Traumatic Events and Mental Health
This book is a generously referenced, well-written account of research on posttraumatic stress disorder (PTSD) by a British psychiatrist with military and civilian clinical experience.
An introductory chapter chronicles the historical development of PTSD, indicating that Vietnam veterans were the focus of most early research. O'Brien distinguishes between PTSD and posttraumatic illness, a recurrent consideration throughout the book. Next, he debates whether PTSD is a normal or abnormal response to a trauma, a question that has enormous legal ramifications addressed later in a fascinating chapter that considers PTSD and the insanity defense, as well as the very weak link between PTSD and criminal behavior.
Coverage of PTSD and posttraumatic illness epidemiology wisely begins with general caveats, such as the impact of priming questionnaire respondents on subsequent symptom endorsement. Major epidemiologic endeavors, such as the National Vietnam Veterans Readjustment Study, are described, and studies of other traumatic events, such as terrorist activities or natural disasters, are also reviewed. A table would help summarize the huge blur of incidence and prevalence rates.
O'Brien next addresses etiology and predisposing factors by considering the importance of trauma severity versus the role of various pretrauma vulnerability factors. Biological etiology, such as the hypothesized role of the hypothalamic-pituitary axis, is nicely summarized. Next, an entire chapter examines the nature of a stressor, which has evolved from DSM-III to DSM-IV. These classification systems are then contrasted with ICD-10. O'Brien explains why the requisite occurrence of a traumatic event may not, in fact, be diagnostically useful as currently dictated.
A chapter on posttraumatic illness other than posttraumatic stress disorder follows. The useful, though short, section on PTSD comorbidity with other diagnoses could serve as a helpful road map of the chapter if placed before the sections on individual, non-PTSD disorders. In addition, explanations of the temporal relationship of the trauma to the disease course seem a bit basic for the modal reader, who is probably a mental health professional.
The chapter on diagnosis and assessment briefly mentions physiological parameters in diagnosis, but it mostly reviews the many survey instruments and interviews in use. Again, a summary table would help convey their psychometric properties and the populations on which they were normed. O'Brien points out the lack of a gold standard, and he also notes later that none of these instruments have been normed in the legal arena—for example, on patients seeking compensation through the judicial system.
A summary of treatment approaches covers the standard, symptom-driven pharmacological remedies as well as various psychotherapies. A description of the principles of combat psychiatry provides an interesting diversion. The section on eye movement desensitization and reprocessing is skimpy and leaves the reader eager for more commentary on this controversial subject.
The medicolegal chapter is followed by one on posttraumatic illness prevention, with a convincing debunking of posttrauma debriefing. A final summary touches on highlights in the book. Summary bullets at the end of each chapter help recapitulate the highlights in this very useful, comprehensive description of the state of PTSD research.
Dr. Lustig is a resident in the Harvard Longwood psychiatric residency training program at the Massachusetts Mental Health Center in Boston.
