Book Review
Psychotherapy 
Psychodynamic Psychiatry in Clinical Practice Glen O Gabbard. Washington (DC):American Psychiatric Publishing Inc; 2005. 629 p. US$89.95.
Reviewer
rating*: Excellent
Review by: John Toews, MD, FRCPC
Calgary, Alberta
It is rare to find a large, single authored text book in this era of edited texts. It was a treat to discover that Glenn Gabbard continues to update his classic text, now in its fourth edition! Much has changed since the first edition of Psychodynamic Psychiatry in Clinical Practice. We have moved from DSM III-R to DSM-IV-TR, and much more is known about neuroscience, including the neuroscience of mental disorders. It is no longer possible to view the psychodynamic approach as an area of psychiatry that considers only the intrapsychic and psychosocial aspects of the individual, to the exclusion of biology. With this volume, Gabbard continues the project of relating the findings of neuroscience to the dynamic understanding of the individual, which he began in his third edition. Ever the consummate teacher, he weaves recent research into a practical approach to the psychodynamics of psychiatric care. He uses a good number of clinical examples.
We are oriented to the subject matter by a consideration of the basic principles of dynamic psychiatry. Attention to the patient=s subjective experience, an understanding of the role of the unconscious, psychic determinism, expression of the past in the present, resistance, and the role of neurobiology are all covered.
With this foundation in place, Gabbard turns his attention to a discussion of the theoretical basis of dynamic psychiatry. He discusses 4 important approaches to psychodynamic understanding of the individual, including ego psychology, object relations theory, self psychology, and attachment theory. The latter is the most difficult chapter to understand. The writing is at times dense, and the reader with little knowledge of dynamic theory could struggle with the concepts. A more explanatory, case-based discussion of each school would help the reader.
The chapters on clinical assessment and treatment in dynamic psychiatry are broadly integrative in scope, including a section on psychodynamic considerations of medication and hospitalization.
The major portion of the monograph deals with selected major psychiatric diagnoses, with attention to disorders classified in Axis I and II. Among the major Axis I disorders discussed are schizophrenia, affective disorders, anxiety disorders, dissociative disorders, sexual dysfunctions, substance-related disorders and eating disorders, and cognitive disorders. Gabbard also covers the Axis II disorders, with major attention devoted to the cluster B disorders. This is appropriate, as these disorders often are more difficult to manage in practice. Thus borderline, narcissistic, antisocial, and hysterical–histrionic disorders are each allotted a full chapter.
The clinical chapters begin with a discussion of presentation, noting issues that relate to each of the 4 schools of dynamic psychiatry. This is followed by a clinical discussion of presentation, assessment, and management. These discussions include biological research evidence that underscores the dynamic issues in order to deepen and complete the discussion of psychodynamics. Excellent, well constructed case-based examples illustrate key points in presentation and management. These chapters shine when Gabbard leaves the theory and deals with the practical aspects of management.
This volume is full of clinical wisdom and advice. An earlier edition of this book has been a mainstay of mine when I need clarity on psychodynamic issues that arise in treatment. The clinical advice has always been helpful. This book extends and deepens the usefulness of previous editions. It is well referenced and has an excellent index. While I will use the index when I am in a hurry, I know I will set aside time to read complete chapters as I struggle with challenges that arise in the care of individuals. I am impressed with the realization that psychodynamic psychiatry is truly a robustly integrative approach. It is still fundamental to the modern practice of psychiatry.
Psychodynamic Psychiatry in Clinical Practice deserves to be on every psychiatrist's and psychiatric resident's book shelf. I am still in awe that this excellent monograph is the integrated view of a single individual. It is the work of a committed and gifted clinician, teacher, and scholar. It is one of the books that should be well thumbed, for it is rich in clinical wisdom.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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