Post Traumatic Stress Disorder: Diagnosis, Management and Treatment PDF

Foreword

When writing an introduction to an already established text the easiest option is to turn to the first edition and see what has changed over the years. And so never one to turn down the easy route, that is what I have done.

Many things remain much the same, which is reassuring, as one sign of a maturing field is stability. Some problems have not been solved. Diagnostic dilemmas remain, both as a chapter, and as a problem. Neuroscience was the great prospect in 2000, and remains a great prospect today. The sense of optimism conveyed in the final chapters in 2000 is undiminished, and indeed some progress has been made. Neuroimaging has delivered at least some goods, although the hope that this would translate into treatment advances expressed ten years ago remains a hope today. Nevertheless, Vermetten is able to highlight for example a study in which long-term treatment of PTSD with paroxetine increased hippocampal volume, suggesting some neurogenerating actions of 5HT, which if replicated represents a genuine advance. Likewise, using the tryptophan depletion paradigm Professor Nutt's team have elegantly shown that 5HT might be critical to restraining the expression of anxiety in PTSD when treated with SSRIs, although this in turn also takes us back to the issue of comorbidity and whether PTSD is just another shuffling of the anxiety disorder cards, rather than a unique diagnostic and biological entity.

A new and impressive addition is an authoritative chapter on genetics. The concept that hereditary factors might play a role in the etiology of PTSD was a baby thrown out with the 1980 bathwater when they sat down to redraft the DSM and turned their backs on the previous half century of thinking on predisposition, so it is good to see it back in there.

And what about treatment? The chapter on debriefing has gone, now incorporated into a general discussion of early interventions. The reawakening of interest into the older literature that suggested that ordinary people are and remain fairly resilient is starting to influence our approaches and reminds us that sometimes in this area we go round and round, and not always forwards. We have rediscovered what was known a generation ago—that the best immediate mental health interventions in the hours and days after a disaster concern issues such as shelter, safety, information, and communication. It is not necessary to immediately ask, "How was it for you?" while the smoke and dust are literally and metaphorically still settling—because the answers might be curt and unprintable. There are also signs of a more sensible public mental health approach gaining ground—not wasting money on immediate treatments of large numbers of people who are going to get better anyway (and who, as study after study shows, vote with their feet in rejecting formal mental health interventions at that stage), but instead concentrating a few weeks later on the smaller numbers who are still in trouble—the policy of "watchful waiting" followed by "screen and treat" advocated in the UK NICE Guidelines and used to good effect in the aftermath of the London bombs.(1)

So how should we be treating the smaller numbers of those who are still in trouble perhaps some months after the event? The book reflects the fact that differences of opinion still exist here. The final chapter, in which the editors use their prerogative to give their own views, have not changed much over the decade. In 2000 SSRIs are the first-line treatment, and remain so in 2009. But in the equally scholarly psychological treatment chapter Ressler and Rothbaum draw attention to the recent statements from the respected US Institute of Medicine that exposure- based psychotherapy remains the best validated treatment, and just like our own NICE Guidelines, are less taken with the evidence for medications.

In truth most people don't get very much anyway. In our studies of UK veterans with mental health problems the majority never get near a doctor, and when they do they tend to get given antidepressants, followed by counseling.(2) Only a very few will receive the NICE- or IOM-approved "best practice" of trauma-focused therapy. Getting any decent treatment is the challenge.

Perhaps the most challenging chapter comes from Professor McFarlane, writing alone in 2000 but now joined by Devon Hinton, who brings his experience of working in Cambodia to the table. I thoroughly commend this chapter to the reader because it is a thoughtful and wideranging contribution that does not duck some difficult questions. For example, the authors use Robert Hughes's "Culture of Complaint," one of my favorite books (3) to suggest that how society conceptualizes personal responsibility is dramatically influenced by the adversarial tradition. But Hughes also goes on to reflect about the cultural role of the victim, of a person defined not by what he or she does, but by what was done to him or her, and identifies the growth of what he called "victim culture" as a source of concern. Hughes is not alone in having these concerns— influential sociologist Frank Furedi, for example, goes even further.(4) As a specialty we have perhaps had a tendency to ignore views that run counter to our own narrative, so it is refreshing for McFarlane and Hinton to be joining in this debate, as well as reminding us of the need to take a broader historical perspective on what we have done and are doing.

If I have a personal hobby horse (and of course I do), it is to take issue with the view that in the field of posttraumatic stress disorder, we are following an upward trajectory, always moving along the path of knowledge in a Whiggish progress from ignorance to enlightenment. My reading of the historical literature suggests that while this is partly true, it is also true that we have also moved in a more circular trajectory during the past 100 years.

It is a great pity that there is still no real intellectual synthesis of trauma in the 20th century—nor how and why the culture of trauma was transformed in the past two or three decades of the last century. Too often trauma studies that delve into history rely on literature as a primary sources, rather than history. The experiences of Sassoon and Owen were hardly typical of the management of psychiatric injury in the First World War, and their accounts in fiction or poetry were little known the immediate postwar years. Captain W E Johns, the inventor of Biggles, was far more popular and gave a heroic narrative that people wanted to hear. Field Marshall Haig was genuinely mourned when he died, and the fact that he still seats on his horse at the top of Whitehall, looking down on the Cenotaph is not an example of postmodern irony, but a mark of the fact that he was credited with masterminding Britain's military victory. When the now classic First World War play, "Journey's End" was premiered in 1928 its author, RC Sherriff, was shocked when he realized that the production was going to be "antiwar," protesting that he had never intended it to be anything of the sort.(5, 6, 7)

True, the publication of "All Quiet on the Western Front" in Germany in 1929 and then in Britain the following signaled the start of a change. Lloyd George's memoirs started the trashing of Haig's reputation in the 1930s, but the real turning point came in the 1950s and 1960s with Alan Clark's "The Donkeys" followed by the premier of "Oh What a Lovely War" in 1963. The way was then clear for the apotheosis of our current views of the Great War in the person of arguably its now most famous participant, Captain Edmond Blackadder, and in particular the poignant last episode, recently voted the nation's most favorite TV episode.

Our own views on our history have I would suggest also been influenced by the same narratives changes that influenced Richard Curtis and Ben Elton when they created Captain Blackadder. It is time for historians not comedy script writers to reclaim the history of trauma and for us as practitioners and researchers to engage with the real history of PTSD, one free from our own modern conceptions of how it "should have been," but instead how it was. How do we account for the very different view of children's resilience in war time given by Melanie Klein to that of our modern commentators? What about the work of pioneering sociologists such as Quarantarelli whose findings on the outcome of disasters reads so differently from our own? Why, for example, did studies from the First World War seem to report that prisoners of war were largely free from anxiety symptoms, whereas now the same group are seen as particularly at risk?

Just before Ben Shephard published his history of war and psychiatry (8) he agreed to talk about it at a major conference on psychological trauma. I recall the buzz of anticipation before he spoke and then the almost palpable shock once the audience started to realize that he was "not one of us." True, he isn't—but the field needs to engage with historians such as Ben Shephard and Mark Micale (9) just as much as with neuroscientists.

One more new chapter deserves mention. Presumably in response to increasing concerns about the increasing scope and spread of PTSD, and/or its increasingly prominence in the Courts, the editors have requested a new chapter on symptom exaggeration, and a very good one it is. But by focusing on exaggeration, inevitably the agenda has to reflect what are often overstated concerns about the malingering of PTSD (not unknown, but not common either) at the expense of the more interesting and relevant topic of the influences on symptom reporting, both positive and negative.

For example, whenever I interview a soldier, there are always contextual effects on what he, or occasionally she, is prepared to admit to at any given time. On my first trip to an operational theatre I witnessed a Royal Marine trying to board the flight with a broken leg and continuing to deny there was anything wrong even when rumbled. He was a rather more blatant example of the symptom minimization that we encounter each time we visit a base shortly before a deployment to administer health questionnaires. Most soldiers have joined the modern professional armies of the developed world because they want to deploy—for the excitement, challenge, and desire to put their training into reality, and also if they have any career ambitions. It is in their interest to minimize any symptom or problem that might result in them being refused permission to deploy, one more reason why predeployment screening for mental health problems is doomed to fail.(10)

We also see minimization of symptoms if personnel are screened directly on their return from deployment. Military personnel are not stupid, and know that if they endorse too many symptoms then they will be held back in order to be interviewed by a psychologist or psychiatrist, and thus miss their postoperational tour leave. So why should we surprised that in another circumstance, perhaps a year later, when they are planning on leaving the military and/or not wanting to return to Iraq or wherever (been there, done that, time to move on), their thoughts now turn to what happens next and how they might guarantee future health care.

In each and every instance, context is intervening to decide what symptoms will be endorsed, when, to whom, and for what purpose. Soldiers, like everyone else, are not disinterested academic observers of their own condition.(11)

It is evidence like this that calls into question one assumption that underlies a few chapters— that there exists the "real" or "true" level of symptoms, which can be determined either with sophisticated questionnaires now or neuroimaging and/or neurophysiology in the future. I am doubtful if this is possible. Not just reporting, but perhaps even experiencing symptoms might be better understood as a pair of scales, in which there are factors promoting expression, and factors promoting suppression, and what happens at any given time is the result of the balance of the forces operating at any given moment. The fact that that rear-end shunts cause whiplash in Sweden but not in Lithuania is also of relevance to PTSD.(12)

And what about the future? As in the first edition, the editors point to promising avenues of research in the neurosciences and to the prospects of new pharmacological agents. However, a new departure is the discussion of possible pharmacological prevention, as opposed to treatment, of PTSD. This is a topic in which the "man in the street" (at least if journalists are to be believed) expresses doubts, usually because of concerns that this in some way diminishes our humanity, often linked to vague analogies with "Brave New World." If the man in the street knew more about epidemiology and public health he might also point out the differences between treating those who clearly have psychiatric disorders and have come forward for treatment, and treating those who have been exposed to a trauma, most of whom won't develop psychiatric disorder, especially when we as yet we have no robust way of separating out that majority from the minority who will. The balance between risk and harm is very different, something which this author believes will take a long time and some pretty heavy evidence to change. Talk of the "golden hour" in major trauma or stroke care needs to done cautiously, as the analogy is far from exact.

Anyway, the reader who opens this volume can be guaranteed a fascinating, scholarly but still accessible account of PTSD in 2010. A warm welcome then for the second edition, a brief rest for the editors, but then it will be time to start on the third.