by Stuart C. Yudofsky
American Psychiatric Publishing, 2005
Review by Elisabetta Sirgiovanni, Ph.D. on Jul 18th 2006
Although I don't share some of its
theoretical constraints, such as some of its psychoanalytic interpretations of
mental disturbs, admittedly this book impressed me. Its wealth of ideas, words
and examples introduce you in a world of psychiatric cases and stories delineated
with notable accuracy and diagnostic reliability.
What the book presents is the
rapidly increasing body of information and research about disorders of both
personality and character. Representatively relevant cases of people treated by
the author, the neuropsychiatrist Stuart C. Yudofsky, are introduced in an
intimate writing style. These representative stories are examples of Fatal
Flaws, which are biological and psychological destructive conditions of
character generally classified in eight personality disorders: hysterical
(histrionic), narcissistic, antisocial, paranoid, obsessive-compulsive,
addictive, borderline and schizotypal disorder. The second part of the book
dedicates one chapter to each of these clinical conditions. Even though the entire
book is coherent and unitary, every chapter can be read and used separately,
due to its definite structure and its differentiated theoretical considerations.
The author himself conceives his
enterprise as both ambitious and unconventional. His book is directed to a
broad audience and designed as a hybrid between a psychiatric textbook and a
self-help manual. The three chapters of the first part define Fatal Flaws,
provide a Fatal Flaw Scale and suggest principles for dealing with them.
It is a general assumption that personality
disorders have, in the first instance, a biological basis (an assumption that is
not under discussion in this book). They are described and clinically treated
as brain-based dysfunctions of thinking and impulse. The standardized
diagnostic definition offered by DSM-IV-TR is taken into account for each
disorder. Nevertheless, a reproachful note shows the well-known criticism of a
DSM approach and highlights its total lack of an etiological criterion for
psychiatric diagnosis. Therefore, an attempt at causal explanation, based on
psychodynamics combined to other theoretical models, such as the cognitive one,
follows the DSM criteria for each disorder.
The story of Shelby Fairmont, a
successful rich girl with pervasive emotionality and attention-seeking behavior,
introduces the reader to an example of Hysterical (Histrionic) Personality Disorder.
Despite admitting the advantages of a non-theoretical approach for categorizing
proper to the DSM, its universal language linked to no blame ascription, the
author integrates the orthodox diagnostic system. Aware of the impossibility of
the best level of specificity for medical conditions, the biological one, he
prefers the theoretical considerations as occasionally the next-best and
criticizes DSM-III for excluding useful psychodynamic criteria. Therefore, he recovers,
according to Dr. Gabbard, an old-fashioned distinction between histrionic and
hysterical personality, modifying it in order to avoid a misogynist clinical
stance. He also identifies the environmental etiology of the Histrionic
(Hysterical) Disorder as the unstable family triangle, theorized by Breuer and
Freud, but also points out the major role of biological factors in the etiology
of the disorder. The latter aspects are conceived of as being strongly related
to the cognitive style which defines people who own histrionic features. Hence,
the treatment is, as commonly accepted, a clinical integration oriented to
solve problems occurring in each of these three levels.
Untreated Narcissistic Personality
Disorder is vividly exemplified by congressman Dennis Smythe's life. What we
understand of this clinical dimension comes from psychoanalysis. In fact,
compared to other disorders, far less is known about the neurobiology of the
narcissistic disorder. According to Yudofsky, this could suggest the prominence
of life experience in its aetiology. However, he also believes that biological
factors are involved as well. In other words, what is commonly conceived as a
psychological cause of this disorder, the misperception of parental neglect, is
indeed a brain-based dysfunction. From a cognitive perspective, its proper
symptoms would be the result of maladaptive mental mechanisms to compensate for
depression. The parallel story of Reverend Martin Smythe, Dennis's son, shows instead
a treated narcissism, which Yudofky prefers to interpret, in accordance with
the psychoanalytic formulation, as an Oedipus complex. Consequently,
psychotherapy is the suggested treatment. In addition, this story offers the
opportunity to dedicate some peculiar paragraphs to the important role of
spirituality and religion in mental illness and in their treatment.
In the case of Andrew Kramer the
reader is resented with an instance of an Antisocial Personality Disorder. The
errors of the clinician who treats Andrew introduce us to the author's position:
that there is not a single theoretical framework which guides a psychiatric
treatment. Thus, it is shown how an extreme trust in psychodynamic psychiatry
and a total lack of biological explanation can produce counterproductive results.
Andrew shows the hallmark symptoms of an antisocial psychopathology, typified by
a complete absence of moral conscience. There is a scientific disagreement
about the specific criteria for the diagnosis of this condition and the absence
of uniformity leads to confusion. According to Yudofsky what psychoanalysts
term as "superego deficit" does not seem to apply to people with this
condition. Multifarious explanations, which involve brain biology, genetics and
learned-behavior, are deemed more appropriate. Various types of treatment are
proposed, and the author clearly explains why psychotherapy is inappropriate in
this condition, whereas a cognitive-behavioral one is preferred. Moreover,
patients can benefit from the use of medications but many features of this
disorder are not responsive to pharmacological treatment. The chapter ends
suggesting how to protect oneself from people who suffers this disturb.
Karl Adler's life is an example of
the perfectionism and self-imposed high standards of Obsessive-compulsive
Personality Disorder, whose causes are posited by Freudians in an arrested anal
development. DSM traces a distinction between obsessive-compulsive personality
disorder and obsessive-compulsive disorder, the former being a disorder of
personality and the latter a disorder of anxiety. Again, a multi-factor
explanation is given, as well as indicating the best treatment in terms of medicaments,
combined both with cognitive-behavioral psychotherapy and psychodynamically informed
Paranoia, as in the case of Wilma
Warren, is conceptualized by Yudofsky as a symptom, and understood from an
evolutionary perspective as a brain device, of survival. It is explained in
biochemical, genetic and psychological terms. Compared to others this chapter
is the poorest one. An important goal for people with Paranoid Personality
Disorder is indicated in insight. But few explanations are given for such a historically
important disturb, originally named "psychosis". A notable distinction
between paranoid personality disorder and delusional disorder is traced as a
continuum of disability associated with the same symptom in which the former is
at the milder end of the spectrum and the latter at its other extreme.
Borderline Personality Disorder,
which is the most commonly diagnosed personality disorder, is presented via
Denise Hughes' story. The author correlates this disorder to poor executive
functions and related neurological signs, such as brain areas and neurotransmitters.
He suggests that borderline people should be treated by experienced clinicians
and opposes the general pessimistic view regarding treatment success. Mrs.
Hughes' treatment offers some clinical clues about how to deal with this condition.
Yudofsky relates this disorder to dual depression, in which a chronic and
low-grade depression dips into major depression during times of crisis.
The case of Robert Woods
exemplifies the Schizotypal Personality Disorder, or a tendency to psychosis which
includes hallucinations, delusions and thought disorders as the adjective "schizotypal"
suggests. This case took place when DSM-II was in use and the proposed criteria
illustrated a simple deteriorative disorder. Today the pervasive pattern of
social deficits combined with cognitive or perceptual distortions describes
such a personality disorder, with important brain-based determinants. The main
diagnostic features are clearly presented. Suggested treatments are medications
in low dosages and various psychotherapies. Fundamental principles are given to
people who are threatened or stalked by a person with this disorder.
At the end, the case of Dr. Maria
Torres illustrates the Addictive Personality Disorder, which is not included in
official DSM-IV-TR. However, the author states that people who persistently
abuse substances shows symptoms and signs of a personality disorder. Alcoholism
and chemical dependencies are firstly explained as brain genetic illnesses. Furthermore,
many are the known effects of abused substances on the brain and other organs.
Yudofsky's book has at least two distinct
qualities. Firstly, it has an analytic and painstaking structure: each chapter
is provided with a DSM criteria table and a historical table of the examined case
ending with a useful list of references and suggested readings. The stories are
divided into two parts, the patient's life before and then during the treatment,
with theoretical considerations appearing in the middle of these story sections.
Secondly, it shows an eclectic
view: what mixed theoretical approaches reveal is that psychopathology depends
on many combined factors. Even if biological factors are always indicated as
primary the psychodynamic explanations might suggest that causes generally fall
on environment. Nevertheless, any story seems consistent with a genetic
predisposition that describes personality traits as basically genetic. Mental
disorders are here understood firstly as biological.
In conclusion, what defines a
personality disorder is a persistent pattern of feeling, thinking and behavior
that alters the subject's behavior in relationship, in controlling impulses and
in social settings. Conceptually this category appears vague and ambiguous. Personality,
temperament and character are a combination of inheritance and environmental
influences. They include a constellation of traits, whose characterization from
normality to pathology is supposed to occur along a continuum.
The contribution of this book is
clinical. It proposes suggestions to clinicians regarding how to recognize
these disorders and it focuses on treatments. Nevertheless, from a theoretical
perspective many raised problems, such as definitions of used concepts and possible
new criteria, turn out to be necessarily open questions.
© 2006 Elisabetta
Sirgiovanni, Ph.D. in Cognitive Sciences, Department of Philosophy and Social
Sciences, University of Siena, Italy