ABSTRACT
In Chapter 5, I discuss patients with severe personality disorders who suffer from disturbances in the form or content of their thinking, in their affect regulation, or in their capacity to contain impulses, that may be severe enough to interfere with progress in various forms of psychotherapy. These patients are not floridly psychotic, and do not readily fit into our current diagnostic terminology. Small doses of atypical neuroleptics may help relieve their symptoms, so they can benefit from psychodynamic group psychotherapy in a day treatment program. This treatment may also be beneficial in other modalities of psychotherapy and in patients being supported by family physicians. Research is needed to determine whether this is the case, and whether patient improvement is due largely to the medication or the psychotherapy. In any situation where neuroleptic medications are used, it is important to review the potentially serious side effects of those medications with patients and to monitor patients for side effects. Advances in psychoanalytic understanding of more severe pathologies with corresponding changes in technique have made it possible to treat patients with a much broader range of disturbances initially thought to be beyond the range of psychoanalytic treatment, including not only patients with psychotic symptoms, but also patients with severe personality disorders and psychosomatic conditions. The psychoanalytic finding that everyone has a psychotic side to their personality, and that psychoanalysis or psychoanalytically informed psychotherapy may be helpful in treating patients whose psychotic parts are too prominent and interfering with their functioning, is not well appreciated in medical circles.
