Post-Traumatic Stress Disorder: Malady or Myth?
by Chris Brewin
Yale £25, pp288
I have heard a psychiatrist pronounce that post-traumatic stress disorder is the most desirable diagnosis for a patient in all of psychiatry: the patient has no responsibility and so can often sue for the condition. Indeed, as the heading of the first chapter proclaims, no other diagnosis has had a more dramatic impact on law and social justice in the United States.
The idea that there is such a condition goes back to the First World War when some soldiers suffered 'shell shock'. It became well publicised in relation to Vietnam war veterans.
There are those who argue that victims of psychological trauma of war, violence, terrible accidents and child abuse are at last being recognised as having a serious psychiatric illness needing special treatment, but sceptics question whether there really is evidence for the disorder. It is to unravel these issues that Brewin, a professor of clinical psychology who specialises in treating trauma patients, has written this important book.
At the core of the problem is the nature of trauma, an event that shatters people's deeply held beliefs about the world being safe and benevolent. Trauma results in a breach of mental structures. For post-traumatic stress disorder the key diagnostic criteria are previous threats of death or serious injury and a response of intense fear or helplessness. There are also recurrent distressing memories, including flashbacks. These debilitating symptoms continue for more than one month. As with other psychiatric conditions, diagnosis is hard: there is no simple biological test as there is for tuberculosis.
Could it not be that responses to trauma are quite natural and resolve with time? The answer appears to be no, as some patients do show clear biological differences from related disorders like depression. But why do so many who go through similar traumas not develop these symptoms? Around two-thirds of the population experience trauma of some kind during their lives, yet only a minority get post-traumatic stress disorder. The factors that have the highest risk for developing the condition are the severity of the trauma, and, more important, lack of social support and further stress later. Yet these patients, like depressives, are not exactly fun to be with, which makes support more difficult.
Flashbacks illustrate the key role emotions and memory play in this disorder. Yet another feature is memory loss. This apparent contradiction may reflect differences in the types of memory, such as perceptual and verbal, declarative and non-declarative.
If the patient tries to suppress those unwanted thoughts, this makes recovery slower. There may be the generation of contradictory selves, one inadequate and one competent, and acquiring a positive identity is a key to recovery. The associated problems are related to recovered memory syndrome, where patients recall the terrible abuses they had suffered as children. This controversial area is explored with care by Brewin. Could a Freudian repression be involved?
Because the disorder is so poorly understood, treatment presents serious problems. It is necessary to bring the fearful memories under control as well as to reappraise the event and gain a stable and positive identity. One treatment involves giving the patient prolonged exposure to images related to the trauma. The other is cognitive therapy, which tries to change the patient's false beliefs. It is not yet clear which is to be preferred. Brewin himself practises the latter. While support and the provision of information can be helpful, individual counselling has little effect and can make things worse.
This book is essential reading for anyone interested in trauma, and it introduces key concepts about emotion and memory. One tiny complaint: Brewin should agree to become a member of my new society, NABGRUAC: No acronyms in books for the general reader under any circumstances.
