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Fatal Flaws
Reviewed by John OLdham
Am J Psychiatry 2006;163:1115-1115.
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by Stuart C. Yudofsky, M.D. Arlington, Va., American Psychiatric Publishing, 2005, 512 pp., $35.00.

From the pen of a master educator and clinician, Fatal Flaws, by Stuart Yudofsky, M.D., is a remarkable gift to mental health practitioners everywhere. Drawing on years of clinical experience, Dr. Yudofsky allows us into his consulting room and shares his views and strategies about how best to help patients who suffer from severe, complex, and disabling personality disorders. Most importantly, after careful “de-identification” of each patient, he presents (from enviably detailed and preserved clinical records) selected dialogues between himself and his patients as well as between his patients and their friends, family members, employers, and others with whom they have interacted regularly.

Fatal Flaws is not designed to comprehensively cover all ten DSM-IV-TR personality disorders, but those presented include the personality disorders that are most disabling and prevalent in clinical practice (antisocial, borderline, histrionic, narcissistic, obsessive-compulsive, paranoid, and schizotypal). In addition, one “unofficial” personality disorder that Dr. Yudofsky labels addictive personality disorder is included.

Each chapter focuses on a particular personality disorder and begins with a brief narrative capturing the essence of that disorder. A beautifully written case presentation follows, drawing the reader into the life story of the patient. A summary of the main features of the personality disorder in question is then provided, including its epidemiology, genetics, neurobiology, and typical psychosocial dynamics. Sidebar tables identify key principles in diagnosis and treatment, and the chapter then returns to the patient to delineate the course of treatment and long-term outcome.

Dr. Yudofsky does not mince words when he states his beliefs, yet his experience, his conviction in the benefit of treatment, and his compassionate presentation of his recommendations to patients or families always preserve the clear principle that treatment is a partnership and that patients must make their own decisions about whether to follow his advice. An example of his wisdom and refreshing candor is as follows: “Many uninformed critics of psychology and psychiatry believe that…advice for extended, intensive treatment is self-serving by professionals, whom they accuse of trying to increase their fees. Rather, similar to dosage and duration requirements for all antidepressants to be effective, the psychotherapy of people with…personality disorder[s] necessitates an adequate frequency…and period of time…. I believe that undertreatment of people with personality disorders is mistreatment” (p. 64). Dr. Yudofsky never demonizes families as presumed causative agents of the personality disorders of their children; he does not, however, shirk from identifying the important role of dysfunctional families when they are central to the problem. On the other hand, he takes pains to point out plausible alternatives; for example, a child biologically predisposed to develop severe narcissism could have loving, caring parents but be unable to perceive their caring, a problem he describes as a brain-based condition in the child (p. 120).

Fatal Flaws is a stimulating and compelling book that, after reading, one feels gratefully mentored, in this case by the author himself—similar to the generous appreciation Dr. Yudofsky expresses in the opening pages of the volume to his own teachers and mentors.

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