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This book consists of a hundred questions related to the aetiology, diagnosis and psychodynamic treatment of severe personality disorders, each responded to by a succinct, theoretically and clinically sophisticated answer. The questions and answers are organised into six Parts: ‘Diagnosis and differential diagnosis’, ‘Structure and dynamics’, ‘Origins and development’, ‘Evaluation and triage’, ‘Psychotherapy and psychoanalysis’ and ‘Prognosis and outcome’. This simple, sensible organisation, together with the author's impressive talents as teacher and writer (he is a published poet) yields a book that rewards the reader with abundant theoretical and/or clinical material on every page, is beautifully written and easy to understand and, most especially, is extremely enjoyable to read.
Part I, ‘Diagnosis and differential diagnosis’, describes the eight personality disorders that the author considers severe. They are the Narcissistic, Borderline, Schizoid, Paranoid, Antisocial, Schizotypal and Histrionic (all DSMIV Axis II diagnoses; they also fit criteria for Kernberg's Borderline Personality Organisation) plus the Hypomanic Personality Disorder, which Akhtar persuasively argues should be included in the group.
Most impressive to me is the author's skill in integrating clinical/descriptive, psychodynamic, psychostructural, developmental and socio-cultural viewpoints. For example,
individuals suffering from these disorders exhibit … chronic restlessness, unstable emotions, vacillating relationships … defective empathy, inability to love [clinical/descriptive] … splitting … is a major defensive operation … accompanied by the subsidiary mechanisms of denial, primitive idealization, and projective identification [psychodynamic] … most important, the lack of an integrated self-concept, resulting in … identity diffusion [psychostructural] … these conditions are associated with an aborted separation-individuation process and the consequent failure to master the Oedipus complex.