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Book Forum: Trauma and Stress   |    
Trauma and Health: Physical Consequences of Exposure to Extreme Stress
FREDERIC FLACH, M.D.
Am J Psychiatry 2005;162:1769-1770. doi:10.1176/appi.ajp.162.9.1769
View Author and Article Information
New York, N.Y.

Edited by Paula P. Schnurr, Ph.D., and Bonnie L. Green, Ph.D. Washington, D.C., American Psychological Association, 2003, 311 pp., $49.95.

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The premise that a close connection exists between emotional states triggered by stress, particularly episodes or prolonged periods of extreme stress, and a variety of physical ailments has received much attention in recent years. Not that the idea hasn’t been around for a very long time. It’s just that more studies have been done to establish support for it. Drs. Paula Schnurr and Bonnie Green have obviously devoted considerable time, thought, and effort to compiling very pertinent information on this subject and assembling an outstanding group of contributors. They have produced a first-rate resource, filled with solid documentation of value to anyone wanting to review the work in this field, although not exactly an easy read.

The book is divided into five sections. Part 1 describes the effect of trauma on physical health. People exposed to one or more traumatic events over their lifetime have more physical symptoms and a greater number of chronic health conditions than do nonexposed individuals. Posttraumatic stress disorder (PTSD) is also associated with higher rates of other disorders and may represent a pathway between stressful events and adverse physical outcomes.

Part 2 focuses on psychological mechanisms. For example, evidence for the interplay between clinical depression and coronary artery disease is compelling. So too for PTSD, which may share biological underpinnings with affective disorders. Unhealthy coping methods, such as avoidant and repressive behaviors, have been linked with greater cardiovascular reactivity and impaired immune function. One point deserving greater emphasis is that "how individuals cognitively appraise situations is the primary determinant of how they cope." I think of the Columbine High School students who sought help not so much from crisis interventionists but from the clergy, who they believed were better able to help them achieve a meaningful perspective on the terrible ordeal they’d just been through.

Part 3 moves on to consider biological mechanisms. Traumatic stressors have effects on the immune system that may increase susceptibility to infections and exacerbations of other diseases as well. The chapter titled "PTSD, Allostatic Load, and Medical Illness" is a must read. "Allostasis" is defined as the organism’s ability to achieve stability through change, namely, by expending and directing energy toward challenges. "Allostatic load" is the cumulative cost to the organism of going through repeated cycles of adaptation, and "allostatic support" refers to mechanisms that confer "resilience" on individuals, making them more resistant to PTSD and other chronic illnesses. Biological abnormalities are associated with chronic stress syndrome, and specific medical problems, many of which involve central and peripheral neuroendocrine activity, are associated with both chronic stress syndrome and PTSD. Here is a framework within which new treatment modalities may be discovered.

Part 4 takes on somatization, a pattern of symptoms for which medical help is sought but adequate medical cause is not found after due investigation. Health risk behaviors are also reviewed—poor dietary habits, obesity, tobacco use, excessive use of alcohol, illicit drug use, and imprudent sexual behavior (often complicated by unintentional pregnancies and venereal diseases, most dangerously AIDS).

Part 5 is the least informative part of this presentation. General suggestions for increasing public and professional awareness of the stress-physical illness connection are made, and the call is for an integrated approach to prevention and treatment, echoing recommendations made for decades. It might have been more fruitful to explore the reasons why these have not yet been successfully implemented and consider new ways to make them happen.

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