I. Four Main Points
- Our personality is a combination of our temperament (inborn/nature) and our character (stable behavioral patterns formed through experiences/nurture).
- Life demands that we, as individual personalities, undergo constant adaptation throughout our lives. While we like to think of ourselves as in control and consciously making life decisions many important coping, defense mechanisms are unconscious. How helpful or problematic our unconscious coping mechanisms are depends on how much of our emotional energy they drain, not whether we use them or not.
- Each of us carries into adulthood psychological issues, both conscious and unconscious, that are shaped in childhood. Among the most important of these for adaptive adult functioning are:
- An unshakable sense of self that we can confidently survive in the world as a "separate other" (autonomy).
- A belief in our fundamental worthiness as individuals despite the inevitable ups and downs of our performance in our many roles.
- The importance of an understanding of personality, unconscious coping mechanisms, and a secure sense of autonomy and self worth for all physicians lies in providing a framework for understanding our patients' behaviors as we encounter them in many states of health or illness. As physicians we need to tailor our approach to patients with an understanding of their individuality, their needs, and the reasons why they may not follow our well-intentioned interventions.
II. Personality Traits
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and one's self and are expected in a wide range of important social and personal contexts; they do not imply pathology.
Personality reflects ways of acting (behaviors) that are relatively stable over fairly long periods of time (predictability)
Personality forms a pattern distinctive for the individual (what is characteristic of a person - i.e. generosity)
- Personality does not equal "character." Personality is the sum of one's temperament and one's character
The inborn, biologic/genetically determined (and biochemically mediated) pre-dispositions or drives to a cluster of responses and behaviors (i.e. shyness).
There are nine dimensions to temperament which tend to be stable throughout childhood:
- Activity level
- Rhythmicity → biologically regular (sleep/GI/hunger/urination)
- Adaptability to change
- Approach/withdrawal to new situations
- Attention span/persistence
- Intensity of reactions (+/-)
- Threshold of responsiveness
- Quality of mood
There are 3 categories of temperament which approximately 70% of children fall into:
- Easy (40%) → Fall into natural biorhythms, fairly positive mood, mid-level intensity, positive approach to new situations
- Difficult (15-20%) → Irregular schedules, may never adapt to feeding schedule, tend to have negative mood, negative approach to new situations
- Slow to warm up (20-25%) → Decreased activity, take time to respond with a positive response, in familiar situations → behave like easy temperament kids, in unfamiliar situations → behave like difficult temperament kids
Personality gives order and congruence to all the different kinds of behaviors in which an individual engages.
D. Many traits
Many traits go together to make up a person. Any character trait is extraordinarily complex involving all components.
- The quality of the relationship between an infant and his/her primary care giver (most often mom) and baby...more based on mom's hormones
- Attachment behavior promotes proximity, keeping caregiver near the vulnerable infant...food, safety, physical comfort, warmth
- Baby's first attachment behavior = crying
- Attachment is assessed by using the Strange Situation Paradigm
- Types of attachment:
- Insecure → baby does not care if mom leaves
- Secure → baby is upset when mom leaves, but not distressed; hugs & kisses mom when she returns
- Anxious → baby doesn't take comfort when parent returns; they are just afraid that they are going to leave again
- Avoidance → the baby is so angry that when the mom comes back, the baby does not go to her
III. Psychodynamic Context
Psychodynamic context is useful in understanding all patients. (adapted from Adaptive ego mechanisms-a hierarchy, ch.5 in Adaption to Life, G. Vaillant. Little, Brown and Co., c1977, pp.75-90 G. Vaillant)
- Adult character reflects early childhood experience.
- These experiences form a developmental sequence (earlier influences later).
- There is a complex interplay of biological and environmental forces.
- The process of unfolding continues throughout life.
- There are critical points: developmental crises of increased conflict between biology, individual development, and society; the resolution of these crises results in a precipitate of character traits determining the individual's capacities to handle later situations.
- Character (as well as the basis of personality disorder) is formed in childhood or adolescence and is characteristic of most adult life.
- How we do in life depends in good measure on what our childhood experiences were; our temperamental drives (of affection and aggression/assertion) are molded by our relationships/families and our society into our character and coping mechanisms.
IV. Adaption and Coping Styles
(adapted from Adaptive ego mechanisms - a hierarchy, ch.5 in Adaption to Life, G. Vaillant. Little, Brown and Co., c1977, pp75-90 G. Vaillant)
A. Adaptive Conception
An Adaptive Conception examines how the individual balances internal needs (drives, dependency, and aspirations) with external demands. All of life is adaptation - converting experiences into mechanisms of coping with life.
- Adaptation is the ability to deal with and balance one's internal needs with external demands (i.e., self-esteem regulation). The ego is always involved in this balancing act.
- We adapt by using unconscious defenses or coping mechanisms as built-in stabilizers on a continuum from adaptive to pathological. They are healthy more often than they are pathological. The use of defenses develops hierarchically (metaphorically) from avoidance through characterologic to neurotic and mature.
- We all use these mechanisms to varying degrees. We need to understand them in ourselves and our colleagues and our patients. We need to take them into account because people draw on them unconsciously especially when they feel in danger or threatened; in order to understand their responses.
B. Evaluating Defense Choices
One cannot evaluate the choice of a defense without considering the circumstances that pull it forth and how it affects relationships with other people (Note: people tend to slide down the scale in times of stress. The further down the scale of defense, the more time and energy is consumed...mature defenses are the most adaptive and require the least amount of energy.)
- Psychotic mechanisms (60-80% psychological energy consumed): alter reality; to the beholder they appear crazy (denial, distortion, delusional projection).
- Immature mechanisms (40-60% psychological energy consumed): character defenses alter distress engendered either by the threat of interpersonal intimacy or the threat of experiencing its loss. These are the typical defenses seen in patients who receive personality disorder diagnoses in addition to the psychotic defense mechanisms. The user is rarely aware he has problems unlike the beholder (projection/projective identification, schizoid fantasy, hyprochondriasis, passive aggression, acting out, splitting).
- Neurotic defenses (20-40% psychological energy consumed): alter inner feelings or instinctual expression but often cause internal distress. Either the affect or the content is lost but not both. We all use them (repression, intellectualization, displacement, reaction formation, dissociation).
- Mature mechanisms (less than 20% psychological energy consumed): integrate reality, interpersonal relationships and internal feelings (altruism, humor, suppression, anticipation, sublimation).
Defense mechanisms can evolve into other mechanisms but they do not disappear. It also is possible to suffer with mature defenses and to master life with immature ones. Defenses are not always the incurably bad habits that they appear. Sometimes they are the means of making a painful truce with people whom we can neither live with nor without.
V. Developmental Conception
- As humans grow from helpless infant to mature adults, we pass through patterns or stages of development. We have different capacities at different stages. There are two fundamental tasks to maturation:
- To become secure as a separate "other" or individual in a neutral world.
- To develop an unshakable sense of worth (who we are, as well as what we do)
- The tasks we face growing up shape the way we deal with these tasks as adults. People wonder why we spend time on childhood development. It is because we know that each of us carries into adulthood psychological issues, both conscious and unconscious. Understanding these issues will help you as a physician know what you can and cannot change, and will help you deal with what you cannot change.
- Theories include Freud's psychosexual development; Erikson's psychosocial development, and Piaget's psychological development (which includes psychological maturation).
We will look at key issues, tasks, and concepts in each stage.
Infancy (ages 0-2): the experience of well-being and developing a trusting relationship.
- The infant experiences positive well-being based upon empathic relationship to others (mirroring-validation): Dependency and Affection Issues; Goodness of fit.
- Mastery: At the same time the sense of self as separate from others develops neurophysiologically (temperament) and psychologically (character); separation remains an issue throughout life
- The emerging self's impact on his/her environment (one's competencies); assertion issues
- Early gender issues: expectation of separation in boys
- Trust vs. Mistrust/Hope vs. Withdrawal: a competent child developing/constructing a self within a supportive environment
- The Psychological Contract: Can we deal with and expect the world to deal with us fairly - or do we withdraw and focus on self (the loner) and suffer with annihilatory panic
Early Childhood (ages 1½ - 4): Toddler-Guidance and Encouragement for self-worth
- Struggling for Autonomy (choices) with limits for self-esteem regulation: the quest for worthiness based on who we are as well as what we do: otherwise self-doubt and shame
- Interacting with others (approval and limit setting) is essential to both becoming an individual and the ability to experience pleasure with others (key area of concern in adulthood)
- The development of a more cohesive self (ego) that begins to regulate self-esteem; now no longer the center of the universe but related to others
- A will of our own vs. compulsion leads to Autonomy vs. Shame/Doubt
Play Age (ages 3-6)
- Further development of self esteem through:
- mastery of skills in interpersonal sphere (play)
- sibling rivalry, competition for approval
- identification with important others and incorporation of standards into the conscience (superego/ego ideal)
- Child finds own way and feels comfortable with separating; follow one's Purpose-Initiative vs. Guilt and Inhibition
- Crucial as a prototype for relationship with authority figures throughout life
- Gender issues: Affiliation (girls) vs. Separation (boys) - lost attachment makes it more difficult for men to develop intimacy
- Further development of self esteem through:
School Age (latency age 5-12)
- Learning how to use our minds and muscles with a sense of confidence (competence) vs. Inferiority/inertia - giving up or taking the initiative to live up to one's potential
- On becoming oneself and having pleasure outside the family (I am what I learn) the world as a place to make things together: The Work Group
- Gender identity elaborated by identification with same sex parent
Adolescence - In adolescence the central issue is identity - or role confusion - who one is in relation to oneself (the development of an independent sense of self and the capacity for intimacy).
- Aggression, affection (sexuality) and dependency issues recur as one begins to experience, integrate and define oneself within a social reality that allows one to give love to others and enter adulthood
- Who am I? Where am I going? Who's boss around here?
VI. Health Status Assessment
Health status assessment is how we begin to measure our adaptive capacities.
- In psychiatry there is a longstanding interest in patients' social, role and emotional functioning, life satisfaction, in addition to their physical functioning.
- Social competence is a better marker for health status than any other indicator → Health is more than just the absence of disease...not just pathology, but also wellness (being social, having friends and having family can positively affect this!)
- The "Family Illness Burden"
- Need to allow caregivers to take care of their own health, as it is stressful to care for people who are sick
- ↑ anxiety = ↑ sickness...due to this fact, now the caregivers are more likely to get sick
- Try to support them using social relationships as a buffer
- As our society moves more toward measuring everything in terms of outcomes, it has become inevitable that this would be demanded of those of us in health care. We are to measure, monitor and manage care with a number of goals in mind:
- Develop standards of care and protocols for treatment.
- Assess the effectiveness of different treatment interventions.
- Enhance informed decision making by providers, patients, and payers.
- Make decisions about utilization of resources.
- There are a number of general health status assessment surveys used in millions of administrations to obtain patients' assessments of their functioning and well-being in both physical and emotional dimensions of life. This information can be useful in assessing and obtaining a better understanding of a patient's overall health status much beyond symptomatic improvement.
- Health concepts that are measured include...physical functioning, role limitations (due to emotional and physical problems), bodily pain, general health perceptions, vitality, social functioning, and general mental health
- This is one example of assessing our adaptive capacities that can be used over time to monitor changes. In a non-burdensome fashion it allows patients themselves to provide us information that we can use to establish baselines of functioning and measure and monitor changes in adaptive functioning over time as we practice medicine.