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Related Topics
Fatal FlawsReview - Fatal Flaws
Navigating Destructive Relationships with People with Disorders of Personality and Character
by Stuart C. Yudofsky
American Psychiatric Publishing, 2005
Review by Elisabetta Sirgiovanni, Ph.D.
Jul 18th 2006 (Volume 10, Issue 29)

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 psychotherapy.

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


Elisabetta Sirgiovanni, Ph.D. in Cognitive Sciences, Department of Philosophy and Social Sciences, University of Siena, Italy


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