Personality Disorder: From Evidence to Understanding By Peter Tyrer and Roger Mulder Cambridge University Press. 2022 £29.99 (pb). 172 pp. ISBN: 9781108948371

a lack of Big Pharma promotional activity but incorrectly states that antipsychotics reduce quality of life. The section on the dopamine hypothesis of schizophrenia neglects to mention virtually all the best evidence to support it. That on genetics is a bit dismissive and confused – there are many reasons why risk genes overlap across disorders and this does not pose any more threat to our diagnostic system than, say, the notable genetic overlap between schizophrenia and multiple sclerosis. Scull is on firmer ground highlighting DSM-III as being driven by a very necessary desire to enhance diagnostic reliability, and he is right that Big Pharma have exploited successive DSMs rather than been in league with psychiatry as some conspiracy theorists would like to believe. To say, however, that there are no diagnostic tests for psychiatric disorders is to ignore all the known causes of intellectual disabilities (known as learning disabilities in the UK health services) and the dementias. Not to compare this with the rest of medicine is to avoid the fact that many diagnoses such as migraine, Parkinson’s disease and most epilepsies remain clinical – generally with a 10% misdiagnosis rate. To state that the causes of major mental illness ‘remain as enigmatic as ever’ is simply wrong, even if that knowledge has not translated into patient benefits. The last chapter is a particular disappointment, being all too reminiscent of some Mad in America polemic and falling back on tired, misplaced calls for a ‘paradigm shift’ away from the perennial purported ‘crisis’ in psychiatry. Yes, at its worst, psychiatric diagnosis could be a DSM tick-box exercise, and out-patient reviews little more than medication checks, but none of my colleagues practise that way. Yes, the general (but not entire) lack of validating biological tests in psychiatry leaves us open to ever increasing numbers of diagnoses but this is not ‘18th century practice’; indeed, it allows for the emergence of novel conditions such as pathological gambling. There is no doubt, however, that the numbers of American children diagnosed and treated for attention-deficit hyperactivity disorder far exceeds the 1% or so likely to benefit – even worse, arguably, are the numbers of children diagnosed with bipolar and treated with lithium. The bottom-line is that most people who present to psychiatric services get evidence-based interventions and are satisfied with their treatment. To help more, better, we principally need better funded mental health and social services. Increased research funding could allow us to target existing therapeutics and develop better interventions for people with histories of childhood adversity and ongoing disadvantage. That would certainly be more useful than repetitively criticising psychiatry – or indeed bemoaning the death of socialism as a political force. One may as well howl into the wind. With the Wellcome Trust and others spending billions on mental health research over the next decade we can expect notable progress, but it takes time – and that does not lend itself to dramatic copy.