Abstract
It is time that more attention was paid to the different types of posttraumatic stress disorder (PTSD). While they would share much in common it seems likely that some PTSD, as currently defined, can be understood and treated with a psychosocial approach, and that others require a biopsychosocial approach. Posttraumatic Stress Disorder: Concepts and Therapies is part of the Wylie series of ‘Clinical Psychology’. It is indicated in the preface that the book represents 10 years' experience of working with survivors of accidents and disasters following the sinking of the Herald of Free Enterprise in 1987 and that PTSD, along with other stress reactions is considered ‘within a broad social psychological perspective’.
The psychosocial aspects of PTSD are comprehensively addressed, but only one of the 15 chapters focuses on what is referred to as the ‘psychobiology’ of the disorder. This is perhaps not surprising. It seems safe to assume that, in the UK, ICD-10 is preferred to DSM-IV. The differences between the DSM-IV criteria for PTSD and the Clinical Guidelines (rather than the Research Criteria) of ICD-10 are described in chapter 1. Neither symptoms of avoidance nor physiological arousal are considered necessary in making the diagnosis, leaving, aside from the stressor criterion, intrusive recollections of the causative event as the primary symptom. Indeed in chapter 8 (devoted to intrusive thinking) symptoms of increased arousal are ignored altogether in a brief reference to the DSM-IV criteria for the diagnosis.
Posttraumatic stress disorder following prolonged or accumulated extremely stressful experience may well be associated with hyperarousal more commonly than in the case of victims of ‘one-off’ disasters, such as the sinking of the Herald of Free Enterprise. Not uncommonly, combat veterans and police officers, for example, can demonstrate gross arousal symptoms with little or no evidence of psychological distress.
The conceptual background for ICD-10 PTSD, as in this book, appears to be psychosocial rather than biopsychosocial. Even with the Research Criteria, as Andrews et al. [1] have recently shown, PTSD is diagnosed with far more frequency using ICD-10 rather than DSM-IV criteria, begging a range of questions. What, for instance, is the natural history of the disorder in those who have ICD-10, but not DSM-IV, PTSD and do they respond differently to cognitive-behavioural therapy?
There is no shortage of theory in this book in relation to various aspects of PTSD, including chapters addressing previous personality, attribution of blame and cognitive theories of PTSD. There are useful chapters on the behavioural and cognitive-behavioural interventions in the treatment of PTSD, cultural aspects, debriefing and crisis intervention. There are also chapters on coping and social support following psychological trauma and a particularly useful chapter on PTSD in children and adolescents.
The overall impression, however, is that the book has been written for a particular professional readership rather than addressing, even briefly, the intriguing complexity of these disorders.
It is recognised in chapter 8 and in ‘Conclusions’ that intrusive thinking is not limited to PTSD or confined to pathological states. Common sense suggests that life-threatening and horrific life events might be vividly etched in the memory and have long-term psychosocial consequences. The same, of course, could be true of very positive experiences like falling in love or achieving some notable success. Strong emotions are associated with such experience, but as LeDoux [2] points out, emotions themselves may be less important than the biological mechanisms that generate them, particularly where health is concerned.
The final paragraph of the book refers to ‘different professional groups claiming expertise and ownership of this area of psychological suffering’ and strongly maintains that such in-fighting is not in the interests of ‘clients whose problems cut across disciplinary boundaries’.
There are only two sentences in the book that refer to pharmacological treatment. In the first (p. 155) it is suggested that study of neurochemical changes that occur during conditions of extreme stress ‘begins to lead to rational suggestions about possible pharmacological treatments’. In the second (p. 262) it is indicated that a mild to moderate level of depression can usually be dealt with with a cognitive-behavioural [1] approach alone, but that antidepressant medication may be indicated for those with a moderate to severe [2] level of depression.
International opinion would accord far more relevance to the pharmacological treatment of PTSD. Thus, while the book is comprehensive as far as it goes, anyone reading it would be wise to read also Neurobiological and Clinical Consequences of Stress [3] and/or Traumatic Stress, The Effects of Overwhelming Experience on Mind, Body and Society [4] in order to have a professionally unbiased understanding of this complex and important group of disorders.