International Society for Traumatic Stress Studies

Scholarly Book Review

Posted 27 May 2015 in StressPoints by Reviewed by Janet Osterman, MD

Posttraumatic and Acute Stress Disorders, Sixth Edition by Matthew J. Friedman is a pithy primer on the current knowledge base of posttraumatic traumatic stress (PTSD) and acute stress (ASD) that incorporates DSM-5 revisions with existing evidence based treatments. The challenge to identify how the DSM-IV and DSM-IV TR evidence base interdigitates with DSM-5 revisions to both PSTD and ASD is successfully met with cogent discussions.

The text contains six focused chapters that address critical issues for clinicians with tables that concisely summarize key points. Each chapter follows the old teaching adage of tell the students what you will teach, teach, and tell them what you taught with its use of a brief introduction, detailed material, and a succinct summary. Chapters are well referenced allowing the reader to find source information to make his or her assessment of the presented materials.

The first chapter provides an overview of PTSD including the evolution of its diagnostic nomenclature, the multiple faces of trauma and its impact that address resiliency factors, as well as states of illness and recovery (chronic, remission with relapses, and sustained remission). This model sets the tone for the student of trauma that moves beyond the lay belief that when terrible things happen, people are forever damaged. Dr. Friedman provides hope for the treaters, the patient/client, family members, and the community that recovery is the norm and that most people who develop PTSD may have a productive and meaningful life.

Chapter two defines diagnostic criteria using current DSM-5 constructs for both adult and childhood PTSD. The first few tables are well-organized and allow for a quick resource for the DSM-5 symptoms that are later expanded upon with relevant clinical vignettes. The later tables give cogent clinical examples for each of the diagnostic criteria to assist the reader in to develop a comprehensive understanding of the multiple criteria to make an accurate diagnosis. Risk factors are identified and given a contextual context as to their true validity. Tools for assessment are identified with the caveat that these are based on prior diagnostic criteria, but at present may be helpful until revisions are made and validity is established. The last section addresses co-morbidity and other diagnostic outcomes for psychological trauma independent of PTSD with a special notation to developments in knowledge of traumatic brain injury.

The next three chapters focus the reader on treatment beginning with overarching treatment issues (chapter 3), psychological treatments (chapter 4), and psychopharmacological treatments (chapter 5). Each of these chapters clearly identifies where the evidence base is strong, weak, or not yet determined. Chapter three begins with the query of “why now” that clinicians often face when someone presents for treatment that is not always explicitly known to the treatment seeker or clinician. Dr. Friedman aptly describes a clinical situation where the presentation is linked to a trauma trigger that might evade the treatment seeker or clinician. Potential emergencies are noted that should result in more intensive treatments. He then gives an overview of treatment options for PTSD and identifies co-morbidities and their treatment options. While identifying the paucity of evidence base for how best to manage PTSD and substance use disorder and the need for a stronger evidence base for these common co-occurring disorders, the recommendation for an approach that has early evidence needs further exploration and references before a strong recommendation is made. A discussion of the family/work/community environment and cultural factors follows with the chapter ending with clinician issues including countertransference, advocacy versus neutrality, vicarious traumatization and the essential need for self-care.

Chapter four is a comprehensive presentation of psychological treatments that range from peer recovery resources to highly tested, evidence based treatments. Treatment for adults and for children/adolescents is discussed separately because age is an important variable in the current evidence base for treatment. Dr. Friedman gives a balanced overview of all treatments, noting again where the evidence is strong or not yet known with detailed references so that the reader can determine the potential use of a therapy for his or her patient/client and/or family.

The psychobiology of trauma, both in its adaptive and maladaptive states, are reviewed with excellent easy to understand drawings that depict the human stress response and identify the brain abnormalities that create problems for the person with PTSD. Pharmacological treatments and the strength of the evidence follow both in a chart format and more detailed discussions by drug class that will assist both prescribers and non-prescribers in his or her knowledge of the potential role of medications in treating PTSD. A brief overview of genetics and epigenetics that touches on the very early constructs in resilience and prevention concludes this chapter.

The final chapter shifts from PTSD to ASD and the emerging knowledge of its treatment that may serve as a prevention for PTSD that may become a chronic condition or a relapsing-remitting disorder, both of which adversely affect a person’s and their family’s quality of life. Dr. Friedman develops a construct for the reader of normal reactions to overwhelming events, using real life clinical examples from 9/11 civilians and from post 9/11 military experiences to define an acute stress reaction and combat operational stress reactions, respectively. The strengths and weakness of immediate interventions, including Psychological First Aid and Psychological Debriefing (civilian) and military approaches to psychological debriefing, are thoughtfully presented and discussed. Acute Stress Disorder is defined in DSM-5 terminology, its risk factors elucidated, its assessment, and treatment are presented, again with the evidence base and references for further exploration by the reader.

In sum, this is a well-written, concisely comprehensive book that is likely to be useful for students of trauma and their teachers who wish a succinct text on assessment and treatment for PTSD and ADS. It is an excellent resource for students across areas of mental health and for early psychiatry residents to serve as bedrock for the current state of knowledge of PTSD and ASD to further his or her exploration and learning. The extensive references enhance its value to serious students of trauma.