Psychodynamic Contours of Post-T raum atic
Stress Disorder
PSYCHOTHERAPY OF THE C O MBAT VETERAN
Harvey J. Schwar tz, M.D ., Ed.
New York , Spec t ru m Publi cation s, 1984
Distribut ed by: In tegrat ed Publish er s, 195 McGregor St.,
Man ch est er, NH 03102 , 603-669-5933
Noah D. Freedman, M.D.
In Psychotherapy ofthe Combat Veteran, Harvey]. Schwartz, M .D . offers th e reader
a n int ell ectuall y challe nging but rewarding j ourney throu gh a psycho dynam ic ex ploration of the " wa r neuroses." Though th e conce pt of a post-t raum a t ic stress di sord er
(PTSD) wa s not ed by Dr. Schwa r t z to have occurred in th e lit era tu re by 1978, a nd it
was ens hrine d in the DSM III in 1980, th e work in this volum e lift s th e veil of t he
purely descriptive approach to explo re th e psych od yn amic con tours of t he top ic. D r.
Schwartz has as sembled m any aspect s of th e lit erature includi ng th e hist ory of
traum atic neu ro ses, sleep research , psych o-pharmacology, gro up t he ra py, bri ef
th erapy, psychoanalytic psychotherapy, prevention, a nd a n investiga ti on of th e effects
of th e broad er socia l environ me n t.
Schwartz fram es th e book with a n exce lle n t int roduct ory cha pte r th at se ts ou t
th e volum e's main tasks: (I) a n investigation of th e psych ological effec ts of massive
trauma, including th e int eraction of overwh elming ex t e rnal eve n ts wit h underlying
infantile conflicts or fantasies; and (2) a n explo ra tion of wha t an effective " ho ldi ng
e nviro nmen t" m ay be for th e suffere rs of PT SD.
Th es e tasks are accom p lish ed with a fin e coll ec tio n of ar ticl es which re vie w p ast
lit erature a nd present origina l formulation s. Transferen ce a nd co unt ert ransference
in work with se ve re ly traumatized patient s are add ressed by Sha piro a nd in two
articl es by Schwartz. Blitz a nd Greenberg postulat e a n a pp roach to d rea m m at eri al
relat ed to conce pts of se lf psych olo gy. Most helpful to m e were t he ab undant case
exa m ples in this volum e, whi ch provid ed vivid glim pses of th e psych ot he ra pe ut ic
work . Those who have had som e ex pe rie nce wi t h t ra u ma survivors a nd ca n a pp rec ia te
th e abstract nature of psychodyn amic lit era ture will be able to ex t ra ct useful point ers
for the direction and pitfalls in psych od yn amic psychoth e rap y wit h sufferers ofPTSD.
Dr. Schwartz presents several cases including a/p a rt icula rly moving st udy of a
seve re ly di ssociat ed pati ent ca ugh t up in relivin g a n overwhelm ing trau m a tic experiNoa h Fr eedman , M.D . is a PGY-IV res ident in psychiat ry a t T ho mas J efferson Universi ty
Ho spital in Phil ad elphia.
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BOOK REVIEWS
e nce . H e evoca t ive ly describes th e co u nte r t ra nsfe re n t ia l as pec ts of his work with this
pati ent, who worked with mutilat ed bodi es in th e g ra ves registry.
T hroughout this volum e, especia lly in th e work of Drs. Sc hwa r tz and Blitz and
Greenberg, it is made clear that a holding e nviro n me nt need s to be created in whi ch
t he pa t ien t is ab le to wor k t hrough th ese traumatic eve n ts a nd feelings a nd have th e
infant ile co nflicts th ey evoke wo rk ed through in th e transference. O f co u rse ea ch
treatm ent must be tai lored to each pati ent, how ever, it seem s clear t ha t to avoid th e
past trauma is d enigrating to th e pati ents who oft en find th emselves re living it in th e
pr es ent. This leads to th e necessity of abreactive work to a llow a ll th e fee lings evo ked
into th e treatment fr am e. Giv en th at lon g-t erm psych othera py is no t eco nom ica lly
feasible for th e majority of trauma sufferers, Dr. Sc hwa r tz sugges ts cu ltural means,
suc h as th e mythology of th e revered warrior, th at may be used to cre a te a symbolic
e nviron me n t whi ch could welcom e vet erans ba ck int o th e commun ity .
D rs. Moses and Coh en, in a pap er di scu ssin g Isr aeli m ilit a ry expe rie nce ove r
four decades , d el ineat e us efu l preventive m easures as well as imm ed iat e, sho rt-t erm ,
and lo ng-t er m posttraumatic int erventions.
The psychobiologi ca l resea rch described in thi s 1984 volu me has been partially
supersed ed in recent years . Studies in th e psych obi ology of m em ory hav e led to
g reate r awa re ness of how m emo ry may be st r uc t u re d beyond t he cog nit ive levels of
th e ce re bra l cortex. Sp ecific che m ica l pr ob es a re now on t he verge of elucida t ing
more pr ecise m eans for a lleviat ing or provoking va rious as pe cts of PTSD . Th e
dissociative as pects of flashback s are bei ng carefully d escribed and provoked in
expe rime n ts whi ch indicat e that individu al s may be suffe ring from eit he r a seroton ergic or noradrenergic dysregul ation (1,2,3). Othe r neu rotran smitt ers are a lso invo lved
(4,5,6).
.
Another weak point in this volum e is th at th er e is little discu ssion of th e
ph enom enon of disso ciation, other th an as sim ply a defen sive as pe ct of t he ego.
Recent work by C arden a (7) has demon strat ed th at traum a ca n di rectly provoke
di sso ciative 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 e nable pa ti en ts to gai n mast e ry over
traumatic 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 book
offe rs many valuabl e insights int o psych otherapeutic work wit h pa t ients (n ot only
co m ba t vet erans) wh o suffer fr om post-traum atic st ress diso rd e r. Dr. Schw art z
pr esents com plex, thou ght-provoking m at erial with pr ofound resp ect for t hose who
still suffer th e effec ts of wartim e traum a.
NO TES
I. Brem ner JD, Sout hwick SM, Brett E, Rosenheck RA, Fonta na A, Ch arney DS: Increased
dissociat ive states in PTSD . Prese nt ed at 1993 Co nvention, Am eri can Psychi atric Associat ion , Sym pos iu m # 52
2. Kr yst alJH , Sou t hwick SM, Ka rp e r LP, Bre m ner JD, Charn ey DS: The e me rg ing neurobi ology of dissocia t ion . Present ed a t 1993 Convention, Am eri can Psychia t r ic Associati on ,
Sym pos ium # 52
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3. van d cr Kolk BA, Levin P, Du cey C : Fluoxe tin e a nd int eg rati on of traumatic m em ori es.
Pr esent ed a t 1993 Co nven t ion, Am eri can Psychi a tri c Ass ociat ion, Symposium # 52
4. van d er Kolk BA, Fis ler RE : The biolog ica l basis of post- t rau m a ti c stress. Primary Care; Clinics
and Office Practice 1993; 20(2) :4 17-32
5. Pitm a n RK , va n d e r Kolk BA, O r r SP, G ree nb erg M S: Na loxone-reversible an al gesic
resp on se to co m ba t-re la te d stim uli in posttraum a ti c st ress di sord e r. A pilot st ud y. Arch ives
of Ge ne ral Psychi atry 1990; 47(6):541-4
6. van d er Kol k BA: The co m p ulsio n to re pea t t he tr a u m a . Reen act m e n t, revictimizati on , a nd
m a sochi sm . Psychi atric C linics of North Am erica 19H9; 12(2) :3H9-4 11
7. Carde na E, Spiege l D : Di ssociative r eaction s to th e Sa n Fran cisco Bay ea rt hq ua ke of 1989.
Am e ri can] Psychi at ry 1993; 150(3):474- 8
8. Spiege l D: H yp nosis in th e t reat m e n t of vic t ims o f sex ua l ab use . Psychia t r ic C linics of Nort h
Ame rica 1989; 12(2) :295-306