Abstract
The current benchmark on post traumatic stress disorder, Saigh and Bremner (Posttraumatic stress disorder: a comprehensive text; Allyn & Bacon, 1999), is strong on both adult and child studies. However, it does not seek to cover the spectrum of post traumatic stress disorders, does not address comorbidity, and does not index post traumatic dissociation. Does the present book address any of these major omissions, or break any new ground? I believe not. Thus, although Gersons notes that ‘Bremner and Marmar have argued that dissociation should be seen as the main mechanism in the development of PTSD’, in the present book, dissociative symptoms, but not dissociative mechanisms or processes, are indexed, and even these are only briefly mentioned in the text.
The field of post traumatic stress, which centres on disorders of consciousness and memory, is benefiting from the rapid contemporary advances in neuropsychology and the neurosciences. Furthermore, the recognition of the fundamental contribution of traumatic stress to all psychopathology (and to much soma-pathology), and the reemergence of dimensional approaches to diagnosis, is dramatically affecting, not only general nosology, but also diagnosis of trauma. No such trends emerged from the ‘Table of contents’, and so I turned from the first to the final chapter: ‘Future prospects and needs’. Its opening assertion, that although PTSD ‘is undoubtedly one of the most important anxiety disorders…it is also one of the least understood’, emphasized the book's basis in defunct dogma. The anxiety disorders, as with the other diagnostic chapters from the DSM, may well reflect nineteenth century nosological categorization at its ‘last gasp’.
There is a useful table (1.1) reporting lifetime exposure rates to traumatic events. These range between 43%, in young adults, to 97%, in all adults. The pervasiveness of traumatic stress, however, has yet to be acknowledged, especially in DSM. ‘Diagnostic dilemmas’ is a useful chapter for trainees and mental health paraprofessionals, which enlarges upon the DSM criteria for PTSD. The step from low key clinical psychopathology to the next chapter, a report on research studies of brain imaging in PTSD, jars, and reflects generally inadequate editorial integration of the text. The sections on treatment do not break new ground. Rothbaum states that there have been ‘impressive advances’, but neither empirical studies nor clinical findings bear out this statement. Furthermore, treatment failure and treatment failures are rarely analysed, and are not considered here. New treatments have been advocated, most notably EMDR, and CBT (the focus of this chapter) has been applied to PTSD. It is by no means clear that patients managed by current practitioners are any better off than those managed by Janet or Freud. Stein et al. tellingly note that ‘there is a substantial gap between preclinical understanding of responses to aversive stress and the confirmation that similar mechanisms play a part in PTSD’. Nevertheless, for the major part, this book either describes or is informed by such studies. Furthermore, Stein et al. believe that there has been a paradigm shift in PTSD studies, albeit incomplete, from psychodynamics to neurobiology (principally neuro-endocrinology). Even were this true, the field has yet, for example, to develop pharmacotherapeutic agents specific for the impact of trauma. Rather, the pharmaceutical industry, backed by a conservative psychiatric profession, continues to seek applications for existing preparations, principally those introduced commercially for the treatment of affective disorders.
Macfarlane's view on adaptation and ‘objective truth’ across cultures, embodied by the notion of ‘the past’, might be seen by some as a challenge to the sovereignty of Divine truth. Although McFarlane probably does not intend to challenge the Divinity, he does draw our attention to the importance of Universal values, not only to understand the cult-ural underpinnings of human behaviour, but also for its change. With the current world wide renaissance of grass roots spirituality, religion appears to be re-entering the vacuum left following the eclipse of traditional general psychological treatment views and values. Nowhere will this be truer than in the field of psychological trauma!