What are the most common factors that determine the psychological characteristics of the patient? The patient is usually deprived of the opportunity without restrictions to do everything that he could do before, often forced to change plans for the future, to refuse to achieve long-planned and very attractive goals. This causes a state of frustration, sometimes manifested in feelings of oppressive tension, anxiety, despair, anger, etc. A vivid example is irreversible loss of vision. Specific problems arise in patients due to the loss of their aesthetic appeal in dermatitis, psoriasis, etc. Pain affects the emotional state. One of the most common forms of CNS response to external and internal harms is asthenia, which ends almost every somatic disease and every case of toxicosis.
It is important to emphasize that all of these factors affect the psyche, refracting through the individual characteristics of a person, although direct somatogenic effects are also possible (for example, through intoxication effects on the central nervous system in kidney disease).
What is useful for the doctor to know about the patient and take into account when communicating with him?
1. Awareness in matters of medicine (especially his knowledge of his disease). Usually, the greater this awareness, the more difficult it is for the doctor to communicate with the patient, whose knowledge is often incomplete and erroneous. Awareness about the disease manifests itself in different ways: in a request or demand to apply some diagnostic methods or treatments, in “self-diagnosis”, a quick and confident listing of all “one’s own” subjective symptoms characteristic of a certain disease, etc.
2. Internal picture of the disease. Until now, one of the best remains the definition of this concept, given more than 50 years ago by R. A. Luria: “The internal picture of the disease is called everything that the patient experiences and experiences, the whole mass of his sensations, not only local painful, but also his well-being, self-observation, his idea of his illness, its causes – everything that is connected for the patient with his coming to the doctor, all that huge inner world of the patient, which consists of very complex combinations of perception and sensations, emotions, effects, conflicts, mental experiences and traumas.
3. Attitude towards the doctor. The attitude to the doctor is usually associated with the attitude towards the upcoming operation, the result of psychotherapeutic influences, adherence to the regimen, the emotional state of the patient, and even the effect of drugs. It is formed mainly under the influence of the patient’s attitudes, his expectations and needs, on the one hand, and the knowledge about the doctor’s business and personal qualities obtained in different ways, on the other. Some patients primarily expect sympathy, empathy, kindness from the doctor, while others place higher in the description of the ideal doctor his mind, a high level of professional knowledge and skills. The first is more typical for women, and the second – for men. The significance of the first impression made by the doctor on the patient is great.
4. Leading motives, value orientations, personality orientation. It is on them that the attitude to their illness, the possibility of rehabilitation largely depends. Those who value health as the most important value are less likely to return to work after a serious illness than those who believe that health is important, but there are other equally important values.
5. Character traits. Let us indicate only some of the patient’s personal qualities that affect his attitude to the disease and the process of communication. Some people take responsibility for what happens to them, mainly on themselves, while others explain what happened to them mainly by circumstances (fate, chance, etc.). The former usually know more about their illness, more actively fight it. For example, if they have diabetes, they follow a diet more strictly, and if they are healthy, they often resort to procedures that protect against diseases.
The patient’s suggestibility determines the possibility of changing his thoughts, feelings, desires, and views without a detailed rationale. It depends both on the personality traits and on the situation. More often suggestible are people characterized by the following qualities: self-doubt, low self-esteem, humility, shyness, gullibility, anxiety, high emotionality, weak logical thinking, low level of development of volitional qualities, slow pace of mental activity. Among the situational conditions of increased suggestibility, one should especially note poor awareness of the issue under discussion, lack of time to make a decision, the psychophysical state of a person (emotional arousal, fatigue, stress, relaxation, etc.). All this shows that “in the hands of a doctor” suggestion can often be a very effective method of influencing the patient.
There are people who have an increased tendency to experience generalized, diffuse or pointless fear (anxiety). Psychologists define it as personal anxiety. It manifests itself in a feeling of helplessness, self-doubt, powerlessness in front of external factors. Usually, anxiety is increased in neuropsychiatric and severe somatic diseases, as well as in healthy people experiencing the consequences of a mental trauma.
As a rule, it is not easy for a doctor to develop relationships with patients who have another personal quality – dogmatism. For the “dogmatist” it is more important who conveyed the information than whether it is objective, reliable and logical. Therefore, in a conversation with him, it is advisable to refer to the opinion of authoritative experts.
6. Properties of temperament. Temperament – these are individually peculiar properties of the psyche that determine the dynamics of a person’s mental activity, which are equally manifested in a variety of activities (regardless of its content, goals, motives), remain constant in adulthood and in their mutual connection characterize the type of temperament. The properties of temperament include sensitivity, reactivity, activity, the ratio of reactivity and activity, the rate of reactions, plasticity, emotional excitability, extraversion or introversion. Let us indicate only some manifestations of the properties of the temperament of patients that are important for the doctor.
It is usually easier to establish contact with extroverts (extroversion is the primary orientation of the personality to the outside world; introversion is the predominant orientation “on oneself”, on the phenomena of one’s subjective world). Rigid (inflexible) and introverted patients are often so “immersed in the disease”, “captured” by painful sensations, that they constantly think about their illness and its consequences.
High or low sensitivity (sensitivity) must be taken into account when analyzing subjective symptoms, patient complaints. Melancholic people often overestimate them, and phlegmatic people underestimate them. High reactivity and emotional excitability increase the likelihood of conflicts between patients and medical personnel and other patients. Rigidity (inflexibility) usually complicates the patient’s adaptation to hospital stay, which can also lead to conflicts. In addition, it is difficult to correct the attitude of “rigid” patients to their illness. In a choleric person, often “language overtakes speech”, and the information communicated to him is perceived superficially. It is useful to “lead” him to think, to ask some questions again, having formulated them differently. The sanguine person often underestimates the severity of their illness. In a conversation, he is easily carried away by an interesting topic, but can easily switch attention. Phlegmatic and melancholy people need time to understand and remember the information being communicated, they should not be rushed with answers. Melancholic people are also usually vulnerable, impressionable. They often do not express their point of view, even considering it to be absolutely correct.
7. Features of the emotional sphere: dominant emotions, emotional excitability, the speed of the emergence and disappearance of emotions and feelings.
8. Features of cognitive processes, attention, speech. Cognitive processes usually include sensations, perception, memory, imagination, thinking. Undoubtedly, they influence the internal picture of the patient’s illness and manifest themselves in communication. It is impossible to ignore when talking with him neither a bad memory, nor a very developed imagination, nor a “stiff” thinking. The properties of attention and speech features are also important, in particular, the ability to quickly and correctly formulate a thought and communicate some information.
There are a number of so-called cognitive styles that manifest themselves in the entire cognitive sphere of a person, as if permeating it at different levels – from sensations to thinking. These, for example, include “analyticity – syntheticity”. The “analyst” usually talks in great detail about his illness, sometimes annoying the “synthetic” by getting stuck on trifles, since there are no trifles for him at all (in particular, with regard to his health). He seeks the same detailed information from the doctor. “Synthetics” satisfies the message containing conclusions and recommendations in a more general form, and he may consider many details of his internal picture of the disease insignificant and not disclose to the doctor.
So, very briefly, we considered the question of what is useful for a doctor to know about a patient. The next question is quite natural: how can he get this information? Often the doctor can find out the necessary information about the patient based on the analysis of behavior and speech messages during communication with him (direct information). The patient does not always willingly and frankly talk about his thoughts, feelings, desires, especially about personal qualities (especially negative, socially disapproved ones). One must be able to put questions in such a way that the patient does not guess about their real orientation.
Thinking can be judged by the logical presentation of thoughts, the depth of analysis of facts, the justification of conclusions, etc. In a conversation, features of attention and memory are often revealed. The patient sometimes says that lately he has to write everything down so as not to forget. “Unpersuasiveness”, the stubborn upholding of completely unfounded thoughts, require to find out whether the complaints are delusional in nature. The doctor should be especially attentive to the patient’s reaction to the communication of information important to him (for example, to a proposal to have an operation). It is in unexpected, stressful situations that the properties of temperament are most clearly manifested.
The possibility of determining the emotional state of the patient by facial expressions should not be overestimated. It is not easy to distinguish the expression of a “genuine” emotion from an attempt to portray it. It is known that with an insincere, “stretched” smile, the lower eyelids do not rise, only the lower part of the face “smiles”. It is shown that knowledge of the features of the functioning of the muscles of the face and their role in the expression of emotions improves the recognition of states. Here is a brief description of the manifestation of sadness and grief: the head is lowered, the seated one rests on the arm; the eyebrows are brought together, on the forehead there is a longitudinal-transverse fold; eyelids drooping; the lower eyelid can be raised, the look is passive; the corners of the mouth are lowered, the center of the lower lip is raised; hands are inactive; the body is relaxed, looking for support, the line of the back is broken; slouch; the legs are relaxed: muscle hypotonia, sometimes the tone is increased to stiffness.
Facial expressions can express not only a momentary emotional state. If a person thinks a lot, often laughs or suffers a lot, then due to the repeated repetition of the corresponding facial expressions, a typical expression (expression) is formed for him, which indicates the most frequent state of a person.
The first (tentative and not very reliable) information about the patient is given by his body type. Recall what, for example, an asthenic and a picnic look like.
Asthenic. Fragile build, relatively tall, flat chest, long face, narrow shoulders, long and thin lower limbs.
Picnic. Rich adipose tissue, small or medium stature, deliquescent torso, round head on a short neck.
Let us give a brief description of the characteristics of behavior and psyche for each type.
Asthenic. Greater (than picnics) emotional resistance to stress. Usually the average (in strength) nervous system. More often representatives of other types have difficulties in communication. Concentrated, subjective thinking. Introverted ( The one who looks, directs his interest, mind or attention to himself ). Poor expression. High sensitivity to pain. The need for solitude in difficult times. It is better that he himself regulates the interpersonal distance and confidentiality of communication with the doctor.
Picnic. Lower than asthenics, emotional resistance to stress, weaker nervous system. Sociability, friendliness in communication. Expressive expression. The need for people in difficult times.
This information about patients with different body types must be verified in the future, moreover, there are fewer “absolutely pure” types than mixed ones.
Information about the patient, obtained in the process of direct communication with him, should be supplemented with other data. First of all, these are messages from relatives, nursing staff, sometimes neighbors in the ward. The people closest to the patient, however, often do not notice the changes in his personality gradually occurring under the influence of the disease. Even with mental pathology, members of his family may not notice deviations from “normal” behavior for a long time.
Several other ways of knowing the patient can be called “inferential”: here the doctor, on the basis of “indirect” information, makes an assumption about psychological characteristics. Such information includes, for example, information about the sex, age, education, profession, social environment and living conditions of the patient, the duration of his illness and previous illnesses. So, knowing that a chronic patient has been treated for a long time and unsuccessfully, one can predict with a certain degree of certainty his attitude towards doctors, an increased likelihood of “going into the disease”, the presence of asthenic syndrome, etc.
The internal picture of the disease depends on the age of the patient. In particular, it has been shown that in youth (18–30 years) the disease is often underestimated. Experiences are sharpened not about the fact of the disease itself, but because of the situation that is caused by the disease, its resonance in the circle of friends and relatives. These patients usually experience pain more acutely, more difficult to endure hospital stay. In adulthood, the most significant is the impact of the disease on the possibility of professional activity and intimate life.
Some psychological characteristics of patients can be predicted by the diagnosis of their disease on the basis of two types of causal relationships:
1) the disease causes personality changes specific to it;
2) people with similar personal characteristics are predisposed to certain diseases.
People predisposed to the disease of heart muscle infarction are usually characterized by developed ambition and increased self-esteem, but at the same time – pessimism (why all the effort?). For patients with pre-ulcerative conditions of the duodenum, rigidity, anxiety, self-doubt, a pessimistic prognosis and the assessment of any obstacle as insurmountable are characteristic. In diabetes mellitus, the main mental disorders are expressed in severe irritability and fatigue, which makes it difficult to communicate with patients. Their heightened emotionality often leads to conflicts and rash acts; sometimes memory impairment is noticeable.
Finally, “output” information about the psychological characteristics of the patient can be obtained on the basis of taking into account the relationship between personal qualities. For example, such qualities are often found together: self-confident, boastful, pleased with himself, strong-willed, energetic, uncompromising, aggressive, vindictive, insensitive to public disapproval. This complex of traits is determined by a certain attitude towards oneself and towards other people and is designated as “authority” (the other pole is “the tendency to obey”). Let us also recall the regular relationships between the properties of temperament, which can be predicted by establishing its type. The classification of accentuated personality types is also well known, when certain character traits are excessively enhanced. Knowing and using this typology is useful for every doctor and nurse.
The patient’s personality type determines the most appropriate doctor-patient relationship in terms of leadership or collaboration. Guidance is more effective for patients with a relatively immature personality who need advice, with weak motivation for treatment and a passive attitude (more often this happens at the 1st stage of treatment).
Patients with opposite features usually require a cooperative relationship.
List of used literature
Nikolaeva VV Influence of chronic illness on the psyche. M., Publishing House of Moscow State University, 1987.
Luria R.A. Internal picture of diseases and iatrogenic diseases. M., 1977, p. 38.
Elshtein N. V. Dialogue about medicine. Tallinn, Valgus, 1986.
Kvasenko A. V., Zubarev Yu. G. Psychology of the patient. L., Medicine, 1980.
Tashlykov V. A. Psychology of the treatment process. L., Medicine, 1984