Personality disorders in the clinical setting

Although the title of this paper suggests that its main focus is on personality disorders, it paints a much broader picture because it discusses aspects of patient behavior that clinicians often find challenging to manage. “Difficult patients” often evoke negative emotions in the caregiver or disrupt their own continuity of care by refusing treatment, angry outbursts, or demanding requests of the treatment staff. An important step not easily achieved is to recognize when it is the stress of illness that is exaggerating normal traits or when the patient has a more pervasive and lifelong disorder.

In many cases the stresses of the cancer illness are responsible for amplification of traits, such as passivity in the person with a dependent personality or exaggerated attention to details exhibited by the obsessive compulsive personality. Recognition of these traits can allow the clinician to adjust his or her behavior to the patient's needs. For example, persons with narcissistic traits (Table 2) may be particularly prone to loss of self-esteem and depression when they undergo disfiguring surgery. Acknowledging the challenge the illness presents to patients and praising them for their perseverance may be a useful strategy. The authors also point out that it is important for busy clinicians not to be annoyed with patients who require more time or patience.

A more serious problem is represented by the 5%–8% of the population affected by a personality disorder such as antisocial behavior or borderline personality. These patients are often challenging in the oncology setting because their behaviors may be more disruptive than that of patients with exaggerated personality traits. Acting out in the form of aggressive behavior or unexpected anger at staff can be particularly troublesome. In the case of the borderline disorder, patients may pit staff against one another or engage in other behaviors, as outlined by the authors (Table 2). In my experience, the clinic and especially the inpatient staff have great difficulty in distinguishing these two situations. Patients are allowed to seriously act out before help in managing the individual is requested. It is important to pay attention to clues that might suggest a more serious disorder. For example, substance abuse revealed through a patient's personal history would be a clue for a borderline or antisocial personality. When serious disruptive behavior does occur, early consultation by mental health professionals can help define the diagnosis and provide management strategies for the treatment team and support for the staff, who often feel frustrated with their ability to manage such problems.