Abstract
This book, written by the eminent neuropsychiatrist Stuart Yudofsky, aims to appeal to both clinicians and their patients. The author describes it as “… part psychiatric textbook and part self-help manual…” and intends it to be used by mental health clinician trainees, patients in therapy and the friends and relatives of those with personality disorders. It is divided into two main sections. The first discusses Dr Yudofsky's concept of the ‘fatal flaw’ and his nine principles for dealing with such problems. It also includes a fatal flaw ‘scale’ to determine whether you or your loved one has a personality or character disorder. The author defines personality flaws as, “brain-based dysfunctions of thinking and impulse that lead to persistent patterns of personality and behaviour that betray trust and destroy relationships”. A ‘fatal flaw’ is defined as a personality disorder that is not amenable to change and one that will likely result in serious injury or violations of the law.
The second section discusses eight of the DSM-IV personality disorders (histrionic [hysterical], narcissistic, antisocial, obsessive-compulsive, paranoid, borderline, schizotypal) that the author believes most often lead to fatal flaws, along with the author's novel description of ‘addictive personality disorder’. Each of these chapters is richly illustrated with case descriptions.
I found this book disappointing. First, because the choice of the title seems to violate the author's own first principle for dealing with fatal flaws, “… people with these conditions should be treated with respect, kindness, and compassion.” Moreover, its underlying assumption that personality disorders are immutable has been shown to be incorrect by a number of studies over the past decade [e.g. [1–3]. While the fatal flaw ‘scale’ is appealing in its simplicity and might assist patients and carers to reflect upon their relationships, it is of dubious reliability and validity and prone to misuse, despite warnings to the contrary.
The case illustrations are well written and interesting to read. They clearly convey the depth and breadth of the author's 30 years of clinical practice. However, they often do not successfully cross the cultural divide between Australia and the US. Moreover, their protagonists are largely from the upper echelons of US society, mostly business people, professionals and Ivy League alumni, making them seem less relevant to everyday clinical encounters and to patients and carers themselves.
It seems that in aiming for multiple audiences, the author fails to cater adequately to the needs of any. His coverage of the scientific aspects of personality disorders is brief and idiosyncratic. His inclusion of his own category of addictive personality disorder is puzzling, as is the omission of other disorders, such as avoidant and dependant personality disorders. It is difficult to imagine how some disorders, such as obsessive-compulsive personality disorder, would fit the author's definition of a fatal flaw. In fact, recent evidence suggests that people with obsessive-compulsive personality disorder tend to be less disabled than those with other personality disorders [4]. Furthermore, separating each of the personality disorders misses the commonest form of personality disorder that patients and families are likely to encounter, namely co-occurring features of a range of personality disorders (‘comorbidity’). Finally, the textbook style of the book is unlikely to be user-friendly to patients or their carers.
Ultimately, I found this book unsatisfying because despite the richness of the case descriptions, its theoretical underpinnings do not place personality disorders in their interpersonal context, where most people experience them. The author's definition of personality flaws as ‘brain-based dysfunctions’ seems overly reductionistic, based upon current evidence and ignores the complex gene–environment interactions involved in the aetiology of personality disorders [5]. Even biological researchers in the field emphasize an integrative approach to personality disorders and the initial scene-setting chapters are too brief to convey this.
Despite my concerns, the book itself is not fatally flawed. The case studies would be of value to interested trainee clinicians. However, I would not recommend it as psycho-educational aid for patients or their loved ones.