This was not an easy book to review, in part because it is quite difficult to identify the target audience. At different times the book is scientific treatise, autobiography, history lesson, and political bully pulpit. Written in the wake of the September 11 tragedy, it clearly is titled and designed to participate in our ongoing national discussion about the nature and impact of psychological trauma.

The book is divided into two main sections. Part 1 presents an introduction to classic thinking about trauma, as well as a fairly detailed discussion of current neurobiological constructs relating to the acute and chronic stress response. Here, Bremner introduces one of his main theories: that the classic fight-flight response is an evolutionary liability. He points out that early man was most concerned with survival as an individual and a species, leading to the evolution of mechanisms for intense and rapid response to threat. Essentially, the goal was to be able to survive long enough to procreate. These mechanisms, helpful to early man, create a vulnerability to pathology in modern man, who lives much longer and does not have to worry about survival on a daily basis. Bremner’s description of this phenomenon, however, is jarring:

An even more startling passage reads as follows:

This type of dramatic prose is typical throughout the book and takes away from some of Bremner’s thoughtful and legitimate analyses.

Chapter 3, "Evolving Concepts for the Biology of Stress," presents a comprehensive discussion of historical and current research in posttraumatic stress disorder (PTSD). It is here that Bremner is strongest, pulling together his encyclopedic knowledge of the area. His description of how research studies are actually conducted is compelling for both lay and professional readers.

The second unifying theme of the book is Bremner’s assertion that current psychiatric nosology is inadequate in the area of trauma-related disorders. He feels strongly that PTSD, borderline personality disorder, dissociative identity disorder, conversion disorder, and acute stress disorder should be included under a new DSM category of trauma-spectrum disorders. This is an intriguing analysis that will be well received by clinicians frustrated with the current inclusion/exclusion DSM diagnostic schema. Bremner convincingly argues that as etiologic knowledge increases, the DSM should be more reflective of neurobiological realities.

The book includes a brief chapter that superficially reviews biological and psychotherapeutic treatment modalities. Bremner goes to some length in this book to establish the idea that neurobiological underpinnings must be considered when thinking about mental illness related to psychological trauma. It is difficult to say whom he is arguing with; modern psychiatry has embraced a biopsychosocial model in research and training for at least the past two decades. Aside from some brief editorial comments, however, he avoids the much thornier issue surrounding the implications of his model for forensic psychiatry. He seems to think patients and society will somehow feel better knowing that PTSD symptoms are biologically based disorders of the brain. He states, "This knowledge has been particularly helpful for trauma survivors, for both their personal satisfaction and their getting compensation and support for disability." This statement is a disappointment from a leader in the field in that it completely ignores the complex issues of disability and secondary gain discussed in Stone’s seminal article on the subject (1) as well as others (2). The discussion of military veterans and PTSD, glamorized throughout the book, does not include any mention of the special problems that arise when psychiatric symptoms become the source of income (3).

Ultimately, this book will be viewed as an important work. Bremner gives us a front row seat to a view on the current thinking about trauma-related disorders at the highest level of academic psychiatry. He also makes an important effort to bring the discussion to the lay reader, using language and clinical vignettes that are readable and illustrative. Unfortunately, the many editorial and subjective elements take away from the science and leave the serious student of the subject frustrated and wanting more.