PSYCHOTHERAPY OF THE COMBAT VETERAN
Harvey J. Schwartz, M.D., Ed.New York, Spectrum Publications, 1984
Distributed by: Integrated Publishers, 195 McGregor St., Manchester , NH 03102, 603-669-593

Freedman, MD, Noah D.

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Psychodynamic Contours of Post-Traumatic Stress Disorder

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Psychodynamic Contours of Post-TraumaticStress DisorderPSYCHOTHERAPY OF THE COMBAT VETERANHarvey J. Schwartz, M.D., Ed.New York , Spec t ru m Publi cation s, 1984Distributed by: In tegrated Publisher s, 195 McGregor St.,Man chest er , NH 03102 , 603-669-5933Noah D. Freedman, M.D.In Psychotherapy ofthe Combat Veteran, Harvey]. Schwartz, M.D . offers th e readera n intellectually challe nging but rewarding journey throu gh a psychodynamic ex plo-ration of the " wa r neuroses." Though th e conce pt of a post-t rauma tic stress di sorder(PTSD) was noted by Dr. Schwa rtz to have occurred in th e lit era tu re by 1978, and itwas ens hrine d in the DSM III in 1980, th e work in this volum e lift s th e veil of thepurely descriptive approach to explore th e psych odynamic con tours of the top ic. Dr.Schwartz has assembled many aspect s of th e lit erature includi ng th e hist ory oftraumatic neu roses, sleep research , psych o-pharmacology, gro up therapy, bri efth erapy, psychoanalytic psychotherapy, prevention, a nd a n investiga tion of th e effectsof th e broader social environme nt.Schwartz frames th e book with a n exce lle n t int roduct ory cha pte r th at se ts ou tth e volume's main tasks: (I) an investigation of th e psych ological effec ts of massivetrauma, including th e interaction of overwhelming ex ternal eve n ts wit h underlyinginfantile conflicts or fantasies; and (2) a n explora tion of wha t an effective " holdi ngenviro nmen t" may be for th e suffere rs of PT SD.Thes e tasks are accom plish ed with a fin e coll ec tion of ar ticl es which re vie w pastlit erature and present original formulation s. Transferen ce and count ert ransferencein work with severe ly traumatized patients are add ressed by Sha piro and in twoarticles by Schwartz. Blitz and Greenberg postulate a n a pproach to d rea m mat eri alrelated to conce pts of se lf psychology. Most helpful to m e were t he ab undant caseexa m ples in this volume, whi ch provided vivid glim pses of th e psych ot he rapeut icwork . Those who have had some ex pe rience wi th t ra uma survivors a nd ca n a pprec ia teth e abstract nature of psychodynamic lit era ture will be able to ex t ra ct useful pointersfor the direction and pitfalls in psych odynamic psychoth erap y with sufferers ofPTSD.Dr. Schwartz presents several cases including a/p a rt icula rly moving study of asevere ly di ssociated patient ca ugh t up in relivin g a n overwhelming trau ma tic experi-Noa h Fr eedman , M.D . is a PGY-IV res ident in psychiat ry a t T ho mas J efferson Universi tyHospital in Phil ad elphia.74BOOK REVIEWS 75e nce . H e evoca t ive ly describes th e counte r t ra nsfe re n t ia l as pec ts of his work with thispatient, who worked with mutilated bodies in th e gra ves registry.T hroughout this volume, especia lly in th e work of Drs. Schwa rtz and Blitz andGreenberg, it is made clear that a holding enviro nme nt need s to be created in whichthe pa t ien t is ab le to wor k through th ese traumatic even ts a nd feelings a nd have th einfant ile conflicts th ey evoke work ed through in th e transference. O f course ea chtreatment must be tai lored to each patient, how ever, it seems clear tha t to avoid th epast trauma is denigrating to th e patients who often find th emselves re living it in th epr esent. This leads to th e necessity of abreactive work to allow a ll th e fee lings evokedinto th e treatment frame. Given th at lon g-t erm psychothera py is not econom ica llyfeasible for th e majority of trauma sufferers, Dr. Schwa r tz sugges ts cu ltural means,such as th e mythology of th e revered warrior, th at may be used to cre a te a symbolicenvironme nt whi ch could welcome vet erans ba ck int o th e community .D rs. Moses and Cohen, in a pap er di scussin g Isr aeli milit a ry expe rience overfour decades , del ineate usefu l preventive measures as well as immed iate, sho rt-term,and long-t er m posttraumatic interventions.The psychobiologi ca l resea rch described in thi s 1984 volume has been partiallysupersed ed in recent years . Studies in th e psychobi ology of memory hav e led togreate r awa re ness of how memory may be st ruc tu re d beyond the cog nit ive levels ofth e ce re bra l cortex. Sp ecific che mical pr ob es are now on the verge of elucida t ingmore pr ecise means for a lleviat ing or provoking va rious as pects of PTSD . Thedissociative as pects of flashbacks are being carefully described and provoked inexpe rime n ts whi ch indicate that individuals may be suffe r ing from eithe r a serotoner-gic or noradrenergic dysregul ation (1,2,3). Other neu rotran smitt ers are a lso invo lved(4,5,6). .Another weak point in this volume is th at th er e is little discu ssion of th eph enomenon of dissociation, other th an as sim ply a defen sive as pe ct of the ego.Recent work by C arden a (7) has demon strated th at trauma ca n di rectly provokedi ssociative expe rie nces in it s victims . Spiegel has investiga ted th e use of hypn osis(which he views as a con trolled di ssociat ion ) to enable pa tien ts to gai n mastery overtraumatic di ssociation (8).Thou gh an ea rly con t ribut ion to th e mod ern lit e ra ture on trauma, thi s bookoffe rs many valuabl e insights into psych otherapeutic work with pa t ients (not onlycom ba t vet erans) who suffer from post-traumatic st ress disord er. Dr. Schwartzpr esents com plex, thought-provoking mat erial with pr ofound respect for those whostill suffer th e effec ts of wartime trauma.NO TESI. Brem ner JD, Sout hwick SM, Brett E, Rosenheck RA, Fonta na A, Ch arney DS: Increaseddissociat ive states in PTSD . Present ed at 1993 Co nvention, Am eri can Psychi atric Associa-t ion , Sym pos ium # 522. Kr yst alJH, Sou thwick SM, Ka rper LP, Brem nerJD, Charney DS: The eme rg ing neurobiol-ogy of dissocia t ion . Presented at 1993 Convention, Am eri can Psychia t r ic Associati on ,Sym pos ium # 5276 J EFFERSO N J O URNAL OF PSYCHIATRY3. van d cr Kolk BA, Levin P, Du cey C : Fluoxe tine a nd int egration of traumatic mem ori es.Pr esented a t 1993 Co nvent ion, Am erican Psychi a tric Associat ion, Symposium # 524. van der Kolk BA, Fis ler RE: The biologica l basis of post- t rau m ati c stress. Primary Care; Clinicsand Office Practice 1993; 20(2) :417-325. Pitman RK , va n der Kolk BA, O rr SP, G ree nb erg MS: Na loxone-reversible an algesicresp on se to comba t-re la te d stim uli in posttrauma ti c st ress di sorder. A pilot st ud y. Arch ivesof Ge ne ral Psychi atry 1990; 47(6):541-46. van der Kol k BA: The com pulsio n to re peat t he tr au ma . Reen act m ent, revictimization , andm asochi sm . Psychi atric C linics of North Am erica 19H9; 12(2) :3H9-4 117. Carde na E, Spiege l D : Dissociative reaction s to the Sa n Fran cisco Bay ea rt hq ua ke of 1989.Am erican] Psychi at ry 1993; 150(3):474- 88. Spiege l D: Hypnosis in th e t reat men t ofvic t ims of sex ua l abuse . Psychia t r ic C linics of Nort hAmerica 1989; 12(2) :295-306

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Psychodynamic Contours of Post-Traumatic Stress Disorder

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