Evaluating the “Good Death” Concept from Iranian Bereaved Family

P E E R V I E W P O I N T
Personality Disorders in the Clinical
Setting
Walter F. Baile, MD
Commentary on “Personality Disorders in the
Oncology Setting” by Meyer et al (page 44)
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 selfesteem
and depression when they undergo disfig-
Correspondence to: Walter F. Baile, MD, Program in Interpersonal
Communication and Relationship Enhancement,
University of Texas MD Anderson Cancer Center, Houston,
TX 77030; telephone: (713) 745-4116; fax: (713) 794-4236;
e-mail: wbaile@mdanderson.org
J Support Oncol 2011;9:52 © 2011 Published by Elsevier Inc.
doi:10.1016/j.suponc.2011.02.003
uring 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.
Dr. Baile is affiliated
with the Program in
Interpersonal
Communication and
Relationship
Enhancement at the
University of Texas MD
Anderson Cancer
Center, Houston,
Texas.
52 www.SupportiveOncology.net THE JOURNAL OF SUPPORTIVE ONCOLOGY