Posttraumatic Stress Disorder

by Chris R. Brewin
Yale University Press, 2003
Review by Mark S. Roberts, Ph.D. on Oct 19th 2004

Like fugue, Munchausen by proxy syndrome, ego-dystonic homosexuality, and numerous other indeterminate or transient psychological disorders, post-traumatic stress disorder (PTSD) has been complicated and obscured by a slurry of external "stressors," many of which are political, social and economic in nature. Chris R. Brewin, a professor of psychology at the University College London and a PTSD experimenter, has attempted to analyze and clarify these external factors, and to find, in the end, some workable, generally acceptable definition of and functional treatment for PTSD. Brewin's work has been largely successful, but, I believe, not without having to overcome enormous difficulties.

The difficulties Brewin faces are not by and large of his own making. Unfortunately, his principal resources in the field are often at odds with one another and the disorder he tries to isolate and clarify has a long tradition of medico-psychiatric construction, myth-making, historical misreading and socio-political and economically biased misinterpretation. What has become the standard text in the field, Allan Young's The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (1995), amply demonstrates many of these difficult problems. In brief, Young argues that grief, fear, trauma and the like are common age-old problems that surfaced throughout history in a variety of forms and for a variety of reasons. He goes on to suggest that it is only in the modern era, largely due to the rise of diagnostic precision, institutional exigencies, and sophisticated medical experimentation, that these common sufferings take on a "disordered quality." On this, he writes: "The disorder (PTSD) is not timeless nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated, and represented and by the various interests, institutions, and moral arguments that mobilized these efforts and resources" (Young, p. 5). But what even further complicates this extraordinarily complicated construction is the fact that PTSD is experienced as real and that real people suffer terribly from it: "If, as I am claiming, PTSD is a historical product, does this mean that it is not real? Is this the significance of the books title? On the contrary, the reality of PTSD is confirmed empirically by its place in people's lives, and by the personal and collective investments that have been made in it" (pp. 102-3).

So, according to Young, Brewin is already faced with a disorder that is both constructed historically, "glued together" by numerous external factors, and which is real and causes terrible pain and suffering to those who are diagnosed with it. The inconsistency is not easy to overcome. Brewin, as a working clinician, begins by trying to flesh out the DSM definition of the disorder, presenting this definition as informed by practical concerns and based on "traumatic events" having "certain objective characteristics," such as involving actual or threatened death or serious injury, but also as having those events produce a reaction of either intense fear, intense helplessness, or intense horror. These symptoms, he notes, are also associated with many other disorders, and therefore subject to considerable interpretation. Consequently, this general definition, which carries considerable weight in Brewin's analysis of the disorder, is plagued by the intrusion of vast array of different symptoms, etiologies, theories and treatment modalities.

Effectively, the better part of Brewin's work is devoted to both analyzing and clarifying this extraordinarily broad set of disparate interpretations of the disorder, and, much to his credit, to adding something of his own clarified definition and treatment modalities to the slurry. Following the abovementioned lucid and cautious analysis of the DSM-IV definition of the disorder--one concerned to demonstrate the external "stressors" involved in DSM decision making--Brewin moves on to discuss PTSD's relation to trauma. His point is quite clear: trauma has a definite place in PTSD, but the analysis of the disorder is largely obscured by the fact that trauma is common to many, many disorders, and, one should add, to many normal reactions and experiences as well. He thus concludes that, although trauma is clearly manifest in almost all cases of PTSD, it is not a specific enough affect to effectively demonstrate the etiology of the disorder. However, for Brewin, trauma is a valuable starting point for the analysis of PTSD, since trauma itself involves a number of readjustments to life, which, in turn, involve questions of self-identity and meaning.

One of the most striking enigmas of PTSD reaction, according to Brewin, is the fact that some people are deeply wounded, that is, appear psychologically scarred, while others appear quite unaffected. He attributes this contrasting reaction to whether the sufferer undergoes a change in his or her sense of self. PTSD is, then, seen as similar to disorders such as depression, where the sufferer experiences abrupt "challenges to fundamental assumptions and beliefs." Loss, humiliation, or betrayal, common feelings associated with PTSD, tend to lead to "intense rumination" on self-identity, human relationships and chains of causation. This leads Brewin to suggest that a thoroughgoing analysis of self-identity is quite crucial to the full understanding and future remediation of PTSD. Briefly stated, there are two primary psychological ways of looking at self: First, the schema theory, and, second, the idea of multiple selves. In the first instance, certain researchers argue that humans follow schematic interpretations of ongoing events. These schemas represent certain core beliefs, and serve as means by which to make certain moral choices. In effect, they are ways in which the individual patterns and correlates certain feelings and experiences. The second way of viewing the development and constitution of the self is the multiple self concept. This concept involves an approach which argues that the self is not unitary in nature, but, rather, is composed of a collection of multiple selves, that is, selves experienced at different times and in different contexts. Naturally, these various selves have differing moral characteristics, and the individual usually envisions these various selves in terms of acceptable or unacceptable behaviors. Given the fact that self is constituted in a complex, non-monolithic way, dependent by and large on various memories, time frames, biological factors, and images, Brewin argues that PTSD represents not a complete collapse and flattening of the self, but, rather, distortions of certain aspects of the self--distortions that can be leveled, rebuilt, replaced, reframed and generally remediated.

Since the very idea of self is abstract, consisting largely of theoretical constructs, Brewin moves on to explore what one might consider more concrete dimensions of the PTSD phenomenon. Among these dimensions he includes emotional memory and brain trauma. Emotional memory, like almost everything else associated with PTSD, can be enigmatic and daunting. The central problem consists in the fact that traumatic memories can be recalled both better or worse. This seemingly contradictory phenomenon is explained by Brewin as follows: "As events begin to increase in emotional intensity, central details are retained longer, often in the form of a visual image, and peripheral details are worse recalled. But there seems to be a point at which the intensity of the emotion interferes with the clarity of recall, with the result that memories become fragmented and disorganized" (pp. 102-3). The answer to the conundrum, Brewin suggests, lies in a more nuanced description of these two types of memories, one that focuses on biological processes associated with extreme stress.

The advantage of biological theories of memory recall is that there are observable variations in certain neurobiological levels in the brain, which, in turn, can be read with somewhat greater objectivity than, say, how an individual goes about constructing a self-image. Brewin thus covers a fairly large number of neurobiological theories in view of clarifying the welter of contradictory feelings and experiences associated with PTSD. In the end, he sees a possible solution to these perplexing trauma experiences in the fact that there are two distinct memory systems at work in the brain: VAM and SAM systems. VAM stands for "verbally accessible memory" system, which involves the integration of trauma memories with other autobiographical memories and are thus capable of being retrieved as and when required. SAM stands for "situationally accessible memory" system, and thus differ from VAM memories in that they are composed largely of non-verbal data processed during the occurrence of some traumatic event. In concluding the section on biological theories of memory, Brewin proposes that this double memory system provides an answer to some of the troublesome inconsistencies associated with PTSD. The answer, he suggests, lies in the fact that this sort of research indicates that there is "an important distinction in memory between higher-level information about traumas and the largely perceptual data." And, ultimately, this distinction is "central to the question of how therapy works for PTSD" (Young, p. 127).

In something of a reversal from the more or less reliable data and theoretical modeling associated with neurobiological studies, Brewin eventually wades into the contemporary quagmire of recovered memory. As is well known, recovered memory has been the subject of enormous controversy, both in the clinical and therapeutic settings. Regarding the latter, much has been asserted, and stridently refuted, about the process of memory recall, its probity, and the ultimate effects such recall has on the subject. In the clinical setting, much has also been said about the nature of memory recall, and, as is the case with therapeutics, much has been stridently refuted. It is to Brewin's credit that he tries to make some sense of the data regarding this controversial phenomenon. In the end, he provides a workable overview of the phenomenon, stating that there is some truth to the claim that some recovered memories do not correspond to real events. But, on the other hand, some do. This is further complicated by the findings of memory theoreticians and experimental researchers in the field who claim that the recall of events that have not actually happened is more likely when similar events actually occur. The solution, for the time being, Brewin argues, is to be extremely careful when dealing with recovered memories, since there may be numerous outside factors--particularly, experimenter or analyst biases--that falsely indicate the memory is attached to some real event that explains the subject's suffering.

In the following chapter, caution about recovered memory extends to the question of repression, a constant companion to recovered memory phenomena. Here Brewin demonstrates a reasonably good grasp of the history of repression as a theory, particularly as it evolved through Freud's work. Much to my liking, he is quite dismissive of those authors who out of hand dismiss Freud's theory of repression. Of special interest here is his critique of Frederick Crews' wildly speculative writings on Freud, which Brewin characterizes as awash in largely unsubstantiated claims about repression. This attack on Crews, however, does not mean that Brewin fully accepts Freud's theory. On the contrary, he is himself quite critical of Freud's view, but bases the criticism on a fundamental uncertainty in Freud's idea of repression, that is, the confusion of repression with forgetting. Besides, he faults Freud for not having produced much in the way of evidence as to what exactly happens in repression, and, perhaps most important, why repression differs significantly from just plain forgetting. The distinction of course is crucial to the prevention and treatment of PTSD, since inaccessible (repressed) memories of trauma would drastically change how one could reveal the contents and the various pathways of traumatic memory recall.

In the final two chapters, Brewin gets to the core of his project: prevention and treatment. In some respects these two goals are interrelated. Prevention requires scientifically sound and accurately targeted treatment, and vice versa. Brewin calls his program of remediation Screen and Test. This involves "careful monitoring of survivors' symptoms and referral for treatment only when symptoms are failing to subside mentally" (p. 205). Interestingly, Brewin, in taking the above position, tends to argue against preset, traditional models of treatment, proposing that the imposition of these type models often tends to restrict recovery rather than facilitating it. So does, in certain cases, early intervention. Much time and energy can be wasted on this sort of action, while the patient may not be demonstrating a true risk. Intervention, Brewin stresses, is really only necessary with victims who have not adapted. If all goes well, then, in the Screen and Test program, the ultimate goal would be to bring the victim back to some semblance of normalcy, though Brewin is not so naïve to think that the fear, horror and pain of trauma will go away forever. In questions of remediation he remains a realist: "Some positive illusion will have gone for good, and the trauma is always likely to loom large in their personal history. Therapists, however, can aspire to helping such people return to normal hopes, normal pleasures, and normal feeling and experience the freedom to think, behave, and make choices unconstrained by fear" (p. 207).

In the end, two questions emerge regarding Brewin's book. First, is it a significant addition to work done in the field, particularly Allan Young's definitive text, The Harmony of Illusions? Second, is, as Brewin indicates in the title of his book, PTSD a malady or a myth? The first question can be answered in the affirmative. Young's book is composed along the lines of a sociological and anthropological analysis of the disorder, and his method could be called critical/historical, following the designation given to the work of constructivist schools of thought, particularly those associated with the work of Michel Foucault. In this regard, much of the material in Young's work delves into the discrete origins and evolution of medical complaints, symptoms, conditions, etc. that emerge within the social, economic and historic extensions of medicine. In short, Young views the disorder from the outside, as would an anthropologist noting the various rites and rituals of a tribal culture. Moreover, not being a psychologist, he does not strongly emphasize the everyday clinical data and methods applied to PTSD sufferers, though he does present a number of the more traditional clinical practices. Brewin, as a working PTSD researcher, is able to lay out the various investigations applied in the field, and, at the same time, add his own views to the mix. The book does not only deal with the historical exigencies of the disorder, but also presents practical strategies for its remediation. Thus the work, though written in the wake of books like The Harmony of Illusions, most certainly makes a significant contribution to the literature in the field of PTSD research and treatment.

The second question posed, Is PTSD a malady or a myth? is a bit deceptive. There is no single definitive answer. On the one hand, PTSD has a long history of myth, beginning in the nineteenth century, when trauma was scientifically classified and studied by the European experimental schools, especially that of Charcot and his followers. The ravages of war, of the pain and suffering demonstrated by returning veterans, the various complaints of railway accident victims, and so on were all largely attributed to the effects of some vague, indefinable notion of trauma. Trauma, in effect, became the basis for virtually all mental suffering. But, for Brewin, this legacy of myth, myth-making, and superstition must be cast off. PTSD will never be given proper attention if practitioners and experimenters continue to incorporate the myths into their research and treatment. "If we are to apply wisely our new understanding of this nineteenth-century malady, we must avoid all forms of myth-making. . .The challenge we face in furthering scientific knowledge of PTSD and deploying it in the real world demands something of the same flexibility and resourcefulness shown by survivors suddenly confronted with the unexpected, the unwanted, and the unimaginable" (224). Given the respect and compassion Brewin's work shows toward the sufferers of this mysterious disorder, it will, I believe, go a long way toward remediating its unexpected, unwanted and unimaginable effects.

Mark Roberts, Ph.D., is co-author with David B. Allison of Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome, (Analytic Press, 1998).

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