says: -Doctor! Doesn't it tell me anything about the eyelids? Did you see how pretty I am?
Memory: More associated with affections than with facts. If they tell any particular situation, it is likely that they include more what they felt than the objective data of the moment.
Perception: It tends more to the global than to the details.
Doctor's feelings and reactions
Due to the strong impact that this type of people generate on the interviewer, it is clear that they can provoke intense sensations and reactions in the doctor. From feeling seduced, to strong rejection. In both situations, the professional loses the objectivity necessary to hear and observe his patients.
You may also feel irritation and discomfort in front of a patient who appears to simulate illness. It is important here to clarify that the patient believes what is happening to him and it is not his intention to deceive the doctor, but it is part of his personal modality based on his already described needs.
These types of people have a great facility to fantasize and express what they feel. It is important, then, that the doctor emphasizes and emphasizes the most objective data, differentiating them from fantasy, to transmit to the patient what he considers essential. The doctor's way should be firm and objective, also taking care not to make the patient feel destitute in his story as if what he brings to the consultation is not important.
Types of pathology
- Hysterical characterization
- Hysterical neurosis with crisis and somatic conversions
- Hysterical psychosis, with partial loss of judgment and reality judgment, delusions and often suicide attempts that seek to attract attention, it is important to take them into account if there is a threat as they can be successful
- Somatic conversions
Demonstrative personality clinical case
Elena is a 44-year-old patient. She comes to the office to open the Medical Record. The office is in a very attractive building architecturally; From the corridor I hear her say to the secretaries in a loud voice (the whole waiting room listened to her): -How beautiful this place! I celebrate my next birthday here!.
The first contact was pleasant. Elena was very well groomed and neatly dressed. She works as a real estate agent. The consultation was to open the HC, therefore there were no active problems to be treated.
Elena: -Doctor, nice to meet you, how lucky I was a young doctor. I come from another prepaid, I clarify that it was excellent, but unfortunately I had to leave it because of financial problems. It was just when I separated from my husband. He was a very good man; good looking man, much older than me, I never thought he would leave me ... on top of a woman younger than me !. I don't know what this man wants, imagine how I looked. (Tears are outlined in his eyes).
Doctor: -Well Elena, I understand that you are undergoing many changes. Now I would need to ask you some questions, could you tell me if you have had any health checks in the last years?.
Elena: -And Dr. after the separation I was very bad. My whole family was worried about me, they didn't know what was happening to me. I was not the same as before. I was always very attentive to my figure, he killed me in the gym, I was always well groomed, they told me Miss Smile, and suddenly they saw me lying in bed all day, I did not want to leave my house ... then they insisted that I had to do a psychological treatment. My mom, sister and brother-in-law ran from one side to the other to help me.
Doctor: - So you did a psychological treatment?
Elena: -Yes, I think it helped me. There I could tell a lot about what was happening to me. The psychologist who attended me was very understandable, you remind me of him. Yes, I think it helped me, if not, it would not be as I am now ... what do you think? I'm fine right?
Doctor: -Yes, from what you tell me she looks quite recovered. Continuing with the health control, was any study done?
Elena: -Look doctor, the last time I was more dedicated to recover. Gynecological controls are quite late ... do you also do Pap tests? I had no children. When I was younger I thought that a pregnancy would deform my body and in the end I was left without a husband and children.
Doctor: -Do you have friends? Do you go out?
Elena: -Actually doctor, I'm a little embarrassed to tell you ... but in the gym I see a boy. He invited me for a drink. He is quite a bit younger than me, and I don't know, every time I see him, I feel something in my chest, just that I wanted to consult him, won't I have something in my heart? Could you check me?
Doctor: -Elena, from what you are telling me, I think that today it will not be necessary. I'm going to ask you some questions, since today I need to complete the HC. Then I will ask him for some gynecological studies and we will see with the results.
Its mode of presentation is what we could call correct. They have a formal way of relating, both in the way of addressing the doctor, and in their personal aspect. They are usually carefully arranged, without neglecting the details. This is not at the service of aesthetic impact but of order, cleanliness and neatness.
Its language is ceremonial and formal. Example - How is doctor ?. I apologize for delaying me.
The secretary stopped me for two minutes. I am Dr. Acosta, a lawyer and I am very interested in consulting you. I know that you are a highly recognized professional and I am very interested in your opinion.
We could say that they are controlled people, with a rigid and structured type of thinking and with little ability to adapt to different situations throughout their lives.
They have great difficulty expressing their feelings or relating their physical ailments to an emotional situation. If the doctor tries to make any relationship between his symptoms and his emotions, they could say: -Excuse me, Dr., that has nothing to do with it, it's a completely different matter.
There is not much room for feeling or pleasure in your life. They are more concerned with doing their duty, doing things correctly.
They are people of strict moral code, tenacious and compliant. They are usually what we could call good patients, since they take the medical indications as orders that they try to fulfill. Example: A patient who had to follow a food plan for alteration in the evacuation rhythm said: - Doctor, tell me exactly what I have to do, I will comply with each of your instructions because I want to be well.
They retain the details. They need to know and know about everything that happens to them. They can ask about technical issues and know as much as the doctor about their disease. This is a way of exercising control and not feeling subject to the figure of the doctor. They need to maintain their autonomy.
They require a lot of time in the consultation due to the type of discourse that is very rich in details, often irrelevant. They can keep a written record of all the studies they have done that the professional does not need; but they insist on the need to review them. They lose the totalizing vision, they can lose what is most important, due to the need to transmit all their thoughts. They cannot make synthesis.
Just as they are thrifty in expressing their affections, they are also cheap with money. They permanently doubt and try to get out of the doubt with a type of dogmatic thought. This characteristic leads them to postpone the action. This presented as an orderly, neat and corrective modality has its counterpart in strong impulses that need to be controlled. These may appear in the consultation as inappropriate expressions, aggressions or insults that impact the doctor. They arise as acts or sayings opposed to all that ceremoniality that we have described, since ambivalence (love-hate) is an accompanying characteristic.
We also want to say that if these traits are not characterized in an obsessive way, order and formality facilitate the task; Both in the activities that they carry out personally, as well as in the medical consultation and in the treatment.
Attention: it is oriented to details, both of themselves and of the other. They do not miss what happens in the consultation and they can retain it and bring it to the next one. Example: -Dr., I don't know if you remember, but last time you recommended such a thing ....
Memory: remember the concrete facts rather than the affective.
Perception: more associated with details than with the whole. As if they could only see the tree and not the forest.
Doctor's feelings and reactions
The type of formal language, the concern for details (often without any importance), the time it takes in the interviews (if one allows to display all his need to include the superfluous) can produce irritation, boredom and / or distraction in the doctor.
It is important to have a certain tolerance for the type of speech, giving rise to your need to give detailed explanations, trying not to respond with anger, irritation and / or boredom. We have to find a way to generate a different dynamic, trying to make their rigid schemes flexible without violence. The complementary style could be the demonstrative, bringing something of the emotions closer or telling a joke, trying to give the interview a less formal tone that helps the patient establish a more affective connection.
They are people who tend to intellectualize and rationalize, therefore it is important not to enter into theoretical discussions with the patient. They may present fears and doubts regarding the treatment indicated. The doctor's proposal must be clear and concrete, trying to offer an operative solution.
Types of pathology
- Obsessive compulsive neurosis. Includes rituals, ceremonials.
- Obsessions of different degrees of severity.
- Gastrointestinal disorders (constipations, diarrhea, etc.)
Logical Personality Clinical Case
Juan is 49 years old, single and healthy. He works in an insurance company where he has a very important position. He is general manager and is responsible for approximately 1,000 employees. He says that he came to that position on his own merit, nobody gave him a hand, he took all the steps he had to take. It took time but it did. He is the only one who came to that position in this way.
In this opportunity, consult for gastrointestinal complaints.
Juan: -Doctor, I have been with these discomforts for a long time ... abdominal pain, gas (meteorism), difficulty evacuating ... in reality this happens to me for ages.
Doctor: -When did you start with these discomforts?
Juan: -If you look at my medical history, you will see that I have already consulted you about this on another occasion.
You had indicated a diet that I followed as you indicated. Back then it relieved me, but now I am struggling again. Because of my work it is very important that I feel good, especially since sometimes it alternates with periods of diarrhea and I find it very difficult to manage it. The doctor who was treating me previously sent me to do a series of studies, I brought them here, I would like you to see them.
Doctor: -Let me please. The results of these analyzes are normal, I see that there are studies for 10 years. Tell me, have you taken any medication?
Juan: -No doctor, first I wanted to consult you. I wouldn't take anything without you telling me. I was reading on the internet and I saw that there is a great list of medicines that I could take, although I suppose that over the counter ones should not be that good.
Doctor: -Let's see Juan ... tell me a little about your life. Is married? who does he live with?...
Juan: - In that aspect I am well doctor, that has nothing to do with what is happening to me now. I would like to tell you about all the treatments I have previously done. For example, the doctor I saw before prescribed me ... (there, he begins with a long list of medications, telling in detail all the effects it produced)
Doctor: -Well Juan, I am going to give you the indications and we will see each other in 15 days.
Suspicious and Distrustful personality
Mistrust is the attitude that characterizes them and is always present. This generates the need to control both the other and the environment. They are hypersensitive, which does not allow them to make a more or less objective evaluation of the dialogue with the doctor. His performances are tinged with feelings of mistrust.
Example: -doctor I don't understand you, what do you mean by that? I am very surprised that he mistrusts me (way of locating in the other, his own mistrust).
They have theories about things they do not know (such as medical issues). It is not easy for them to believe what the professional explains to them, many times they have to do their own research to corroborate what the professional tells them.
Example: -Dr. Are you sure this is not going to hurt me? I read the prospectus and it has many risks, I also searched the internet...
The language they use is accurate. Their speech is serious, with little spontaneity and unavoidably contestatory, since they are permanently defending themselves. Any question or intervention on the part of the doctor can be experienced as an attack.
The control modality is extended many times to the office. They have an immediate perception of objects or some unknown instrument; they will surely ask what it is about as a way to make them more reliable. Example: A patient observed a film camera on a wall of the doctor's office and said: -I suppose they won't be filming me, right? because it would be illegal. The doctor clarified that he would not film it without consulting him and without his permission. To this answer he insisted: - Are you sure Dr.?.
They often file complaints that may be from the system, from the secretaries, or if they were made to wait. If you question her life, it is likely that several legal trials have been initiated. They tend to be arrogant. They are very self-confident and generally aggressive and authoritarian.
Attention: It is focused on the topics of your interest and do not lose detail.
Memory: It is good in relation to what was said to them. In this way they verify if the other is complying with what has been said or if they have been told the truth.
Perception: It is wide, both in terms of the set and the detail.
Doctor's feelings and reactions
At first, when the patient is being met, the doctor may be surprised by the kind of impatient, demanding, and aggressive attitude that these patients often display. The feelings they often cause are rejection, anger or fear. They put the other in an examination situation and are likely to generate a fear of making a wrong diagnosis or treatment. They are people for whom the subject of judgment is always present.
This can lead to the doctor acting, asking for many studies and analyzes as a way of confirmation, since they usually make him hesitate.
Knowing the characteristics of these patients and the sensations they can generate, means that the professional may not react by attacking in the same way that they do. Recall that your need for attack and reinvidication is due to your own feeling of being chased.
The situation of being patient and requiring help can be experienced by them as a humiliation. Therefore, it is necessary to be very careful in the treatment they are given and not make them feel subject, since the role that the doctor occupies can be lived by them as an authority from which they must defend themselves.
It is recommended to work with another member of the team as a way to attenuate the projections that these patients need to make on the other, to avoid that the doctor does not feel invaded and / or harassed. On the other hand, the presence of a third party gives the doctor the possibility of making comments and thus helps the patient to differentiate their distorted perception of reality.
Types of pathology
- Any organic disturbance (pain or disease) can be perceived as attacks from inside your body. In the same way they can feel persecuted by the other or by an external situation.
Example: -This pain is killing me (referring to a minor ailment).
Clinical case of suspicious and distrustful personality
Clara is 40 years old. Her doctor has been treating her for a couple of months. She comes under control for her dyslipidemia.
She enters the office very seriously, she seems to be angry.
Doctor: -Good morning, Clara, how are you?
Clara: -Good morning, you excuse me, but I've been waiting for 15 minutes. I think it is a lack of consideration, I also have a schedule in my work and that's why I take the first shift so there are no delays.
Doctor: - Excuse me Clara, what happens is that an emergency arose. What brings you here today ?.
Clara: -I come for the control of my cholesterol. Do you not remember that the last time I had not done well and then you asked me to repeat it? Do you want to see the analyzes ?, I was already seeing them and it seems to me that the HDL rose a little. But the LDL doesn't go down so I'm very worried, because I can't eat less than I eat.
Doctor: -Let me please.
Clara: - Could it be that the medication I'm taking is insufficient? You may have to change your medication ... look at the hepatogram is not quite right either.
Doctor: -What dose was I taking simvastatin ?.
Clara: -I'm not taking Simvastatin, doctor! I am taking Atorvastatin. Do you not remember the dose? Do you not have it registered?
Doctor: -If I am seeing it here in the medical record, I remember that in the last consultation it was misplaced.
Clara: -I am not to blame. They would have to be more careful with those things. The truth is that I am not very happy with the system. Well let's do my thing. Do not you think doctor, that it would be good to see a specialist ?. You. Do you remember that I have a family history of cardiovascular disease?
A maternal uncle died of a heart attack. When I was in the other prepaid I consulted several specialists and they changed my treatments, since I am a complicated case. At least that's what they told me. So I think now someone who knows the subject well would have to see me too.
Doctor: -As far as I remember, your parents don't have cardiovascular problems, do they?
Clara: - No, they don't even have high cholesterol. My father has prostate problems and my mother has osteoarthritis and a little osteoporosis, nothing more.
Doctor: -Clara, her analyzes are not bad, they have improved since the last time I saw her. It has no other risk factors. You know that this is a chronic disease and that you have to take care of yourself all the time. But I think that what you are doing is very good, sometimes it is necessary to change treatment because we do not have the results that we expect, but in your case it seems to me that the analyzes are quite good.
It is also important that you continue with physical activity, as you have been doing. Let's continue like this and I'll see her again in three months with the new studios. I am very happy with his evolution and I find him very well.
Fearful and elusive personality
The attitude of fear and care is the most outstanding feature of this type of people. They are solicitous and respectful, it seems that they are permanently asking for permission or forgiveness. This is not due, as in the logical modality, to a formality, but to the feeling that a danger lies in wait and thus find a way to control it.
They maintain a childish relationship with the other, placing the doctor in a situation of certain power, which they fear and try to appease with their apologies. The control that they try to exercise, by being alert, is at the service of feeling safe. The attitude is different from the suspicious person since her observation is not furtive and disguised but direct and defined.
They usually speak quietly and slowly. They are of few words, as if they were measuring them.
They prefer to be questioned and answer questions without being able to elaborate too much. They seem like people with difficulties in expression, but this can change as they get to know each other and the place or gain confidence.
They need to maintain with the other, what we could call an optimal distance: neither too close to live as a danger, nor too far to feel ignored. A certain anxious feeling is perceived in them. They can talk about their fears by always referring them to some external situation. Example: -You. Dra. saw, the things that happen, the street is a danger. I had to leave the course I was doing, because I was very scared to go home alone.
Attention: Generalized, covers the entire field.
Memory: They especially remember those situations that were distressing to them. Faced with the doctor's questions, they may take time to answer, until they are placed in their world of fears.
Perception: They have a type of immediate general perception, which is implemented from the outset as a way of reinsuring themselves. Example: - Dr. here there are changes, it seems to me that the stretcher was somewhere else, right?
Doctor's feelings and reactions
They are people who are insecure and helpless, therefore needy, this awakens in the other the desire to protect and help them.
They are patients with whom doctors generally feel comfortable working, since they are usually docile. They allow professionals to satisfy their protective and reparative aspects, characteristic of this profession.
The interviewer has to make the patient feel confident. For this you need to keep a distance that allows you to transmit interest and affection, without invading the patient.
It is important to know that time is an essential element for these people. In this way they get to know the other and gain security. Therefore there is no need to rush it, it is necessary to allow time for a trustworthy relationship to be established and therefore of greater dedication.
Types of Pathology
- Phobic neuroses, postpartum and lactation crises related to child care, panic attack, panic attacks.
- They are very fearful of any disease and can appear as hypochondriacs.
Clinical case of fearful and elusive personality
Miriam is 58 years old. She always comes to the office without a shift and if she ever asks for it, she is late, for which she comes in apologizing. Her consultations are frequent, due to different annoyances, she is always afraid of having something serious.
Miriam: - Excuse me Dra. I was late, it was not my intention. I always tease her when she's about to go. My mother has also had osteoarthritis and was deformed, I am very afraid to be like this.
Until a year ago, she worked as a secretary in a medical publishing house where, according to her, she had a lot of responsibility. A year ago she lost her job and since then she says: I can't find my place, before I felt useful, even indispensable. Now I have nothing to do, I don't know if the money will last me until the end of the month. I am looking for a job, but in this state no one will take me.
Miriam suffers from asthma since she was a child, when she lost her job she began to have asthma attacks more frequently. She is at home all day, she comes to the office always late because she says she can't go out in the morning, she's scared.
Doctor: -Miriam, stay calm. Let's see what is happening to her and how I can help her. I think this is a very special moment. She lost her job and, as you say, from having many responsibilities she went on to have time to spare. That does not help all those feelings of fear that are awakened.
Let's see if he has nothing to do or if there are things he is doing ... you told me that you are looking for a job, tell me what is it about? ...
Miriam tells a story about the job search. Although it has not yet succeeded, some possibilities are looming.
Doctor: -Well, it seems that it is not to despair. There are things that can come out, I think she is doing very well. Let me review it.
After the physical exam:
Doctor: -Regarding osteoarthritis, you don't have to worry. We are going to do the studies that we do annually, so that you will be calmer. We will see each other again when I have the results. Ask for a shift, so we have more time in the consultation.
Miriam: -Thanks, Dra. It does me good to talk to you, thank you very much, I'm leaving more calm.
These characterizations may be exaggerated since they are taken from pathology. We try to adapt them to the modalities that each person may have, without implying illness. We could say didactic cartoons (5).
The objective is that the doctor knows different ways of presenting a subject in the clinical interview, in such a way that it serves not only to get to know the patient and what can awaken him, but also to offer the possibility of enriching the relationship and doing consultation more operational.
These shapes are never pure. The same person can present a combination of the features described in the previous tables.
This attempt at classification should be taken as a guide, which each doctor will be able to adapt to his personal style in the best possible way, in order to facilitate his task.
Lic. Silvia Chajud
Dra. Adriana Goldman
Mental Health Area
MF Foundation, for the development of Family Medicine and Primary Health Care
Family and Preventive Medicine Unit
Hospital Italiano de Buenos Aires
(1) Merea César. The extension in psychoanalysis. Paidos. Deep Psychology. 1994 Edition.
(2) Lía Ricon, Silvia Di Segni and collaborators. Problems in the field of mental health. Paidos. Psychiatry. 1991 Edition.
(3) David Liberman, Linguistics, Communicative Interaction and Psychoanalytic Process. Volume 1 and 2.
(4) David Liberman. Communication and Psychoanalysis. Alex Editor 1991.
(5) Lía Ricon, Silvia Di Segni and collaborators. Problems in the field of mental health. Paidos. Psychiatry. 1991.