The effective treatment of cancer in patients who may already suffer from significant heart disease, poorly controlled diabetes, or another chronic medical condition requires extra monitoring, consultation, or even modification of chemotherapy regimens or surgeries. In general, however, these additional needs are known to the oncologist through clear history, symptoms, and objective measures, and oncologists therefore have readily available means to manage the attendant risks. Patients who have challenging personality traits or personality disorders will require as much or more attention and management, both for the success of their own treatments and for the sake of minimizing disruption in the clinic itself.

The needs of these patients are usually less clear to the oncologist at the outset. Many personality disorders remain unidentified in the community or are never treated consistently, and the oncologist may have no knowledge of the diagnosis. Further complications may arise when a patient's challenging personality traits that have not previously risen to a diagnosable disorder worsen under the stress of a cancer diagnosis. The patient's behavior may become increasingly disordered at precisely the time when the challenges of a serious illness require the most fully adaptive response. In this issue, Meyer and Block¹ address the problem of personality disorders in the oncology setting and offer some practical information about identifying and responding to the needs of these patients.

The complexity of diagnosing personality disorders is suggested by the multiple classification systems summarized by the authors (ie, formal diagnostic criteria for individual disorders, “clusters” of personality traits, as well as descriptive categories that emerge from James Groves' classic work on “the hateful patient”²). Whatever the challenges of describing personality disorders, they differ from other chronic conditions complicating cancer care in one important way: the emotional responses of physicians themselves provide information that can be critical to identifying and managing the problem. Meyer and Block provide a useful summary of observable behaviors and emotional reactions in both patients and clinicians, along with general principles and particular responses for managing those behaviors.

Of equal interest to the oncologist is the question of when managing such behaviors will require psychiatric involvement for treatment of the patient, for advice to staff, or both. Although the authors do not address this issue directly, they do introduce the principle of regarding the physician's behaviors and reactions as sources of information that are as important as observations of the patients themselves. Returning to this principle may be the most useful strategy for oncologists who might seek psychiatric consultation. A psychiatric referral might be helpful when: (1) interactions of staff members regarding a particular patient become less effective or less professional than usual; (2) emotional responses of staff members become difficult for themselves or others around them to understand or tolerate; or (3) the patient is consuming more resources or staff time than the clinic can sustain. In general, referral may become not only helpful but also necessary if the behaviors of a given patient and the responses of staff have reached the point at which the patient is no longer receiving the same standard of oncology care as other complicated patients. Although the literature on personality disorders is vast, this summary by Meyer and Block, and in particular its emphasis on attending to staff responses, may be of use in meeting everyday needs of oncologists, oncology clinics, and some of their most vulnerable patients.