Evaluating the “Good Death” Concept from Iranian Bereaved Family

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Specific Personality Disorders Some types of personality disorders tend to be reasonably well-tolerated in the medical setting, as noted below. SCHIZOID AND SCHIZOTYPAL PERSONALITY DISORDERS Schizoid patients tend to be detached from others and indifferent to intimate relationships; schizotypal patients are awkward in their interpersonal relationships and demonstrate perceptual distortions and eccentric ideas and behavior. Clinicians often have trouble connecting with these patients and may note that they seem “strange” and are socially isolated, but in general these disorders are less difficult in the medical setting because of the patients’ isolation and distance from clinicians. AVOIDANT PERSONALITY DISORDER Avoidant patients display social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Although their traits limit socialization and intimate relationships, avoidant patients are tolerated relatively easily in the medical setting because their internal difficulties are usually carefully protected and not shared with the clinician; however, they often lack the social support that helps patients through the cancer experience. Table 2 describes characteristics of the individual personality disorders that are problematic in medical settings (paranoid, antisocial, narcissistic, borderline, histrionic, dependent, obsessive-compulsive) with observed behaviors, clinician countertransference, possible therapeutic responses, and medication treatment strategies. MIXED PERSONALITY DISORDERS Many difficult patients exhibit characteristics of more than one personality disorder. For example, at our institution, a young female survivor of a high-risk breast cancer allowed transfer of some, but not all, prior treatment records from other cancer centers. She became angry when her new psychiatrist placed restrictions on the prescription of controlled substances, including a requirement for prior collateral history, and fired that psychiatrist (paranoid). Toward her prior psychiatrist, who had previously prescribed the medication, she expressed in one moment idealization of his empathy and professionalism and in the next moment a desire to file a complaint or even sue him for not providing the standard of care (borderline). She further stated that as a “cancer patient” she deserved considerations, including prompt attention even if she arrived hours late for an appointment (narcissistic). Assessment of Personality Disorders Clues to a personality disorder diagnosis include multiple lifetime changes in jobs, relationships, and personal goals and personal histories including substance abuse, physical and sexual abuse, or childhood neglect. The clinician’s feelings of confusion, anger, frustration, boredom, or anxiety may also signal personality pathology, and it is important for clinicians to pay attention to their own emotional responses as “data.” For example, boredom often provides a clue to narcissistic personality, in Meyer and Block which the patient uses the clinician as a “sounding board” (eg, behaving as if the clinician has nothing more important to do than listen to the patient talk at length about his/her concerns), or obsessive-compulsive traits, in which the patient provides excessively detailed information. Under stress, borderline patients may appear disorganized, psychotic, or out of touch with reality, although without obvious hallucinations or delusions, prompting confusion in the clinician. Anger in the clinician tends to signal narcissistic or borderline pathology in the patient. Poor responses to usual treatment for anxiety and depression, frequent reports of suicidal ideation, or frequent unusual side effects and patient misunderstandings are other potential indicators of character disorders. Treatment of Patients with Personality Disorders GENERAL PRINCIPLES Basic elements of management for all personality disorders include the following: ● building and maintaining a therapeutic alliance; ● acknowledging and empathizing with the real stresses in the patient’s situation; ● setting realistic expectations for outcomes; recognizing that therapeutic goals are best limited to containment of behavior and not improvement and that protection of team relationships from the negative effects of the patient needs to be a central goal; ● containment of dangers to patient and staff through setting of consistent, appropriate expectations, limits, and boundaries; ● evaluating for suicidality and homicidality and acting to protect the patient and/or potential victims; and ● ongoing reflection on how the clinician’s clinical response to the patient is affected by his/her own emotions. When a patient is suspected of having a personality disorder, a mental health clinician should be consulted even if the patient refuses to be seen by the consultant; the consultant can help clarify the dynamics and diagnosis of the patient, help medical clinicians tailor their approach to the patient’s particular personality style, 12 set appropriate limits and boundaries with the patient, guide team meetings to reduce conflict among staff, and provide education and emotional support to the team. 19 When an on-site clinician is unavailable, teams should obtain the patient’s written consent to collaborate with any existing mental health treaters. Convening the oncology team to discuss the care of the patient can help clinicians stay on the same page, reduce staff conflict, support a unified treatment plan, contain dysfunctional patient behavior, and support the treatment team in a way that allows them to help the patient through treatment. MEDICATION The focus of medication for patients with personality disorders should be on symptom management. Psychotropic medications do not alter underlying personality structure, but can be effective in treating target symptoms. Selective serotonin reuptake inhibitors (SSRIs) are effective for anxiety, depression, and irritability, which can also be targeted by VOLUME 9, NUMBER 2 � MARCH/APRIL 2011 www.SupportiveOncology.net 47
Personality Disorders in the Oncology Setting Table 2 Personality Disorders and Management Strategies PERSONALITY DISORDER CHARACTERISTICS COMMON BEHAVIORS Paranoid Suspicious Misinterprets others’ actions as malevolent Antisocial Charming and ingratiating Manipulative Has history of prior incarceration and probation Histrionic Flirtatious or sexually provocative Intensely emotional (which hinders rational discussion of treatment options) Dependent Intensely needy, anxious, seeks constant reassurance Narcissistic Entitled Exquisitely sensitive to losses in physical vitality and cognitive function experienced as a result of cancer therapy Behaves well in medical settings when needs are being met Borderline Emotionally labile Fears abandonment Frequently changes residences, jobs and/ or relationships Obsessive-compulsive High need for control, orderliness, and perfectionism Focuses on details as opposed to the larger medical picture Depressive (not yet a DSM diagnosis, but under consideration for the next edition of DSM) Resists medications or chemotherapy Mistrusts clinician Threatens legal action Tells compelling stories about life difficulties that induce the clinician to offer extra help or favors; stories later turn out to be lies Brings weapons to the clinic Provides vivid or exaggerated descriptions of physical symptoms Has difficulty tolerating delay or ambiguity Amplifies somatic complaints, prompting workups Calls and pages frequently between appointments Has difficulty making independent decisions Has trouble leaving office Fails to ask appropriate questions Feels a need for intensive care and support, including hospitalization, to get through cancer treatment Requests special consideration Directs even minor concerns to the oncologist rather than ancillary staff Talks at length to extend appointment times Becomes extremely distressed by hair loss, sexual function difficulties, “chemobrain,” and loss of function Displays impulsive behaviors such as self-injury, substance abuse, binge eating, or sexual promiscuity Nonadherent with medications Misses appointments Develops new symptoms during transition points in treatment (active treatment to survivorship; active treatment to palliative care) because of feelings of abandonment Repeatedly questions clinicians regarding small details of care Keeps meticulous logs of symptoms and medications Has difficulty tolerating the imperfections of the process of receiving medical care Interprets events negatively Anticipates the worst: predicts negative outcomes of treatment even in the face of evidence to contrary POSSIBLE COUNTERTRANSFERENCE RESPONSES PROVOKED IN CLINICIAN Impatience, anger, fear Sympathy followed by anger and fear Arousal Fatigue Fatigue, guilt, aversion Anger; wish to counterattack Depression, self-doubt, anger Irritation, anger Depression, therapeutic nihilism 48 www.SupportiveOncology.net THE JOURNAL OF SUPPORTIVE ONCOLOGY
Page 1 and 2: Editor-in-Chief Michael J. Fisch, M
Page 3 and 4: Michael J. Fisch David Cella Thomas
Page 5 and 6: Mission The mission of The Journal
Page 7 and 8: R E V I E W Personality Disorders i
Page 9: Personality Disorders in the Oncolo
Page 13 and 14: Personality Disorders in the Oncolo
Page 15 and 16: P E E R V I E W P O I N T Personali
Page 17 and 18: H O W W E D O I T Recognizing Depre
Page 19 and 20: Recognizing Depression in Patients
Page 21 and 22: Recognizing Depression in Patients
Page 23 and 24: Evaluating the “Good Death” Con
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Page 27 and 28: O R I G I N A L R E S E A R C H Sym
Page 29 and 30: Symptom Experience in Patients with
Page 35 and 36: O R I G I N A L R E S E A R C H Est
Page 37 and 38: Estimating MIDs for the Worst Pain
Page 43 and 44: Truthful Information all three onco
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Page 47 and 48: Truthful Information these prelimin
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Evaluating the “Good Death” Concept from Iranian Bereaved Family

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