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Book Review   |    
Susan E. Bailey
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.3.422
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by Robert O. Friedel, M.D.; New York, Marlowe and Company, 2004, 250 pages, $15.95

Dr. Bailey is an instructor in psychiatry at the Johns Hopkins University School of Medicine, Baltimore.

Robert Friedel wrote this admirable book primarily for individuals who suffer from borderline personality disorder. In doing so, however, he renders a valuable service to the rest of us—the loved ones, family members, and treatment teams of people with this disabling condition. While reading his book, I squirmed with chagrin, realizing how often I've rolled my eyes, grimaced, and explained to my residents a patient's latest annoying exploit with the dismissive phrase, "She's a borderline!" I need to develop—and inculcate in my students—the understanding, patience, clarity, and hopefulness of Dr. Friedel.

I will no doubt do everyone more good by emphasizing the author's most insistent point: the impulsive, self-destructive behaviors and frantic manipulations of these patients arise less from willfulness than from impaired neurotransmitter activity, brain dysfunction along important neural pathways, and learned, maladaptive behaviors that substitute for flexible coping skills.

Friedel dedicates his book to his sister, Denise, who suffered from borderline personality disorder. She died much too early from one of the common complications and comorbidities of her disease. And there are many—substance abuse, mood disorders, eating disorders, panic attacks, and posttraumatic stress disorder. He thus brings to his book not only the voice of the psychiatric researcher and clinician—he is distinguished clinical professor of psychiatry at Virginia Commonwealth University and professor emeritus at the University of Alabama at Birmingham—but also the voice of family and relationship. He knows intimately the frustration and anger that family members can feel in relation to the person with borderline personality disorder, but he has also focused an impressive career upon the biology of this disorder and the most effective treatments, particularly pharmacologic ones.

Friedel organizes his book, initially created as a series of handouts for his patients and their families, in such a way that one can skip about easily among topics of special interest, such as medications, psychotherapies, and symptoms. Nevertheless, if reading the book straight through, one discovers that Friedel carefully lays the groundwork for understanding both the symptoms—emotional storms, impulsivity, and bizarre or paranoid reasoning and perceptions—and the pharmacologic treatment—primarily selective serotonin reuptake inhibitors, low-dose neuroleptics, and mood stabilizers—of the disorder by describing impaired brain function in the amygdala, the anterior cingulate and orbitomedial prefrontal cortex, and the dorsolateral prefrontal cortex. None of his reports of research findings is footnoted within his text, but he supplies a bibliography keyed to each chapter at the end of his book.

Although Friedel devotes more of his text to pharmacologic treatments, he doesn't overlook the importance of therapy and the multiple types that can be useful, including dialectical behavior therapy, interpersonal group therapy, and individual supportive therapy. He maintains an optimistic outlook on both treatment fronts. As our understanding of brain chemistry and neural systems deepens, so will our ability to target more accurately and effectively our pharmacologic and therapeutic interventions.

Friedel's compassion, wisdom, and skillful writing result in a highly readable, useful book for patients, families, and providers.




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