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Book Reviews

Psychodynamic Psychotherapy for Personality Disorders: A Clinical Handbook

David I. Joseph, MD

Published: November 15, 2011

Psychodynamic Psychotherapy for Personality Disorders: A Clinical Handbook

edited by John F. Clarkin, PhD; Peter Fonagy, PhD, FBA; and Glen O. Gabbard, MD. American Psychiatric Publishing, Inc, Arlington, VA, 2010, 485 pages, $72.00 (paper).

This collection of well-written, concise articles by international leaders in the field is a thorough exploration of the psychodynamic treatment of personality disorders. The editors have approached the topic from 3 perspectives, each constituting a section of the book: (I) Personality Pathology: Defining the Focus of Intervention, (II) Psychodynamic Treatment Approaches, and (III) Research and Future Directions. The volume provides a comprehensive overview of the field as well as practical information that is expected from a clinical handbook. Considerable attention is given to relating the psychodynamic understanding of personality disorders to relevant neurobiological findings and to reviewing the data on treatment efficacy of psychotherapy. In addition to an extensive bibliography, each chapter includes a short list of suggested readings.

The first section provides a detailed orientation to the field and frames the topic such that the following, more narrowly focused chapters can be readily considered from a wide perspective. Many of the authors base their understanding and treatment of personality disorders upon the model of object relations developed by Otto Kernberg, emphasizing conflictual motivations and the importance of aggression. In the first chapter, "An Object Relations Model of Personality and Personality Pathology," Eve Caligor and John Clarkin place much importance on "inborn affect dispositions and their interactions with early attachment relationships" (p9). They understand identity to be "the structural correlate of both the subjective sense of self and the experience of significant others, which in this model are viewed as inextricably linked" (p17). Their discussion of "social reality testing" highlights the degree to which persons with "identity pathology" often cannot accurately read social cues, especially when under stress. In their chapter, the authors distinguish between Kernberg’s formulation of a borderline personality organization that characterizes "severely maladaptive personality rigidity" with a predominance of "lower-level, splitting defensive operations" and the borderline personality disorder that is a specific DSM-IV-TR diagnosis subsumed under the broader concept of borderline personality organization. The authors clearly define the 2 concepts and distinguish between them, but readers unfamiliar with this important distinction will need to be alert not to confuse them, in this chapter and throughout the book in which both are used frequently.

Chapter 2, "Attachment and Personality Pathology," written by 7 authors, the lead author being Peter Fonagy, is a remarkable synthesis of the field of attachment and mentalization. Like Caligor and Clarkin, these authors also emphasize the development of self and object representations as well as the importance of interpersonal relationships. Writing clearly without jargon, the authors have managed to operationalize the processes they describe without simplifying the topic. To buttress their emphasis on early attachment relationships, they note that there is a 68%-75% correlation between the "attachment classification" observed in infancy and that observed in adulthood. The chapter also offers a broad review of the neurobiology of attachment and mentalization that provides a reader unfamiliar with this literature with an understanding of the relationship between these different frames of reference. The authors state that the attachment behaviors of an infant are "activated when something about his environment makes him insecure" (p39), a view that, to my mind, excludes such behaviors as nursing, cooing, smiling, and other behaviors that fall under the concept of "attachment behaviors" but are not responses to insecurity. But this is a small quibble with a chapter that is a superb review of an important topic.

Chapter 3, "The Neurobiology of Personality Disorders" by Gerhard Roth and Anna Buchheim, is based on the assumption that "affective and personality disorders result from a combination of (1) genetic polymorphisms affecting predominantly the serotonin and hypothalamic-pituitary-adrenal axis, (2) deficits in brain development, (3) early adverse (traumatizing) childhood experience, and (4) later (adolescent) adverse experience" (p89). This condensed, data-packed chapter presents a great deal of carefully organized information but overwhelmed this reader with the sheer amount of information. The chapter, like some others, would be greatly improved by the inclusion of visual presentations of the neuroanatomical structures under consideration. Among the most striking findings cited in this overview is that "unsuccessful psychopaths" when compared with controls and successful psychopaths have a reduction of over 22% in the volume of prefrontal gray matter.

Jonathan Shedler and Drew Westen’s chapter, "The Shedler-Westen Assessment Procedure: Making Personality Diagnosis Clinically Meaningful," is a carefully reasoned, thoughtfully organized, clinically useful approach to the objective assessment of personality. Using clinical inference and drawing upon the impact of the patient on the mind of the clinician, Shedler and Westen conceptualize personality in a way that anchors each of the other chapters. While respecting the inadequacies of DSM-II that resulted in DSM-III and its subsequent revisions, they argue convincingly that, with regard to personality disorders, DSM-IV has many serious problems and identify 10 reasons why Axis II requires a major revision. The Shedler-Westen Assessment Procedure (SWAP) is a list of 200 statements, developed and refined over many years. A clinician, after at least 6 patient hours, indicates whether each item describes a patient very well, somewhat, or not at all. "The problem with clinical observation and inference," as they see it, "is not that it is inherently unreliable’ ¦.The problem is that it tends to come in a form that is difficult to study systematically" (p130). The SWAP is intended to "harness clinical judgment and inference rather than eliminate it and to combine the best features of the clinical and empirical traditions" (p127). Shedler and Westen also argue that the SWAP allows for a more accurate classification of personality disorders. One striking finding from their data is that depressive (dysphoric) personality, which is not included in DSM-IV, is the prevalent personality syndrome seen in the community. Clinicians, regardless of their psychotherapeutic orientation, will find that the SWAP successfully operationalizes psychodynamic concepts in a manner that sharpens one’s observational skills. Psychodynamic clinicians will find the authors’ conviction that "meaningful assessment of personality requires clinical judgment and inferences about underlying psychological processes" (p 154) congruent with the frame of reference of their work. This chapter should be required reading for all psychiatric residents and other students of psychotherapy.

Section II explores psychodynamic treatment approaches with considerable attention devoted to the more serious personality disorders: borderline personality, "malignant" narcissism, and antisocial personality. The emphasis on these disorders creates the unfortunate possibility that readers may come to believe that the principles are not relevant to the treatment of less disturbed patients. For example, the excellent discussion by Bateman and Fonagy of "Mentalization-Based Treatment of Borderline Personality Disorder" contains much that, to my mind, is readily useful in the treatment of patients with less severe pathology who may have "defective mentalization" in more circumscribed aspects of their personalities but can benefit from concepts advanced in this discussion of borderline patients. Many of the 10 chapters in this section provide general guidelines (eg, "Once the patient is in treatment, a capacity in the therapist for flexibility and careful attention to fluctuating countertransference experiences will improve treatment prospects" [p 167]) that are of limited usefulness in the absence of more detailed case material. On the other hand, the chapter by Frank Yeomans and Diana Diamond on "Transference-Focused Psychotherapy and Borderline Personality Disorder" provides meaningful case material and clarifies the differences between their approach and mentalization-based psychotherapy of the same group of patients. Glen Gabbard’s discussion of therapeutic action in the treatment of the borderline patient is clear and comprehensive. Those unfamiliar with the work of Mardi Horowitz will find his chapter (written with Uma Lerner) on the "Treatment of Histrionic Personality Disorder" a good introduction to "configurational analysis," an approach to treatment that is highly structured and combines psychodynamic understanding with treatment techniques central to more cognitively based treatments. The inclusion of some detailed case material would have helped to operationalize his treatment ideas. This section concludes with Michael Stone’s thoughtful overview of the treatment of personality disorders, an overview that reflects the distillation of a long career at the center of psychotherapy with personality disorders.

The final section of this book is brief, devoting chapters to the "Evidence for Psychodynamic Psychotherapy in Personality Disorders: A Review" by Falk Leichsenring and John Oldham’s discussion of "Psychodynamic Treatment Planning and the Official Diagnostic System: Toward DSM-5." Both are carefully written and provide a good overview of their respective topics.

This is a book that warrants being studied and not merely read. It captures the essence of the neurobiological and psychodynamic underpinnings of the field of psychiatry and avoids the reductionist application of genetic and neurobiological knowledge. The emphasis on patients with more severe psychopathology creates an unfortunate tilt, but the basic concepts presented here are applicable to the treatment of all personality disorders and, more importantly, to all patients, each of whom has a personality that one must engage in whatever treatment is recommended.

David I. Joseph MD

Author affiliation: George Washington University School of Medicine, Washington, DC. Potential conflicts of interest: None reported.

Volume: 72

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