Abstract
A central theme of Bremner's work is that stress can have lasting effects on the individual leading to demonstrable changes in the function and the anatomy of the brain as well as causing other physical symptoms. He states that such stress ‘results in long-standing changes in neurological function that underlie symptoms of stress-related psychiatric disorders’. He quoted studies that have shown 25–50% of Americans being exposed to psychological trauma at some time in their lives with post-traumatic stress disorder affecting, at some point, 8% of the entire population. Bremner reviews the history of how trauma has been conceptualized, including references to: French philosophers; Da Costa; Freud; World War I and World War II; Vietnam; modern disasters; and the child abuse literature. He takes the reader through a selective review of the neurobiology of stress, including how neuroimaging (particularly position emission tomography) has assisted in demonstrating actual physical changes in the brains of traumatized individuals.
While the work provides useful coverage of the factual areas central to the stated subject matter of the book and focuses in particular on the research of the author, I have nevertheless a few difficulties with the style and substance of the book.
The book includes a number of substantial factual errors. Contrary to what is repeatedly claimed, ‘Anna O.’ or Bertha Pappenheim was never a patient of Sigmund Freud. Neither did the Space Shuttle Challenger explode ‘on the launch pad’. (It exploded in flight.) It is equally inaccurate to state that: ‘In 1953, Watson and Crick made the amazing discovery that all of the information that determines who and what we will become is contained in a small space of 23 pairs of chromosomes.’ (Watson and Crick, with considerable assistance, discovered the molecular structure of DNA, though DNA's role as the means of conveying genetic information had been identified in 1944 by Oswald Avery [1].) Equally imprecise is the claim that ‘the last half of the 20th century was unusual in the Western world in that there weren't any major military conflicts between nations.’ Clearly American, British, Australian and other troops fought openly in the early '50s against Chinese and North Korean troops. (General Douglas MacArthur was removed from command in Korea for favouring an escalation to nuclear weapons.) The Iran–Iraq war in which millions died could hardly be described as a ‘minor’ military conflict, nor could the 1967 and 1973 Arab-Israeli wars, Gulf War I, etc…
The book is not even consistent in its inaccuracies. Early in the book it is stated that the September 11 attacks took ‘roughly 5000 lives’. Later in the book a figure of ‘more than 3000 people’ is quoted.
The style of the book is a tad self-congratulatory, with the author repeatedly addressing questions that occupied Freud, though answered with a certainty that Freud himself would perhaps have been cautious about. In describing a study which showed an inverse correlation between PTSD symptomatology and the size of the hippocampus, and which involved the author, the reader is told: ‘This was exciting news from the scientific standpoint – the first suggestion that stress may cause damage to the brain. However, needless to say, it took some time before my psychiatrist colleagues could accept that this might be a possibility.’
Elsewhere the reader is told that one of the central tenets of the book ‘is that several diagnoses in the DSM that are related to stress are best thought of as linked together in a cluster of what I have termed “traumaspectrum psychiatric disorders” which, in turn, are best thought of as neurologically based disorders that result from the effects of stress on the brain’. While most would have little difficulty agreeing with the basic concept, it is puzzling that such an observation, which has been in the literature for many years, is presented as if it is new, without reference to the many writers such as Judith Herman, Bessel van der Kolk et al. who have previously said much the same. Indeed other concepts in the book, which seem to have been discovered anew, include the particular damage associated with emotional deprivation/abuse, psychosomatic medicine and the biopsycho-social model. Yet George Engel or even the word ‘psychosomatic’ are never mentioned.
The book is a trifle burdened with pseudo-profundity, repetition and anecdotal discourse. For example we are told that: ‘We should stop limiting our thinking to psychiatric disorder, and instead broaden our conceptualizing to include the effects of stress on the heart, mind, brain, immune system, and metabolism, as well as on the soul.’
Whilst the book seems intent on writing the obituary of many psychiatric concepts, it probably goes a bit far when it announces the obsolescence of traditional clinical medicine. ‘Traditional physical diagnosis, such as listening to the heart with a stethoscope, or palpation, is basically extinct: however, physicians perpetuate the teaching of physical diagnosis out of tradition, much like an ancient priesthood that won't give up muttering spells and prayers in a lost language.’