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Gabbard, G.O. (1995). Broken Structures: Severe Personality Disorders and Their Treatment. By Salman Akhtar. Northvale, NJ: Aronson, 1992, 419 pp., $50.00.. J. Amer. Psychoanal. Assn., 43:627-629.

(1995). Journal of the American Psychoanalytic Association, 43:627-629

Broken Structures: Severe Personality Disorders and Their Treatment. By Salman Akhtar. Northvale, NJ: Aronson, 1992, 419 pp., $50.00.

Review by:
Glen O. Gabbard

The ascendancy of descriptive, neo-Kraepelinian psychiatry in recent years has brought with it a host of problems well known to all psychoanalytic clinicians. One of the major casualties of this preference for surface over depth has been the manner in which personality disorders are now viewed. The emphasis on a Chinese menu of “objective” criteria sorely neglects the rich psychoanalytic tradition that stresses the interior life of the person, with its unique constellation of defenses, drives, internal object relations, and self-schema.

In this significant new contribution, Salman Akhtar has sought to integrate the descriptive literature on severe personality disorders with the psychoanalytic knowledge about these conditions accumulated over decades of clinical work. His formidable effort, which for the most part succeeds admirably, builds a clinically and heuristically useful bridge between two seemingly disparate bodies of knowledge. He focuses on eight primary personality disorders: narcissistic, borderline, schizoid, paranoid, hypomanic, antisocial, histrionic, and schizotypal. In each case he demonstrates impressive scholarship in his comprehensive review of both the descriptive and the psychoanalytic literature relevant to the disorder.

One of the author's most creative approaches to his task is to examine overt and covert manifestations in six areas of psychosocial functioning: (1) self-concept, (2) interpersonal relations, (3) social adaptation, (4) love and sexuality, (5) ethics, standards, and ideals, and (6) cognitive style. This bifurcated approach to the understanding of personality disorders allows for both phenomenological and psychodynamic observations and restores depth and complexity to the reductionistic and superficial descriptive classifications.

As Akhtar is the first to admit, this method of cataloguing the clinical features of personality disorders works better with some conditions than with others. With a diagnostic entity like schizoid personality disorder, the author's system is elegant in its elucidation of the hidden side of the personality that lies beneath the surface. In the domain of interpersonal relations, for example, Akhtar points out that the flip side of the overt withdrawal is a covert hunger for love and a profound need for involvement with others. The work of Kretschmer is seamlessly integrated with the seminal contributions of Fairbairn and Winnicott.

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