Stress Response Syndromes (4th Ed)

American Journal of Clinical Hypnosis,  Apr 2003  by Hollander, Harriet E

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Stress Response Syndromes (4" Ed). Mardi J. Horowitz. Northvale, NJ: Jason Aronson (2001). 451 pages, $50.00. Reviewed by Harriet E. Hollander, Ph.D. Princeton, New Jersey

How does psychotherapy evolve to incorporate new research findings and changes in clinical practice? Mardi Horowitz, a practicing psychiatrist, and a professor at the University of California, San Francisco, sets himself the task of integrating psychoanalytically oriented psychotherapy, with the stresses caused by traumatic life crises and loss, into work with the self system of individuals diagnosed with different psychiatric conditions.

The treatment approach is based on a psychodynamic-cognitive model emphasizing interpretation and insight. Treatment interventions are designed to help clients with previous histories of adequate adjustment as well as those with a history of depression or narcissistic personality disorder who must struggle with the aftermath of trauma and/ or complicated grief. Composite case histories illustrate treatment. The book expands on the experience associated with symptoms of posttraumatic stress disorder and the phases of mourning.

The author assumes a bio-psychological mind-body view, though his book emphasizes the psychosocial meaning of trauma and grief. He theorizes that intrusive symptoms of trauma are held in active memory in a dysfunctional state. Active memory in trauma fails to instigate the next step of cognitive processing. Trauma memory therefore remains vivid and intrusive. Dr. Horowitz considers that his psychodynamic version of active memory and inactive memory corresponds to neurophysiological concepts of short and long term, explicit and implicit memory.

Hypnotic interventions are not considered in this framework. There is a passing mention of how desensitization procedures might be utilized during a revisiting of trauma. The transcript of a therapy session briefly alludes to the use of relaxation to block or desensitize painful imagery during a therapeutic reliving of a traumatic event.

Posttraumatic Stress Disorder is refrained in the larger context of psychoanalysis. The author notes that the concept of trauma has been around for millennia, although its origin in recent times can be traced to Charcot, Breuer and Freud. The author equates Freud's observation that trauma tends to repeat itself with the concept of repetitive flashbacks. Repetitions can also take the form of intrusive states and unbidden images. Nightmares are an example of repetition through dreams.

Trauma is followed by both repetitions or flashbacks, and numbness and denial. The author conceptualizes these sets of symptoms as alternating or phasic in character. The phasic nature of intrusion and numbness is interpreted in treating symptoms of PTSD during treatment. A focus on the desired state of equilibrium is suggested as a way to break through the impasse of alternating intrusion and numbness states. Hypnotherapists will recognize this approach as analagous to suggestions for current and future orientation in treatment of trauma.

The author devotes a chapter to delineating the life events that give rise to PTSD. Drawing from the clinical literature, he reviews the impact of military combat, the experience of concentration camp victims, the life in the middle of death experiences of the populations of Hiroshima and Nagasaki, railway disasters, rape, serious personal illness, dying and bereavement.

The author reviews the phases of grief and mourning in the context of Posttraumatic Stress Disorder. Going beyond diagnostic symptoms of PTSD the author describes shame, guilt, depression, alienation, and in the case of grief, irrational urges to find the lost person, sense of internal loss, and identity changes.

The discussion of how grief and trauma affect the sense of self is particularly illuminating. The internal self-system of beliefs and expectations that is destroyed by trauma requires a therapeutic process that the author calls "re-schematization." For some persons, trauma can diminish self-esteem and competence while increasing dependency; for others, dire events lead to growth, while in some cases adult traumas repeat and reactivate childhood traumas.

The author takes grief and mourning as a special example of the need for reschematization. His exploration of grief and mourning and treatment for the bereaved individual is sensitive and deeply insightful. He draws a parallel between intrusive imagery in trauma and the unexpected visual and auditory imagery that may occur about the deceased. Blocking or numbness in PTSD is compared to the failed attempts of the bereaved person to recall memories about the deceased. The mourner may want to cry but cannot.

The author builds on the work of Pollock in describing the phases of the mourning process. He suggests parallels with PTSD. Phases of mourning include denial and avoidance of loss, anxiety, restlessness and irritability as occurs in PTSD. Particular to the mourning process is anger and guilt, feelings of internal loss, and adoption of aspects of the personality of the deceased, and eventually acceptance and resolution.