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Book Forum: Stress and Trauma   |    
Treating Trauma Survivors With PTSD
HEATHER W. CLAGUE, M.D.; MARDI J. HOROWITZ, M.D.
Am J Psychiatry 2003;160:1019-a-1020. doi:10.1176/appi.ajp.160.5.1019-a
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Edited by Rachel Yehuda, Ph.D. Washington, D.C., American Psychiatric Publishing, 2002, 216 pp., $36.95 (paper).

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This book contains proceedings from a conference titled Advances in the Diagnosis and Treatment of Posttraumatic Stress Disorder (PTSD) held in New York City in 1999 and sponsored by the Mount Sinai School of Medicine. There are seven chapters ably introduced by the editor, Dr. Yehuda. The focus is on intervention. Each chapter has information of value, but, as in most books on proceedings, the reader has to integrate diverse approaches to treatment without centralized guidance.

The book’s introduction offers an interesting exploration of why the empirical treatment literature does not always guide common clinical practice. Most obvious is the fact that many important treatment questions have not yet been addressed empirically. For example, few, if any, well-controlled studies examine combined treatment with medications and psychotherapy or the use of multiple medications. More fundamentally, clinicians and researchers are often separated by boundaries of inconvenience. Clinicians use techniques with which they are familiar, and researchers favor interventions, treatment settings, and diagnoses that are tractable to study. Therefore, most intervention studies exclude complicated patients (such as those with medical problems, substance abuse, or suicidal behavior) with whom clinicians struggle most. Additionally, outcome studies do not speak to the crucial processes of identifying and linking trauma to symptoms, establishing a therapeutic contract, and engaging patients in treatment planning. As the authors of chapter 1 point out, "Rather than studying the initiation of the treatment relationship, clinical trials begin at the end of this process."

Chapter 1 presents a good discussion of some relevant considerations in planning treatment, but there is meager discussion here or elsewhere in the book about psychodynamic components of case formulation. Chapter 2 reviews the DSM-IV diagnostic criteria for and epidemiology of PTSD and describes a number of validated instruments used in research to assess PTSD with some potential applications for clinical practice. This list is a useful reference. Chapter 3 reviews specialized treatments for PTSD and attempts to address the question of matching patients to the appropriate treatment, but psychodynamic approaches are slighted. Exposure therapy is advocated and found effective in clinical trials, but issues of retraumatization of some patients using these techniques are not sufficiently discussed. The brief section on treatment matching is based only on the authors’ own studies, and the evidence cited is indirect.

Chapter 4 reviews the current evidence for medication treatment of PTSD, which is quite scanty (only seven published randomized trials). Chapter 5 thoroughly reviews the intervention literature for PTSD in children and describes an interesting theory about how trauma alters a child’s threat detection system and how a therapist can help recalibrate that system. However, there is little reference to any basic science literature supporting this theory, and no attempt to relate this theory to an understanding of the pathophysiology of PTSD.

Chapter 6 discusses assessment and treatment of complex PTSD. The author discusses symptoms linked to trauma from childhood abuse and outlines research on developing a new diagnostic category for complex PTSD (or, as he terms it, disorders of extreme stress not otherwise specified). He outlines a phase-oriented approach to treatment for this disorder and appropriately decries the lack of funding to study this important population. The book wraps up with chapter 7, which discusses treatment of trauma survivors in the immediate aftermath of traumatic events.

Despite its limitations, this book is a helpful summary of the most recent research on the treatment of PTSD, although it may be more cited for its individual chapters than as a coherent whole. It will be useful for experienced trauma experts, but is not a good starting place for beginners.

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