David M. Benedek and Gary H. Wynn Eds. (2011) Washington: American Psychiatric Publishing, Inc. xxv + 468 pp. soft cover.
In the Clinical Manual for Management of PTSD, editors David Benedek and Gary Wynn sought to create a reference book for clinicians that summarizes a vast body of recent clinical research and that would be readable and useful for practice. They have succeeded.
A better title might have been Encyclopedia for Management of PTSD; so vast is this book's breadth and depth in just under 500 pages. The volume is divided into three sections. The first offers an overview, the second focuses on treatment, and the third focuses on special topics such as military populations, traumatic brain injury and its relation to PTSD, and sociocultural considerations. At the end of every chapter, except for the Introduction, there is an excellent Key Clinical Points summary.
The overview section includes chapters on epidemiology, biology, assessment, and comorbidities. Only 35 years ago, the legitimacy of posttraumatic stress disorder (PTSD) as a diagnosis was questioned by many mental health clinicians and public policymakers who were responsible for funding programs for health care for Vietnam War veterans. Taken together, the various authors in the overview section provide the clinician with a convincing comprehensive evidence-based picture of PTSD as it is currently understood.
The second section, focusing on treatment, includes chapters on the use of medication, psychosocial interventions, new and alternative therapies, functioning and disability assessment, and the incidence of violence and aggression. Here, again, the authors review the evidence relating to each topic, providing the clinician with an outline of what requires attention in the PTSD patient and how to provide care consistent with an emerging body of research. The reader learns about the randomized controlled treatment trials that have been conducted and is in a position to apply clinical strategies that are based on scientific observation.
The third section is on special topics, including PTSD in the young, in victims of sexual assault, in military and veteran populations, and in the aged. Another chapter discusses the complex relationship between traumatic brain injury and PTSD, a topic of particular interest in the current population of Iraq and Afghanistan veterans. The final chapter frames PTSD within the context of culture, noting the way societal considerations influence the way individuals experience potential traumas, demonstrate the effects of traumas, and are seen in their cultures as victims of trauma. This chapter also cautions the clinician to be culturally informed when trying to help the individual who has experienced trauma.
Because this is a very big book, it is hard to do more than scratch its surface in a relatively short review. Here are a few important points the reader takes away from a careful reading of the text. The use of selective serotonin reuptake inhibitors has been carefully studied and is effective in treating PTSD. However, well-administered psychosocial interventions, when carefully studied, are more effective. These interventions involve cognitive-behavioral techniques and are conducted using manuals. They can use technology. Their goal is cognitive restructuring: reorganizing cognition regarding traumatic stressors, reorganizing the way traumatic memories are experienced and processed.
There are three chapters that are of particular relevance to active duty military and veterans of war. These focus on PTSD in military and veteran populations, on violence and aggression, and on traumatic brain injury (TBI). Because it was the plight of Vietnam War veterans that called attention to PTSD and because the current military and veteran populations are clearly experiencing traumatic stress, these chapters are particularly important. They tell us that exposure to combat makes PTSD more likely, that pressures to deny mental distress within the military culture complicate identification and treatment of PTSD among soldiers, that future violence is a risk factor among soldiers and veterans with combat experience who manifest PTSD, and that all this is complicated by a history of TBI. The way in which PTSD and TBI relate to each other is still unclear, and much research is underway. It is possible that TBI makes PTSD more likely under some circumstances because the soldier with a history of TBI is already at a cognitive disadvantage when experiencing traumatic stress and is then less able to process that stressful event effectively.
It is the responsibility of the reviewer to also point out the way a book might have been better. My first criticism, and I do consider it significant, is that there are no clinical vignettes in this volume. I believe the clinician would have been better served if, in each chapter, there were case reports illustrating the ways patients with PTSD might present the issues in focus. My second criticism is that the psychodynamic issues were not sufficiently discussed. Rage, guilt, grief in the patient, and countertransference in the healer are only briefly mentioned. Psychodynamic psychotherapy is still the treatment of choice for some victims of PTSD and is still an important vehicle for hypothesis building about the condition. I wish that there had been an entire chapter devoted to psychodynamics and PTSD.
Stephen M. Sonnenberg, MD
The Humanities Institute
The University of Texas at Austin
and Baylor Medical College