This concise and clearly written book has a lay audience in mind. It covers territory well known to mental health professionals and reproduces a position shared by many of them, which we might call “psychiatric positivism”. According to this, a psychiatric label is as scientifically valid as any other medical diagnosis. Critics, however, note that these diagnoses rarely have biological markers and are made inconsistently. Disagreements about their validity (accuracy) and aetiology (primary cause) are common. The same applies to the types of treatment prescribed and their effectiveness.
Moreover, a good medical diagnosis is usually experienced as helpful by patients. It reassures them that treatments will be appropriate to their needs and offers an account of why they are experiencing their symptoms. However, in the case of “personality disorder”, the diagnosis is frequently resented and queried by the labelled patient. It is largely others who find the diagnosed person to be burdensome or disagreeable and who tend to welcome professional intervention. What is at issue here is whether the medicalisation of deviations from social norms is helpful and, if so, to whom.
Traditionally, diagnosis and treatment are assumed to be inherently helpful by doctors and their supporters. Accordingly, Peter Tyrer explains the nature of personality disorder and the helpful role of psychiatry. He covers the nature of personality, the difference between normal and abnormal personalities, borderline personality disorder, subtypes of the diagnosis, versions of treatment and their effectiveness.
The author is an eminent psychiatrist and expert in “PD”. His chapters summarise the field with optimism, although he does concede that the diagnosis is not particularly liked by many psychiatrists. To confirm this, two international advisers on the topic in the run-up to the launch of the fifth (2013) edition of the Diagnostic and Statistical Manual of Mental Disorders resigned in protest at the serious scientific flaws in the emerging diagnostic proposals. Indeed, here and previously, Tyrer has rehearsed some points of controversy about the diagnosis, so the book he has written is seemingly unexceptionable.
So why, within weeks of its publication, did he face a storm of protest and hostile reviews from service users? The main answer is that proponents of psychiatric positivism are earnestly committed to discerning what is wrong with people, before “treating” them. A diagnosis is a doctor-centred starting point, whereby cases are slotted into their own a priori version of categorical knowledge.
By contrast, disaffected psychiatric patients tend to want to start from their unique biography: what has happened to them in their lives and what meanings they attach to it. Accordingly, they find diagnostic psychiatry to be stigmatising, uncompassionate and “othering”.
Tyrer did himself no favours with his title, but I suspect this added to, rather than created, the furore. The book could have been written by any traditional psychiatrist and the angry reaction would probably have been much the same. The problem is not the good intentions, eminence or competence of the author but the unreflective and contestable psychiatric ideology he reflects. That ideology has offended its critics for the past 50 years, and will continue to do so for the foreseeable future.
David Pilgrim is visiting professor of clinical psychology at the University of Southampton.
Taming the Beast Within: Shredding the Stereotypes of Personality Disorder
By Peter Tyrer
Published 17 May 2018