Psychodynamic Psychiatry in Clinical Practice, 3rd ed.

The publication of DSM-III in 1980 marked a sharp transition in the United States from a psychodynamic understanding of psychiatric illnesses to a strictly phenomenological, theory-neutral, voyeuristic description of conditions in “behavioral medicine.” This neo-Kraepelinian nomenclature is more behaviorally precise, more globally communicable, more biologically attuned to psychopharmacological treatment, and more practically exploitable by commerce and managed care. Of apparently minimal moment, it leaves out only—as Saul Bellow put it in a different context—that which the living man is preoccupied with—“such questions as who he is, what he lives for, what he is so keenly and interminably yearning for, what his human essence is” (1). Small price to pay for greater statistical certainty. Psychodynamic Psychiatry in Clinical Practice, Glen Gabbard’s assertive account of the “moral obligation to be intelligent” (2) in the practice of psychiatry, tells the magnitude of the price we paid for that transformation and brings us back to where we are supposed to be.

“Psychodynamic psychiatry is an approach to diagnosis and treatment characterized by a way of thinking about both patient and clinician,” writes Dr. Gabbard, “that includes unconscious conflict, deficits and distortions of intrapsychic structures, and internal object relations and that integrates these elements with contemporary findings from the neurosciences” (p. 4). Dr. Gabbard goes on to describe, in quick succession, the work of Freud, the unconscious, and the topographic model of the mind; the Nobel-prize-winning work of Eric Kandel with the marine snail Aplysia californica; preliminary evidence that in lower species (crayfish) social clues in the environment influence how the neurotransmitter serotonin affects the organism; recent findings in Finland that psychodynamic therapy may have a significant impact on serotonin metabolism; the work of psychoanalysts Melanie Klein, Otto Kernberg, and Heinz Kohut; and the infant developmental theories of Margaret Mahler and Daniel Stern (no relation to this reviewer).

Dr. Gabbard, whose earlier co-authored books include Management of Countertransference With Borderline Patients (3) and Boundaries and Boundary Violations in Psychoanalysis (4) is no stranger to expressing his views about the gargantuan finagling and deceitful practices of managed care companies that express contempt for some psychiatric patients (5) and adversely affect these people, their families, and those who treat them(6). He has written a solid, technically attuned book that is realistic, reliable, and sound.

First published in 1990, Psychodynamic Psychiatry sold 33,000 copies in its previous two editions; translations were published in four foreign languages: Italian, Spanish, Portuguese, and Japanese. One of the better decisions for the current edition was to eliminate the subtitle “The DSM-IV Edition,” a subtitle that in reality was an oxymoron. The book is divided into three approximately equal sections: Basic Principles and Treatment Approaches in Dynamic Psychiatry (168 pages), Dynamic Approaches to Axis I Disorders (213 pages), and Dynamic Approaches to Axis II Disorders (192 pages). This is as it should be, since patients and psychiatrists spend so much of their time in psychotherapy with idiosyncratic traits of personality functioning.

The early chapters of the book provide background, beginning with theories of dynamic psychiatry; patient assessment; description of individual, group, family/marital psychotherapy, and pharmacotherapy; and hospital and partial hospital treatments. Dr. Gabbard states,

Expanded or new descriptions in the first section are concerned with the unconscious and current memory research, mind and brain, post-Kohut contributions, postmodern views, developmental considerations, and mechanisms of change. The discussion of Kohut’s bipolar self and the narcissistic transferences he defined (pp. 44–48) are far too succinct in 4 pages for beginners to understand the theory and appreciate the far-reaching practical consequences it entails in the conduct of psychotherapy. Then again, Margaret Mahler in less than 1 page (p. 54) and Daniel Stern in 1 page (p. 55) cannot be properly understood and appreciated. So much of Margaret Mahler’s work can best be grasped through her graphic descriptions of individual child-mother interactions during the various developmental phases she postulated. For an appreciation of Daniel Stern’s theories, examples of some of the very sophisticated experimental observations of infants are necessary as well as an explanation of what a representation of interactions that have been generalized (self with other as a subjective experience) is. This can be done (7), but not in the very abbreviated space assigned to these tasks by the author. The very brief description of Mahler’s work is particularly regrettable because there is an important reference to her in connection with the psychodynamic understanding of borderline personality disorder (p. 419). Missing are Kernberg’s structural interview and structural diagnostic criteria for neurotic, borderline, and psychotic personality organization (8); on page 39 Kernberg is linked to borderline personality disorder instead of borderline personality organization. Ambivalence, object constancy, and borderline personality organization are not listed in the index.

Along the way Dr. Gabbard introduces schizophrenia; affective, anxiety, and dissociative disorders; paraphilia and sexual dysfunctions; substance-related and eating disorders; and dementia and other cognitive disorders. There is a new general introduction to affective illnesses and a generously expanded discussion of dissociative disorders. The psychodynamics of suicide (pp. 211–214) and treatment of the suicidal patient (pp. 222–227) are largely unchanged but immensely helpful.

The final section on personality disorders has a greatly revised 50-page chapter on borderline personality disorder that includes medication strategies (Table 15-7, p. 430). This section also includes a largely unchanged discussion of narcissistic personality disorders presenting, in contrast to DSM-IV-TR, two types of narcissists, the oblivious and the hypervigilant (Table 16-2, p. 467), together with a clear comparison of Kernberg’s and Kohut’s approaches to the treatment of people with these disorders. A slightly expanded presentation of the antisocial personality with a continuum of antisocial and psychopathic behavior (Table 17-2, p. 499) is also included. Finally, there are unchanged but sharply observed and well summarized distinctions between histrionic and hysterical personalities, their contrast not captured by DSM-IV-TR or its predecessors because of their sole reliance on purely behavioral characteristics rather than on psychodynamic understanding. The review here of the management of erotic transferences is outstanding.

Three pivotal sources might be added to the discussion on the evolution of the term “borderline” in the chapter on borderline personality disorder. First, Adolph Stern (no relation) used the term “border line” first for these patients. Of the two articles he published as early as 1938 and 1945, the latter (9) is brief, brilliant, compassionate, empathic, incisive, and as clear today as it was about 60 years ago. Stern’s recommendations for the psychotherapy of these individuals are along lines not dissimilar from those advocated by Dr. Gabbard.

Second, when Gunderson and Singer (10) published their memorable article on patients with borderline disorder on page 1 of The American Journal of Psychiatry in 1975 there were possibly 50 publications on these patients written by adult and child psychoanalysts, psychiatrists, and psychologists describing behavior, dynamic formulations, intuition, psychological test results, and symptoms in a welter of jargon and semantic confusion. It was a major achievement for Gunderson and Singer to be able to distill this material and identify the six coherent features they judged characteristic of most borderline patients according to most of the publications.

Third, it was then left to Spitzer et al. (11) to review the literature, contact such researchers as Wender, Kety, and Rosenthal on the one hand and Gunderson, Sheehy, Stone, Rinsley, and Kernberg on the other, and develop a 22-item set,which they mailed to 4,000 members of APA in January 1977. There were 808 usable responses, and these ultimately resulted in the first formulation of criteria for borderline personality disorder and schizotypal personality disorder. So great was the confusion before the work of Spitzer et al. that these authors could write, “Kety, Wender, and Rosenthal have acknowledged that although they are able to agree with each other in categorizing patients as having borderline schizophrenia, they are not confident that they could convey to others the clinical cues to which they are responding” (11). The same authors recalled that at the General Clinical Service of the New York State Psychiatric Institute, where Kernberg was director, “A few of the therapists claimed not to know well any nonborderline, nonschizophrenic patients!”

On the other hand, Dr. Gabbard refers to an article on “pseudoneurotic schizophrenia” by Hoch and Polatin (12) published in 1949—11 years after Adolph Stern’s first article—in his discussion of the evolution of the term “borderline.” I have always considered this article sensationalist, mostly without merit, and not contributing much of value. It misled a generation of psychiatrists and may have contributed to the broadening of the schizophrenic diagnosis and the tragic, unjustified categorization of perhaps hundreds or thousands of people as suffering from the disease on the basis of little evidence other than symptoms of ambivalence, anxiety, depression, hypochondriasis, identity diffusion, narcissism, obsessions, depersonalization, and derealization.

The heart of Psychodynamic Psychiatry is in Dr. Gabbard’s braided summaries under the headings Psychodynamic Understanding and Treatment Considerations for each disorder. The author’s intelligence and style allow each chapter naturally to unfold twin narratives: one about how these people got ill, the other about how they can be treated successfully. Attentiveness and patience in following his detailed, informed, and integrative discussions will be amply rewarded. Dr. Gabbard’s descriptions are both captivating and complex, and the ultimate effect of this articulate, carefully wrought, and sober book is to stress how much easier it is to pigeonhole people and their problems into nosological schemes, or squeeze square pegs into round holes, than to conceive and carry out well-considered treatment plans and strategies.

When medical students first register at the School of Medicine of Case Western Reserve University in Cleveland they are given, free of charge, a laptop computer with electronic access to representations of every hour of the first 2-year core academic program with defined learning objectives and the educational materials, slides, journal articles, etc., they need to meet those objectives. I suggest that in a similar vein psychiatric residency training programs provide every entering resident with a free copy of this book. In due time that will surely improve psychiatric morbidity and mortality reports and psychiatric statistical and epidemiological data. Directors of the American Board of Psychiatry and Neurology ought to take note: no candidate should be Board certified in general psychiatry or child psychiatry who does not demonstrate an equivalent working knowledge of the core content and message of this invigorating and outstanding book.