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Severe Personality Disorders: Psychotherapeutic Strategies
BOOK REVIEWS Anxiety Disorders and Phobias: A Cognitive Perspective By Aaron T. Beck and Gary Emery. New York. Basic Books. 1985. $26.95.
• This book deals with the use of cognitive therapy to treat anxiety disorders. Clinicians who have used cognitive therapy to treat depression will enjoy the extension of this approach to anxiety disorders. For those unfamiliar with this technique, the book can serve as a thorough introduction to cognitive theory and the application of behavioral techniques to clinical problems. The book has two parts. Part I, written by Beck, is entitled "Theoretical and Clinical Aspects." He begins by discussing the paradox of anxiety: by being anxious, an anxious person often creates what he fears most. A public speaker who is afraid of making a mistake becomes fearful and thereby increases the likelihood that he will lapse. Anxiety disorders are viewed as a conglomeration of physiologic, affective, behavioral, and cognitive components that become joined in a vicious cycle. Maladaptive cognitions may not be the ultimate "cause" of anxiety disorders, but they become a prominent factor in their perpetuation. The interventions ofcognitive therapy are designed to interrupt the anxiety cycle by modifying cognitions, affects. behaviors, and physiologic responses. The approach to treatment is structured and problem-oriented. In the first part of the book, Beck goes on to elaborate a theoretical model of anxiety disorders. Although his theory is closely tied to phenomenologic observations, the discussion is, at times, overly abstract. In the book's second half, •'Cognitive Therapy:
FEBRUARY 1986' V0L27· NO 2
Techniques and Applications," Emery offers a basic "how to" approach to treatment of anxiety disorders. A large variety of techniques are described and illustrated with clinical vignettes. Because of the limited number of experimental trials, the efficacy of cognitive therapy for anxiety disorders has not yet been proven. Beck and Emery present a comprehensive treatment system here, and they propose that therapy should be brief, time-limited, directive, and educational. Therapists who may be uncomfortable with such a system can still glean useful ideas about the etiology, phenomenology, and treatment of anxiety disorders and phobias. James T. Dietch. M.D. University ofCalifornia. Irvine
Severe Personality Disorders: Psychotherapeutic Strategies By Otto Kemberg. New Haven. Conn. Yale University Press. 1984.381 pp. $35.
• Dr. Otto Kemberg's prolific work in the development of psychoanalytic theory and treatment of patients with severe personality disorders has been an invaluable contribution to clinicians treating patients with borderline and narcissistic personalities. In this most recent book, he continues to develop his approach with a major focus on diagnostic and treatment issues. Additional important issues addressed in this volume are treatment approaches to suicidal patients, paranoid regressions, severe narcissism, and the use of hospitalization for patients with borderline and narcissistic personalities. lWo areas described in detail are
the structural diagnostic interview and the indications for and practice of expressive and supportive psychotherapy. These issues are of great clinical relevance. Descriptive criteria developed for DSM-III have gained central prominence in the diagnosis of borderline patients, but these descriptive criteria do not address dynamic issues, which are so critical for psychotherapeutic treatment. Kernberg's structural diagnositc interview, which can be completed in one to two hours, combines a psychoanalytic approach with an assessment of psychopathologic symptoms and of personality structure. The use of this structural diagnostic interview, which emphasizes identity integration, defensive operations, and reality testing, offers the clinician several advantages over the use of DSM-III, including a diagnostic approach to the patient as a unique individual and guidelines for treatment and prognosis. In a very elaborate fashion, Kernberg presents specific indications for the use of expressive (psychoanalytic) psychotherapy and supportive therapy. In his view, expressive psychotherapy is the preferred treatment modality for most patients with borderline personality organization. Supportive psychotherapy should be offered only if expressive psychotherapy is contraindicated. Guidelines regarding such contraindications are very clearly delineated. In the chapters describing these forms oftherapy, the author describes the psychotherapeutic techniques involved in each approach. Expressive psychotherapy is characterized by the uses of clarification, transference interpretation, and the maintenance of technical neutrality. In supportive psychotherapy, the author suggests partial uses of clarifi-
155
BOOK REVIEWS cation and suggestion as well as Bibring's concept ofmanipulation, which he redefines as environmental intervention. Transference, in Kernberg's view, is not to be interpreted during supportive psychotherapy. For any clinician working with individuals with severe personality disorders, this book provides invaluable clarification of diagnostic and therapeutic approaches. This is an important work that extends Kernberg's pioneering contributions. RobertC. Guerette, M.D. Pittsfield, Mass.
Current Themes in Psychiatry, vol 3 Edited by Raghu N. Gaind. Fawzy I. Fawzy, Barbara L. Hudson. et a1. New York. SP Medical & Scientific Books. 1984.356 PP. $35.
• This book is a collection of disparate articles on a wide array of subjects. Each chapter covers a separate topic. Some subjects are political ("Who needs psychiatry, anyway?") while others are clinical ("Anxiety and its management"). Other topics in the 14 chapters by 22 authors include dementia, psychological aspects of physical illness, changing diagnostic fashion and its implications, geriatric psychiatry (the subject of two chapters), drugs and sexual dysfunction, phannacology ofaggression, management of obesity, the future of psychiatry (two chapters), affective disorder, and work with primary care physicians. The topics can be read discretely and in any order, since there is no thread binding one chapter to another. The articles are based on lectures originally given to a British audience. The individual chapters are generally well written and interesting, but the book as a whole lacks a central theme.
156
Reading this book is much like attending psychiatric grand rounds, with the topics changing each week. Although the book in its entirety is both enjoyable and informative, the lack of focus may lessen its appeal to the busy clinician interested in reading intensively on specific topics. For those with more leisurely reading habits, this book will be ofvalue in a similar way that weekly grand rounds keep one generally informed. Students and those with limited access to university-type weekly conferences may find this book particularly useful. RichardC. Preisman. M.D. Detroit
Human Sexuality: Psychosexual Effects of Disease Edited by Martin Farber. New York. Macmillan. 1985. 335 pp. $34.95 hardcover. $24.95 paperback.
• Most textbooks on human sexuality are edited by mental health professionals. Human Sexuality: Psychosexual Effects of Disease, however, is edited by an obstetrician-gynecologist. Its strength lies in its focus on traditional disease states. The book is divided into four sections. Unit I, "Psychosocial development," has an excellent chapter reviewing the history of psychosexual medicine. Chapters that follow include detailed endocrinologic discussions of prepubertal sexual development; an interesting chapter on the educational process, which contains more sociologic review than basic psychological data; and a very good discussion of marriage by Ned Gaylin. Unfortunately, this chapter does not include data regarding the basic sexual response cycle as delineated by Masters and Johnson. The section concludes with chap-
ters discussing sexuality during normal pregnancy and during menopause. Both of these chapters are wellreferenced, clear commentaries on the topics. Section 2, •• Pathophysiology of Human Sexuality in Obstetric and Gynecologic Disease," is the most valuable section of the book. A superb chapter on external genital ambiguity by Drs. Bertrand and Maria New presents a topic rarely found in books dedicated to human sexuality. Chapters on anomalous female genital duct development, endocrinologic correlates of feminine sexual behavior, the role of contraception in psychosexual functioning, and sexuality in common gynecologic conditions such as infertility, pelvic pain, and various neoplasms are all worthwhile contributions. The puerperium is placed within the section on gynecologic disease states; it is not clear why this could not have gone in the section on normal psychosexual development. The third section deals with sexual pathophysiology in medical and surgical disease. The chapters on sexual dysfunction in cardiac disease, the role of impotence and its treatment, and neurologic diseases that compromise sexuality are well written. The book closes with a series of chapters on pathophysiology of human sexuality in psychosocial disease. The selection of topics here is problematic-drug addiction, rape, and gender identity disorders--and the variety of psychiatric disorders noted in DSMIII are ignored. Overall, the book is excellently written and extensively referenced. It would be a welcome addition to a practitioner's library as an adjunct but not primary text in human sexuality. ThomasN. Wise. M.D. Georgetown University
PSYCHOSOMATICS
• This book deals with the use of cognitive therapy to treat anxiety disorders. Clinicians who have used cognitive therapy to treat depression will enjoy the extension of this approach to anxiety disorders. For those unfamiliar with this technique, the book can serve as a thorough introduction to cognitive theory and the application of behavioral techniques to clinical problems. The book has two parts. Part I, written by Beck, is entitled "Theoretical and Clinical Aspects." He begins by discussing the paradox of anxiety: by being anxious, an anxious person often creates what he fears most. A public speaker who is afraid of making a mistake becomes fearful and thereby increases the likelihood that he will lapse. Anxiety disorders are viewed as a conglomeration of physiologic, affective, behavioral, and cognitive components that become joined in a vicious cycle. Maladaptive cognitions may not be the ultimate "cause" of anxiety disorders, but they become a prominent factor in their perpetuation. The interventions ofcognitive therapy are designed to interrupt the anxiety cycle by modifying cognitions, affects. behaviors, and physiologic responses. The approach to treatment is structured and problem-oriented. In the first part of the book, Beck goes on to elaborate a theoretical model of anxiety disorders. Although his theory is closely tied to phenomenologic observations, the discussion is, at times, overly abstract. In the book's second half, •'Cognitive Therapy:
FEBRUARY 1986' V0L27· NO 2
Techniques and Applications," Emery offers a basic "how to" approach to treatment of anxiety disorders. A large variety of techniques are described and illustrated with clinical vignettes. Because of the limited number of experimental trials, the efficacy of cognitive therapy for anxiety disorders has not yet been proven. Beck and Emery present a comprehensive treatment system here, and they propose that therapy should be brief, time-limited, directive, and educational. Therapists who may be uncomfortable with such a system can still glean useful ideas about the etiology, phenomenology, and treatment of anxiety disorders and phobias. James T. Dietch. M.D. University ofCalifornia. Irvine
Severe Personality Disorders: Psychotherapeutic Strategies By Otto Kemberg. New Haven. Conn. Yale University Press. 1984.381 pp. $35.
• Dr. Otto Kemberg's prolific work in the development of psychoanalytic theory and treatment of patients with severe personality disorders has been an invaluable contribution to clinicians treating patients with borderline and narcissistic personalities. In this most recent book, he continues to develop his approach with a major focus on diagnostic and treatment issues. Additional important issues addressed in this volume are treatment approaches to suicidal patients, paranoid regressions, severe narcissism, and the use of hospitalization for patients with borderline and narcissistic personalities. lWo areas described in detail are
the structural diagnostic interview and the indications for and practice of expressive and supportive psychotherapy. These issues are of great clinical relevance. Descriptive criteria developed for DSM-III have gained central prominence in the diagnosis of borderline patients, but these descriptive criteria do not address dynamic issues, which are so critical for psychotherapeutic treatment. Kernberg's structural diagnositc interview, which can be completed in one to two hours, combines a psychoanalytic approach with an assessment of psychopathologic symptoms and of personality structure. The use of this structural diagnostic interview, which emphasizes identity integration, defensive operations, and reality testing, offers the clinician several advantages over the use of DSM-III, including a diagnostic approach to the patient as a unique individual and guidelines for treatment and prognosis. In a very elaborate fashion, Kernberg presents specific indications for the use of expressive (psychoanalytic) psychotherapy and supportive therapy. In his view, expressive psychotherapy is the preferred treatment modality for most patients with borderline personality organization. Supportive psychotherapy should be offered only if expressive psychotherapy is contraindicated. Guidelines regarding such contraindications are very clearly delineated. In the chapters describing these forms oftherapy, the author describes the psychotherapeutic techniques involved in each approach. Expressive psychotherapy is characterized by the uses of clarification, transference interpretation, and the maintenance of technical neutrality. In supportive psychotherapy, the author suggests partial uses of clarifi-
155
BOOK REVIEWS cation and suggestion as well as Bibring's concept ofmanipulation, which he redefines as environmental intervention. Transference, in Kernberg's view, is not to be interpreted during supportive psychotherapy. For any clinician working with individuals with severe personality disorders, this book provides invaluable clarification of diagnostic and therapeutic approaches. This is an important work that extends Kernberg's pioneering contributions. RobertC. Guerette, M.D. Pittsfield, Mass.
Current Themes in Psychiatry, vol 3 Edited by Raghu N. Gaind. Fawzy I. Fawzy, Barbara L. Hudson. et a1. New York. SP Medical & Scientific Books. 1984.356 PP. $35.
• This book is a collection of disparate articles on a wide array of subjects. Each chapter covers a separate topic. Some subjects are political ("Who needs psychiatry, anyway?") while others are clinical ("Anxiety and its management"). Other topics in the 14 chapters by 22 authors include dementia, psychological aspects of physical illness, changing diagnostic fashion and its implications, geriatric psychiatry (the subject of two chapters), drugs and sexual dysfunction, phannacology ofaggression, management of obesity, the future of psychiatry (two chapters), affective disorder, and work with primary care physicians. The topics can be read discretely and in any order, since there is no thread binding one chapter to another. The articles are based on lectures originally given to a British audience. The individual chapters are generally well written and interesting, but the book as a whole lacks a central theme.
156
Reading this book is much like attending psychiatric grand rounds, with the topics changing each week. Although the book in its entirety is both enjoyable and informative, the lack of focus may lessen its appeal to the busy clinician interested in reading intensively on specific topics. For those with more leisurely reading habits, this book will be ofvalue in a similar way that weekly grand rounds keep one generally informed. Students and those with limited access to university-type weekly conferences may find this book particularly useful. RichardC. Preisman. M.D. Detroit
Human Sexuality: Psychosexual Effects of Disease Edited by Martin Farber. New York. Macmillan. 1985. 335 pp. $34.95 hardcover. $24.95 paperback.
• Most textbooks on human sexuality are edited by mental health professionals. Human Sexuality: Psychosexual Effects of Disease, however, is edited by an obstetrician-gynecologist. Its strength lies in its focus on traditional disease states. The book is divided into four sections. Unit I, "Psychosocial development," has an excellent chapter reviewing the history of psychosexual medicine. Chapters that follow include detailed endocrinologic discussions of prepubertal sexual development; an interesting chapter on the educational process, which contains more sociologic review than basic psychological data; and a very good discussion of marriage by Ned Gaylin. Unfortunately, this chapter does not include data regarding the basic sexual response cycle as delineated by Masters and Johnson. The section concludes with chap-
ters discussing sexuality during normal pregnancy and during menopause. Both of these chapters are wellreferenced, clear commentaries on the topics. Section 2, •• Pathophysiology of Human Sexuality in Obstetric and Gynecologic Disease," is the most valuable section of the book. A superb chapter on external genital ambiguity by Drs. Bertrand and Maria New presents a topic rarely found in books dedicated to human sexuality. Chapters on anomalous female genital duct development, endocrinologic correlates of feminine sexual behavior, the role of contraception in psychosexual functioning, and sexuality in common gynecologic conditions such as infertility, pelvic pain, and various neoplasms are all worthwhile contributions. The puerperium is placed within the section on gynecologic disease states; it is not clear why this could not have gone in the section on normal psychosexual development. The third section deals with sexual pathophysiology in medical and surgical disease. The chapters on sexual dysfunction in cardiac disease, the role of impotence and its treatment, and neurologic diseases that compromise sexuality are well written. The book closes with a series of chapters on pathophysiology of human sexuality in psychosocial disease. The selection of topics here is problematic-drug addiction, rape, and gender identity disorders--and the variety of psychiatric disorders noted in DSMIII are ignored. Overall, the book is excellently written and extensively referenced. It would be a welcome addition to a practitioner's library as an adjunct but not primary text in human sexuality. ThomasN. Wise. M.D. Georgetown University
PSYCHOSOMATICS