Personality disorders become exacerbated under stressful cancer-related situations and may lead to adverse consequences and outcomes.
ABSTRACT: Personality disorders exist on a spectrum in the general population and therefore may coexist in patients who have cancer. Patients with these disorders exhibit character rigidity resulting from enduring patterns of inner experience and behavior and may experience some level of interpersonal conflict among medical staff caring for them. These conditions become exacerbated under stressful cancer-related situations and may lead to adverse consequences and outcomes. This review highlights the conceptual and diagnostic issues of personality disorders for practicing oncologists and provides recommendations for recognizing and managing cancer patients with difficult personality traits or personality disorders.
The inner experience of patients with personality disorders tends to be chaotic, fearful, scary, and/or intense and these feelings become transmitted and transposed onto their caretakers or anyone near them. Patients with personality disorders tend to invoke strong feelings in their clinicians and are often talked about informally outside of bedside rounds. These patients are recognized by staff for their atypical behavioral and communication styles and can cause conflict among providers. Relational interactions are difficult for patients with personality disorders, almost by definition; the complexity of cancer care (e.g., specific staff roles, interchanging medical care systems) heightens these difficulties, which are also felt by oncology staff.
Patients with severe personality traits and/or personality disorders are more frequently seen in medical/surgical clinics than in the psychiatrist’s or therapist’s office, despite long standing patterns of interpersonal dysfunction. They could benefit from psychiatric or psychological intervention if the patient were amenable to treatment. The reason for this is in itself diagnostic. Even with high levels of social impairment, personality disorders are “ego-syntonic” and therefore the patient does not see his or her way of living, interacting, and communicating with others as problematic. Patients with other major categories of psychiatric illness (e.g., major depressive disorder, bipolar disorder, schizophrenia) are distressed by their symptoms which are seen as “other,” not part of what the patient considers to be his or her core self. “Other” psychiatric disorders are “ego-dystonic” or experienced as foreign or disturbing to the person experiencing them. Also, they have higher levels of impairment and inability to function in routine daily life. Patients with personality disorders display dysfunctional patterns of communication and behavior; they function much less well in the midst of stressful life-changing circumstances. They usually do not seek help until they are gravely ill or have suffered multiple personal losses. However, there are always signs of impaired functioning such as dysfunctional relationships, odd communication styles, unusual demands or threats, or excessive emotion over tasks that cause even a slight amount of discomfort. Limited recognition of pervasive dysfunction tends to persist or is not usually appreciated until later in life. They are more likely to seek out medical rather than psychiatric care to remedy physical complaints and ailments, for example.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides general definitions and direction that apply to each of the 10 specific personality disorder types. In general, a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Personality traits are also enduring and pervasive in terms of motivation, emotion, interpersonal style, attitudes, and behaviors, but they are not necessarily maladaptive and may not cause distress or impairment. The DSM-5 provides diagnostic criteria for 10 distinct personality disorders (see below). While these diagnostic categories are certainly useful and recognizable from a clinical perspective, they do not complete the entire picture of these disorders. Mental health clinicians often note either overlap or hybrid descriptions or apparent personality disorders that do not clearly meet any one particular subtype criteria. As noted above, the inner experience and behaviors must be enduring throughout many life circumstances or context and have begun by adolescence or early adulthood. This is particularly important because many other psychological/mental conditions, especially when a person is under stress for one reason or another, can mimic behaviors attributable to personality disorders. Identifying a disorder helps clinicians direct their care in a more appropriate way. But caution must be used to protect against overdiagnosis. For this reason, mental health clinicians will often document a “rule out” x,y, or z personality disorder. It is always crucial to critically assess the acute situation in which the patients are evaluated and think of alternative diagnoses. The diagnosis of personality disorders requires comprehensive and longitudinal assessments of behavior patterns that must have manifested prior to age 18.
Character rigidity is the key characteristic of personality disorders resulting in communication and behavioral styles that are not flexible under the changing or evolving circumstances inherent to the cancer trajectory. Typically, patients with personality disorders lack the coping reserve to be adaptable, which is clearly necessary to transition between social and environmental contexts and tends to be more pronounced under stressful situations such as a cancer diagnosis. Interestingly, personality disorder communication and behavior are adaptive for a particular situation in which it may actually work well. These are typically traumatic situations and since they tend to have happened early on in the patient’s life, they are generally long-standing patterns by adulthood. The communication or behavior style which is fixed does not work well in most other situations. It becomes overused in more routine settings, generally leading to pervasive patterns of social and interpersonal dysfunction. Although their interpersonal tools are limited, they usually do not have sufficient insight into these issues. These behavioral patterns tend to develop after early trauma and during crucial times of self-development. They are passed down from generation to generation but their etiology is not altogether clear. Genetics clearly plays a role but also influences the nurturing style of the early childhood environment. Differentiating between genetics and nurturing is difficult in this context. Severe personality traits or personality disorders may even be influenced epigenetically by the home environment as well.
The DSM-5 classifies personality disorders into three categories or clusters of disorders: A) odd or eccentric; B) dramatic, emotional, or erratic, and C) anxious or fearful. (Table 1)
Cluster A. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. They are clustered together based on behaviors that are odd or eccentric in comparison to societal norms. The hallmark of these personality styles is the experience of pervasive social discomfort. Therefore, interpersonal closeness is either of no interest or experienced as highly unpleasant and can lead to avoidant, odd, or eccentric behaviors. These patients typically want to be left alone; they may or may not desire social contact to some extent.
Cluster B. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. This cluster is based on struggling to relate to others or with relationship structures, which can be particularly problematic in the medical setting where many patients adopt a passive role. Patients in Cluster B are typically uncomfortable with high levels of interpersonal stress, decision-making, and shifting relationships (i.e., with medical staff). Interpersonal ambiguity or strain on relationship definition is particularly difficult for these patients.
Cluster C. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. Cluster C personality disorders hang together based on the anxiety and fearfulness that is imbued into these personality styles. Primary or important relationships are either to be avoided, completely enmeshed without a separate sense of self, or controlled.
Personality is a relational style based on environment and genetics that is gradually established during childhood and adolescence. It starts to become fixed in one’s 20’s and only changes minimally after age of 30 years old. These patterns of relating to others and the world at large are mostly adaptive and relate to our innate temperament, imitative patterns, and repetitive reinforcement regarding what has worked in the past. For the most part, adults are diagnosed with cancer with their personality and personality traits firmly in place.
The intersection of cancer, adaptation, coping, and personality style has long fascinated researchers. At one time, having difficulty 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. This idea of a cancer-prone personality type has been debunked in longitudinal studies. 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. Many of these types of models have been applied to dealing with cancer-related stress. Other coping styles have been investigated such as “fighting spirit”, where the patient views cancer as a challenge with optimism to overcome the adversity; ultimately, consequences of a “fighting spirit” on cancer-related outcomes remains undefined and should not be considered as a prognostic factor for cancer-related survival.[15-17]
Three basic personality traits have mainly been researched in relation to cancer: neuroticism, extraversion, and conscientiousness. Neuroticism is essentially a state of nervousness that exists on a spectrum from safe to anxious. Extraversion concerns an interest in social company from minimal (introverted) to maximal (extraverted). And conscientiousness (personal reliability) is a personality construct that varies from being responsible and efficient to being irresponsible and lacking efficiency.[10,18] Similar to Hippocrates’ original idea of personality based on the varied construction of four basic personality types composed of varied body fluids, these three personality constructs exist on a spectrum and everyone has essentially a unique contrast that remains relatively stable over time. Optimism may also be considered, especially in its relation to cancer and as a trait in “positive psychology,” but it has also been thought of as the inverse of neuroticism. High optimism is generally thought of as protective in stressful situations.
There are several ways in which personality may intersect with cancer. Since personality is life-long and pervasive, its features, consequences, and implications endure and are manifest by specific patterns of behavior, choices, environment, stress, and internal hormonal dysregulation. The central nervous system, where personality originates, has a strong influence on biological and cellular systems over long periods of time. This stands in contrast to acute changes one may encounter throughout life. Therefore, personality may influence cancer development and progression through 1) perpetuation of unhealthy lifestyle that is personality driven; 2) negative affect (depressive or anxious symptoms, anger) or poor coping; and 3) being an etiological factor for somatic diseases or mental disorders that predispose to cancer. Epidemiological studies of personality and cancer development and/or progression show a few studies with a positive association but the majority shows no significant association leading researchers to conclude that there is no significant association between personality and increased risk of cancer.[17,21,22]
According to the American Cancer Society, men have a 39.66% risk of developing cancer in their lifetimes, while women have a 37.65% chance. At the same time, a national epidemiologic study of 43,093 patients found an overall prevalence of 14.79% of adult Americans with at least one personality disorder. Obsessive-compulsive (7.88%), paranoid (4.41%), antisocial (3.63%), schizoid (3.13%), avoidant (2.36%), histrionic (1.84%), and dependent (0.49%) were the most common types of personality disorders. Other community epidemiological studies have shown that approximately 10% of the general population has a personality disorder. Limited data exist on the prevalence of personality traits, but up to 20% of the general population may have severe personality traits that cause significant impairment not meeting a diagnostic specification.[20,26]
Surprisingly, the overlap between cancer and personality disorders remains relatively unexplored. While it is difficult to generalize “normal” reactions to life-threatening cancer-related medical issues, oncology clinicians observe patterns of reactions to life-threatening news and develop a sense for who is reacting “too much or too little”, which may be indicative of a personality- or other mood-related issue.
It should be noted that the vast majority of uncooperative patients do not have a personality disorder. Personality disorders are pervasive patterns that require understanding a patient’s behavior in multiple contexts over many years. In fact, personality disorders cannot be diagnosed under the age of 18.
Nonetheless, a cancer diagnosis followed by treatments and numerous life changes requires patients to not only adapt but to thrive in order to face all the unique challenges. Adaptability, flexibility, and resourcefulness are needed to meet the multitude of cancer-related challenges. These characteristics are the exact opposite of the character rigidity of personality disorders. In fact, some personality disorders, such as narcissistic or obsessive-compulsive personality disorders, can be very adaptive for particular work environments. However, even patients with adaptive personality disorders who have been successful in their work-life endeavors find that those same attitudes and behaviors don’t necessarily select for success as a cancer patient.
Personality traits and disorders exist on a spectrum. While patients with severe personality disorders represent a minority of patients that the oncologist will see, they will inevitably require a considerable amount of time and patience due to their extreme difficulty adjusting to the new environment of being treated for cancer.
Major psychiatric issues (e.g., major depressive episode, generalized anxiety disorder) tend to go unnoticed in the cancer context as patients and doctors are paying attention to other more life-threatening matters. While screening for psychiatric disorder in the cancer setting is helpful diagnostically, it is not always done and can still miss more varied or subtle presentations. There is considerable overlap between mood and personality disorders, especially in the cancer setting.[27,28] A personality disorder may provide the context in which a mood or other disorder presents itself. For example, patients with schizoid or schizotypal personality disorder are more vulnerable to psychosis; borderline and narcissistic patients are prone to depression. Cluster C personalities are prone to anxiety disorders perhaps through distortion of social perception and alienating interpersonal styles. In addition, patients with long-standing psychiatric disorders may develop behaviors that look like personality disorders but may not be pervasive and may not have started before early adulthood. Distorted perceptions isolate patients leaving them without social buffers against adverse life events. Solitary coping is less effective and reinforces aberrant patterns of thinking, feeling, and relating. At the same time, other disorders may be precursors to a personality disorder if it is long standing. Chronic mood, anxiety, or substance abuse disorders may restrict social interactions and may obscure opportunities to learn social coping strategies. This restricted repertoire of interpersonal interactions constitutes the character rigidity that defines personality disorders.
The cancer experience is a series of acute and chronic stressors that can alienate patients with personality disorders and severe personality traits. A longitudinal study found that neuroticism is associated with distinctly worse quality-of-life following localized breast cancer treatment. In a similar population, poor quality of life after treatment was more strongly predicted from pre-morbid psychological characteristics (e.g., depression and personality factors) than from actual cancer-related variables (e.g., treatment types and cancer severity). Among testicular cancer survivors, neuroticism was associated with somatic and mental morbidities.
The majority of intervention data has focused on cancer control and prevention and how personality disorders influence outcomes. In general, research into the specific management of patients with personality disorders and cancer is lacking. Table 1 highlights various suggestions specific to each type of personality disorder. The primary issue is to acknowledge feelings and emotions raised among staff and to avoid patient blame. It is also helpful to remember that these behaviors have likely been successful in another environment in which the patient has found him or herself, particularly early in life and indicate a severe deficiency of interpersonal skills.
Aside from managing the emotions of the treating team, setting appropriate boundaries and expectations is very important. For the suspicious, incredulous patient, it is crucial to make sure that they understand the information clearly and can repeat it back to you. For the patient who is overly intrusive (e.g., with agreeableness or even seduction), stating and maintaining boundaries helps them establish a working relationship that can be negotiated since many patients with personality disorders tend to sabotage their relationships. Patients who are fearful, anxious, or avoidant should be approached with respect, concern, and space to feel in control of the doctor-patient relationship. Physicians often rely on the inherent power dynamic to move forward with important medical issues that need to be attended to. The typical passive role of the patriarchal medicine paradigm can be very uncomfortable for some patients with personality disorders. Therefore, considered attention should be placed on shared decision making and even discussing how the patient would like the relationship to work. Although these are not typical conversations in the oncologic medical setting, they can be invaluable in terms of preserving doctor-patient relationship integrity.
It is critical to consider a formal mood or thought disorder diagnosis as well when unusual behaviors or thought patterns are encountered. There should be a low threshold to seek help from mental health professional colleagues. Screening programs can be helpful in determining other mood components but usually a skilled interview is also needed to assess patients for both mood and psychotic disorders. If the patient has family or a significant other who is involved in the patient’s care, alignment is very important so that the patient feels everyone understands each other and opportunities for splitting are minimized.
Patients with personality disorder and personality traits will test our limitations of interpersonal skills as physicians. In general, they are relying on the treating doctors to provide organization, structure, and a blueprint for acceptable behavior in order to move forward with their medical care. Although their oncologic management may be more involved, more time-consuming, and may frequently require interdisciplinary care, addressing these personality issues in a humane way is an integral part of their overall comprehensive care. It is no less important than their actual oncologic management.
Financial Disclosure: The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.
Personality Factors in All Patients
Roxanne Sholevar, MD, Carrie Wu, MD, and John Peteet, MD
This paper offers a clear review of personality disorders for the oncologist, with helpful suggestions for their management. Clinicians may also benefit from considering a few additional points: First, just as diagnosable personality disorders imply the need for specific approaches to management, personality styles, which are even more common, similarly benefit 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). One example from this paper is the long-suffering, self-sacrificing (masochistic) patient who may escalate complaints when reassurances are given but responds well to validation of suffering. Second, personality disordered patients often cause difficulty by engendering strong emotional reactions in their caregivers, which are important to recognize and take into account since they can influence care. James Groves’ 1978 paper The Hateful Patient highlights some of the ways this can present problems in their care. Third, disruptive behavior, often but not always caused by personality disordered oncology patients, benefits from a clear process of differential diagnosis, teamwork and clarification 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. Finally, the prudent clinician may recall the fundamental attribution error, the tendency to over-emphasize internal factors in judging others’ behaviors. A comprehensive evaluation should consider psychosocial factors as well as personality changes secondary to disease- or treatment-related ones.
Financial Disclosure: The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.
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.