Passport to personality: Is it the patient who's 'difficult'?

You know that you’ve been at a valuable meeting when you can use on Monday morning the "take-home messages" you gathered over the weekend.

 The annual conference of the American Psychosocial Oncology Society was just such a meeting, filled with valuable data and perspective on distress screening tools, survivorship guidance, and ways to integrate psychosocial care comfortably into the evolving medical model of cancer care.

But the lessons I put into play before I unpacked my briefcase were gleaned in a dynamic workshop led by Dr. John D. Wynn of the Swedish Cancer Institute in Seattle.

A psychiatrist, Dr. Wynn has long been regarded as an expert on the uneasy intersection of cancer and Axis II personality traits and disorders, having written the chapter on this topic in Dr. Jimmie Holland’s classic textbook Psycho-Oncology (New York: Oxford University Press, 2010).

Sorting through Axis II diagnoses, he frames Clusters A, B, and C as "weird," "wild," and "worried." Along the way, he challenged the accepted dogma that personality disorders are easily defined, enduring, and inflexible when research calls into question all of these notions.

To be sure, there are individuals whose ways of dealing with others and the world fall far outside the reassuring central band of "average." But labels – formal or informal –may be overused and unhelpful, he argued.

For example, "uncooperative" and "difficult" aren’t assigned codes in the DSM-IV or ICD-9, but they’re quasi-diagnoses used with great frequency in rounds, case conferences, and at the nursing station.

Dr. Wynn drove home the point that such terms are relative. Members of the treatment team are likely viewed as "difficult" by the very same patients who elicit the label from us. Consider the context, he counseled.

"Medical care encourages and reinforces dependency, passivity, and attention seeking," he explained.

While most people in society are able to adapt to the highly structured culture of Western medicine, grinning and bearing it in their new costumes (cotton gowns) and subservient patient roles, others may simply not possess that flexibility, particularly in the context of extreme fear, embarrassment, or mistrust.

Dr. Wynn argues that the people who are often diagnosed with personality disorders really have "adaptive failure" – a term he wishes would have made it into DSM-5. They have both a poor sense of self and a poor capacity for interpersonal functioning.

And this is a painful combination when it comes to coping with a life-threatening diagnosis in a strange new world, where amicability, conformity, and allegiance to the treatment plan are highly prized.

So how does all this play out in the clinic?

Dr. Wynn’s advice is to use our own reactions to such patients as diagnostic cues, tapping into our professionalism to guide our responses.

See each patient as unique and uniquely challenged by the circumstances of his or her disease, and respond based on what you see and feel, he advised.

Take extra time to listen to patients who fail to follow through with treatment, appear needy or overly-entitled, and even those who may "frighten or repel us."

Do fear, shame, or confusion lie at the heart of such behavior?

Could respect, collaboration, and limit setting put in check the most troubling interactions with such patients?

With Dr. Wynn’s conceptualization fresh in my mind, I was inspired to step back and put into context my own reactions to patients I find difficult.

I found myself more patient, more understanding, and more curious about the underpinnings of behaviors that play havoc with the treatment schedule and have the potential to bring out the worst in us all.

What particularly helps for me is to remember (and remind colleagues) that our shared enemy is cancer, not the patient. By seeing the patient as our ally in that fight, we are motivated to compassionately demystify our traditions and find creative bridges to connection with all types of people who need our care.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.

You know that you’ve been at a valuable meeting when you can use on Monday morning the "take-home messages" you gathered over the weekend.

 The annual conference of the American Psychosocial Oncology Society was just such a meeting, filled with valuable data and perspective on distress screening tools, survivorship guidance, and ways to integrate psychosocial care comfortably into the evolving medical model of cancer care.

But the lessons I put into play before I unpacked my briefcase were gleaned in a dynamic workshop led by Dr. John D. Wynn of the Swedish Cancer Institute in Seattle.

A psychiatrist, Dr. Wynn has long been regarded as an expert on the uneasy intersection of cancer and Axis II personality traits and disorders, having written the chapter on this topic in Dr. Jimmie Holland’s classic textbook Psycho-Oncology (New York: Oxford University Press, 2010).

Sorting through Axis II diagnoses, he frames Clusters A, B, and C as "weird," "wild," and "worried." Along the way, he challenged the accepted dogma that personality disorders are easily defined, enduring, and inflexible when research calls into question all of these notions.

To be sure, there are individuals whose ways of dealing with others and the world fall far outside the reassuring central band of "average." But labels – formal or informal –may be overused and unhelpful, he argued.

For example, "uncooperative" and "difficult" aren’t assigned codes in the DSM-IV or ICD-9, but they’re quasi-diagnoses used with great frequency in rounds, case conferences, and at the nursing station.

Dr. Wynn drove home the point that such terms are relative. Members of the treatment team are likely viewed as "difficult" by the very same patients who elicit the label from us. Consider the context, he counseled.

"Medical care encourages and reinforces dependency, passivity, and attention seeking," he explained.

While most people in society are able to adapt to the highly structured culture of Western medicine, grinning and bearing it in their new costumes (cotton gowns) and subservient patient roles, others may simply not possess that flexibility, particularly in the context of extreme fear, embarrassment, or mistrust.

Dr. Wynn argues that the people who are often diagnosed with personality disorders really have "adaptive failure" – a term he wishes would have made it into DSM-5. They have both a poor sense of self and a poor capacity for interpersonal functioning.

And this is a painful combination when it comes to coping with a life-threatening diagnosis in a strange new world, where amicability, conformity, and allegiance to the treatment plan are highly prized.

So how does all this play out in the clinic?

Dr. Wynn’s advice is to use our own reactions to such patients as diagnostic cues, tapping into our professionalism to guide our responses.

See each patient as unique and uniquely challenged by the circumstances of his or her disease, and respond based on what you see and feel, he advised.

Take extra time to listen to patients who fail to follow through with treatment, appear needy or overly-entitled, and even those who may "frighten or repel us."

Do fear, shame, or confusion lie at the heart of such behavior?

Could respect, collaboration, and limit setting put in check the most troubling interactions with such patients?

With Dr. Wynn’s conceptualization fresh in my mind, I was inspired to step back and put into context my own reactions to patients I find difficult.

I found myself more patient, more understanding, and more curious about the underpinnings of behaviors that play havoc with the treatment schedule and have the potential to bring out the worst in us all.

What particularly helps for me is to remember (and remind colleagues) that our shared enemy is cancer, not the patient. By seeing the patient as our ally in that fight, we are motivated to compassionately demystify our traditions and find creative bridges to connection with all types of people who need our care.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.

You know that you’ve been at a valuable meeting when you can use on Monday morning the "take-home messages" you gathered over the weekend.

 The annual conference of the American Psychosocial Oncology Society was just such a meeting, filled with valuable data and perspective on distress screening tools, survivorship guidance, and ways to integrate psychosocial care comfortably into the evolving medical model of cancer care.

But the lessons I put into play before I unpacked my briefcase were gleaned in a dynamic workshop led by Dr. John D. Wynn of the Swedish Cancer Institute in Seattle.

A psychiatrist, Dr. Wynn has long been regarded as an expert on the uneasy intersection of cancer and Axis II personality traits and disorders, having written the chapter on this topic in Dr. Jimmie Holland’s classic textbook Psycho-Oncology (New York: Oxford University Press, 2010).

Sorting through Axis II diagnoses, he frames Clusters A, B, and C as "weird," "wild," and "worried." Along the way, he challenged the accepted dogma that personality disorders are easily defined, enduring, and inflexible when research calls into question all of these notions.

To be sure, there are individuals whose ways of dealing with others and the world fall far outside the reassuring central band of "average." But labels – formal or informal –may be overused and unhelpful, he argued.

For example, "uncooperative" and "difficult" aren’t assigned codes in the DSM-IV or ICD-9, but they’re quasi-diagnoses used with great frequency in rounds, case conferences, and at the nursing station.

Dr. Wynn drove home the point that such terms are relative. Members of the treatment team are likely viewed as "difficult" by the very same patients who elicit the label from us. Consider the context, he counseled.

"Medical care encourages and reinforces dependency, passivity, and attention seeking," he explained.

While most people in society are able to adapt to the highly structured culture of Western medicine, grinning and bearing it in their new costumes (cotton gowns) and subservient patient roles, others may simply not possess that flexibility, particularly in the context of extreme fear, embarrassment, or mistrust.

Dr. Wynn argues that the people who are often diagnosed with personality disorders really have "adaptive failure" – a term he wishes would have made it into DSM-5. They have both a poor sense of self and a poor capacity for interpersonal functioning.

And this is a painful combination when it comes to coping with a life-threatening diagnosis in a strange new world, where amicability, conformity, and allegiance to the treatment plan are highly prized.

So how does all this play out in the clinic?

Dr. Wynn’s advice is to use our own reactions to such patients as diagnostic cues, tapping into our professionalism to guide our responses.

See each patient as unique and uniquely challenged by the circumstances of his or her disease, and respond based on what you see and feel, he advised.

Take extra time to listen to patients who fail to follow through with treatment, appear needy or overly-entitled, and even those who may "frighten or repel us."

Do fear, shame, or confusion lie at the heart of such behavior?

Could respect, collaboration, and limit setting put in check the most troubling interactions with such patients?

With Dr. Wynn’s conceptualization fresh in my mind, I was inspired to step back and put into context my own reactions to patients I find difficult.

I found myself more patient, more understanding, and more curious about the underpinnings of behaviors that play havoc with the treatment schedule and have the potential to bring out the worst in us all.

What particularly helps for me is to remember (and remind colleagues) that our shared enemy is cancer, not the patient. By seeing the patient as our ally in that fight, we are motivated to compassionately demystify our traditions and find creative bridges to connection with all types of people who need our care.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.