Handbook of PTSD: Science and Practice
Haunted by Combat: Understanding PTSD in War Veterans Including Women, Reservists, and Those Coming Back from Iraq


Handbook of PTSD: Science and Practice
Edited by Matthew J. Friedman, Terence M. Keane, and Patricia A. Resick. 592 pp. New York, Guilford Press, 2007. $75. ISBN 978-1-59385-473-7.

Haunted by Combat: Understanding PTSD in War Veterans Including Women, Reservists, and Those Coming Back from Iraq
By Daryl S. Paulson and Stanley Krippner. 177 pp. Westport, CT, Praeger Security International, 2007. $44.95. ISBN 978-0-275-99187-6.

The publication of Handbook of PTSD represents an extraordinary effort to consolidate the immense, complex, and at times contradictory body of knowledge on post-traumatic stress disorder (PTSD) in a single textbook. The editors and more than 50 other contributors successfully deliver a book that meets the goal stated in the preface: to provide a sophisticated introduction to the trauma field for graduate students, interns, fellows, scientists, and practitioners. This scholarly textbook, designed for an advanced-level curriculum on PTSD and trauma, is highly organized, balanced, evidence-based, and comprehensive.

The book's chapters are divided into four sections, starting with a historical overview of trauma studies from the end of the 19th century to the present. The authors ensure that this overview provides the context for readers to understand the subsequent contributions that span various disciplines. The second section covers the scientific foundations and theoretical perspectives of PTSD, including epidemiology, risk pathways, psychological theories, studies of traumatic memories and dissociation, neurobiology, interactions between genes and the environment, sex differences, and special populations (children and older adults). Each chapter is an exploration of the techniques that are needed to acquire knowledge pertinent to the specific topic, the current state of the art, the generalizability of the data, and future directions for research on the topic. This section is particularly noteworthy for its balanced approach. The authors provide evidence to show how each theory explains — but not fully — the observed clinical phenomena that are associated with PTSD or trauma.

Tight organization is evident within each chapter and in the sequencing of the chapters. For example, one chapter in which the phenomena of remembering and forgetting are explored gives a primarily neurocognitive perspective. It is followed by a chapter with an equally evidence-based dialectic presentation on dissociation, which brings the meaning and adaptive qualities of dissociation into the discussion. The reader will find that this book is as much about how PTSD is studied as it is about PTSD.

The third section of the book is a comprehensive overview of current clinical practice, including an outstanding chapter on the various structured instruments for the assessment of PTSD, as well as chapters on early intervention, psychosocial treatments, pharmacotherapy, the treatment of children, cultural issues, and the strong association of PTSD with physical health problems. As is appropriate in a textbook, the authors' focus in these chapters is on the body of knowledge that supports the evidence for each treatment and mechanism of action. Although the overview of the scientific evidence is extensive, clinicians should not expect to find an algorithm for the management of difficult PTSD cases; the book is not intended as a clinical treatment manual. The final section of the book, titled "Uncharted Territory," explores areas in which there are more questions than answers: forensic issues, emerging treatments, the concept of resilience, public health interventions, and the agenda for future research.

Handbook of PTSD will be an essential resource for anyone who works as a clinician or researcher in the trauma field, and it is recommended for residency and graduate training programs. The most extraordinary aspect of the book, however, can best be described by sharing our experience of writing this review. After reading and evaluating this work separately, we convened to discuss it, and we were struck by the fact that we were drawn to completely different chapters and learning points that were unique to our own perspectives and personal interests. Irrespective of the reader's school of thought, discipline, or level of training, this book provides a multitude of ways to enrich and inspire a better understanding of this complex field.

The title of Daryl S. Paulson and Stanley Krippner's very different book on PTSD, Haunted by Combat, belies one of the most valuable take-home points of the work — that the responses to combat trauma that military veterans experience not only debilitate, haunt, and afflict them, but also can serve as the impetus for personal growth that might otherwise be unattainable. The authors demonstrate that the complexity and paradoxes of combat trauma for individual veterans are much broader than the current medical construct of PTSD. These points are essential to the understanding of PTSD, yet often they are not well understood by therapists who are trying to help combat veterans through the healing process — a path that is necessarily difficult.

The book carries the reader through a series of discussions that encompass the history and phenomenology of PTSD, its treatment, and the unique factors that men and women face in today's asymmetric warfare. It highlights the challenges of U.S. National Guard and Reserve veterans, as well as the differences between today's force and the force that served in Vietnam, with its large percentage of draftees. The authors describe the limitations of the definition of PTSD, the conceptualization of PTSD along a spectrum of responses to trauma, and the neurobiologic mechanisms that underlie hypotheses about its causes and treatment. A holistic approach is advocated — that PTSD is a biologic, psychological, social, and existential phenomenon that exists on a continuum of predisposing, precipitating, perpetuating, and protective elements in each veteran's experience. The authors convey its debilitating signs and symptoms while encouraging the reader to recognize and respect the adaptive function that these responses serve in the combat zone. The chapters include moving quotes and vignettes of soldiers' own experiences from the Vietnam War to the current war in Iraq.

The book provides an overview of the various evidence-based and alternative approaches to the treatment of PTSD. The authors place special emphasis on existential and humanistic approaches within a framework that reassures veterans that they are heard, valued, respected, and appreciated. This is poignantly illustrated in Paulson's engrossing narrative of his call to duty in Vietnam, his return from the trials of combat, the unexpected and painful struggles he faced as he integrated back into society, and the story of his own healing process.

Perhaps because the book is aimed at a wide audience — the lay public, veterans, and families of veterans, as well as therapists — there is some lack of focus. The contrasts between the immediacy of the veterans' stories and a somewhat removed, theory-driven discourse may not resonate with all readers. The discussion and exploration of women as a subpopulation in the treatment of combat PTSD falls short of expectations, given the explicit mention of women in the book's subtitle. The treatment sections do not clearly identify which modalities have the strongest base of evidence, and there is a notable lack of discussion of prolonged exposure therapy, a treatment with strong evidence for effectiveness. However, we do not wish to let these criticisms detract from the overall value of this book. The testimonials by Paulson and other war veterans, the easily comprehensible discussion of neurobiologic mechanisms, and the authors' recommendations of essential therapeutic elements make Haunted by Combat a solid contribution.


Eugene H. Kim, M.D.
Walter Reed Army Medical Center
Washington, DC 20307

Charles W. Hoge, M.D.
Walter Reed Army Institute of Research
Silver Spring, MD 20910

The views expressed in this review are those of the authors and do not reflect the official position of the Department of Defense or the institutional affiliations listed.