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419O N C O L O G Y C A N C E R N E T W O R K . C O M

COMOR BI DITY CON S U LTPE R SONALITY DI SOR DE R S

dependent, and obsessive-compulsive personality disorders.[9] Cluster C per- sonality disorders hang together based on the anxiety and fearfulness that is imbued into these personality styles.[6] Primary or important relationships are either to be avoided, completely enmeshed without a separate sense of self, or controlled.[9]

Personality, Personality Traits, and Cancer Personality is a relational style based on environment and genetics that is gradually established during childhood and adoles- cence. It starts to become � xed in one’s 20’s and only changes minimally after age of 30 years old.[10] These patterns of relating to others and the world at large are mostly

adaptive and relate to our innate temper- ament, imitative patterns, and repetitive reinforcement regarding what has worked in the past. For the most part, adults are diagnosed with cancer with their person- ality and personality traits � rmly in place.

The intersection of cancer, adaptation, coping, and personality style has long fascinated researchers. At one time, having dif� culty in expressing emotions and an attitude or tendency towards helplessness/hopelessness (the so-called Type C personality) was thought to be a cancer-prone personality.[11] This idea of a cancer-prone personality type has been debunked in longitudinal studies. [12] However, there is a rich literature of distinct coping styles during stressful

situations. For example, Lazarus and Folkman presented the “transactional model of stress” where a given situation requires both a cognitive appraisal about the situation and the person’s relation to the situation.[13] Many of these types of models have been applied to dealing with cancer-related stress.[14] Other coping styles have been investigated such as “� ght- ing spirit”, where the patient views cancer as a challenge with optimism to overcome the adversity; ultimately, consequences of a “� ghting spirit” on cancer-related outcomes remains unde� ned and should not be considered as a prognostic factor for cancer-related survival.[15-17]

Three basic personality traits have main- ly been researched in relation to cancer:

Personality Factors in All Patients

T his paper offers a clear review of personality disor- ders for the oncologist, with helpful suggestions for their management. Clinicians may also benefi t from

considering a few additional points: First, just as diagnosable personality disorders imply the need for specifi c approaches to management, personality styles, which are even more common, similarly benefi t from approaches tailored to their needs. These styles often become evident, and can interfere with care, in a very ill cancer patient. Kahana and Bibring’s 1965 paper Personality Types in Medical Management is a classic resource, which considers personality attitudes that do not necessarily fall under a disorder from the Diagnostic Statistical Manual of Mental Disorders Fifth Edition (DSM- 5)[1]. One example from this paper is the long-suffering, self-sacrifi cing (masochistic) patient who may escalate complaints when reassurances are given but responds well to validation of suffering. Second, personality disor- dered patients often cause diffi culty by engendering strong emotional reactions in their caregivers, which are important to recognize and take into account since they can infl u-

ence care. James Groves’ 1978 paper The Hateful Patient highlights some of the ways this can present problems in their care[2]. Third, disruptive behavior, often but not always caused by personality disordered oncology patients, benefi ts from a clear process of differential diagnosis, teamwork and clarifi cation of expectations and limits. John Peteet et. al’s 2011 “Possibly Impossible Patients” paper provides several practical principles and goals for responding to disruptive behavior[3]. Finally, the prudent clinician may recall the fundamental attribution error, the tendency to over-empha- size internal factors in judging others’ behaviors. A com- prehensive evaluation should consider psychosocial factors as well as personality changes secondary to disease- or treatment-related ones.

FINANCIAL DISCLOSURE: The authors have no signifi cant fi nancial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

Roxanne Sholevar, MD, Carrie Wu, MD, and John Peteet, MD

PERSPECTIVE BY

Dr. Sholevar is Resident Physician in Psychiatry, Virginia Commonwealth University Health System, Richmond, Virgnia Dr. Wu is Clinical Fellow, Adult Psychosocial Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts. Dr. Peteet is Associate Professor of Psychiatry, Harvard Medical School, Fellowship Site Director, Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, and Physiatrist, Brigham and Women’s Hospital, Boston, Massachusetts.

For references visit cancernetwork.com/CC-PD10-19

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