Abstract
This is an excellent book which the editors present as offering not only a coverage of current understanding of the effects of traumatic experiences at a physiological level, but as also providing insight into the psychological effects of such events. In addition, there is authoritative advice on treatment and management over a wide range of possible situations. Andrew Sims, past president of the Royal College of Psychiatrists, makes the important point in his foreword that ‘psychological trauma is an example of that class of phenomena that we, as human beings, have known over many centuries to be significant, but because we had believed there was so little we could do about it, we had chosen to ignore or deny’. This book seriously refutes the idea that psychological trauma should be ignored and denied, or that there is little to be done about it.
One of the book's strengths is that authors of the various chapters have pre-eminence in a variety of professional backgrounds, including mental health, sociology and psychiatry. Some of this professional cross-pollination is especially serendipitous, for instance, the authoritative chapter by Thomas Dickie, Chief Superintendent of Strathclyde Police Glasgow, who provides a fascinating insight into how the police deal with the logistics of disasters and at the same time facilitate the work of specialist colleagues in other services, such as medicine.
The editors mention that they have not dealt specifically with such personal disasters as childhood physical and sexual abuse, chronic marital and domestic violence or the traumatic effects on children of medical treatments for life-threatening illnesses, although they suggest they may be dealt with in future editions. In fact, it does seem unfortunate that there is not greater emphasis on these more common experiences, so that the excellent chapters on the physiological and psychological effects of traumas and disasters could be linked more readily by the reader with the often adverse outcomes experienced by victims in these less newsworthy situations. When the editors say that ‘psychological traumatisation is an under-recognised risk to the health of individuals and societies’ (p.393) it would have been useful to present this as an unfortunately common experience rather than the result of ‘the extremes of interpersonal and mass violence and disaster’, which is the book's focus. This issue deserves emphasis because in such an otherwise authoritative text it is an important omission that the common causes of a lifetime of psychological distress are not more fully recognised and accorded appropriate status.
The book commences with an overview of the history of the concept of posttraumatic stress disorder by Allan Beveridge. He makes the point that Victorian psychiatry, being overwhelmingly ‘organic’ and focused on ‘moral’ causes for insanity, such as hereditary taint or the ravages of a debauched lifestyle, paid no regard to the effects of noxious environmental events. Gradual recognition of the importance of traumatic events came with the advent of railway accidents where victims who had suffered no physical injury might nevertheless suffer from various functional physical symptoms which became known as ‘railway spine’. This was seen variously as due to micro damage to the nervous system or as a functional response to shock. Later, the First World War, where 80 000 cases of ‘shell-shock’ were reported in Britain alone, brought about a reappraisal of the prevailing view of innate degeneracy since the condition occurred at all levels of society and often among those who had distinguished themselves for courage. At this time, Freud's concept of intrapsychic conflict was utilised by William Rivers, working with shell-shocked soldiers, who saw his patients' symptoms as reflecting a conflict between duty and fear of being killed, and maintained that psychological methods were beneficial in treatment.
Colin Murray Parkes' chapter on normal and abnormal responses to stress provides the model of three overlapping behavioural systems which underlie the human response to stress, namely the response to threat, the response to separation and the response to change which may bring about a ‘psychosocial transition’, a new way of ordering the individual's assumptions about the world. Where such change has been anticipated, it is easier to cope. Drawing on the findings of attachment theory, Parkes makes a case for the early relationship between the infant and care-giver as the paradigm for the way that individuals may cope with stress later in life. Surprisingly, he does not quote the work of Allan Schore [1] who argues for changes in the architecture of the brain as a result of early trauma, and so offers an explanation of the difficulties in affect regulation found in the more severe personality disorders.
A chapter on the different DSM and ICD classifications and the differential diagnosis of the condition clarifies a number of contentious points and again offers a useful historical perspective.
In her chapter on the interaction of trauma and grief, Beverley Raphael makes the important point that symptoms of posttraumatic stress disorder such as intrusive images of the events surrounding a death, may coexist with those of grief over bereavement, and that both issues will need to be addressed in therapy. She gives a number of helpful examples.
Daniel Siegel's (p.44ff) chapter on memory and trauma is an authoritative review of an area which has been receiving much attention, perhaps most commonly as a result of the so-called ‘false memory debate’. A crucial new insight is the recognition of implicit (or procedural) memory which refers to information encoded at a non-conscious level, and which is likely to reside in the brain structures which mediate initial encoding, such as the basal ganglia and amygdala. By contrast, consciously recognised memories or explicit memory, is now thought to be mediated via the temporal lobe system including the hippocampus. By a separate and subsequent process of ‘cortical consolidation’, memories are recorded permanently in the cortex and so become independent of the hippocampus for retrieval. This process may become disrupted by traumatic experiences which raise corticosteroid levels and may impair hip-pocampal functioning so that explicit processing may become impaired. Siegel's comments on the possibility of impaired explicit memory with intact implicit memory-processing offer a valuable insight which should be of particular benefit to psychiatrists as they seek to understand the vicissitudes of memory where early trauma may be an important factor. His concept of therapeutic intervention as being focused on metacognitive functioning (the ability to reflect on experience) should prove to be of particular benefit where the individual has a problem in ‘thinking about thinking’. As he says, ‘a therapeutic goal is to enable specific memories to become more complex’.
The chapter on theoretical models includes Ronan Mclvor's informative section on psychobiological models which are reviewed in terms of their ability to explain both the intrusive phenomena, arousal and avoidant responses seen in posttraumatic stress disorder, giving both a sense of the complexity of the area and a useful overview of its current status. As the author notes, neuroimaging techniques may be expected to offer advances in knowledge of this area in the foreseeable future. By contrast, the psychoanalytic model of posttraumatic stress disorder propounded by Cleo van Velson is disappointing in that it suffers from a confusion of approaches and would have been much improved if there had been better links between the concepts of early trauma already mentioned and a psychodynamic viewpoint. For instance, an exploration of how traumatic events laid down in implicit memory (e.g. before the development of language) can continue to have an adverse effect later in the person's life would have integrated this section with other parts of the book and provided a useful perspective. The section on psychodynamic therapy as a treatment is also disappointing. There is by now a wealth of information in the literature about the deleterious long-term effects of early trauma, and its connection with a lack of resilience later in life. The author does mention such difficulty as the impairment of the capacity to symbolise, but again does not link this with earlier events, nor with a discussion as to which victims of trauma need to progress to more intensive and longer term therapy, and how they should be selected.
By contrast, the section on cognitive-behavioural therapy (CBT) models written by the psychologist Deborah Lee and psychiatrist Stuart Turner, acknowledges the contribution of psychodynamic understanding in formulating approaches and offers a succinct summary of Horowitz's contributions in terms of understanding the emotional processing of traumatic events. There is a useful summary of theories of conditioning and equally of the cognitive models of ‘learned helplessness’ and various views of information processing. It would seem that dynamic and behavioural understanding in this area are beginning to overlap. For instance, the notion of ‘pre-existing cognitive schema’ which may be at odds with the traumatic experience begin to sound very like the notions of conflict propounded by dynamic theorists. Finally this section concludes with an overview of the deficiencies in each of the various approaches. Again, the section on CBT treatments is informed and comprehensive. Perhaps unexpectedly to those of us who have become used to hearing that CBT approaches are the only ones where outcome studies have validated the treatment, the authors make the point that there is a paucity of studies of the effectiveness of all of the usual approaches in this population of severely trauma-tised people. Their clinical examples are most instructive, but a comment must be that the last one of a former incest victim where structured follow-up is arranged, does not suggest major difference from the sort of patient one might expect to benefit from intensive psychotherapy. At least there is here a tacit recognition that earlier trauma may greatly complicate therapy. The section on treatment also has useful contributions on crisis intervention, debriefing and stress inoculation, bereavement counselling and finally a brief section on eye movement desensitisation (EMD). Here, it seems extraordinary that eight years after Shapiro's initial papers, Martin Newman still cannot quote outcome studies as to its efficacy.
Dora Black, an acknowledged expert, has contributed an authoritative chapter on the treatment of children and adolescents, while a further section here in psychodynamic psychotherapy from Ricky Emanuel and Annette Mendelsohn is excellent because it links examples to the theories propounded, and early developmental issues to the clinical situation.
The second section of the book contains a comprehensive overview of various types of traumatic event, usefully divided into a typology by Parkes: namely small, medium and large scale, and affecting people at predominantly local, national or international levels. The nine subcategories so established are then considered in terms of public health planning and particular needs in terms of special services. For instance a small international disaster such as an airline crash where the victims may come from all quarters of the world will require a very different response to that of say, a medium-scale local disaster such as the 1966 Aberfan disaster where 116 children and 28 adults were killed in a small Welsh mining village when the local primary school was obliterated by an avalanche of mud from mining wastes. A number of actual disasters are then considered in detail, with attention being given to both positive and negative outcomes and lessons learned. Excellent chapters follow on the effects of war, both on combatants and civilians, with some special reference to children and the aged, and to the effects of torture.
The third section of the book deals with legal aspects of victims as witnesses and claimants with a number of authoritative chapters which should prove indispensable to any psychiatrist who is contemplating involvement with the legal system.
This book should prove an invaluable reference and teaching text. It is, on the whole, authoritative and immensely informative. The lack of integration of the early trauma which a number of contributors recognise with later psychopathology is regrettable, but this is an area which is presently the focus of new discovery and emerging understanding. Perhaps we may find future editions will bridge this gulf.