Treatment of Stress Response Syndromes. Second Edition

May 2022

BOOK REVIEWS: Treatment of Stress Response Syndromes. Second Edition

May
2022
Vol. 34. No. 2
Richard Balon, MD

Departments of Psychiatry and Behavioral Neurosciences and Anesthesiology
Wayne State University School of Medicine
Detroit, Michigan, USA

Treatment of response to stress and to psychological trauma is one of the most important and difficult issues clinicians face. In DSM-5 classification, most of the responses are part of trauma- and stressor-related disorders; these “include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion.”1 These disorders include posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders. Psychotherapy has been the main treatment modality for all of them, as pharmacotherapy has only limited use and efficacy. The question each clinician faces is which of the many existing therapies should be used? Some would prefer prolonged exposure, some cognitive-behavioral therapy, some other modalities. But can a clinician use just 1, hopefully the most appropriate and best approach for all disorders whose hallmark is stress and trauma response? Dr. Mardi Horowitz, a foremost expert in the treatment of stress and trauma response, thinks so. He presents his view and his proposed approach in the second edition of his popular book on treatment of stress response syndromes (the first edition was published in 2003).

As he says in the preface, Dr. Horowitz takes an integrative and transtheoretical approach that does not “compartmentalize its recommendations into treatment modalities such as cognitive-behavioral therapy, prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, dialectical behavior therapy, interpersonal therapy, short-term dynamic therapy, and cognitive-dynamic therapy. Research studies confirm that these modalities are effective but also can be improved on” (p vii). He presents here “an integrated approach based on repeated assessments and formulations that lead to individualized plans for the patient” (p vii). He also emphasizes that his “values lead to supporting therapies of whatever length is required in order to provide full benefit to patients and lead to personality growth” (p viii).

The book consists of 9 brief chapters, most of them using very good clinical presentations, tables, and diagrams. The first chapter outlines the principles of psychological responses to stressor events, discussing first memories of trauma and loss events, avoidance symptoms, intrusive symptoms, and cognitive processing. Dr. Horowitz postulates that reactions to stressor events can take several forms, and that clinicians should look for “the five Ds: dissociation, disavowal, denial, depersonalization, and derealization” (p 4). He adds that “The five D experiences are maladaptive and distressing when the individual reflects on them, but they are part of defensive coping because emotional flooding may be reduced for a time” (p 4). He also outlines the phases of response to trauma and losses outcry; denial, numbing, and avoidance; intrusions, pangs, and repetitions; working through; and restoration of equilibrium. Finally, he discusses personality factors, as “individuals experience trauma in terms of their prior life experiences and personality characteristics” (p 6).

The following 6 chapters— Assessment and Treatment Planning; Providing Support; Linking the Meaning of Stressor Events to the Self; Renarration and Reschematization; Terminating; and Assessing Change— present the stages or parts of his treatment approach.

The chapter on assessment and treatment planning emphasizes that patient complaints and symptoms must be put into a historical context, that the initial formulations should be considered tentative and will likely be revised, and that clinicians should provide some information on the likely course of stress response symptoms and the possible progress in treatment, and some realistic hope. He discusses the biopsychosocial formulation in relation to predisposing, precipitating, protective, and perpetuating factors. He brings in the concept of configurational analysis for planning and revising psychotherapy that has 5 steps “from surface to depth”: phenomena; states of mind; topic of concern; identity and relationships; and integration and therapy planning. Dr. Horowitz also discusses the concept of complex PTSD, which is not part of the DSM-5, but is included in the ICD in its latest, 11th edition.

The chapters bring up various important issues, such as “reducing symptom acuity may be essential to increasing emotional regulation and rational organization of thinking and decision making” (p 28); that one needs to watch for patient self-medication and provide nutritional advice; that in reveries and dialogues, “a person is gradually associating the meanings of stressor events to overall self-organization” (p 41); or that in stress response syndromes “most patients have some difficulty coping with frequent, intense, and negative valence emotions … and personality traits play a role in such processes for increased coping” (p 45).

The chapter on renarration and reschematization raises important concepts. For instance, in renarration, the patient learns how “to translate meaning across modes of representation in the process of consolidating memories into therapy dialogues” (p 57). This chapter also addresses levels of personality functioning (harmonious, conflicted, vulnerable, very disturbed, fragmented), and general principles of renarration and reschematization. The chapter on assessing change reviews the self-reporting scales that could be used in assessing change, eg, Impact of Event Scale, Positive States of Mind Scale, and Sense of Self-Regard Scale.

As Dr. Horowitz emphasizes at the beginning of his book, “Various degrees of cognitive processing of the meaning of the event and the consequences to the self may occur” and “psychotherapy can assist individuals in making such restorative changes. In addition to symptom relief, attitudes formed during the process of working through can lead to more self-efficacy and enhanced emotional regulation. The treatment of an impacted person may help that individual achieve personality growths” (p 2). This sounds promising and hopefully can be validated in further research and found useful by clinicians taking care of people exposed to stress and psychological trauma. His transdiagnostic and atheoretical approach to treatment of stress and trauma responses seems to be a rational and reasonable approach patients will benefit from. I would recommend this slim book to all clinicians taking care of people exposed to stress and trauma, as it is a good and useful read.

CORRESPONDENCE

Richard Balon, MD
Wayne State University
Detroit, Michigan, USA