DOI: 10.1097/01.nmd.0000106005.23648.12
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Issn Print: 0022-3018
Publication Date: 2004/01/01
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Excerpt
Psychiatric problems that commonly arise in response to adversity have been relatively slow in gaining formal recognition and professional acceptance. The reluctance to include psychiatric conditions consequent to stress within official diagnostic nomenclatures can be explained in part by the nature of the clinical phenomenon itself. The symptomatic presentation can be quite protean and varied, often alternating between extreme sensitivity and overwhelming affects through emotional numbness, denial, and outright dissociation. Such problems are also commonly comorbid with other psychiatric conditions, compounding the difficulty of specifying the phenotype precisely. Given such dynamic variation in core symptoms and overlap with other diagnostic entities, it is not hard to envision how the heterogenous group of stress response syndromes might be slow to come into clinical focus and to gain independent diagnostic status.
The hesitation to embrace stress response syndromes formally, however, may also stem from the vexing challenges such conditions pose for understanding etiology, and in particular for satisfying the DSM desideratum of differentiating “merely an expectable and culturally sanctioned response to a particular event” from psychiatric disorder (American Psychiatric Association, 2000). Although one aspect of etiology is obvious (ie, the stressor), it is not so apparent why some people break down and others do not in the face of apparently similar adverse conditions. And as one descends the gradient of adversity—from the horrors of war and other extreme traumas through the more common, yet often psychologically destructive, losses and disappointments of everyday life—the dividing line between the normal and the abnormal, the understandable and the pathologic response, becomes especially difficult to detect (or even arbitrarily to draw). This situation, too, has presented obstacles to recognizing formally the stress response syndromes.
Fortunately, over the past few decades, astute theoreticians and clinicians have been able to see past such obstacles and to recognize the need for helping people who suffer from a variety of psychologic problems after exposure to severe stress. Mardi Horowitz, the author of this book, has been at the forefront of theory and research in this arena for approximately 3 decades, and has extensively written about and investigated the nature and treatment of stress response syndromes. The present diminutive volume represents a very readable and useful distillation of ideas, data, and clinical practices pertaining to these all too prevalent psychiatric disorders.
The structure of the book reflects the range of responses that can occur after exposure to severe stress and that constitute the stress response syndromes. The clinical presentations do not fit tidily with existing diagnostic nomenclature. Rather, as described by the author, they cut across current DSM diagnostic boundaries, spanning such traditional diagnostic categories as posttraumatic stress disorder, acute stress disorder, adjustment disorder, substance abuse disorder, major depressive episode or disorder, complicated grief disorder, generalized anxiety disorder, panic disorder, and phobic disorder precipitated by major life stressors. People with personality problems also may experience flare-ups of symptoms when confronted with severe stressors, particularly when the stressors echo themes of past adverse experiences (eg, childhood trauma). The common core uniting these diverse presentations is the intricate interplay between intrusion and avoidance of stress-related emotions and memories exhibited by the person, both contemporaneously and over time. The general structure of the book makes good sense in terms of focusing on the triggering circumstances of the problem (ie, response to serious stress) and then more extensively describing the myriad consequences for symptom presentation, coping, and social functioning.
