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In Broken Structures Salman Akhtar sets out to do for a contemporary psychoanalysis, which is preoccupied with the serious personality disorders, including narcissistic, borderline, schizoid, paranoid, hypomanic, antisocial, histrionic, and schizotypal, what Otto Fenichel accomplished in his now classic 1945 systematization of knowledge about the neuroses. Recognizing that we now live in an age of medical psychiatry and the DSM, Dr. Akhtar further attempts to synthesize psychoanalytic thinking about these primitive personality disturbances with the currently prevailing medical-psychiatric model that views descriptive syndromes not as rough starting points for extensive and individual analytic investigations, but as indices potentially reducible to underlying disease processes. The result of Dr. Akhtar's effort is best characterized as a textbook—an extensive and remarkable compendium of psychoanalytically related information that is invaluable in some respects and perhaps misleading in others.
The book is divided into three sections and a coda. The first is devoted to the concept of identity and the syndrome of identity diffusion, which Akhtar feels underlies all the serious personality disorders. The second is an accumulation of descriptive diagnostic and theoretical knowledge about each of the personality disorders, concluding with a summary description of each condition according to seven intrapsychic and interpersonal categories, each divided into “overt” and “covert” dimensions, which roughly correspond to descriptive surface and psychoanalytic depth, respectively. The third section comprises the structured diagnostic interview and a discussion of a single treatment modality, psychoanalytic psychotherapy. Unfortunately, this modality is not clearly distinguished from psychoanalysis. The book concludes with a schematic classification of higher-, intermediate-, and lower-level disorders according to the presence or absence of a multiplicity of genetic, structural,