IN THE COURSE OF our efforts to implement and study the integration of medicine and psychiatry within a general hospital, the diagnosis of personality structure has become an important element in the psychological management of the physically ill patient (G. Bibring, 1951, 1956; Dwyer & Zinberg, 1957; Kahana, 1959). We have found it convenient to delineate seven basic categories of personality types and attitudes:
The first three types especially bear the direct imprint of specific developmental periods in childhood (S. Freud, 1905, 1908; Abraham, 1921, 1924, 1925). In the following four, the leading attitudes represent certain defensive reactions directed against impulses stemming from these early phases of development (Fenichel, 1945; A. Freud, 1946; S. Freud, 1905; Jones, 1913; Loewenstein, 1957; Reik, 1947). The above diagnostic categories do not designate personality disorders. They refer to the psychologically normal, well-functioning person and are especially applicable to the individual in any stressful, anxiety-producing situation. Physical illness invariably represents an emotional crisis, which may be very intense but will be transient if well handled by the patient and the environment. A psychopathological diagnosis in a given case may be warranted if there is marked accentuation of character traits, neurotic or psychotic symptoms, serious difficulty in dealing adequately with social relationships, limited capacity for work, and even impaired ability to gain satisfaction and enjoyment in life. As with much of our fundamental psychological knowledge, the recognition of personality structures has been derived in part from the study of the abnormal. These types and attitudes became familiar to psychiatrists first in their pathologically exaggerated forms, and were named respectively oral, compulsive, hysterical, masochistic, paranoid, narcissistic and schizoid personalities. We have not used the psychiatric terms because they seem to blur the important distinction between health and disease, but we shall include them parenthetically in the headings of the descriptive subtitles, to indicate the pathological correlates. These personalities are paradigms and, as with other models such as a "classical" example of a disease, few actual patients will represent one of them in pure culture. As we describe each category, we shall formulate briefly the meaning of physical illness to the particular kind of person in terms of his basic needs, the threat that he is trying to cope with, and the kind of defensive and adaptive behavior that has become intensified under this stress. Some general inferences for medical psychotherapy—the employment of psychotherapeutic measures in medical management (G. L. Bibring, 1956; E. Bibring, 1954; Kahana, 1959) will be drawn.
This type of person often impresses the physician with the urgent quality of all his requests. He seems to need special attention or an unusual amount of advice. He may reach out quickly and impulsively, putting himself in the hands of the doctor with an optimistic and naive or self-assured expectation of limitless care. Even when he appears generous and concerned about others, he expects manifold repayment and becomes strongly resentful if this does not materialize. It becomes easily apparent that this sort of patient is very dependent upon others to protect him and to help him feel accepted and secure. His frustration tolerance is reduced, and unfulfilled needs may lead him to intense anger, depression, the feeling of helplessness, or apathy. If his formative childhood experiences were marked by feelings of disappointment, then revengeful, nagging, and demanding attitudes may prevail; the patient comes with a chip on his shoulder, expecting that the doctor will not make any effort to help him. The craving for satisfaction or stimulation through overeating, drinking, smoking, and taking medicine may be prominent, and a tendency toward addiction may be observed. These personality traits stem from the earliest period of childhood when the helpless infant's biological needs for food and protection become linked up with his growing awareness and interest in the outside world through the attention, affection, and care provided by his mother. For this patient, being given food or medicine or special consideration has persisted as an equivalent to being loved.
The Meaning of Illness
We may say that for this person the anxiety accompanying illness tends to be transformed into the wish for boundless interest and abundant care, and into a deep fear of being abandoned, helpless, and starving. Thus, sickness presents the temptation to return to an early, blissfully secure, infantile state, but it is also perceived as the consequence of a lack of concern and protection on the part of others. In the struggle over these intense fears and wishes, we may see any of the following responses, representing attempts to re-establish equilibrium: the patient may become extremely demanding or overdependent upon what his doctor prescribes; he may react strongly against his unconscious wishes and overindependently fight any need for care; he may become depressed, apathetic or withdrawn, perhaps feeling as small children often do, that if he suffers it must be because nobody loves him; he then may blame others for his discomfort in a complaining, vengeful, or spiteful way.
When the physician understands the meaning of illness, he can decide to what extent it is possible to help the patient by attempting to satisfy his needs for special attention, whether or not the setting of certain limits is indicated, and how to facilitate or modify the patient's defensive efforts. Many elements of psychological management suggest themselves. Directly or implicitly, by word, action, or attitude, the doctors, nurses, and other medical attendants should convey their readiness to care for the patient as completely as possible. For the many acutely ill in whom dependent tendencies have become temporarily active, simple undemanding nursing care directed to physical comfort is not only a basic part of professional help, but is specifically important in meeting their psychological needs. If limits have to be set because the patient's demands have become excessive and self-perpetuating, great care must be exercised not to introduce them as if they were the expression of impatience or punitiveness. Setting of limits should not take the harsh form of a withdrawal of interest and consideration, but rather should be presented through thoughtful explanation. This patient may be willing to accept necessary restrictions if the doctor offers some form of concession as compensation. Such concessions may be of a minor nature, simply expressing the friendly interest of the physician, like a desired change in the diet, or helping his family to visit by providing transportation to the hospital, etc.
This person offers an example of excellent self-discipline. When under stress, he relies upon having as much knowledge as possible about his situation, not only as a basis for dealing with problems rationally, but also as his preferred way of handling his anxieties. Alongside of his logical approach, we can often observe a ritualistic tendency as a clue to diagnosis: he may keep to a set order of procedure even in small matters in daily life. The woman who spends a major amount of time eradicating the last speck of dust in her house, and the man who takes special pride in the exact fulfillment of obligations, including the most minute ones, are often of this type. This kind of patient tends to be remarkably orderly, tidy, punctual, conscientious, and preoccupied with right and wrong. With his rectitude and careful way of proceeding, we are not surprised to find that he can be quite obstinate. He places great value upon collecting and retaining possessions and is frugal in money matters. The formation of an orderly, controlled personality appears to be related to factors operative in the period from ages two to four years. Precocious development of motor and intellectual abilities and increased strength of aggressive impulses in the child play a part. Strong early insistence by the parents that the child be clean and good may have an intimidating effect, or the parents' excessive preoccupation with control of body functions and behavior may achieve a like result through intensifying the child's inner struggle between compliance and rebellion. Similarly, overindulgent disregard of the child's need to achieve a comfortable balance between expression and suppression of these tendencies may lead eventually to excessive and inflexible self-restraint. Early-maturing intellectual abilities are brought into the service of curbing impulsive behavior. Thinking tends to become a substitute for action, rather than a preparation and guide. Characteristically, impulses are warded off by the development of rigid opposite attitudes. The leading traits of orderliness, obstinacy, and frugality represent overcompensation against childhood tendencies to disorderliness, dirtiness, impulsively aggressive behavior, and pleasurable indulgence.
The Meaning of Illness
Sickness threatens the individual with loss of control over these impulses. It may impair or interfere with his capacity to master aggression and to satisfy his conscience through accomplishing "good" constructive hard work. He tries to cope with the danger by redoubled efforts to be responsible and orderly, and to suppress uncontrolled emotions. There is often an intensification of self-restraint, formalized behavior, and obstinacy so that the patient seems inflexible and opinionated. His increased striving for intellectual control, with the need to be certain that he understands and has taken into account every aspect of his problems, may lead to hesitation, doubting, and indecisiveness over the question of whether he knows all the essential facts. At times, we might be startled to see the breakthrough of disorderliness and anger, but generally his self-control predominates.
The orderly, controlled person usually finds the scientific medical approach a congenial one. He responds well to the precise and systematic efforts that characterize the doctor's careful, rational method of procedure in history-taking, physical diagnosis, laboratory studies, and treatment. He values highly the emphasis upon sympathetic efficiency and cleanliness in nursing care. In fact, these qualities are so important to him that he may evince unexpectedly strong disapproval of any lapse of routine or contradictory statement, which he cannot fit into his logical framework. When his equilibrium becomes taxed under the stress of illness, perhaps leading to anxiety and intensification of characteristic reactions, an explicit therapeutic approach is indicated to facilitate his adaptation to the threatening situation. He should be informed methodically and in sufficient detail about his illness and the appropriate steps in diagnosis and therapy so that he can establish intellectual control over his anxiety. In doing this, one proceeds cautiously, carefully considering the risk of introducing new sources of anxiety, and not feeling bound to discuss all of the upsetting possibilities and unpleasant minutiae for the sake of "completeness." The patient's active participation in decisions is welcomed and, whenever it is feasible, he might be encouraged to carry out details of his actual medical care—for example, exercises or changing certain dressings, or carefully calculating his caloric intake. The physician will do well to give him recognition for his discernment, comprehension, sound reasoning, and high standards.
The physician usually finds himself interested, charmed, fascinated, and challenged with this kind of person. However, at times he might feel mystified and suspect the patient of not really being sick, or even of malingering. The patient tends to react to the doctor in an eager, warm, very personal way, and to expect a similar response from him in return. He or she may be imaginative, dramatic, flighty, teasing or inviting, and characteristically strives for an intense, idealizing relationship with the doctor. This type of person may have an accentuated need to be noticed and admired as attractive and outstanding, and may show jealousy of the doctor's interest in any other patient. A man may repeatedly attempt to prove and even exaggerate his manliness and courage, especially before nurses and women doctors. In turn, with a male physician, a woman of this personality type may bring out in an inviting way her defenselessness and need for gallant support and protection. She will dress and make up in an attractive manner, notwithstanding rather severe physical conditions. This colorful, lively personality readily develops anxiety in connection with even minor medical procedures. The patient will avoid frightening situations if possible, but sometimes, in an attempt to overcome the fear, will rush into danger. A tendency toward denial or not remembering previous upsetting experiences may be apparent, so that the doctor may feel drat this patient is not the most reliable informant. These personal traits are most typically derived from a period of development between three and six years of age, in which the child forms a strong attachment to the parent of the opposite sex. In his or her warm, colorful response, the adult of this type gives emotional expression to impulses stemming from this early affection. Guilt over hostile urges toward the parent of the same sex who is seen as a rival by the child, and fear of punishment and retaliation, form the basis for the later characteristic anxieties of the patient.
The Meaning of Illness
To the dramatizing, emotionally involved kind of person a sickness may feel like a personal defect; it means being weak and unattractive, unappreciated, and unsuccessful. It is often taken unconsciously as a punishment for forbidden childhood wishes. In men, the major fears are of bodily damage and loss of manly accomplishment and power: exertion of physical strength, competitiveness or pugnacity in order to deny these anxieties may dominate the picture, and amorous fantasies involving nurses or other attending women may be actively pursued. Women of this type feel threatened with the loss of their attractiveness: they may become flirtatious or dress up on the ward as for a special occasion. The struggle against anxiety in both men and women may be marked by increased efforts to gain admiration, dramatic bids for attention, or even an attitude of indifference to serious implications of disease if the illness is used by the patient to secure the attention and sympathy of the environment. Under intense anxiety, these reactions can go a step further and lead to a paradoxical condition in which the patient pushes for those very events that he fears the most. For instance, he may show an inappropriately light-hearted readiness to venture into a serious operation, without truly appreciating and accepting its necessity and consequences. Such "foolhardiness" in an otherwise intelligent and realistic person is reminiscent of the stunts of anxious adolescents who carelessly expose themselves to dangers in order to cope with anxiety by proving that they are not "chicken."
Since these patients seek appreciation of their attractiveness and courage, it would be an error for the doctor to be too reserved. At the same time, the physician should remain aware of the patients' readiness for emotional involvement and anxiety, and should proceed with a measure of calmness and firmness to avoid stirring up these reactions. If anxieties are intense, reassuring explanations about the illness and the medical procedures will help the patient to distinguish reality from alarming fantasies. These discussions need not be as comprehensive and systematic as they should be with the orderly, controlled personality. It is often useful to allow the patient of this type a chance to discuss his fears repeatedly, if necessary, and in this way discharge some of his pent-up feelings.
Physicians frequently see patients with a history of repeated suffering whether from illnesses, disappointments, or other adversities and failures. These people often regard their difficulties as a sign of bad luck. Upon closer examination of their experiences, we can discern that among those patients there is a group with a strong unconscious tendency to precipitate their own misfortunes—perhaps by placing themselves in difficult positions or by reacting too sensitively to the unpleasant aspects of life situations. They are inclined to disregard their own comfort and be of service to other people. Despite their apparent humility and modesty, we usually observe in such patients a tendency to display suffering in an exhibitionistic way. They evoke sympathy and praise from most people but also may arouse in them uneasiness and a guilty intolerance.
The desire to seek suffering is difficult to understand since it is contrary to the prevalent notion that pain can only be unpleasant. Though we cannot here do justice to the complexity of this attitude, it may be helpful to discuss this problem more extensively. The picture may become less puzzling if we consider the relation of pleasure to pain and the dynamic function of suffering and self-sacrifice. Pleasure and pain are often closely associated both physically and psychologically. For example, we are familiar with the co-existence or fusion of pleasure and pain in athletic exertion and in bittersweet states of experience such as love-sickness or the adolescent Weltschmerz. In women, menstruation, intercourse, and childbirth are intimately associated with discomfort and yet also with the most deeply gratifying feminine experiences. Furthermore, as children we may have frequently encountered painful situations which were linked with satisfaction. Children repeatedly discover that when they become ill they can receive more than their usual share of love and attention from their parents. Beyond this, looking at the seeking of suffering from a dynamic point of view, we find in some individuals a search for punishment in order to expiate and relieve the pressure of a deep feeling of guilt. We are familiar with people who consciously or unconsciously believe that they do not deserve to succeed in life. They expect that when things go well something bad has to happen, and sometimes they bring about their setbacks, so that this suffering may temporarily atone and pacify the guilty worry in them. The extreme instance of this type of personality is exemplified in the martyr who finds glory and resolution of his guilt by achieving his social, political, or religious ideal through severe self-sacrifice and suffering. The co-existence of pain and satisfaction in the biological function of the woman, the young person with Weltschmerz, the child who is cherished and forgiven because he is ill, the person who atones unknowingly for guilt, and the martyr—all are models that demonstrate involuntary self-victimization.
Among the early experiences that appear to contribute to the development of this attitude we find severely repressive upbringing in which the child was made to feel excessively guilty, was not permitted to show anger even in a harmless manner, and was given corporal punishment, which in some children provokes excitement that is tinged with pleasure. An attachment to a parent who was aggressive toward the child may have shaped later relationships to important figures in life according to this pattern, or the child may have unconsciously modeled himself upon a suffering parent. In the youngster who felt especially favored and loved when he was sick, this satisfaction may take over as an end in itself and become established as a pattern that is carried throughout life.
The Meaning of Illness
The basic striving of this personality is to gain love, care and acceptance, although he feels too guilty and anxious to expect this without self-sacrifice and suffering. The dangers and discomforts of illness may be elaborated by the patient in intensified attitudes of submission and suffering, complaining, or self-effacement and feeling martyred. For the doctor, the most frequently encountered form of this attitude is the childlike expectation, "you have to love me because I suffer so terribly.'' But when he tries to comfort a patient of this kind, perhaps a pitiably distressed elderly lady, he discovers a paradoxical phenomenon. He is confronted with a person who seems to work against his encouragement and above all to deny any improvement. As he offers helpful suggestions or comforting reassurance, her complaints increase. She disregards evidence of progress toward recovery and accentuates those aspects of her illness, which have not improved. Very understandably, this may lead to feelings of disappointment and irritation on the part of the doctor if he does not recognize her reaction as fitting into a special pattern of behavior. When a person of this type says, "it's not easy, doctor," he is not asking for encouraging remarks but for acknowledgement of his pain and sacrifices. Accordingly, the doctor should express his appreciation of the difficulties of illness as they are experienced by this patient. The long-suffering, self-sacrificing person is better able to co-operate in a medical regimen out of a readiness to add to the "burden" that he must carry, than for the personal relief that health would bring to him. The physician may have to present the recovery to the patient as a special additional task, if possible for the benefit of others. For example, an older woman of this type who repeatedly refused a rehabilitating operation when it was urged as essential to preserve her well-being and comfort, was able to accept it only when it was pointed out that she could not continue to be of help to her children unless her physical condition was corrected.
This patient is openly or covertly watchful of other persons, inclined to be suspicious of their intentions, or querulous and blameful of their motives. He may nurse grievances, especially a deep sense of having been let down by people. He particularly fears being placed in a vulnerable position in which he could be unexpectedly hurt or taken advantage of. Patients who consistently expect the worst are oversensitive to slights and to hints of negative feelings in other people. They easily feel oppressed and even persecuted and are likely to react with a self-righteous counterattack, exaggerated out of all proportion to actual insults. This excessive sensitivity to criticism and expectation of being assaulted reflects a deeper concern with their own faults and weaknesses. They deal with their inner problems and self-reproaches in a very interesting way, by disclaiming them entirely as if they had no place within themselves, and reading them, with indignant disapproval, into the attitudes of other people. We can understand this kind of reaction in an adult better by referring back to the behavior of small children. In its simplest form, we see the youngster who hurts himself by running into a table and then blames the "bad, nasty table." At a somewhat older age, we may observe the little girl who, when chided for misbehaving, says with guilty defiance that her naughty doll did it, not she. An echo of this childhood cry of "I didn't do it— he did it" is found in those adults who have to get rid of whatever is painful, dangerous, or intolerable within themselves by attributing it to others. By thus freeing themselves from what seems unworthy, they both elevate their self-regard and perceive other people as threatening and bad. We are familiar with the individual of this type who does not want to acknowledge in himself impulses to infidelity but is hypersensitive and very critical when he has any possibility of finding and fighting these urges in his marital partner.
The Meaning of Illness
The guarded, querulous patient tends to blame others for his illness. During periods of sickness, his tensions and aggressive tendencies and his expectations of being harmed may be intensified. He becomes even more fearful, guarded, suspicious, quarrelsome and controlling of others. In medical management, it is essential to let this kind of person know, as far as foreseeable, the strategy of diagnosis and treatment so that his suspicions may be kept in abeyance. The frequent oversensitivity to slights of individuals of this type should be respected so as not to create a conflict between patient and doctor. A friendly and courteous attitude on the doctor's part, that avoids getting too close to or excessively involved with the patient, is often indicated. If the physician goes beyond this, there is the risk that the patient will feel he is either being forced or manipulated. Arguing with him or ignoring his suspicious attitude does not help, and if as his doctors we try to convince him that everyone has the best of intentions, he is unable to believe it and it might lead to further mistrust.
In the case of a man with these personality traits who had undergone a very serious cancer operation and who complained bitterly about any inconvenience or irregularity in the hospital routine, we could observe two different reactions of the people attending him. Some were drawn into agreeing with him, sharing his irritation over the coldness of the food, the slowness of the nurses, and the inaccessibility of the doctors. This had the effect of increasing his acrimonious discontent. Others tried to point out how exaggerated his reproaches were, or, becoming provoked, told him in effect that he was asking for too much and was ungrateful for the care that he had been given. He responded with recriminations against them as well as undiminished anger at the hospital. We were able to lessen his preoccupation and mitigate his querulous response by taking a third approach. He was assured that we could appreciate how upsetting these inconveniences and delays can be for a person of his sensitivity who had gone through such a trying illness. By acknowledging and giving him full credit for his feelings as his way of perceiving and encountering the world —without disputing his complaints, but especially without reinforcing them—we could help him to detach himself and reduce the intensity of his reactions. Only then was it possible to take the next step: to appeal to his tolerance regarding these experiences in the hospital, which, although very distressing to him, were less significant compared with the lifesaving surgery and rehabilitating postoperative care. Thus, we were able to regain his co-operation.
Among our patients, we find people who have to see themselves as powerful and all-important. This need may lead to an attitude of self-confidence so exaggerated that a person of this type appears smug, vain or grandiose. Or his basic frame of mind may be covered by an artificial, patronizing humility. Frequently, associated characteristics include a kind of arrogance (he looks down on most other people), the tendency to surround himself with an aura of mysterious knowledge, and sometimes a fondness for holding forth—mainly in monologues. A considerable amount of every adult's interest centers around his own self. If this attitude is not excessive, we speak of self-respect rather than a feeling of superiority. As we have discovered with so many exaggerated tendencies which serve the purpose of counteracting doubts, the patient who feels superior has an urgent need to surpass everyone else, coupled with an underlying uncertainty about his own transcendence. When he falls ill and must turn to a doctor, this person deems only the most eminent or senior physician worthy of serving him, choosing someone who will reinforce the sense of his own grandeur. Even in a large teaching hospital where he is cared for by a medical team, such a patient may only acknowledge that he is being treated by the Chief of Service. His attitude toward the younger physicians is frequently that of a benevolent supervisor who tolerantly aids them in their quest for education. In spite of his need for a doctor who has the utmost competence, the patient is bound at the same time to vie with him and outdo him. He may allow that he himself is not a medical expert (if this be the case), yet he might feel free to reject his doctor's counsel on the basis of his own conclusions and considerations which he believes to be of greater moment. This patient tends to search constantly for weaknesses in the doctor and is inclined to lose confidence in him, dwelling upon his faults and belittling him at the slightest provocation.
The Meaning of Illness
The person with the feeling of superiority is likely to react to a sickness as if it threatened his self-image of perfection and invulnerability. His characteristic behavior becomes intensified, often in the direction of a defensive grandiosity. Accordingly, he will feel most comfortable and secure if the doctor fulfills his need of being implicitly acknowledged as a person of achievement in his own right. Of course, this does not mean that the physician can or should deny his own expert knowledge and skill. In fact, this kind of person, in spite of all his effort to find weaknesses in the doctor, is at the same time deeply afraid of discovering that he might be in the hands of an incompetent physician.
This person gives an impression of remoteness, reserve, and lack of involvement with everyday events and concerns of people. His emotional expression may be reduced to a minimum and he may appear quiet, distant, seclusive, and unsociable. He may pursue his own way of life, seemingly with little need for emotional ties with others, appearing quite independent and not easily impressed. Beneath this surface, such a person often is oversensitive, fragile, and lacking resilience, so that his inner equilibrium is too easily upset in the course of the ordinary difficulties of human relationships. His aloofness is a protective denial of these excessively painful experiences. The life history of such a person reflects solitary interests. He gravitates to noncompetitive jobs that require a minimum of contact with others. Within this group, we find eccentric persons engrossed individually with dietary and health fads, religious movements, and social improvement schemes. The aloof, eccentric patient may exhibit an unusual manner of dressing or behaving without concern for the reactions of conventional people.
We often find in the childhood history of this kind of patient that his earliest efforts to form a loving attachment to another person led to repeated disappointments, with the result that the child could invest feelings in others only in a tentative and limited way. This might be the consequence of repeated separations from mother, or of a lack of consistent responsive, empathic care by the environment. The infantile experience then is carried into the patient's later relationships, leading finally to the type of personality who impresses us as uninvolved and remote. There are also indications that constitutional factors may play an important role in the genesis of this kind of personality, especially in its most pronounced form.
The Meaning of Illness
The aloof person tries to remain undisturbed by life, seeking solace and satisfaction within himself. Illness intrudes into this system, threatening to upset this careful equilibrium. The patient frequently protects himself against this by intensifying his denial in proportion to the increase in underlying anxiety and thus seems to remain strikingly unperturbed and even more seclusive and distant than usual. Foremost in the psychological management of this patient, his "unsociability" has to be understood and accepted. We should make as few demands as possible upon him for personal involvement with others, yet he should not be permitted to withdraw completely. This may be achieved by trying to maintain a considerate interest in him, quietly and reassuringly, without requesting a reciprocal effort on his part.
We have taken up only major aspects of personality diagnosis. Clinical experience reveals a wide vista of possible shades and combinations of characteristics in the make-up of different individuals. In practice, one must avoid the premature and rigid use of a diagnostic classification of personality since this involves the hazard of becoming limited in one's perception of the patient's structure. This will happen if "typing" a patient becomes a shortcut, replacing the natural development of a relationship and full observation of the distinguishing qualities of the person. Moreover, it is not always easy to establish quickly the correct personality diagnosis. The problem of perceiving the leading personality traits is complicated by the fact that in some degree everyone has passed through similar phases of early development and, therefore, in his adult personality tends to show an admixture of all modes of behavior. Nevertheless, each person has his particular means of adjustment and should be judged by his predominant psychological organization. But while the basic personality structure of an adult remains relatively stable, under special stress shifts between a variety of defenses and needs may occur (G. L. Bibring, 1961; Prange and Abse, 1957). With these pitfalls in mind, let us now take up a clinical example illustrating the task of managing flexibly the medical psychotherapy of a patient whose leading attitudes varied in the course of his illness.
A thirty-nine-year-old man with an acute, severe myocardial infarction, the fourth within nine years, was extremely apprehensive during his first days in the hospital. Fully aware of the nature of his disease, he was terrified that he might die. Yet, despite his desperate desire to live, he frequently refused to rest or take medication. This handsome, physically powerful man regarded any request by the nurses as arbitrary and refused to be "commanded" by them. He was also aggressively seductive towards them. His previous pattern of reaction to illness suggested that a tendency toward hyperactivity might interfere with his recovery. Though he had been advised to return to only moderate physical activity after his earlier coronary thromboses, he had vigorously pursued water polo, handball and wrestling with his children. We discovered that these attitudes had a long history.
He had run away from home at the age of thirteen, shortly after his father had died of a malignant tumor. His flight had followed a quarrel in which he felt that his oldest brother had tried to order him around. He was a big youngster and passed himself off as sixteen or seventeen when he got a job with a traveling carnival. In subsequent years, he worked as a roustabout and rigger of amusement "rides," a bulldozer operator, a truck driver and a two-fisted bouncer in a penny arcade—nothing was too difficult for him to take on. In his marriage, he immediately established his position as the master of the household. Both in the home and at work, he felt that challenges and fights gave meaning to his life. He boasted about his manly prowess, yet, in listening to the account of his many successes, one had the definite impression that he exaggerated. All of this indicated his need to see himself as prepotent. It was evident that this colorful, lively man had many features of the dramatizing, emotionally involved personality. Typically, he responded to his life-endangering illness as if it threatened his masculinity. Because he suffered from this anxiety and, therefore, might jeopardize himself by premature and excessive exercises, it was necessary to give immediate attention to help the patient re-establish his psychological equilibrium. It was found that he accepted the nurses' care with more comfort and appreciation when all medical recommendations were given to him personally, as far as possible, by his male doctor. At the same time, it was considered essential to permit him to apply some initiative and strength. Thus, even while he had to remain strictly on bed rest, he was encouraged to carry out his own schedule of simple leg exercises and rest periods and to help in dietary planning. As an essential part of the therapeutic program, he did some light work with the occupational therapist. His physician repeatedly acknowledged the great discipline, which the patient applied, and expressed his appreciation of the difficulties this illness may create for an active, vigorous man. Information about his illness was offered with the aim of reducing some of his uncertainty about the outcome of his condition, and to prepare him to cope with the illness in a more rational way. In responding to his questions about the future, emphasis was placed on his improved chances of survival with collateral coronary circulation, if he maintained his activities within limits under continued medical observation.
With this approach, the patient was helped to make the shift from displaying his strength by muscular activity to exercising it through intelligent self-control. He became less quarrelsome and more optimistic, and was full of high praise for his house physician who had explained thoroughly some of the medical problems to him. However, as we have seen in similar cases, this patient who had dealt with the acute, critical, and life-threatening situation by the protective mechanism of denying his weakness, in the convalescent period displayed different attitudes and needs in dealing with his underlying anxieties. This in turn required modification of the psychological management. When the patient returned home, he became very apprehensive whenever he went outside of the house. He had to lie down and complain to his wife that she did not realize how sick he was. He would ask whether he looked pale; his pulse seemed fast and weak to him. Pains occurred in his upper abdomen and chest, which were not relieved by nitroglycerine but were helped by sedation. It was apparent that he needed special care and attention at this time in a dependent, anxious way. In response, his physician took a definitely protective attitude. He told the patient that his doctors were willing and able to take full responsibility for his treatment, and could be trusted and depended upon. With this assurance, the patient's anxiety lessened. When he returned to work, he felt better on the job than at home because he could be more active there and was less prone to yield to his dependent wishes. He was able to relinquish his bid for extra attention from his family and knew that he could be a well-functioning man in his own right. He came to the clinic less frequently, but kept a solid, confident relationship with his doctors and was able to adhere to the medical regimen.
In a long-term program aimed at blending psychological understanding with medical practice in a general hospital, it has been found that a knowledge of personality structure is an important basis for the physician in order to employ appropriate psychotherapeutic principles in the management of physically ill patients. A paradigmatic classification of personalities is described that is useful as a guide for medical psychotherapy. It includes the following "types": the dependent, over-demanding personality; the orderly, controlled personality; the dramatizing, emotionally involved, captivating personality; the long-suffering, self-sacrificing patient; the guarded, querulous patient; the patient who feels superior; the patient who seems uninvolved and aloof. For each type, a brief formulation is made of the essential psychological meaning of physical illness and inferences for medical management are drawn. The classification is particularly applicable to the normal personality under stress. A case illustrating medical psychotherapy is presented.