Akhtar - Broken structures : severe personality disorders and their treatment

Otto F. Kernberg, M.D.

The most important contributions to the contemporary understanding of the symptoms, psychopathology, diagnosis, and treatment of personality disorders stem from the psychoanalytic exploration in depth of patients with significant character pathology. The dramatic deployment of pathological character traits as transference resistances has constituted the raw material for our understanding of this area of psychopathology. Our developing understanding of the frequency of these disorders in the general population, their relationships to other types of psychopathology, and their etiological factors has come from two broad sources: infant research and descriptive psychiatry. Infant research has, in turn, been stimulated by psychoanalytic investigation.

It might have been expected that these converging approachesparticularly psychoanalysis and descriptive psychiatrywould have cross-fertilized each other; in practice such has not however been the case. This failure has had frustrating, negative effects on the integration of knowledge in the area of character pathology and the personality disorders. As a consequence, important findings in the psychoanalytic investigation of a broad spectrum of patients with personality disorders has not been adequately incorporated into the descriptive phenomenology and the psychiatric classification of these disorders. At the same time, important findings derived from empirical research on severe personality disorders and from epidemiological studies of the pathology of early development have not found their way into the mainstream of psychoanalytic thinking.

In this elegant volume, Dr. Akhtar has sought to bridge this gap and to integrate, at a sophisticated level of contemporary knowledge, the findings from descriptive psychiatry and from the psychoanalytic study of severe personality disorders. His is not an eclectic combination of disparate findings and thinking; to the contrary, Dr. Akhtar critically analyzes the developments in both psychodynamic and descriptive psychiatry, and establishes a historical frame of reference for the approaches in both fields, one that separates out the essential from the marginal and even trivial.

Dr. Akhtar has cogently selected the clinically most prevalent severe personality disorders and reviewed the significant contributions from descriptive psychiatry and psychoanalysis, including a broad spectrum of continental European psychiatric thinking as well as the more familiar English and American literature in this field. At a time when the study in depth of descriptive psychiatry has tended to be neglected in favor of listing the principal symptomatic constellations found in clinical practice, Dr. Akhtar brings back the rich contributions to descriptive phenomenology of classical psychiatry, providing the clinician with sophisticated, subtly discriminating tools. Dr. Akhtar also reviews critically the psychoanalytic contributions to the understanding of the major personality disorders from both structural and dynamic perspectives. Bringing together the findings from contemporary ego psychology, object relations theory, self psychology, and interpersonal psychoanalysis, he replicates here the same broad, international perspective that characterizes his review of descriptive psychiatry.

In condensing and integrating these areas and approaches for each of the major personality disorders, Dr. Akhtar, with a remarkable clarity and economy of style, provides an enormous amount of information without ever overwhelming the reader. The result is a comprehensive update on the principal personality disorders, ongoing controversial issues, research in progress, and a critical analysis of DSM-III-R. By adding a careful differential diagnosis, he gives the clinician valuable instruments with which to assess the patients psychopathology, prognosis, and treatment indications.

A significant, original contribution is Dr. Akhtars presentation of a comprehensive frame that permits a comparison of these personality disorders from six viewpoints: the patients self concept, his interpersonal relations, his social adaptation, his functioning in the area of love and sexuality, his ethics and ideals, and his cognitive style. This approach clearly transcends counting descriptive traits in order to arrive at a diagnostic formulation.

At the same time, Dr. Akhtar leaves open the challenging, still unresolved issue of a satisfactory classification of personality disorders that would integrate both categorical and dimensional criteria. He points to the importance of considering the ways in which some of the personality disorders differ in degree of severity rather than structurally, but he also stresses the categorical nature of several personality disorders. A fully satisfactory classification of personality disorders will require a clear understanding of the mechanisms of their development and crystallization, of the interaction of genetic, neurophysiological, early developmental, familial, and, above all, psychodynamic and psychostructural features that should permit such an integration. Dr. Akhtars book gives the reader a comprehensive overview of the evidence currently available in all these fields, without attempting premature closure.

Dr. Akhtar also addresses the methodology of clinical evaluation of patients with personality disorders. He conveys valuable advice to the diagnostician, illustrated with lively clinical examples, and then proceeds to spell out his own approach to psychoanalytic psychotherapy. The reader might or might not agree with Dr. Akhtars approach to the psychotherapy of personality disorders. The richness, cogency, and fairness of his review of alternative psychotherapeutic approaches, however, always permit the reader to reach his own conclusion.