I picked up this book with interest, partly because its title suggested a practical book that deals with what are probably the most difficult patients that the average clinician comes across in ordinary practice, but I also hoped that this volume might open the lid on what is a highly significant diagnostic issue for psychiatrists involved in specialist care. The general evidence from the literature of personality assessment suggests the following law: ‘the proportion of patients with severe personality disorder in a psychiatric service is directly related to the degree of specialisation of that service’. So I judge that almost all tertiary referral services (and this includes those in adolescence as well as adult psychiatry) have at least 50% of people with comorbid significant, if not severe, personality disorder as well as the primary diagnosis attracting the label of the service. Any helpful advice for practitioners in these services will therefore be of immense assistance.

Unfortunately, this book may arouse expectations that are too high and although it is described as ‘a holistic, practical guide to the treatment of patients with a range of these disorders and should be read by all the members of the mental health team in dealing with this challenging clinical group’ I guess that disappointment would be the primary reaction of the average clinician after reading this book. Why should this be the case? First, severe personality disorders are not defined anywhere by any of the contributors to this book. Severity is somehow assumed and perhaps is best equated with the adjective ‘difficult’. This is not a satisfactory way of describing any psychiatric disorder and adding other adjectives such as ‘challenging’ just add to the tautology. The problem is most of the authors deal in highly specialised services, predominately concerned with one group of personality disorders, those with borderline conditions, and either do not recognise or have nothing to say which is the slightest bit useful, about other groups of personality disorder. So for example, the importuning attentions of the dependent patient, the fulminating hostility of the angry one and the gross rigidity of the ultimate obsessional, do not get a mention within the 200 odd pages of this book. I am also concerned that in this super-specialised age that very few of the authors seem to be engaged in direct regular face-to-face management of severe personality disorder, and this seems to reflect a cynical comment made to me by a colleague some years ago that, ‘the aim of promotion in psychiatry is to get away from the most difficult patients’. This may allow you to write about them with a better sense of perspective, but it makes your writings less valuable to the present day practising psychiatrist who reads about concepts such as ‘ego-syntonic sadism’, ‘differential therapeutics’, ‘projective counter identification’, ‘meta-cognitive awareness’, ‘surgency’ and ‘homeostatic attunement’ with mild amusement at first and alarm later, as though going on a stroll from a new holiday destination and finishing up on the surface of the moon. The best chapters are on practical issues such as managing suicidal crises (Paris) and day treatment programmes for borderline personality disorder (Bateman & Fonagy), and by John Livesley who in a measured summary of all that has gone before concludes that we need to be ‘less concerned with comparing different modestly effective therapies and more concerned with determining the most effective intervention strategies for each domain of personality pathology’. We are at the beginning of developing good treatments for personality disorder but time after time during the reading of this book I wished for a little gentle modesty rather than stentorian proclamations of dramatic change.