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Book Forum: Stress and Anxiety Disorders   |    
Posttraumatic Stress Disorder: A Comprehensive Text ? Treating Psychological Trauma and PTSD
JUDITH L. HERMAN, M.D.
Am J Psychiatry 2002;159:1452-1453. doi:10.1176/appi.ajp.159.8.1452
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Cambridge, Mass.

Edited by Philip A. Saigh and J. Douglas Bremner. Needham Heights, Mass., Allyn & Bacon, 1999, 434 pp., $69.00. • Edited by John P. Wilson, Matthew J. Friedman, and Jacob D. Lindy. New York, Guilford Publications, 2001, 467 pp., $45.00.

In a field as lively and fast-growing as traumatic stress studies, editing a comprehensive textbook is a daunting task, and one has to admire anyone with the temerity to attempt it. Saigh and Bremner’s textbook, unfortunately, fails to achieve its laudable goal. In fact, the authors’ view of the field seems strangely limited. Some topics, such as assessment, are covered quite exhaustively, but others, such as treatment, receive only cursory or highly selective attention. For example, group psychotherapy is reviewed only as it pertains to one particular population, Vietnam combat veterans. In the epidemiology section, publicly recognized traumatic events such as disasters, wars, and street crimes are heavily emphasized, but the private, secret, and often-repeated traumas most commonly experienced by women and girls, such as sexual abuse and domestic violence, tend to be noted only in passing. This seems curious, considering that posttraumatic stress disorder (PTSD) is twice as common in women as in men in the United States.

Some of the most intriguing issues in the trauma field are not addressed at all. Dissociation, for example, is barely mentioned. One would never guess, from reading this text, that for the past 100 years, major theorists have postulated that dissociative states are central to the pathogenesis of PTSD, or that we now have a large body of research identifying peritraumatic dissociation as one of the most powerful predictive factors for the disorder. The authors’ avoidance of this important topic is simply inexplicable. For all of these reasons, one must conclude that the comprehensive textbook of PTSD has yet to be written.

Treating Psychological Trauma and PTSD also attempts an ambitious goal. At present, we have a wide diversity of approaches and no shortage of controversy regarding the most effective treatments for traumatized people. Achieving a balanced and sensible overview is no mean feat. Wilson, Friedman, and Lindy approach this task with refreshing humility and tolerance. Wisely, these editors do not attempt to codify an authoritative text, which no doubt would soon become obsolete, given the rapid pace of innovation. Instead, they advance a set of guiding principles that affirm the value of pluralistic treatment modalities. They view the traumatized person dynamically, as a resilient organism seeking to reestablish homeostasis within a larger ecosystem, and they argue forcefully for an integrative, biopsychosocial approach to treatment.

They propose a "tetrahedral model" of PTSD, presenting a three-dimensional image in an attempt to capture the complexity of adaptation to trauma and the interrelatedness of posttraumatic symptoms. They also identify five "portals of engagement" for establishing treatment goals. Three of these portals correspond to the standard descriptive triad of PTSD symptoms (hyperarousal, intrusion, and avoidance); the other two recognize the impact of trauma on personal identity and relationships.

Rather than presenting a formulaic, "one-size-fits-all" protocol applicable to all patients, the editors emphasize the importance of fit between the patient and the treatment modality. They also recognize that treatment may unfold in stages, with new aspects of the traumatic disorder becoming more salient and amenable to different types of treatment once the initial presenting complaint is addressed. These general principles are illustrated as they apply to particular patient populations (for example, dual-diagnosis patients, refugee survivors of political persecution, survivors of childhood abuse). The editors conclude with a warning against overly aggressive or zealous interventions and a reminder that the best treatment is not a prescription but a collaboration that respects the patient’s autonomy, resourcefulness, and capacity for choice. "The site of recovery…is not in our office, our words…nor our prescriptions, behaviors or technologies. Rather, the site of recovery is within the…space of the survivor." With its broad and capacious view of the field, this book is a welcome companion volume to the recently published practice guidelines of the International Society for Traumatic Stress Studies (1).

Foa EB, Keane TM, Friedman MJ (eds): Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. New York, Guilford, 2000
 
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References

Foa EB, Keane TM, Friedman MJ (eds): Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. New York, Guilford, 2000
 
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